The Hospitalist

Clinical Question: Do risk-assessment models (RAMs) accurately predict which hospitalized medical patients are at risk for venous thromboembolism (VTE)?

Background: Predicting which patients are at high risk for VTE is important. Several models exist, but limited data support their generalizability and accuracy in medical inpatients.

Study Design: Retrospective cohort.

Setting: Hospitals participating in the Michigan Hospital Medicine Safety Consortium (MHMSC).

Synopsis: Data collected through MHMSC for selected medical patients were used in the Kucher, Padua, predictive IMPROVE, and Intermountain DVT risk-assessment models. Patients were classified as “low risk” or “at risk” based on each RAM. Follow-up data came from chart extraction (100% of patients) and 90-day post-discharge telephone calls (58% of patients). The primary outcome was image-confirmed hospital associated VTE, including proximal upper- or proximal lower-extremity DVT or pulmonary embolism. These RAMs classified less than 20% of patients as “at risk.” The incidence of VTE was less than 1%. In this external validation study, the Kucher RAM was the least discriminate and the Intermountain was the best, but none yielded results equivalent to the original studies.

This study was limited by the retrospective design, subjectivity of some risk factors (such as immobility), and inability to obtain 90-day telephone follow-up in all patients. Lastly, the binary approach (“at risk” versus “low risk”) may not align with the original derivation studies in which each factor was evaluated independently.

Bottom Line: The incidence of VTE is low in medical inpatients, and current RAMs may not accurately identify at-risk patients.

Citation: Greene MT, Spyropoulos AC, Chopra V, et al. Validation of risk assessment models of venous thromboembolism in hospitalized medical patients. Am J Med. 2016;129(9):1001.e9-1001.e18. doi:10.1016/j.amjmed.2016.03.031.

Clinical Question: Do risk-assessment models (RAMs) accurately predict which hospitalized medical patients are at risk for venous thromboembolism (VTE)?

Background: Predicting which patients are at high risk for VTE is important. Several models exist, but limited data support their generalizability and accuracy in medical inpatients.

Study Design: Retrospective cohort.

Setting: Hospitals participating in the Michigan Hospital Medicine Safety Consortium (MHMSC).

Synopsis: Data collected through MHMSC for selected medical patients were used in the Kucher, Padua, predictive IMPROVE, and Intermountain DVT risk-assessment models. Patients were classified as “low risk” or “at risk” based on each RAM. Follow-up data came from chart extraction (100% of patients) and 90-day post-discharge telephone calls (58% of patients). The primary outcome was image-confirmed hospital associated VTE, including proximal upper- or proximal lower-extremity DVT or pulmonary embolism. These RAMs classified less than 20% of patients as “at risk.” The incidence of VTE was less than 1%. In this external validation study, the Kucher RAM was the least discriminate and the Intermountain was the best, but none yielded results equivalent to the original studies.

This study was limited by the retrospective design, subjectivity of some risk factors (such as immobility), and inability to obtain 90-day telephone follow-up in all patients. Lastly, the binary approach (“at risk” versus “low risk”) may not align with the original derivation studies in which each factor was evaluated independently.

Bottom Line: The incidence of VTE is low in medical inpatients, and current RAMs may not accurately identify at-risk patients.

Citation: Greene MT, Spyropoulos AC, Chopra V, et al. Validation of risk assessment models of venous thromboembolism in hospitalized medical patients. Am J Med. 2016;129(9):1001.e9-1001.e18. doi:10.1016/j.amjmed.2016.03.031.

Clinical Question: Do risk-assessment models (RAMs) accurately predict which hospitalized medical patients are at risk for venous thromboembolism (VTE)?

Background: Predicting which patients are at high risk for VTE is important. Several models exist, but limited data support their generalizability and accuracy in medical inpatients.

Study Design: Retrospective cohort.

Setting: Hospitals participating in the Michigan Hospital Medicine Safety Consortium (MHMSC).

Synopsis: Data collected through MHMSC for selected medical patients were used in the Kucher, Padua, predictive IMPROVE, and Intermountain DVT risk-assessment models. Patients were classified as “low risk” or “at risk” based on each RAM. Follow-up data came from chart extraction (100% of patients) and 90-day post-discharge telephone calls (58% of patients). The primary outcome was image-confirmed hospital associated VTE, including proximal upper- or proximal lower-extremity DVT or pulmonary embolism. These RAMs classified less than 20% of patients as “at risk.” The incidence of VTE was less than 1%. In this external validation study, the Kucher RAM was the least discriminate and the Intermountain was the best, but none yielded results equivalent to the original studies.

This study was limited by the retrospective design, subjectivity of some risk factors (such as immobility), and inability to obtain 90-day telephone follow-up in all patients. Lastly, the binary approach (“at risk” versus “low risk”) may not align with the original derivation studies in which each factor was evaluated independently.

Bottom Line: The incidence of VTE is low in medical inpatients, and current RAMs may not accurately identify at-risk patients.

Citation: Greene MT, Spyropoulos AC, Chopra V, et al. Validation of risk assessment models of venous thromboembolism in hospitalized medical patients. Am J Med. 2016;129(9):1001.e9-1001.e18. doi:10.1016/j.amjmed.2016.03.031.

SHM recently partnered with the Human Diagnosis Project. Human Dx is the world’s first open diagnostic system, which aims to understand the fundamental data structure of diagnosis and, in the future, considerably impact the cost of, access to, and effectiveness of healthcare globally.

Human Dx’s Global Morning Reports feature weekly case competitions of differential diagnoses and clinical reasoning skills. Each day, attendings, fellows, residents, and medical students have the opportunity to solve the best cases from around the world from the prior day and submit cases for the next day. This partnership with SHM provides a unique, interactive learning platform with cases tailored to hospitalists.

The rules are simple:

• Increase your “Impact” by creating and solving cases online.
• Creating cases creates more “Impact” than solving cases.

The team and individual with the most “Impact” each week win. Sign up today and test your skills in hospital medicine diagnostics at www.humandx.org/shm/.

SHM recently partnered with the Human Diagnosis Project. Human Dx is the world’s first open diagnostic system, which aims to understand the fundamental data structure of diagnosis and, in the future, considerably impact the cost of, access to, and effectiveness of healthcare globally.

Human Dx’s Global Morning Reports feature weekly case competitions of differential diagnoses and clinical reasoning skills. Each day, attendings, fellows, residents, and medical students have the opportunity to solve the best cases from around the world from the prior day and submit cases for the next day. This partnership with SHM provides a unique, interactive learning platform with cases tailored to hospitalists.

The rules are simple:

• Increase your “Impact” by creating and solving cases online.
• Creating cases creates more “Impact” than solving cases.

The team and individual with the most “Impact” each week win. Sign up today and test your skills in hospital medicine diagnostics at www.humandx.org/shm/.

SHM recently partnered with the Human Diagnosis Project. Human Dx is the world’s first open diagnostic system, which aims to understand the fundamental data structure of diagnosis and, in the future, considerably impact the cost of, access to, and effectiveness of healthcare globally.

Human Dx’s Global Morning Reports feature weekly case competitions of differential diagnoses and clinical reasoning skills. Each day, attendings, fellows, residents, and medical students have the opportunity to solve the best cases from around the world from the prior day and submit cases for the next day. This partnership with SHM provides a unique, interactive learning platform with cases tailored to hospitalists.

The rules are simple:

• Increase your “Impact” by creating and solving cases online.
• Creating cases creates more “Impact” than solving cases.

The team and individual with the most “Impact” each week win. Sign up today and test your skills in hospital medicine diagnostics at www.humandx.org/shm/.

• The percentage of the hospital’s total patient volume (for the population the group serves, i.e., adult versus children versus both) that the hospital medicine group (HMG) was responsible for caring for
• The presence of medical hospitalists within the HMG focusing their practice on a specific medical subspecialty, such as critical care, neurology, or oncology
• The value of CME allowances for hospitalists
• The utilization of prolonged service codes by hospitalists
• Charge capture methodologies being used by HMGs
• For academic HMGs, the dollar amount of financial support provided for non-clinical work

Order your copy now and improve your practice today at www.hospitalmedicine.org/survey.

• The percentage of the hospital’s total patient volume (for the population the group serves, i.e., adult versus children versus both) that the hospital medicine group (HMG) was responsible for caring for
• The presence of medical hospitalists within the HMG focusing their practice on a specific medical subspecialty, such as critical care, neurology, or oncology
• The value of CME allowances for hospitalists
• The utilization of prolonged service codes by hospitalists
• Charge capture methodologies being used by HMGs
• For academic HMGs, the dollar amount of financial support provided for non-clinical work

Order your copy now and improve your practice today at www.hospitalmedicine.org/survey.

• The percentage of the hospital’s total patient volume (for the population the group serves, i.e., adult versus children versus both) that the hospital medicine group (HMG) was responsible for caring for
• The presence of medical hospitalists within the HMG focusing their practice on a specific medical subspecialty, such as critical care, neurology, or oncology
• The value of CME allowances for hospitalists
• The utilization of prolonged service codes by hospitalists
• Charge capture methodologies being used by HMGs
• For academic HMGs, the dollar amount of financial support provided for non-clinical work

Order your copy now and improve your practice today at www.hospitalmedicine.org/survey.

Clinical Question: How common are neurologic findings in acute HIV infection?

Background: The incidence of neurologic findings with acute HIV is unknown.

Study Design: Cohort study.

Setting: Bangkok, Thailand.

Synopsis: In this study, 134 patients were identified after presenting for voluntary HIV testing. Five others were enrolled through an ongoing local study. All 139 participants underwent structured neurologic evaluations at enrollment (median of 19 days after presumed exposure), then at four and 12 weeks. Combination antiretroviral therapy (cART) was initiated immediately after initial evaluation.

The cohort was 93% male. Mean age was younger than 30 years. Fifty-three percent of participants experienced some neurologic finding within 12 weeks of diagnosis. One-third (33%) were cognitive symptoms, predominantly problems of concentration (24% of patients) and memory (16% of patients). One-third (34%) were motor findings, and 11% were neuropathy. Forty-nine percent of the neurologic issues were present at diagnosis. Symptoms were mostly mild, although one patient developed fulminant Guillain-Barré syndrome. Patients with neurologic findings had higher viral loads at diagnosis (mean plasma log10 HIV RNA 5.9 versus 5.4; P = 0.006). Participants with and without neurologic findings had similar cerebral spinal fluid viral loads (mean log10 HIV RNA 3.7 versus 3.1, P = 0.14) and serum CD4 counts (339 versus 381 cells/mm3; P = 0.46). Neurologic findings resolved within one month of cART treatment in 90% of patients. Study limitations include lack of a control cohort and potential confounding from illicit drug use among participants.

Bottom Line: Acute HIV infection commonly causes mild neurologic problems, which remit with treatment.

Citation: Hellmuth J, Fletcher JL, Valcour V, et al. Neurologic signs and symptoms frequently manifest in acute HIV infection. Neurology. 2016;87(2):148-154.

Clinical Question: How common are neurologic findings in acute HIV infection?

Background: The incidence of neurologic findings with acute HIV is unknown.

Study Design: Cohort study.

Setting: Bangkok, Thailand.

Synopsis: In this study, 134 patients were identified after presenting for voluntary HIV testing. Five others were enrolled through an ongoing local study. All 139 participants underwent structured neurologic evaluations at enrollment (median of 19 days after presumed exposure), then at four and 12 weeks. Combination antiretroviral therapy (cART) was initiated immediately after initial evaluation.

The cohort was 93% male. Mean age was younger than 30 years. Fifty-three percent of participants experienced some neurologic finding within 12 weeks of diagnosis. One-third (33%) were cognitive symptoms, predominantly problems of concentration (24% of patients) and memory (16% of patients). One-third (34%) were motor findings, and 11% were neuropathy. Forty-nine percent of the neurologic issues were present at diagnosis. Symptoms were mostly mild, although one patient developed fulminant Guillain-Barré syndrome. Patients with neurologic findings had higher viral loads at diagnosis (mean plasma log10 HIV RNA 5.9 versus 5.4; P = 0.006). Participants with and without neurologic findings had similar cerebral spinal fluid viral loads (mean log10 HIV RNA 3.7 versus 3.1, P = 0.14) and serum CD4 counts (339 versus 381 cells/mm3; P = 0.46). Neurologic findings resolved within one month of cART treatment in 90% of patients. Study limitations include lack of a control cohort and potential confounding from illicit drug use among participants.

Bottom Line: Acute HIV infection commonly causes mild neurologic problems, which remit with treatment.

Citation: Hellmuth J, Fletcher JL, Valcour V, et al. Neurologic signs and symptoms frequently manifest in acute HIV infection. Neurology. 2016;87(2):148-154.

Clinical Question: How common are neurologic findings in acute HIV infection?

Background: The incidence of neurologic findings with acute HIV is unknown.

Study Design: Cohort study.

Setting: Bangkok, Thailand.

Synopsis: In this study, 134 patients were identified after presenting for voluntary HIV testing. Five others were enrolled through an ongoing local study. All 139 participants underwent structured neurologic evaluations at enrollment (median of 19 days after presumed exposure), then at four and 12 weeks. Combination antiretroviral therapy (cART) was initiated immediately after initial evaluation.

The cohort was 93% male. Mean age was younger than 30 years. Fifty-three percent of participants experienced some neurologic finding within 12 weeks of diagnosis. One-third (33%) were cognitive symptoms, predominantly problems of concentration (24% of patients) and memory (16% of patients). One-third (34%) were motor findings, and 11% were neuropathy. Forty-nine percent of the neurologic issues were present at diagnosis. Symptoms were mostly mild, although one patient developed fulminant Guillain-Barré syndrome. Patients with neurologic findings had higher viral loads at diagnosis (mean plasma log10 HIV RNA 5.9 versus 5.4; P = 0.006). Participants with and without neurologic findings had similar cerebral spinal fluid viral loads (mean log10 HIV RNA 3.7 versus 3.1, P = 0.14) and serum CD4 counts (339 versus 381 cells/mm3; P = 0.46). Neurologic findings resolved within one month of cART treatment in 90% of patients. Study limitations include lack of a control cohort and potential confounding from illicit drug use among participants.

Bottom Line: Acute HIV infection commonly causes mild neurologic problems, which remit with treatment.

Citation: Hellmuth J, Fletcher JL, Valcour V, et al. Neurologic signs and symptoms frequently manifest in acute HIV infection. Neurology. 2016;87(2):148-154.

Clinical Question: Is the 10-point cognitive screener (10-CS) effective in screening for delirium in older adults with hip fracture?

Background: Delirium in elderly hip fracture patients has been established as a significant comorbidity. There is, however, no agreement on the most appropriate and practical screening tool. Commonly used screening methods, which focus on the detection of cognitive impairment as a surrogate, are time-consuming, insensitive for mild impairment, and limited in their application to patients with impaired dexterity and poor education.

Study Design: Prospective cohort study.

Setting: Tertiary referral hospital in São Paulo, Brazil.

Synopsis: In the study, 147 consecutive hip fracture patients over age 60 were screened using the 10-CS. This test stratifies patients into three categories: normal, possible, and probable cognitive impairment. Development of in-hospital delirium was evaluated by daily Confusion Assessment Method testing administered by a geriatrician. Patients categorized as probable cognitive impairment were more likely to develop delirium (hazard ratio, 7.48; 95% CI, 2.2–25.4).

Hospitalists involved in perioperative care should consider using this simple screening tool. With an area under ROC curve of 0.83 (95% CI, 0.76–0.89), it effectively detects delirium in this high-risk population. Independently, patients who developed delirium had a longer length of stay (median 11.0 versus 7.0; P < 0.001). This serves as a reminder of the importance of screening and preventing delirium in this population.

Bottom Line: The 10-CS tool is practical in its application and effective in identifying elderly hip fracture patients at risk for delirium.

Citation: Fortes-Filho SQ, Apolinario D, Melo JA, Suzuki I, Sitta MD, Garcez-Leme LE. Predicting delirium after hip fracture with a 2-min cognitive screen: prospective cohort study [published online ahead of print May 17, 2016]. Age Ageing. pii:afw084.

Clinical Question: Is the 10-point cognitive screener (10-CS) effective in screening for delirium in older adults with hip fracture?

Background: Delirium in elderly hip fracture patients has been established as a significant comorbidity. There is, however, no agreement on the most appropriate and practical screening tool. Commonly used screening methods, which focus on the detection of cognitive impairment as a surrogate, are time-consuming, insensitive for mild impairment, and limited in their application to patients with impaired dexterity and poor education.

Study Design: Prospective cohort study.

Setting: Tertiary referral hospital in São Paulo, Brazil.

Synopsis: In the study, 147 consecutive hip fracture patients over age 60 were screened using the 10-CS. This test stratifies patients into three categories: normal, possible, and probable cognitive impairment. Development of in-hospital delirium was evaluated by daily Confusion Assessment Method testing administered by a geriatrician. Patients categorized as probable cognitive impairment were more likely to develop delirium (hazard ratio, 7.48; 95% CI, 2.2–25.4).

Hospitalists involved in perioperative care should consider using this simple screening tool. With an area under ROC curve of 0.83 (95% CI, 0.76–0.89), it effectively detects delirium in this high-risk population. Independently, patients who developed delirium had a longer length of stay (median 11.0 versus 7.0; P < 0.001). This serves as a reminder of the importance of screening and preventing delirium in this population.

Bottom Line: The 10-CS tool is practical in its application and effective in identifying elderly hip fracture patients at risk for delirium.

Citation: Fortes-Filho SQ, Apolinario D, Melo JA, Suzuki I, Sitta MD, Garcez-Leme LE. Predicting delirium after hip fracture with a 2-min cognitive screen: prospective cohort study [published online ahead of print May 17, 2016]. Age Ageing. pii:afw084.

Clinical Question: Is the 10-point cognitive screener (10-CS) effective in screening for delirium in older adults with hip fracture?

Background: Delirium in elderly hip fracture patients has been established as a significant comorbidity. There is, however, no agreement on the most appropriate and practical screening tool. Commonly used screening methods, which focus on the detection of cognitive impairment as a surrogate, are time-consuming, insensitive for mild impairment, and limited in their application to patients with impaired dexterity and poor education.

Study Design: Prospective cohort study.

Setting: Tertiary referral hospital in São Paulo, Brazil.

Synopsis: In the study, 147 consecutive hip fracture patients over age 60 were screened using the 10-CS. This test stratifies patients into three categories: normal, possible, and probable cognitive impairment. Development of in-hospital delirium was evaluated by daily Confusion Assessment Method testing administered by a geriatrician. Patients categorized as probable cognitive impairment were more likely to develop delirium (hazard ratio, 7.48; 95% CI, 2.2–25.4).

Hospitalists involved in perioperative care should consider using this simple screening tool. With an area under ROC curve of 0.83 (95% CI, 0.76–0.89), it effectively detects delirium in this high-risk population. Independently, patients who developed delirium had a longer length of stay (median 11.0 versus 7.0; P < 0.001). This serves as a reminder of the importance of screening and preventing delirium in this population.

Bottom Line: The 10-CS tool is practical in its application and effective in identifying elderly hip fracture patients at risk for delirium.

Citation: Fortes-Filho SQ, Apolinario D, Melo JA, Suzuki I, Sitta MD, Garcez-Leme LE. Predicting delirium after hip fracture with a 2-min cognitive screen: prospective cohort study [published online ahead of print May 17, 2016]. Age Ageing. pii:afw084.

(Reuters) - Sanofi SA said on Monday the U.S. Department of Health and Human Services (HHS) approved $43.18 million in funding to accelerate the development of a Zika vaccine, as efforts to prevent the infection gather momentum.

The funding from the HHS' Biomedical Advanced Research and Development Authority (BARDA) will be used for mid-stage trials, expected to begin in the first half of 2018, and for manufacturing, the French drugmaker said.

The contract runs through June 2022, but if the data is positive, the contract includes an option for up to additional $130.45 million for late-stage trials necessary for eventual approval.

Work on the vaccine began in March as a collaborative effort between the U.S. Department Of Defense's Walter Reed Army Institute of Research (WRAIR), BARDA and the National Institutes of Health. Sanofi in July teamed up with WRAIR to co-develop the vaccine.

Earlier this month, BARDA gave Japanese drugmaker Takeda Pharmaceutical Co nearly $20 million in initial funding to develop a Zika vaccine.

Sanofi is one of the many companies around the world looking to develop a vaccine against the virus that has spread rapidly since the current outbreak was first detected last year in Brazil.

Hundreds of thousands of people are estimated to have been infected with Zika in the Americas and parts of Asia. Most have no symptoms or experience only a mild illness.

The virus can penetrate the womb in pregnant women, causing a rare but crippling birth defect known as microcephaly. In adults, it has been linked to Guillain-Barre syndrome, a form of temporary paralysis.

Zika, a member of the flavivirus species that includes dengue, yellow fever and West Nile virus, is typically spread by the bite of the Aedes aegypti mosquito.

It can be also passed on through sex, a unique characteristic among mosquito-borne viruses.

Sanofi Pasteur, the vaccine unit of Sanofi, already has several vaccines approved for others flaviviruses, such as yellow fever, dengue and Japanese encephalitis.

As of September, the HHS has awarded at least $433 million in repurposed funds to support Zika response and preparedness activities.

(Reuters) - Sanofi SA said on Monday the U.S. Department of Health and Human Services (HHS) approved $43.18 million in funding to accelerate the development of a Zika vaccine, as efforts to prevent the infection gather momentum.

The funding from the HHS' Biomedical Advanced Research and Development Authority (BARDA) will be used for mid-stage trials, expected to begin in the first half of 2018, and for manufacturing, the French drugmaker said.

The contract runs through June 2022, but if the data is positive, the contract includes an option for up to additional $130.45 million for late-stage trials necessary for eventual approval.

Work on the vaccine began in March as a collaborative effort between the U.S. Department Of Defense's Walter Reed Army Institute of Research (WRAIR), BARDA and the National Institutes of Health. Sanofi in July teamed up with WRAIR to co-develop the vaccine.

Earlier this month, BARDA gave Japanese drugmaker Takeda Pharmaceutical Co nearly $20 million in initial funding to develop a Zika vaccine.

Sanofi is one of the many companies around the world looking to develop a vaccine against the virus that has spread rapidly since the current outbreak was first detected last year in Brazil.

Hundreds of thousands of people are estimated to have been infected with Zika in the Americas and parts of Asia. Most have no symptoms or experience only a mild illness.

The virus can penetrate the womb in pregnant women, causing a rare but crippling birth defect known as microcephaly. In adults, it has been linked to Guillain-Barre syndrome, a form of temporary paralysis.

Zika, a member of the flavivirus species that includes dengue, yellow fever and West Nile virus, is typically spread by the bite of the Aedes aegypti mosquito.

It can be also passed on through sex, a unique characteristic among mosquito-borne viruses.

Sanofi Pasteur, the vaccine unit of Sanofi, already has several vaccines approved for others flaviviruses, such as yellow fever, dengue and Japanese encephalitis.

As of September, the HHS has awarded at least $433 million in repurposed funds to support Zika response and preparedness activities.

(Reuters) - Sanofi SA said on Monday the U.S. Department of Health and Human Services (HHS) approved $43.18 million in funding to accelerate the development of a Zika vaccine, as efforts to prevent the infection gather momentum.

The funding from the HHS' Biomedical Advanced Research and Development Authority (BARDA) will be used for mid-stage trials, expected to begin in the first half of 2018, and for manufacturing, the French drugmaker said.

The contract runs through June 2022, but if the data is positive, the contract includes an option for up to additional $130.45 million for late-stage trials necessary for eventual approval.

Work on the vaccine began in March as a collaborative effort between the U.S. Department Of Defense's Walter Reed Army Institute of Research (WRAIR), BARDA and the National Institutes of Health. Sanofi in July teamed up with WRAIR to co-develop the vaccine.

Earlier this month, BARDA gave Japanese drugmaker Takeda Pharmaceutical Co nearly $20 million in initial funding to develop a Zika vaccine.

Sanofi is one of the many companies around the world looking to develop a vaccine against the virus that has spread rapidly since the current outbreak was first detected last year in Brazil.

Hundreds of thousands of people are estimated to have been infected with Zika in the Americas and parts of Asia. Most have no symptoms or experience only a mild illness.

The virus can penetrate the womb in pregnant women, causing a rare but crippling birth defect known as microcephaly. In adults, it has been linked to Guillain-Barre syndrome, a form of temporary paralysis.

Zika, a member of the flavivirus species that includes dengue, yellow fever and West Nile virus, is typically spread by the bite of the Aedes aegypti mosquito.

It can be also passed on through sex, a unique characteristic among mosquito-borne viruses.

Sanofi Pasteur, the vaccine unit of Sanofi, already has several vaccines approved for others flaviviruses, such as yellow fever, dengue and Japanese encephalitis.

As of September, the HHS has awarded at least $433 million in repurposed funds to support Zika response and preparedness activities.

[WpProQuiz 14]

[WpProQuiz 14]

[WpProQuiz 14]

As compared with the general population, hospitalists are especially prone to stress and burnout, according to an abstract published in the Journal of Hospital Medicine.

The study’s scoring showed that hospitalists started with higher levels of perceived stress than the general population of adults of similar ages. Among hospitalists who attended an average of two mindfulness sessions over five weeks, there was a statistically significant increase in mindfulness and a decrease in perceived stress.

The low number of participants, seven hospitalists, makes extrapolation difficult, but the results are suggestive.

“Even with those seven people, we did see there was a significant difference in their stress and an increase in their mindfulness, which I thought was kind of impressive just for going to only two or three sessions,” says study co-author Dennis Chang, MD, of the Icahn School of Medicine at Mount Sinai. “I think the biggest thing that I would like to see is if it actually improves how we take care of our patients, not just ourselves.”

Dr. Chang says one factor that inspired the study was a hospital survey.

“We do an annual survey of our hospitalists, and it seemed that we had, as a lot of hospital groups do, a burnout problem: People were feeling a little bit burnt out,” Dr. Chang says. “We read some articles on mindfulness, and we thought it might be interesting to see if it would help our hospital.”

Starting this Fall, Mount Sinai will offer a tailored mindfulness session for providers.

“We’re hoping we’ll see if these results really stand up,” Dr. Chang says.

He encourages hospitalists to learn more about mindfulness and to realize that small changes can have an impact.

“Even doing some breathing exercises for a couple of minutes a day can actually make a big difference,” he says. “It doesn’t take a lot of time. Maybe even going to one mindfulness session can give you some tools that you can use. It can make a huge difference in your stress levels and how you take care of patients.”

Reference

1. Chablani S, Nguyen VT, Chang D. Mindfulness for hospitalists: a pilot study investigating the effect of a mindfulness initiative on mindfulness and perceived stress among hospitalists [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed September 9, 2016.

As compared with the general population, hospitalists are especially prone to stress and burnout, according to an abstract published in the Journal of Hospital Medicine.

The study’s scoring showed that hospitalists started with higher levels of perceived stress than the general population of adults of similar ages. Among hospitalists who attended an average of two mindfulness sessions over five weeks, there was a statistically significant increase in mindfulness and a decrease in perceived stress.

The low number of participants, seven hospitalists, makes extrapolation difficult, but the results are suggestive.

“Even with those seven people, we did see there was a significant difference in their stress and an increase in their mindfulness, which I thought was kind of impressive just for going to only two or three sessions,” says study co-author Dennis Chang, MD, of the Icahn School of Medicine at Mount Sinai. “I think the biggest thing that I would like to see is if it actually improves how we take care of our patients, not just ourselves.”

Dr. Chang says one factor that inspired the study was a hospital survey.

“We do an annual survey of our hospitalists, and it seemed that we had, as a lot of hospital groups do, a burnout problem: People were feeling a little bit burnt out,” Dr. Chang says. “We read some articles on mindfulness, and we thought it might be interesting to see if it would help our hospital.”

Starting this Fall, Mount Sinai will offer a tailored mindfulness session for providers.

“We’re hoping we’ll see if these results really stand up,” Dr. Chang says.

He encourages hospitalists to learn more about mindfulness and to realize that small changes can have an impact.

“Even doing some breathing exercises for a couple of minutes a day can actually make a big difference,” he says. “It doesn’t take a lot of time. Maybe even going to one mindfulness session can give you some tools that you can use. It can make a huge difference in your stress levels and how you take care of patients.”

Reference

1. Chablani S, Nguyen VT, Chang D. Mindfulness for hospitalists: a pilot study investigating the effect of a mindfulness initiative on mindfulness and perceived stress among hospitalists [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed September 9, 2016.

As compared with the general population, hospitalists are especially prone to stress and burnout, according to an abstract published in the Journal of Hospital Medicine.

The study’s scoring showed that hospitalists started with higher levels of perceived stress than the general population of adults of similar ages. Among hospitalists who attended an average of two mindfulness sessions over five weeks, there was a statistically significant increase in mindfulness and a decrease in perceived stress.

The low number of participants, seven hospitalists, makes extrapolation difficult, but the results are suggestive.

“Even with those seven people, we did see there was a significant difference in their stress and an increase in their mindfulness, which I thought was kind of impressive just for going to only two or three sessions,” says study co-author Dennis Chang, MD, of the Icahn School of Medicine at Mount Sinai. “I think the biggest thing that I would like to see is if it actually improves how we take care of our patients, not just ourselves.”

Dr. Chang says one factor that inspired the study was a hospital survey.

“We do an annual survey of our hospitalists, and it seemed that we had, as a lot of hospital groups do, a burnout problem: People were feeling a little bit burnt out,” Dr. Chang says. “We read some articles on mindfulness, and we thought it might be interesting to see if it would help our hospital.”

Starting this Fall, Mount Sinai will offer a tailored mindfulness session for providers.

“We’re hoping we’ll see if these results really stand up,” Dr. Chang says.

He encourages hospitalists to learn more about mindfulness and to realize that small changes can have an impact.

“Even doing some breathing exercises for a couple of minutes a day can actually make a big difference,” he says. “It doesn’t take a lot of time. Maybe even going to one mindfulness session can give you some tools that you can use. It can make a huge difference in your stress levels and how you take care of patients.”

Reference

1. Chablani S, Nguyen VT, Chang D. Mindfulness for hospitalists: a pilot study investigating the effect of a mindfulness initiative on mindfulness and perceived stress among hospitalists [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed September 9, 2016.

NEW YORK (Reuters Health) - Sustained viral response (SVR) to hepatitis C virus (HCV) treatment is associated with a reduction in liver and non-liver complications in patients with compensated cirrhosis, researchers from France report.

"The achievement of HCV eradication strikingly decreases the risks of liver-related complications, a benefit that was up to now only suggested by retrospective studies," Dr. Pierre Nahon from Hôpital Jean Verdier in Bondy, France, told Reuters Health by email.

"These benefits extend beyond liver-related complications, in particular for cardiovascular disease and MACE (major adverse cardiovascular events) as well as bacterial infection," he said. "These positive effects are translated into survival benefits, whether considering liver-related or extra-hepatic mortality."

Dr. Nahon and colleagues from 35 clinical centers in France evaluated the impact of SVR in 1,671 patients, 1,323 of whom had HCV-related compensated cirrhosis.

After a median follow-up of 58.2 months, 59.5% of patients had a negative viral load, including 668 patients (51.7%) with SVR and 119 HCV-negative patients who were still undergoing antiviral treatment.

Male gender, absence of esophageal varices, and absence of diabetes were independent predictive factors for SVR, the researchers report in Gastroenterology, online the September 15.

SVR was associated with a significantly decreased risk of hepatocellular carcinoma (HCC; hazard ratio, 0.29) and mortality among patients who had HCC at baseline.

Patients who achieved SVR were also 74% less likely to develop liver decompensation during follow-up.

Extrahepatic events - including bacterial infections and cardiovascular events - were less than half as common among patients who achieved SVR than among others, but SVR had no apparent effect on the occurrence of extrahepatic malignancies.

SVR independently predicted a lower risk of hepatic and extrahepatic complications, a finding that was confirmed by a supporting propensity-matching analysis.

SVR was a protective factor for all-cause mortality (HR, 0.27; p<0.001), as well as a predictive factor for survival without liver-related or extrahepatic deaths.

"The present report, with the advantage of a longer follow-up and by studying virological clearance at endpoint as a time-dependent covariate after interferon- or direct-acting antivirals (DAA)-based regimen, now clearly shows that achieving SVR in HCV-infected cirrhotic patients leads to an improved prognosis," the researchers conclude.

"Overall, the present data are able to specifically highlight the independent influence of SVR on the incidence of liver complications, including HCC and mortality and interestingly a positive impact on the occurrence of extrahepatic manifestations," they add.

"However," the team notes, "the achievement of SVR in DAA-treated patients is too recent to draw any definite conclusion on this point, which will require a longer follow-up of the CirVir cohort to be adequately addressed."

"Although HCV eradication is achievable in almost all patients, physicians must be aware of the persisting risk of HCC occurrence in cirrhotic patients despite viral clearance, in particular in case of associated metabolic syndrome," Dr. Nahon cautioned. "These patients must be maintained in liver cancer surveillance programs."

The study did not have commercial funding. Several authors, including Dr. Nahon, reported financial ties to Gilead Sciences and other companies selling drugs for hepatitis C.

NEW YORK (Reuters Health) - Sustained viral response (SVR) to hepatitis C virus (HCV) treatment is associated with a reduction in liver and non-liver complications in patients with compensated cirrhosis, researchers from France report.

"The achievement of HCV eradication strikingly decreases the risks of liver-related complications, a benefit that was up to now only suggested by retrospective studies," Dr. Pierre Nahon from Hôpital Jean Verdier in Bondy, France, told Reuters Health by email.

"These benefits extend beyond liver-related complications, in particular for cardiovascular disease and MACE (major adverse cardiovascular events) as well as bacterial infection," he said. "These positive effects are translated into survival benefits, whether considering liver-related or extra-hepatic mortality."

Dr. Nahon and colleagues from 35 clinical centers in France evaluated the impact of SVR in 1,671 patients, 1,323 of whom had HCV-related compensated cirrhosis.

After a median follow-up of 58.2 months, 59.5% of patients had a negative viral load, including 668 patients (51.7%) with SVR and 119 HCV-negative patients who were still undergoing antiviral treatment.

Male gender, absence of esophageal varices, and absence of diabetes were independent predictive factors for SVR, the researchers report in Gastroenterology, online the September 15.

SVR was associated with a significantly decreased risk of hepatocellular carcinoma (HCC; hazard ratio, 0.29) and mortality among patients who had HCC at baseline.

Patients who achieved SVR were also 74% less likely to develop liver decompensation during follow-up.

Extrahepatic events - including bacterial infections and cardiovascular events - were less than half as common among patients who achieved SVR than among others, but SVR had no apparent effect on the occurrence of extrahepatic malignancies.

SVR independently predicted a lower risk of hepatic and extrahepatic complications, a finding that was confirmed by a supporting propensity-matching analysis.

SVR was a protective factor for all-cause mortality (HR, 0.27; p<0.001), as well as a predictive factor for survival without liver-related or extrahepatic deaths.

"The present report, with the advantage of a longer follow-up and by studying virological clearance at endpoint as a time-dependent covariate after interferon- or direct-acting antivirals (DAA)-based regimen, now clearly shows that achieving SVR in HCV-infected cirrhotic patients leads to an improved prognosis," the researchers conclude.

"Overall, the present data are able to specifically highlight the independent influence of SVR on the incidence of liver complications, including HCC and mortality and interestingly a positive impact on the occurrence of extrahepatic manifestations," they add.

"However," the team notes, "the achievement of SVR in DAA-treated patients is too recent to draw any definite conclusion on this point, which will require a longer follow-up of the CirVir cohort to be adequately addressed."

"Although HCV eradication is achievable in almost all patients, physicians must be aware of the persisting risk of HCC occurrence in cirrhotic patients despite viral clearance, in particular in case of associated metabolic syndrome," Dr. Nahon cautioned. "These patients must be maintained in liver cancer surveillance programs."

The study did not have commercial funding. Several authors, including Dr. Nahon, reported financial ties to Gilead Sciences and other companies selling drugs for hepatitis C.

NEW YORK (Reuters Health) - Sustained viral response (SVR) to hepatitis C virus (HCV) treatment is associated with a reduction in liver and non-liver complications in patients with compensated cirrhosis, researchers from France report.

"The achievement of HCV eradication strikingly decreases the risks of liver-related complications, a benefit that was up to now only suggested by retrospective studies," Dr. Pierre Nahon from Hôpital Jean Verdier in Bondy, France, told Reuters Health by email.

"These benefits extend beyond liver-related complications, in particular for cardiovascular disease and MACE (major adverse cardiovascular events) as well as bacterial infection," he said. "These positive effects are translated into survival benefits, whether considering liver-related or extra-hepatic mortality."

Dr. Nahon and colleagues from 35 clinical centers in France evaluated the impact of SVR in 1,671 patients, 1,323 of whom had HCV-related compensated cirrhosis.

After a median follow-up of 58.2 months, 59.5% of patients had a negative viral load, including 668 patients (51.7%) with SVR and 119 HCV-negative patients who were still undergoing antiviral treatment.

Male gender, absence of esophageal varices, and absence of diabetes were independent predictive factors for SVR, the researchers report in Gastroenterology, online the September 15.

SVR was associated with a significantly decreased risk of hepatocellular carcinoma (HCC; hazard ratio, 0.29) and mortality among patients who had HCC at baseline.

Patients who achieved SVR were also 74% less likely to develop liver decompensation during follow-up.

Extrahepatic events - including bacterial infections and cardiovascular events - were less than half as common among patients who achieved SVR than among others, but SVR had no apparent effect on the occurrence of extrahepatic malignancies.

SVR independently predicted a lower risk of hepatic and extrahepatic complications, a finding that was confirmed by a supporting propensity-matching analysis.

SVR was a protective factor for all-cause mortality (HR, 0.27; p<0.001), as well as a predictive factor for survival without liver-related or extrahepatic deaths.

"The present report, with the advantage of a longer follow-up and by studying virological clearance at endpoint as a time-dependent covariate after interferon- or direct-acting antivirals (DAA)-based regimen, now clearly shows that achieving SVR in HCV-infected cirrhotic patients leads to an improved prognosis," the researchers conclude.

"Overall, the present data are able to specifically highlight the independent influence of SVR on the incidence of liver complications, including HCC and mortality and interestingly a positive impact on the occurrence of extrahepatic manifestations," they add.

"However," the team notes, "the achievement of SVR in DAA-treated patients is too recent to draw any definite conclusion on this point, which will require a longer follow-up of the CirVir cohort to be adequately addressed."

"Although HCV eradication is achievable in almost all patients, physicians must be aware of the persisting risk of HCC occurrence in cirrhotic patients despite viral clearance, in particular in case of associated metabolic syndrome," Dr. Nahon cautioned. "These patients must be maintained in liver cancer surveillance programs."

The study did not have commercial funding. Several authors, including Dr. Nahon, reported financial ties to Gilead Sciences and other companies selling drugs for hepatitis C.

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

Hospitalist groups and their stakeholders must continually adapt to evolving reimbursement models and their attendant financial foci on quality. Even in the midst of care models that rely less heavily on volume of care as a marker for reimbursement, the use of criteria by insurers to separate hospital stays into inpatient or observation status remains widespread. Hospitalist groups vary in the reimbursement model environment they work in, and different reimbursement models can drive hospitalist group behavior in different ways.

SHM’s 2016 State of Hospital Medicine Report revisits the issue of observation status utilization raised in previous surveys.1 The 2012 survey’s methodology reports admissions classified as observation status based on CPT coding.2 The 2016 survey continues the 2014 survey methodology of using discharges classified as observation status based on CPT coding, along with same-day admission and discharge reported as a third hospitalization status category. In groups serving adults only, observation discharges accounted for 21.2% of all discharges, which represents an increase from 16.1% in the 2014 survey3 and a general return to the 2012-reported percentage of 20%. If same-day admissions and discharges, many of which are likely classified as observation status, are added, then observation status use in the 2016 survey may be as high as 24% of all admissions. This represents a considerable increase from the combined 19.6% rate in 2014.

Changes in non-academic status hospitalist groups largely account for this increase. Academic hospitalist groups reported an observation status utilization rate of 15.3% of admissions in 2012 and 19.4% in 2014, with a subsequent decrease to 17.5% reported in the 2016 survey. Inclusion of same-day admission and discharge with reported observation status use also reveals a decrease from 22.8% in 2014 to 20.8% in the new survey. In contrast, non-academic hospitalist groups now report a substantial change in observation status utilization, up to 21.4% in the 2016 survey from 15.6% in 2014 and similar to the 2012 level of 20.4%. When same-day admission and discharge codes are also included, the totals for non-academic hospitalist groups also evidence an increase, to 24.3% in the new survey from 19.2% in 2014.

I postulated in 2015 that the comparative increase in observation status utilization by academic groups as compared with non-academic groups in the 2014 survey may have been associated with greater proficiency in documentation and related billing inherent in a bedside clinical workforce entirely composed of physicians who have completed postgraduate training. Other phenomena may now potentially explain the increase in observation status use we see in the 2016 survey. These include adoption of the two-midnight rule by the Centers for Medicare & Medicaid Services, use of readmission rates in hospitalist group incentive structures, sharing of cost savings between hospitalist groups and healthcare organizations mutually engaged in third-party bundled payment arrangements, or risk-avoidant strategies executed by clinicians and institutional coders perhaps in excess of their institutions’ needs for risk avoidance. For many of these events, the 2016 State of Hospital Medicine Report provides further benchmark data, in a national and regional context, to inform understanding for hospitalist groups facing challenges associated with observation status utilization.

G. Randy Smith Jr., MD, MS, FRCP(Edin), SFHM, is an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago.

References

1. 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
2. 2012 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
3. 2014 State of Hospital Medicine Report. Society of Hospital Medicine website.

   Accessed September 11, 2016.

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

Hospitalist groups and their stakeholders must continually adapt to evolving reimbursement models and their attendant financial foci on quality. Even in the midst of care models that rely less heavily on volume of care as a marker for reimbursement, the use of criteria by insurers to separate hospital stays into inpatient or observation status remains widespread. Hospitalist groups vary in the reimbursement model environment they work in, and different reimbursement models can drive hospitalist group behavior in different ways.

SHM’s 2016 State of Hospital Medicine Report revisits the issue of observation status utilization raised in previous surveys.1 The 2012 survey’s methodology reports admissions classified as observation status based on CPT coding.2 The 2016 survey continues the 2014 survey methodology of using discharges classified as observation status based on CPT coding, along with same-day admission and discharge reported as a third hospitalization status category. In groups serving adults only, observation discharges accounted for 21.2% of all discharges, which represents an increase from 16.1% in the 2014 survey3 and a general return to the 2012-reported percentage of 20%. If same-day admissions and discharges, many of which are likely classified as observation status, are added, then observation status use in the 2016 survey may be as high as 24% of all admissions. This represents a considerable increase from the combined 19.6% rate in 2014.

Changes in non-academic status hospitalist groups largely account for this increase. Academic hospitalist groups reported an observation status utilization rate of 15.3% of admissions in 2012 and 19.4% in 2014, with a subsequent decrease to 17.5% reported in the 2016 survey. Inclusion of same-day admission and discharge with reported observation status use also reveals a decrease from 22.8% in 2014 to 20.8% in the new survey. In contrast, non-academic hospitalist groups now report a substantial change in observation status utilization, up to 21.4% in the 2016 survey from 15.6% in 2014 and similar to the 2012 level of 20.4%. When same-day admission and discharge codes are also included, the totals for non-academic hospitalist groups also evidence an increase, to 24.3% in the new survey from 19.2% in 2014.

I postulated in 2015 that the comparative increase in observation status utilization by academic groups as compared with non-academic groups in the 2014 survey may have been associated with greater proficiency in documentation and related billing inherent in a bedside clinical workforce entirely composed of physicians who have completed postgraduate training. Other phenomena may now potentially explain the increase in observation status use we see in the 2016 survey. These include adoption of the two-midnight rule by the Centers for Medicare & Medicaid Services, use of readmission rates in hospitalist group incentive structures, sharing of cost savings between hospitalist groups and healthcare organizations mutually engaged in third-party bundled payment arrangements, or risk-avoidant strategies executed by clinicians and institutional coders perhaps in excess of their institutions’ needs for risk avoidance. For many of these events, the 2016 State of Hospital Medicine Report provides further benchmark data, in a national and regional context, to inform understanding for hospitalist groups facing challenges associated with observation status utilization.

G. Randy Smith Jr., MD, MS, FRCP(Edin), SFHM, is an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago.

References

1. 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
2. 2012 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
3. 2014 State of Hospital Medicine Report. Society of Hospital Medicine website.

   Accessed September 11, 2016.

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

Hospitalist groups and their stakeholders must continually adapt to evolving reimbursement models and their attendant financial foci on quality. Even in the midst of care models that rely less heavily on volume of care as a marker for reimbursement, the use of criteria by insurers to separate hospital stays into inpatient or observation status remains widespread. Hospitalist groups vary in the reimbursement model environment they work in, and different reimbursement models can drive hospitalist group behavior in different ways.

SHM’s 2016 State of Hospital Medicine Report revisits the issue of observation status utilization raised in previous surveys.1 The 2012 survey’s methodology reports admissions classified as observation status based on CPT coding.2 The 2016 survey continues the 2014 survey methodology of using discharges classified as observation status based on CPT coding, along with same-day admission and discharge reported as a third hospitalization status category. In groups serving adults only, observation discharges accounted for 21.2% of all discharges, which represents an increase from 16.1% in the 2014 survey3 and a general return to the 2012-reported percentage of 20%. If same-day admissions and discharges, many of which are likely classified as observation status, are added, then observation status use in the 2016 survey may be as high as 24% of all admissions. This represents a considerable increase from the combined 19.6% rate in 2014.

Changes in non-academic status hospitalist groups largely account for this increase. Academic hospitalist groups reported an observation status utilization rate of 15.3% of admissions in 2012 and 19.4% in 2014, with a subsequent decrease to 17.5% reported in the 2016 survey. Inclusion of same-day admission and discharge with reported observation status use also reveals a decrease from 22.8% in 2014 to 20.8% in the new survey. In contrast, non-academic hospitalist groups now report a substantial change in observation status utilization, up to 21.4% in the 2016 survey from 15.6% in 2014 and similar to the 2012 level of 20.4%. When same-day admission and discharge codes are also included, the totals for non-academic hospitalist groups also evidence an increase, to 24.3% in the new survey from 19.2% in 2014.

I postulated in 2015 that the comparative increase in observation status utilization by academic groups as compared with non-academic groups in the 2014 survey may have been associated with greater proficiency in documentation and related billing inherent in a bedside clinical workforce entirely composed of physicians who have completed postgraduate training. Other phenomena may now potentially explain the increase in observation status use we see in the 2016 survey. These include adoption of the two-midnight rule by the Centers for Medicare & Medicaid Services, use of readmission rates in hospitalist group incentive structures, sharing of cost savings between hospitalist groups and healthcare organizations mutually engaged in third-party bundled payment arrangements, or risk-avoidant strategies executed by clinicians and institutional coders perhaps in excess of their institutions’ needs for risk avoidance. For many of these events, the 2016 State of Hospital Medicine Report provides further benchmark data, in a national and regional context, to inform understanding for hospitalist groups facing challenges associated with observation status utilization.

G. Randy Smith Jr., MD, MS, FRCP(Edin), SFHM, is an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago.

References

1. 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
2. 2012 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
3. 2014 State of Hospital Medicine Report. Society of Hospital Medicine website.

   Accessed September 11, 2016.