The Hospitalist

NEW YORK - Patients dependent on prescription opioids are likely to quit if they get individual drug counseling with their prescribed medications, according to long-term follow-up results.

"Medication-assisted treatment for opioid dependence benefited people who were dependent on prescription opioids. Good standard medical management, medically based counseling, can be effective for these people if given in conjunction with buprenorphine treatment," said lead author Dr. Roger D. Weiss, professor of psychiatry at Harvard Medical School in Boston and chief of the Division of Alcohol and Drug Abuse at McLean Hospital in Belmont, Massachusetts.

"Over time, with treatment, these patients have relatively optimistic outcomes, but there are a number of risks involved, including people shifting from prescription opioids to heroin who had never injected drugs, injecting them, and a higher death rate," he told Reuters Health by phone.

Dr. Weiss and colleagues examined the outcomes over a 42-month follow-up period among adult participants in POATS (the Prescription Opioid Addiction Treatment Study), the first long-term multisite randomized trial to investigate whether outcomes for patients dependent on prescription opioid analgesics can be improved with standard medical management by adding individual drug counseling to prescribed buprenorphine (combined with naloxone to prevent withdrawal symptoms).

The researchers enrolled 653 participants at 12 medical centers in nine states through the National Institute on Drug Abuse (NIDA) Clinical Trials Network. They examined the results at four and 12 weeks and conducted follow-up assessments of opioid and other substance abuse through telephone interviews with 375 patients at 1.5 years, 2.5 years, and 3.5 years from study entry.

At 1.5 years, most follow-up participants no longer depended on opioids, and at 3.5 years, fewer than 10% of them were opioid dependent. Patients who reported a lifetime history of heroin use at study entry were more likely to be opioid dependent at 3.5 years (odds ratio 4.56, p<0.05).

At 2.5 years, 61% of patients reported that they had abstained from opioids for one month. The roughly one-third of the sample who received opioid agonist treatment during follow-up were more likely to be abstinent at month 42. Even so, 27 (8%) of 338 patients used heroin for the first time during follow-up and 10.1% reported that they had injected heroin for the first time.

The results were presented in a poster May 16 at the Annual Meeting of the American Psychiatric Association (APA) in Atlanta, Georgia.

"Prior to this study, there had never been a study of treatment in people dependent on prescription opioids. There had been many opioid-dependence treatment studies, but they had all focused on people who exclusively or primarily used heroin, and most were done in methadone maintenance programs. This was the first study done with people receiving office-based buprenorphine treatment," Dr. Weiss told Reuters Health.

"A real strength of this study is that it was very large and included a mixture of urban, suburban, and rural sites. No other study has looked at even 100 people," he added.

Regarding future related research, Dr. Weiss told Reuters Health that it would be good to learn exactly which people do well over time and how to increase their success rate.

The authors reported no funding or disclosures.

SOURCE: http://bit.ly/28MTqd6 APA 2016.

NEW YORK - Patients dependent on prescription opioids are likely to quit if they get individual drug counseling with their prescribed medications, according to long-term follow-up results.

"Medication-assisted treatment for opioid dependence benefited people who were dependent on prescription opioids. Good standard medical management, medically based counseling, can be effective for these people if given in conjunction with buprenorphine treatment," said lead author Dr. Roger D. Weiss, professor of psychiatry at Harvard Medical School in Boston and chief of the Division of Alcohol and Drug Abuse at McLean Hospital in Belmont, Massachusetts.

"Over time, with treatment, these patients have relatively optimistic outcomes, but there are a number of risks involved, including people shifting from prescription opioids to heroin who had never injected drugs, injecting them, and a higher death rate," he told Reuters Health by phone.

Dr. Weiss and colleagues examined the outcomes over a 42-month follow-up period among adult participants in POATS (the Prescription Opioid Addiction Treatment Study), the first long-term multisite randomized trial to investigate whether outcomes for patients dependent on prescription opioid analgesics can be improved with standard medical management by adding individual drug counseling to prescribed buprenorphine (combined with naloxone to prevent withdrawal symptoms).

The researchers enrolled 653 participants at 12 medical centers in nine states through the National Institute on Drug Abuse (NIDA) Clinical Trials Network. They examined the results at four and 12 weeks and conducted follow-up assessments of opioid and other substance abuse through telephone interviews with 375 patients at 1.5 years, 2.5 years, and 3.5 years from study entry.

At 1.5 years, most follow-up participants no longer depended on opioids, and at 3.5 years, fewer than 10% of them were opioid dependent. Patients who reported a lifetime history of heroin use at study entry were more likely to be opioid dependent at 3.5 years (odds ratio 4.56, p<0.05).

At 2.5 years, 61% of patients reported that they had abstained from opioids for one month. The roughly one-third of the sample who received opioid agonist treatment during follow-up were more likely to be abstinent at month 42. Even so, 27 (8%) of 338 patients used heroin for the first time during follow-up and 10.1% reported that they had injected heroin for the first time.

The results were presented in a poster May 16 at the Annual Meeting of the American Psychiatric Association (APA) in Atlanta, Georgia.

"Prior to this study, there had never been a study of treatment in people dependent on prescription opioids. There had been many opioid-dependence treatment studies, but they had all focused on people who exclusively or primarily used heroin, and most were done in methadone maintenance programs. This was the first study done with people receiving office-based buprenorphine treatment," Dr. Weiss told Reuters Health.

"A real strength of this study is that it was very large and included a mixture of urban, suburban, and rural sites. No other study has looked at even 100 people," he added.

Regarding future related research, Dr. Weiss told Reuters Health that it would be good to learn exactly which people do well over time and how to increase their success rate.

The authors reported no funding or disclosures.

SOURCE: http://bit.ly/28MTqd6 APA 2016.

NEW YORK - Patients dependent on prescription opioids are likely to quit if they get individual drug counseling with their prescribed medications, according to long-term follow-up results.

"Medication-assisted treatment for opioid dependence benefited people who were dependent on prescription opioids. Good standard medical management, medically based counseling, can be effective for these people if given in conjunction with buprenorphine treatment," said lead author Dr. Roger D. Weiss, professor of psychiatry at Harvard Medical School in Boston and chief of the Division of Alcohol and Drug Abuse at McLean Hospital in Belmont, Massachusetts.

"Over time, with treatment, these patients have relatively optimistic outcomes, but there are a number of risks involved, including people shifting from prescription opioids to heroin who had never injected drugs, injecting them, and a higher death rate," he told Reuters Health by phone.

Dr. Weiss and colleagues examined the outcomes over a 42-month follow-up period among adult participants in POATS (the Prescription Opioid Addiction Treatment Study), the first long-term multisite randomized trial to investigate whether outcomes for patients dependent on prescription opioid analgesics can be improved with standard medical management by adding individual drug counseling to prescribed buprenorphine (combined with naloxone to prevent withdrawal symptoms).

The researchers enrolled 653 participants at 12 medical centers in nine states through the National Institute on Drug Abuse (NIDA) Clinical Trials Network. They examined the results at four and 12 weeks and conducted follow-up assessments of opioid and other substance abuse through telephone interviews with 375 patients at 1.5 years, 2.5 years, and 3.5 years from study entry.

At 1.5 years, most follow-up participants no longer depended on opioids, and at 3.5 years, fewer than 10% of them were opioid dependent. Patients who reported a lifetime history of heroin use at study entry were more likely to be opioid dependent at 3.5 years (odds ratio 4.56, p<0.05).

At 2.5 years, 61% of patients reported that they had abstained from opioids for one month. The roughly one-third of the sample who received opioid agonist treatment during follow-up were more likely to be abstinent at month 42. Even so, 27 (8%) of 338 patients used heroin for the first time during follow-up and 10.1% reported that they had injected heroin for the first time.

The results were presented in a poster May 16 at the Annual Meeting of the American Psychiatric Association (APA) in Atlanta, Georgia.

"Prior to this study, there had never been a study of treatment in people dependent on prescription opioids. There had been many opioid-dependence treatment studies, but they had all focused on people who exclusively or primarily used heroin, and most were done in methadone maintenance programs. This was the first study done with people receiving office-based buprenorphine treatment," Dr. Weiss told Reuters Health.

"A real strength of this study is that it was very large and included a mixture of urban, suburban, and rural sites. No other study has looked at even 100 people," he added.

Regarding future related research, Dr. Weiss told Reuters Health that it would be good to learn exactly which people do well over time and how to increase their success rate.

The authors reported no funding or disclosures.

SOURCE: http://bit.ly/28MTqd6 APA 2016.

In early 2014, I decided to use the six state licenses I had obtained as a locum tenens physician to start practicing telemedicine. Since then, I have worked with several telemedicine platforms. I have found that telemedicine companies differ dramatically in their overall ease of use for the provider. Here are my top tips for deciding which telemedicine company to work with.

1. Technology support: Telemedicine is dependent on technology. If it is difficult to get help from tech support, do not credential with the company. Tech support is your lifeline to your patients. Make sure you can get help right away if you are having problems finishing or starting a consult. Companies that send automatic emails saying they will get back to you within 24 hours are the most difficult to work with.
2. Nursing support: All of the telemedicine companies that I have worked with have amazing nurses, but some are overwhelmed with work. Telemedicine nurses are able to connect to your patients via direct callback numbers in a way that you cannot connect. They are able to call in prescriptions to pharmacies if the platform is down or if the patient put in the wrong pharmacy information. Make sure that the company has a nurse that is able to call you back right away. A few telemedicine companies are understaffed with nurses, and it can take hours for a callback. If the key to telemedicine is volume, this is frustrating to deal with.
3. Chief complaints: Many telemedicine companies are moving away from making the “chief complaint” visible to providers before choosing to take the consult. For me, this is a big red flag. It can be as simple as, “I have a cold.” I like this because if I see a patient who says, “I have abdominal pain,” I know to triage them first.
4. Volume: Telemedicine is great for staying connected to outpatient medicine. If you are looking to work on a telemedicine platform for your main source of income, then volume is key. A lot of telemedicine companies will tell you how many calls they get per day; the key question is how many calls they get for the states that you are licensed in and how many providers they have licensed in those states. If you want higher volume, then ask if they will pay for your license in states with higher needs (some will). If you are willing to pay to be licensed in additional states, make sure the volume is high enough to make that extra out-of-pocket cost worth it.
5. Malpractice coverage: Many companies provide malpractice coverage as part of their credentialing package. If they do not, make sure your malpractice coverage covers you for telemedicine.
6. Documentation: Documentation during your telemedicine consult is arguably even more important than in an outpatient visit. Everything is on the phone or by video, so make sure, in the subjective area, that you are quoting what the patient is telling you. You are not able to do a physical exam, so your recommendations will be based on what the patient is saying.

Have fun! Telemedicine has been really enjoyable for me. I like being able to have the time to educate my patients about things like antibiotics. I enjoy the technological aspects and understanding all of the different platforms. Telemedicine gives you a unique opportunity to practice your skills from the comfort of your own home. TH

Geeta Arora, MD, locum tenens hospitalist

In early 2014, I decided to use the six state licenses I had obtained as a locum tenens physician to start practicing telemedicine. Since then, I have worked with several telemedicine platforms. I have found that telemedicine companies differ dramatically in their overall ease of use for the provider. Here are my top tips for deciding which telemedicine company to work with.

1. Technology support: Telemedicine is dependent on technology. If it is difficult to get help from tech support, do not credential with the company. Tech support is your lifeline to your patients. Make sure you can get help right away if you are having problems finishing or starting a consult. Companies that send automatic emails saying they will get back to you within 24 hours are the most difficult to work with.
2. Nursing support: All of the telemedicine companies that I have worked with have amazing nurses, but some are overwhelmed with work. Telemedicine nurses are able to connect to your patients via direct callback numbers in a way that you cannot connect. They are able to call in prescriptions to pharmacies if the platform is down or if the patient put in the wrong pharmacy information. Make sure that the company has a nurse that is able to call you back right away. A few telemedicine companies are understaffed with nurses, and it can take hours for a callback. If the key to telemedicine is volume, this is frustrating to deal with.
3. Chief complaints: Many telemedicine companies are moving away from making the “chief complaint” visible to providers before choosing to take the consult. For me, this is a big red flag. It can be as simple as, “I have a cold.” I like this because if I see a patient who says, “I have abdominal pain,” I know to triage them first.
4. Volume: Telemedicine is great for staying connected to outpatient medicine. If you are looking to work on a telemedicine platform for your main source of income, then volume is key. A lot of telemedicine companies will tell you how many calls they get per day; the key question is how many calls they get for the states that you are licensed in and how many providers they have licensed in those states. If you want higher volume, then ask if they will pay for your license in states with higher needs (some will). If you are willing to pay to be licensed in additional states, make sure the volume is high enough to make that extra out-of-pocket cost worth it.
5. Malpractice coverage: Many companies provide malpractice coverage as part of their credentialing package. If they do not, make sure your malpractice coverage covers you for telemedicine.
6. Documentation: Documentation during your telemedicine consult is arguably even more important than in an outpatient visit. Everything is on the phone or by video, so make sure, in the subjective area, that you are quoting what the patient is telling you. You are not able to do a physical exam, so your recommendations will be based on what the patient is saying.

Have fun! Telemedicine has been really enjoyable for me. I like being able to have the time to educate my patients about things like antibiotics. I enjoy the technological aspects and understanding all of the different platforms. Telemedicine gives you a unique opportunity to practice your skills from the comfort of your own home. TH

Geeta Arora, MD, locum tenens hospitalist

In early 2014, I decided to use the six state licenses I had obtained as a locum tenens physician to start practicing telemedicine. Since then, I have worked with several telemedicine platforms. I have found that telemedicine companies differ dramatically in their overall ease of use for the provider. Here are my top tips for deciding which telemedicine company to work with.

1. Technology support: Telemedicine is dependent on technology. If it is difficult to get help from tech support, do not credential with the company. Tech support is your lifeline to your patients. Make sure you can get help right away if you are having problems finishing or starting a consult. Companies that send automatic emails saying they will get back to you within 24 hours are the most difficult to work with.
2. Nursing support: All of the telemedicine companies that I have worked with have amazing nurses, but some are overwhelmed with work. Telemedicine nurses are able to connect to your patients via direct callback numbers in a way that you cannot connect. They are able to call in prescriptions to pharmacies if the platform is down or if the patient put in the wrong pharmacy information. Make sure that the company has a nurse that is able to call you back right away. A few telemedicine companies are understaffed with nurses, and it can take hours for a callback. If the key to telemedicine is volume, this is frustrating to deal with.
3. Chief complaints: Many telemedicine companies are moving away from making the “chief complaint” visible to providers before choosing to take the consult. For me, this is a big red flag. It can be as simple as, “I have a cold.” I like this because if I see a patient who says, “I have abdominal pain,” I know to triage them first.
4. Volume: Telemedicine is great for staying connected to outpatient medicine. If you are looking to work on a telemedicine platform for your main source of income, then volume is key. A lot of telemedicine companies will tell you how many calls they get per day; the key question is how many calls they get for the states that you are licensed in and how many providers they have licensed in those states. If you want higher volume, then ask if they will pay for your license in states with higher needs (some will). If you are willing to pay to be licensed in additional states, make sure the volume is high enough to make that extra out-of-pocket cost worth it.
5. Malpractice coverage: Many companies provide malpractice coverage as part of their credentialing package. If they do not, make sure your malpractice coverage covers you for telemedicine.
6. Documentation: Documentation during your telemedicine consult is arguably even more important than in an outpatient visit. Everything is on the phone or by video, so make sure, in the subjective area, that you are quoting what the patient is telling you. You are not able to do a physical exam, so your recommendations will be based on what the patient is saying.

Have fun! Telemedicine has been really enjoyable for me. I like being able to have the time to educate my patients about things like antibiotics. I enjoy the technological aspects and understanding all of the different platforms. Telemedicine gives you a unique opportunity to practice your skills from the comfort of your own home. TH

Geeta Arora, MD, locum tenens hospitalist

NEW YORK - Several hepatitis C virus core antigen (HCVcAg) tests accurately diagnose hepatitis C virus (HCV) infection and could replace nucleic acid testing (NAT) in settings where HCV is prevalent, according to a systematic review and meta-analysis.

"Overall, several of the tests perform very well and while they are not equal to NAT, the lower costs may improve diagnostic capacity in the appropriate setting," Dr. J. Morgan Freiman from Boston Medical Center in Massachusetts told Reuters Health by email.

The current two-step diagnostic procedure for diagnosing HCV infection -- screening for antibodies to HCV followed by NAT for those with anti-HCV antibodies -- is a major bottleneck for addressing the HCV elimination strategy proposed by the World Health Organization. Currently, there are five tests for HCVcAg commercially available.

Dr. Freiman and colleagues evaluated the accuracy of diagnosis of active HCV infection among adults and children for these five commercially available tests compared with NAT in their systematic review and meta-analysis of 44 published reports.

The pooled sensitivity and specificity were 93.4% and 98.8% for the Abbott ARCHITECT assay, 93.2% and 99.2% for the Ortho HCV Ag ELISA, and 59.5% and 82.9% for the Hunan Jynda HCV Ag ELISA. There was insufficient information for a pooled analysis of the Eiken Lumispot HCV Ag and the Fujirebio Lumipulse Ortho HCV Ag assays.

Three reports showed that the HCVcAg correlated well with RNA when levels were at least 3000 IU/mL when the Abbott ARCHITECT assay was used, according to the June 21 Annals of Internal Medicine report.

"Although even tests with the highest performance are not as sensitive as NAT, well-performing HCVcAg tests with an analytic sensitivity reaching into the femtomolar range (equal to 3000 IU/mL) could replace NAT for HCV detection, particularly if a lower cost per test allows more patients to be served," the researchers conclude. "Therefore, HCVcAg should be explored for point-of-care (POC) testing to increase the number of patients diagnosed and streamline the HCV cascade of care."

"There is much more work to be done to determine at what sensitivity threshold a POC test would be clinically useful," Dr. Freiman said. "In settings with reliable access to centralized laboratory processing and higher diagnostic capacity, a POC test may still prove to be useful as a screening tool, but would be less likely to replace confirmatory nucleic acid testing (NAT)."

"We have the technology to detect circulating HCV RNA down to 15 IU/mL - amazing -- but how clinically relevant is that threshold when access to testing is equally as important as accuracy in resource limited settings?" he wondered.

Dr. Jose-Manuel Echevarria, from Carlos III Health Institute, Madrid, Spain, who recently reported that HCV core-specific antibody may represent occult HCV infection among blood donors, told Reuters Health by email, "Physicians should conclude from the report that HCVcAg testing provides trustful diagnostic results for the characterization of their anti-HCV positive patients as viremic or non-viremic before deciding about antiviral treatment."

"I would add that HCVcAg testing is particularly useful for the purpose of transfusion centers," he said. "Chronically infected blood donors are detected by anti-HCV screening, and HCVcAg will detect efficiently almost every blood unit obtained from donors experiencing the window period of the acute HCV infection, who test negative for anti-HCV."

"At present, high-resource settings will for sure use NAT testing because of its higher sensitivity, and because automatic equipment has reduced the chance for false-positive results because sample-to-sample contamination (is kept) to a minimum," Dr. Echevarria concluded. "However, HCVcAg testing is extremely useful and convenient for low-resource settings, and also for emergency units everywhere."

The National Institutes of Health funded this research. Three coauthors reported disclosures.

SOURCE: http://bit.ly/28LpRcU Ann Intern Med 2016.

NEW YORK - Several hepatitis C virus core antigen (HCVcAg) tests accurately diagnose hepatitis C virus (HCV) infection and could replace nucleic acid testing (NAT) in settings where HCV is prevalent, according to a systematic review and meta-analysis.

"Overall, several of the tests perform very well and while they are not equal to NAT, the lower costs may improve diagnostic capacity in the appropriate setting," Dr. J. Morgan Freiman from Boston Medical Center in Massachusetts told Reuters Health by email.

The current two-step diagnostic procedure for diagnosing HCV infection -- screening for antibodies to HCV followed by NAT for those with anti-HCV antibodies -- is a major bottleneck for addressing the HCV elimination strategy proposed by the World Health Organization. Currently, there are five tests for HCVcAg commercially available.

Dr. Freiman and colleagues evaluated the accuracy of diagnosis of active HCV infection among adults and children for these five commercially available tests compared with NAT in their systematic review and meta-analysis of 44 published reports.

The pooled sensitivity and specificity were 93.4% and 98.8% for the Abbott ARCHITECT assay, 93.2% and 99.2% for the Ortho HCV Ag ELISA, and 59.5% and 82.9% for the Hunan Jynda HCV Ag ELISA. There was insufficient information for a pooled analysis of the Eiken Lumispot HCV Ag and the Fujirebio Lumipulse Ortho HCV Ag assays.

Three reports showed that the HCVcAg correlated well with RNA when levels were at least 3000 IU/mL when the Abbott ARCHITECT assay was used, according to the June 21 Annals of Internal Medicine report.

"Although even tests with the highest performance are not as sensitive as NAT, well-performing HCVcAg tests with an analytic sensitivity reaching into the femtomolar range (equal to 3000 IU/mL) could replace NAT for HCV detection, particularly if a lower cost per test allows more patients to be served," the researchers conclude. "Therefore, HCVcAg should be explored for point-of-care (POC) testing to increase the number of patients diagnosed and streamline the HCV cascade of care."

"There is much more work to be done to determine at what sensitivity threshold a POC test would be clinically useful," Dr. Freiman said. "In settings with reliable access to centralized laboratory processing and higher diagnostic capacity, a POC test may still prove to be useful as a screening tool, but would be less likely to replace confirmatory nucleic acid testing (NAT)."

"We have the technology to detect circulating HCV RNA down to 15 IU/mL - amazing -- but how clinically relevant is that threshold when access to testing is equally as important as accuracy in resource limited settings?" he wondered.

Dr. Jose-Manuel Echevarria, from Carlos III Health Institute, Madrid, Spain, who recently reported that HCV core-specific antibody may represent occult HCV infection among blood donors, told Reuters Health by email, "Physicians should conclude from the report that HCVcAg testing provides trustful diagnostic results for the characterization of their anti-HCV positive patients as viremic or non-viremic before deciding about antiviral treatment."

"I would add that HCVcAg testing is particularly useful for the purpose of transfusion centers," he said. "Chronically infected blood donors are detected by anti-HCV screening, and HCVcAg will detect efficiently almost every blood unit obtained from donors experiencing the window period of the acute HCV infection, who test negative for anti-HCV."

"At present, high-resource settings will for sure use NAT testing because of its higher sensitivity, and because automatic equipment has reduced the chance for false-positive results because sample-to-sample contamination (is kept) to a minimum," Dr. Echevarria concluded. "However, HCVcAg testing is extremely useful and convenient for low-resource settings, and also for emergency units everywhere."

The National Institutes of Health funded this research. Three coauthors reported disclosures.

SOURCE: http://bit.ly/28LpRcU Ann Intern Med 2016.

NEW YORK - Several hepatitis C virus core antigen (HCVcAg) tests accurately diagnose hepatitis C virus (HCV) infection and could replace nucleic acid testing (NAT) in settings where HCV is prevalent, according to a systematic review and meta-analysis.

"Overall, several of the tests perform very well and while they are not equal to NAT, the lower costs may improve diagnostic capacity in the appropriate setting," Dr. J. Morgan Freiman from Boston Medical Center in Massachusetts told Reuters Health by email.

The current two-step diagnostic procedure for diagnosing HCV infection -- screening for antibodies to HCV followed by NAT for those with anti-HCV antibodies -- is a major bottleneck for addressing the HCV elimination strategy proposed by the World Health Organization. Currently, there are five tests for HCVcAg commercially available.

Dr. Freiman and colleagues evaluated the accuracy of diagnosis of active HCV infection among adults and children for these five commercially available tests compared with NAT in their systematic review and meta-analysis of 44 published reports.

The pooled sensitivity and specificity were 93.4% and 98.8% for the Abbott ARCHITECT assay, 93.2% and 99.2% for the Ortho HCV Ag ELISA, and 59.5% and 82.9% for the Hunan Jynda HCV Ag ELISA. There was insufficient information for a pooled analysis of the Eiken Lumispot HCV Ag and the Fujirebio Lumipulse Ortho HCV Ag assays.

Three reports showed that the HCVcAg correlated well with RNA when levels were at least 3000 IU/mL when the Abbott ARCHITECT assay was used, according to the June 21 Annals of Internal Medicine report.

"Although even tests with the highest performance are not as sensitive as NAT, well-performing HCVcAg tests with an analytic sensitivity reaching into the femtomolar range (equal to 3000 IU/mL) could replace NAT for HCV detection, particularly if a lower cost per test allows more patients to be served," the researchers conclude. "Therefore, HCVcAg should be explored for point-of-care (POC) testing to increase the number of patients diagnosed and streamline the HCV cascade of care."

"There is much more work to be done to determine at what sensitivity threshold a POC test would be clinically useful," Dr. Freiman said. "In settings with reliable access to centralized laboratory processing and higher diagnostic capacity, a POC test may still prove to be useful as a screening tool, but would be less likely to replace confirmatory nucleic acid testing (NAT)."

"We have the technology to detect circulating HCV RNA down to 15 IU/mL - amazing -- but how clinically relevant is that threshold when access to testing is equally as important as accuracy in resource limited settings?" he wondered.

Dr. Jose-Manuel Echevarria, from Carlos III Health Institute, Madrid, Spain, who recently reported that HCV core-specific antibody may represent occult HCV infection among blood donors, told Reuters Health by email, "Physicians should conclude from the report that HCVcAg testing provides trustful diagnostic results for the characterization of their anti-HCV positive patients as viremic or non-viremic before deciding about antiviral treatment."

"I would add that HCVcAg testing is particularly useful for the purpose of transfusion centers," he said. "Chronically infected blood donors are detected by anti-HCV screening, and HCVcAg will detect efficiently almost every blood unit obtained from donors experiencing the window period of the acute HCV infection, who test negative for anti-HCV."

"At present, high-resource settings will for sure use NAT testing because of its higher sensitivity, and because automatic equipment has reduced the chance for false-positive results because sample-to-sample contamination (is kept) to a minimum," Dr. Echevarria concluded. "However, HCVcAg testing is extremely useful and convenient for low-resource settings, and also for emergency units everywhere."

The National Institutes of Health funded this research. Three coauthors reported disclosures.

SOURCE: http://bit.ly/28LpRcU Ann Intern Med 2016.

Clinical question: Is one dose of dexamethasone comparable to five days of prednisone for treating mild-to-moderate asthma exacerbations?

Background: Corticosteroids are the mainstay of initial treatment for asthma exacerbations. The National Heart, Lung, and Blood Institute recommends a minimum of five days of prednisone, though studies have shown incomplete adherence to prolonged therapies. Dexamethasone has a longer duration of action than prednisone.

Study design: Randomized, controlled, double-blinded trial.

Setting: Urban, safety-net, teaching hospital.

Synopsis: The study included 376 adults ages 18–55 presenting to the emergency department for a mild-to-moderate asthma exacerbation who were randomized to two treatment courses of corticosteroids: one 12 mg dose of oral dexamethasone followed by four days of placebo versus five days of 60 mg of oral prednisone. Two weeks later, a telephone survey asked if they had relapsed and had to seek medical attention. This study did not show noninferiority of the dexamethasone option compared to the standard of care. Specifically, it showed a 12.1% relapse rate in the dexamethasone group versus a 9.8% relapse rate for prednisone (95% CI, -4.1% to 8.6%).

This was a small study looking at adults without other chronic lung diseases or diabetes. The authors did not include those patients who were either lost to follow-up (20% of those initially randomized) or ultimately admitted after their emergency department course.

Hospitalists who care for patients with asthma should look to the current standards of corticosteroid selection and duration to minimize clinical relapses and possibly readmissions.

Bottom line: One large dose of dexamethasone is inferior to the standard five days of prednisone for treating acute asthma exacerbations in adults.

Citation: Rehrer MW, Liu B, Rodriguez M, Lam J, Alter HJ. A randomized controlled noninferiority trial of single dose of oral dexamethasone versus 5 days of oral prednisone in acute adult asthma [published online ahead of print April 14, 2016]. Ann Emerg Med. doi:10.1016/j.annemergmed.2016.03.017.

Short Take

Guideline Recommends ED Asthma Management Associated with Shorter Inpatient Stay

Observational study found ED treatment concordance with four guideline-based processes for acute asthma treatment (inhaled beta-agonists, inhaled anticholinergics, systemic corticosteroids, and avoidance of methylxanthines) is associated with a 17% shorter hospital length of stay.

Citation: Hasegawa K, Brenner BE, Nowak RM, et al. Association of guideline-concordant acute asthma care in the emergency department with shorter hospital length of stay: a multicenter observational study. Acad Emerg Med. 2016;23(5):616-622.

Clinical question: Is one dose of dexamethasone comparable to five days of prednisone for treating mild-to-moderate asthma exacerbations?

Background: Corticosteroids are the mainstay of initial treatment for asthma exacerbations. The National Heart, Lung, and Blood Institute recommends a minimum of five days of prednisone, though studies have shown incomplete adherence to prolonged therapies. Dexamethasone has a longer duration of action than prednisone.

Study design: Randomized, controlled, double-blinded trial.

Setting: Urban, safety-net, teaching hospital.

Synopsis: The study included 376 adults ages 18–55 presenting to the emergency department for a mild-to-moderate asthma exacerbation who were randomized to two treatment courses of corticosteroids: one 12 mg dose of oral dexamethasone followed by four days of placebo versus five days of 60 mg of oral prednisone. Two weeks later, a telephone survey asked if they had relapsed and had to seek medical attention. This study did not show noninferiority of the dexamethasone option compared to the standard of care. Specifically, it showed a 12.1% relapse rate in the dexamethasone group versus a 9.8% relapse rate for prednisone (95% CI, -4.1% to 8.6%).

This was a small study looking at adults without other chronic lung diseases or diabetes. The authors did not include those patients who were either lost to follow-up (20% of those initially randomized) or ultimately admitted after their emergency department course.

Hospitalists who care for patients with asthma should look to the current standards of corticosteroid selection and duration to minimize clinical relapses and possibly readmissions.

Bottom line: One large dose of dexamethasone is inferior to the standard five days of prednisone for treating acute asthma exacerbations in adults.

Citation: Rehrer MW, Liu B, Rodriguez M, Lam J, Alter HJ. A randomized controlled noninferiority trial of single dose of oral dexamethasone versus 5 days of oral prednisone in acute adult asthma [published online ahead of print April 14, 2016]. Ann Emerg Med. doi:10.1016/j.annemergmed.2016.03.017.

Short Take

Guideline Recommends ED Asthma Management Associated with Shorter Inpatient Stay

Observational study found ED treatment concordance with four guideline-based processes for acute asthma treatment (inhaled beta-agonists, inhaled anticholinergics, systemic corticosteroids, and avoidance of methylxanthines) is associated with a 17% shorter hospital length of stay.

Citation: Hasegawa K, Brenner BE, Nowak RM, et al. Association of guideline-concordant acute asthma care in the emergency department with shorter hospital length of stay: a multicenter observational study. Acad Emerg Med. 2016;23(5):616-622.

Clinical question: Is one dose of dexamethasone comparable to five days of prednisone for treating mild-to-moderate asthma exacerbations?

Background: Corticosteroids are the mainstay of initial treatment for asthma exacerbations. The National Heart, Lung, and Blood Institute recommends a minimum of five days of prednisone, though studies have shown incomplete adherence to prolonged therapies. Dexamethasone has a longer duration of action than prednisone.

Study design: Randomized, controlled, double-blinded trial.

Setting: Urban, safety-net, teaching hospital.

Synopsis: The study included 376 adults ages 18–55 presenting to the emergency department for a mild-to-moderate asthma exacerbation who were randomized to two treatment courses of corticosteroids: one 12 mg dose of oral dexamethasone followed by four days of placebo versus five days of 60 mg of oral prednisone. Two weeks later, a telephone survey asked if they had relapsed and had to seek medical attention. This study did not show noninferiority of the dexamethasone option compared to the standard of care. Specifically, it showed a 12.1% relapse rate in the dexamethasone group versus a 9.8% relapse rate for prednisone (95% CI, -4.1% to 8.6%).

This was a small study looking at adults without other chronic lung diseases or diabetes. The authors did not include those patients who were either lost to follow-up (20% of those initially randomized) or ultimately admitted after their emergency department course.

Hospitalists who care for patients with asthma should look to the current standards of corticosteroid selection and duration to minimize clinical relapses and possibly readmissions.

Bottom line: One large dose of dexamethasone is inferior to the standard five days of prednisone for treating acute asthma exacerbations in adults.

Citation: Rehrer MW, Liu B, Rodriguez M, Lam J, Alter HJ. A randomized controlled noninferiority trial of single dose of oral dexamethasone versus 5 days of oral prednisone in acute adult asthma [published online ahead of print April 14, 2016]. Ann Emerg Med. doi:10.1016/j.annemergmed.2016.03.017.

Short Take

Guideline Recommends ED Asthma Management Associated with Shorter Inpatient Stay

Observational study found ED treatment concordance with four guideline-based processes for acute asthma treatment (inhaled beta-agonists, inhaled anticholinergics, systemic corticosteroids, and avoidance of methylxanthines) is associated with a 17% shorter hospital length of stay.

Citation: Hasegawa K, Brenner BE, Nowak RM, et al. Association of guideline-concordant acute asthma care in the emergency department with shorter hospital length of stay: a multicenter observational study. Acad Emerg Med. 2016;23(5):616-622.

Clinical question: Does nasal high-flow (NHF) oxygen after extubation reduce reintubation rates in low-risk patients?

Background: NHF oxygen devices deliver warmed and humidified oxygen up to 60 liters per minutes. NHF provides positive end-expiratory pressure and dead-space washout. NHF in higher-risk post-extubation patients has been shown to have clinical benefits. Whether NHF post-extubation benefits patients at low risk of reintubation is unknown.

Study design: Randomized control trial (RCT).

Setting: Seven ICUs in Spain.

Synopsis: In this RCT, post-extubation NHF oxygen for 24 hours reduced the risk of reintubation among 527 ICU adults at low risk of reintubation when compared to conventional oxygen therapy (by nasal cannula or face mask). Patients with hypercapnia during weaning trials were excluded. The risk of reintubation was 4.9% versus 12.2% in NHF versus standard oxygen therapy, with an absolute difference of 7.2% (95% CI, 2.5–12.2%; P=0.004). ICU length of stay and mortality were not significantly different between the groups. The strengths of the study were adequate sample size, prespecified criteria for reintubation, and low number of crossover patients.

Limitations of the trial were the high percentage of surgical and neurologic cases, exclusion of patients with a variety of common comorbidities, and the inability to blind the physicians to the treatment arm of the subjects. Select patients may benefit from noninvasive ventilation to prevent reintubation, which was not studied. These results are highly relevant to post-extubation patients, with the optimum therapy for low-risk patients now appearing to be NHF.

Bottom line: NHF oxygen reduced reintubation compared to conventional oxygen therapy (nasal cannula or face mask) in extubated patients at low risk of reintubation.

Citation: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354-1361. doi:10.1001/jama.2016.2711.

Clinical question: Does nasal high-flow (NHF) oxygen after extubation reduce reintubation rates in low-risk patients?

Background: NHF oxygen devices deliver warmed and humidified oxygen up to 60 liters per minutes. NHF provides positive end-expiratory pressure and dead-space washout. NHF in higher-risk post-extubation patients has been shown to have clinical benefits. Whether NHF post-extubation benefits patients at low risk of reintubation is unknown.

Study design: Randomized control trial (RCT).

Setting: Seven ICUs in Spain.

Synopsis: In this RCT, post-extubation NHF oxygen for 24 hours reduced the risk of reintubation among 527 ICU adults at low risk of reintubation when compared to conventional oxygen therapy (by nasal cannula or face mask). Patients with hypercapnia during weaning trials were excluded. The risk of reintubation was 4.9% versus 12.2% in NHF versus standard oxygen therapy, with an absolute difference of 7.2% (95% CI, 2.5–12.2%; P=0.004). ICU length of stay and mortality were not significantly different between the groups. The strengths of the study were adequate sample size, prespecified criteria for reintubation, and low number of crossover patients.

Limitations of the trial were the high percentage of surgical and neurologic cases, exclusion of patients with a variety of common comorbidities, and the inability to blind the physicians to the treatment arm of the subjects. Select patients may benefit from noninvasive ventilation to prevent reintubation, which was not studied. These results are highly relevant to post-extubation patients, with the optimum therapy for low-risk patients now appearing to be NHF.

Bottom line: NHF oxygen reduced reintubation compared to conventional oxygen therapy (nasal cannula or face mask) in extubated patients at low risk of reintubation.

Citation: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354-1361. doi:10.1001/jama.2016.2711.

Clinical question: Does nasal high-flow (NHF) oxygen after extubation reduce reintubation rates in low-risk patients?

Background: NHF oxygen devices deliver warmed and humidified oxygen up to 60 liters per minutes. NHF provides positive end-expiratory pressure and dead-space washout. NHF in higher-risk post-extubation patients has been shown to have clinical benefits. Whether NHF post-extubation benefits patients at low risk of reintubation is unknown.

Study design: Randomized control trial (RCT).

Setting: Seven ICUs in Spain.

Synopsis: In this RCT, post-extubation NHF oxygen for 24 hours reduced the risk of reintubation among 527 ICU adults at low risk of reintubation when compared to conventional oxygen therapy (by nasal cannula or face mask). Patients with hypercapnia during weaning trials were excluded. The risk of reintubation was 4.9% versus 12.2% in NHF versus standard oxygen therapy, with an absolute difference of 7.2% (95% CI, 2.5–12.2%; P=0.004). ICU length of stay and mortality were not significantly different between the groups. The strengths of the study were adequate sample size, prespecified criteria for reintubation, and low number of crossover patients.

Limitations of the trial were the high percentage of surgical and neurologic cases, exclusion of patients with a variety of common comorbidities, and the inability to blind the physicians to the treatment arm of the subjects. Select patients may benefit from noninvasive ventilation to prevent reintubation, which was not studied. These results are highly relevant to post-extubation patients, with the optimum therapy for low-risk patients now appearing to be NHF.

Bottom line: NHF oxygen reduced reintubation compared to conventional oxygen therapy (nasal cannula or face mask) in extubated patients at low risk of reintubation.

Citation: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354-1361. doi:10.1001/jama.2016.2711.

U.S. hospitals may be getting paid for more of the care they actually provide thanks to the Affordable Care Act, if research from Michigan reflects the situation around the country.

While the study didn't look directly at hospital finances, researchers found that the proportion of uninsured adults discharged from Michigan hospitals fell after public insurance options expanded in 2014.

"What we found is that the overwhelming majority of hospitals experienced a decrease in the proportion of uninsured patients and an increase in Medicaid covered patients," said lead author Dr. Matthew Davis, deputy director of Institute for Healthcare Policy and Innovation at the University of Michigan Health System in Ann Arbor.

Under the Affordable Care Act, also known as Obamacare, some U.S. states - including Michigan - expanded Medicaid, which is the joint federal and state insurance program for the poor.

Previous studies showed many people who gained health insurance through the law were previously uninsured, Davis told Reuters Health.

For the new study, he and his colleagues analyzed data on young adults discharged from 130 Michigan hospitals before and after Medicaid became more broadly available in 2014.

About 6 percent of young adults discharged at those hospitals between April and December before the Medicaid expansion were uninsured, compared to about 2 percent during those months in 2014, according to the findings scheduled for online publication June 21 in JAMA.

The proportion of discharged young adults on Medicaid rose from 23 percent in 2012 and 24 percent in 2013 to 30 percent in 2014.

There was a small decline in the number of people discharged with private or other insurance, they found.

The researchers were surprised at how uniform the impact of Medicaid expansion seemed to be in hospitals across Michigan, Davis said.

"This impact wasn't limited to urban areas or population centers, or safety net hospitals," he said.

According to Davis, past research shows that decreases in the number of uninsured patients are tied to decreases in healthcare that goes unpaid for.

"As we have more and more years of the Affordable Care Act that have provided expanded coverage for millions of Americans, it's going to be important to understand how that coverage translates into positive health," he said.

"Coverage through insurance plans and programs like Medicaid is most (needed) when our health is at its worst and we need to be hospitalized," he said. "Yet, that coverage is also essential in times when our health is better and we need to be focused on preventing the next illness rather than just responding to it."

SOURCE: http://bit.ly/WddS8K JAMA 2016.

U.S. hospitals may be getting paid for more of the care they actually provide thanks to the Affordable Care Act, if research from Michigan reflects the situation around the country.

While the study didn't look directly at hospital finances, researchers found that the proportion of uninsured adults discharged from Michigan hospitals fell after public insurance options expanded in 2014.

"What we found is that the overwhelming majority of hospitals experienced a decrease in the proportion of uninsured patients and an increase in Medicaid covered patients," said lead author Dr. Matthew Davis, deputy director of Institute for Healthcare Policy and Innovation at the University of Michigan Health System in Ann Arbor.

Under the Affordable Care Act, also known as Obamacare, some U.S. states - including Michigan - expanded Medicaid, which is the joint federal and state insurance program for the poor.

Previous studies showed many people who gained health insurance through the law were previously uninsured, Davis told Reuters Health.

For the new study, he and his colleagues analyzed data on young adults discharged from 130 Michigan hospitals before and after Medicaid became more broadly available in 2014.

About 6 percent of young adults discharged at those hospitals between April and December before the Medicaid expansion were uninsured, compared to about 2 percent during those months in 2014, according to the findings scheduled for online publication June 21 in JAMA.

The proportion of discharged young adults on Medicaid rose from 23 percent in 2012 and 24 percent in 2013 to 30 percent in 2014.

There was a small decline in the number of people discharged with private or other insurance, they found.

The researchers were surprised at how uniform the impact of Medicaid expansion seemed to be in hospitals across Michigan, Davis said.

"This impact wasn't limited to urban areas or population centers, or safety net hospitals," he said.

According to Davis, past research shows that decreases in the number of uninsured patients are tied to decreases in healthcare that goes unpaid for.

"As we have more and more years of the Affordable Care Act that have provided expanded coverage for millions of Americans, it's going to be important to understand how that coverage translates into positive health," he said.

"Coverage through insurance plans and programs like Medicaid is most (needed) when our health is at its worst and we need to be hospitalized," he said. "Yet, that coverage is also essential in times when our health is better and we need to be focused on preventing the next illness rather than just responding to it."

SOURCE: http://bit.ly/WddS8K JAMA 2016.

U.S. hospitals may be getting paid for more of the care they actually provide thanks to the Affordable Care Act, if research from Michigan reflects the situation around the country.

While the study didn't look directly at hospital finances, researchers found that the proportion of uninsured adults discharged from Michigan hospitals fell after public insurance options expanded in 2014.

"What we found is that the overwhelming majority of hospitals experienced a decrease in the proportion of uninsured patients and an increase in Medicaid covered patients," said lead author Dr. Matthew Davis, deputy director of Institute for Healthcare Policy and Innovation at the University of Michigan Health System in Ann Arbor.

Under the Affordable Care Act, also known as Obamacare, some U.S. states - including Michigan - expanded Medicaid, which is the joint federal and state insurance program for the poor.

Previous studies showed many people who gained health insurance through the law were previously uninsured, Davis told Reuters Health.

For the new study, he and his colleagues analyzed data on young adults discharged from 130 Michigan hospitals before and after Medicaid became more broadly available in 2014.

About 6 percent of young adults discharged at those hospitals between April and December before the Medicaid expansion were uninsured, compared to about 2 percent during those months in 2014, according to the findings scheduled for online publication June 21 in JAMA.

The proportion of discharged young adults on Medicaid rose from 23 percent in 2012 and 24 percent in 2013 to 30 percent in 2014.

There was a small decline in the number of people discharged with private or other insurance, they found.

The researchers were surprised at how uniform the impact of Medicaid expansion seemed to be in hospitals across Michigan, Davis said.

"This impact wasn't limited to urban areas or population centers, or safety net hospitals," he said.

According to Davis, past research shows that decreases in the number of uninsured patients are tied to decreases in healthcare that goes unpaid for.

"As we have more and more years of the Affordable Care Act that have provided expanded coverage for millions of Americans, it's going to be important to understand how that coverage translates into positive health," he said.

"Coverage through insurance plans and programs like Medicaid is most (needed) when our health is at its worst and we need to be hospitalized," he said. "Yet, that coverage is also essential in times when our health is better and we need to be focused on preventing the next illness rather than just responding to it."

SOURCE: http://bit.ly/WddS8K JAMA 2016.

Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.

“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”

“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”

The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.

“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P

Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”

Reference

1. Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.

Quick Byte

Telehealth Expansion

In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.

Reference

1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.

Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.

“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”

“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”

The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.

“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P

Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”

Reference

1. Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.

Quick Byte

Telehealth Expansion

In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.

Reference

1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.

Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.

“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”

“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”

The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.

“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P

Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”

Reference

1. Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.

Quick Byte

Telehealth Expansion

In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.

Reference

1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.

“I recently discharged a complex patient from the hospital, and I was shocked to see the poor quality of his clinical summary,” says Erin Sarzynski, MD, MS, of Michigan State University’s Department of Family Medicine. This observation drove the research underlying the paper she co-wrote titled “Opportunities to Improve Clinical Summaries for Patients at Hospital Discharge,” published in BMJ Quality & Safety.

The problem, the paper lays out, is that, “presently, it is unclear whether clinical summaries include relevant content or whether healthcare organizations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge.”

As a first step toward improving these documents, Dr. Sarzynski worked with a team to evaluate 100 clinical summaries generated at two Michigan hospitals based on content, organization, and understandability. They became aware of systemic problems.

“Clinical summaries are produced from templates, but physicians’ workflows do not prompt them to preview the document before the nurse prints it to review with the patient,” Dr. Sarzynski says. “Clinical summaries are lengthy yet omit key discharge information. They are poorly organized, written at the 8th- to 12th-grade reading level, and score poorly on assessments of understandability and actionability.

“Medication lists illustrate a key safety issue resulting from poor-quality clinical summaries; for example, we routinely send patients home without parameters for sliding-scale insulin.”

The study highlights opportunities to improve clinical summaries for guiding patients’ post-discharge care.

“We developed an audit tool based on the Meaningful Use view-download-transmit objective and the SHM Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organization); and five readability formulas and the Patient Education Materials Assessment Tool,” the authors write.

“If possible, hospitalists should preview their patients’ clinical summaries before printing—it’s an opportunity to ensure key discharge information is correct and appropriately emphasized,” Dr. Sarzynski says.

Reference

1. Sarzynski E, Hashmi H, Subramanian J, et al. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf. doi:10.1136/bmjqs-2015-005201.

“I recently discharged a complex patient from the hospital, and I was shocked to see the poor quality of his clinical summary,” says Erin Sarzynski, MD, MS, of Michigan State University’s Department of Family Medicine. This observation drove the research underlying the paper she co-wrote titled “Opportunities to Improve Clinical Summaries for Patients at Hospital Discharge,” published in BMJ Quality & Safety.

The problem, the paper lays out, is that, “presently, it is unclear whether clinical summaries include relevant content or whether healthcare organizations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge.”

As a first step toward improving these documents, Dr. Sarzynski worked with a team to evaluate 100 clinical summaries generated at two Michigan hospitals based on content, organization, and understandability. They became aware of systemic problems.

“Clinical summaries are produced from templates, but physicians’ workflows do not prompt them to preview the document before the nurse prints it to review with the patient,” Dr. Sarzynski says. “Clinical summaries are lengthy yet omit key discharge information. They are poorly organized, written at the 8th- to 12th-grade reading level, and score poorly on assessments of understandability and actionability.

“Medication lists illustrate a key safety issue resulting from poor-quality clinical summaries; for example, we routinely send patients home without parameters for sliding-scale insulin.”

The study highlights opportunities to improve clinical summaries for guiding patients’ post-discharge care.

“We developed an audit tool based on the Meaningful Use view-download-transmit objective and the SHM Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organization); and five readability formulas and the Patient Education Materials Assessment Tool,” the authors write.

“If possible, hospitalists should preview their patients’ clinical summaries before printing—it’s an opportunity to ensure key discharge information is correct and appropriately emphasized,” Dr. Sarzynski says.

Reference

1. Sarzynski E, Hashmi H, Subramanian J, et al. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf. doi:10.1136/bmjqs-2015-005201.

“I recently discharged a complex patient from the hospital, and I was shocked to see the poor quality of his clinical summary,” says Erin Sarzynski, MD, MS, of Michigan State University’s Department of Family Medicine. This observation drove the research underlying the paper she co-wrote titled “Opportunities to Improve Clinical Summaries for Patients at Hospital Discharge,” published in BMJ Quality & Safety.

The problem, the paper lays out, is that, “presently, it is unclear whether clinical summaries include relevant content or whether healthcare organizations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge.”

As a first step toward improving these documents, Dr. Sarzynski worked with a team to evaluate 100 clinical summaries generated at two Michigan hospitals based on content, organization, and understandability. They became aware of systemic problems.

“Clinical summaries are produced from templates, but physicians’ workflows do not prompt them to preview the document before the nurse prints it to review with the patient,” Dr. Sarzynski says. “Clinical summaries are lengthy yet omit key discharge information. They are poorly organized, written at the 8th- to 12th-grade reading level, and score poorly on assessments of understandability and actionability.

“Medication lists illustrate a key safety issue resulting from poor-quality clinical summaries; for example, we routinely send patients home without parameters for sliding-scale insulin.”

The study highlights opportunities to improve clinical summaries for guiding patients’ post-discharge care.

“We developed an audit tool based on the Meaningful Use view-download-transmit objective and the SHM Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organization); and five readability formulas and the Patient Education Materials Assessment Tool,” the authors write.

“If possible, hospitalists should preview their patients’ clinical summaries before printing—it’s an opportunity to ensure key discharge information is correct and appropriately emphasized,” Dr. Sarzynski says.

Reference

1. Sarzynski E, Hashmi H, Subramanian J, et al. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf. doi:10.1136/bmjqs-2015-005201.

Americans are adding more whole grains,nuts and seeds to their diets and cutting back on sodas and sugary drinks, a U.S. study suggests.

While these changes point to some improvements in U.S.eating habits over the past decade, many people still consume too much sugar and processed food and not enough whole fruits and vegetables, the study scheduled for online publication June 21 in JAMA found.

"The overall diet is still far from optimal - less than one-third of American adults meet guidelines for most foods," said senior study author Dr. Dariush Mozaffarian, dean of the Tufts Friedman School of Nutrition Science and Policy in Boston.

"The single biggest focus should be on reducing highly processed foods rich in refined grains, starch, added sugars and salt; and increasing minimally processed healthful foods such as fruits, non-starchy vegetables, nuts, seeds, beans, fish and yogurt," Mozaffarian added by email.

Researchers looked at trends in eating habits for almost 34,000 adults aged 20 or older who participated in seven nationally representative surveys from 1999 to 2012.

The study team scored diets based, among other things, on how well people followed recommendations from the American Heart Association (AHA) that are designed to help prevent chronic health problems like cardiovascular disease.

Under these guidelines, a healthy diet includes at least 4.5 cups a day of fruits and vegetables, at least three ounces a day of fiber-rich whole grains and at least seven ounces a week of fish. It also caps sodium intake at 1,500 mg a day, the amount in three quarters of a teaspoon (3.75 g) of salt, and limits sodas and sugary juices at 36 ounces (1 liter) a week.

Overall, the percentage of Americans with poor diets based on these AHA standards dropped from 56 percent to 46 percent during the study period. The proportion of people with ideal diets was low but inched up to 1.5 percent from less than 1 percent.

Racial disparities in eating habits persisted throughout the study period. The proportion of white people with poor diets declined, while remaining little changed among black and Hispanic adults.

More affluent adults saw greater improvements in diet than lower-income people, the study also found.

For some eating patterns - including consumption of total vegetables, whole grains, unprocessed red meat and milk - trends over time were similar regardless of race, ethnicity, income or education levels. Intake of these things was consistently higher for more affluent people and white people and lower for poor people and black and Hispanic adults.

At the same time, salt intake was unchanged for white people but increased for black and Hispanic people during the study period.

Refined grain consumption dropped for white and black adults while increasing for Hispanics.

Limitations of the study include its reliance on survey participants to accurately recall and report what they ate and drank, as well as the potential for diet fads or food trends in popular culture to influence how people described their diets, the authors note.

Even so, the findings suggest that doctors need to do a better job educating patients about how to eat and how food choices influence their health, Dr. Margo Denke, a former researcher at the University of Texas Southwestern Medical Center in Dallas noted in an accompanying editorial.

Physicians also have to recognize that improving diets may be not be just a question of education, but of access and affordability, Denke added by email. While it's possible some people are confused about what to eat, the bigger problem is that they aren't sure what to do when fresh produce isn't at their local store.

"The import of less expensive fruits and vegetables I believe drove improved intake among those who have higher incomes," Denke said. "How can we pass this on to those who are financially struggling?"

SOURCE: http://bit.ly/28LE2ye JAMA 2016.

Americans are adding more whole grains,nuts and seeds to their diets and cutting back on sodas and sugary drinks, a U.S. study suggests.

While these changes point to some improvements in U.S.eating habits over the past decade, many people still consume too much sugar and processed food and not enough whole fruits and vegetables, the study scheduled for online publication June 21 in JAMA found.

"The overall diet is still far from optimal - less than one-third of American adults meet guidelines for most foods," said senior study author Dr. Dariush Mozaffarian, dean of the Tufts Friedman School of Nutrition Science and Policy in Boston.

"The single biggest focus should be on reducing highly processed foods rich in refined grains, starch, added sugars and salt; and increasing minimally processed healthful foods such as fruits, non-starchy vegetables, nuts, seeds, beans, fish and yogurt," Mozaffarian added by email.

Researchers looked at trends in eating habits for almost 34,000 adults aged 20 or older who participated in seven nationally representative surveys from 1999 to 2012.

The study team scored diets based, among other things, on how well people followed recommendations from the American Heart Association (AHA) that are designed to help prevent chronic health problems like cardiovascular disease.

Under these guidelines, a healthy diet includes at least 4.5 cups a day of fruits and vegetables, at least three ounces a day of fiber-rich whole grains and at least seven ounces a week of fish. It also caps sodium intake at 1,500 mg a day, the amount in three quarters of a teaspoon (3.75 g) of salt, and limits sodas and sugary juices at 36 ounces (1 liter) a week.

Overall, the percentage of Americans with poor diets based on these AHA standards dropped from 56 percent to 46 percent during the study period. The proportion of people with ideal diets was low but inched up to 1.5 percent from less than 1 percent.

Racial disparities in eating habits persisted throughout the study period. The proportion of white people with poor diets declined, while remaining little changed among black and Hispanic adults.

More affluent adults saw greater improvements in diet than lower-income people, the study also found.

For some eating patterns - including consumption of total vegetables, whole grains, unprocessed red meat and milk - trends over time were similar regardless of race, ethnicity, income or education levels. Intake of these things was consistently higher for more affluent people and white people and lower for poor people and black and Hispanic adults.

At the same time, salt intake was unchanged for white people but increased for black and Hispanic people during the study period.

Refined grain consumption dropped for white and black adults while increasing for Hispanics.

Limitations of the study include its reliance on survey participants to accurately recall and report what they ate and drank, as well as the potential for diet fads or food trends in popular culture to influence how people described their diets, the authors note.

Even so, the findings suggest that doctors need to do a better job educating patients about how to eat and how food choices influence their health, Dr. Margo Denke, a former researcher at the University of Texas Southwestern Medical Center in Dallas noted in an accompanying editorial.

Physicians also have to recognize that improving diets may be not be just a question of education, but of access and affordability, Denke added by email. While it's possible some people are confused about what to eat, the bigger problem is that they aren't sure what to do when fresh produce isn't at their local store.

"The import of less expensive fruits and vegetables I believe drove improved intake among those who have higher incomes," Denke said. "How can we pass this on to those who are financially struggling?"

SOURCE: http://bit.ly/28LE2ye JAMA 2016.

Americans are adding more whole grains,nuts and seeds to their diets and cutting back on sodas and sugary drinks, a U.S. study suggests.

While these changes point to some improvements in U.S.eating habits over the past decade, many people still consume too much sugar and processed food and not enough whole fruits and vegetables, the study scheduled for online publication June 21 in JAMA found.

"The overall diet is still far from optimal - less than one-third of American adults meet guidelines for most foods," said senior study author Dr. Dariush Mozaffarian, dean of the Tufts Friedman School of Nutrition Science and Policy in Boston.

"The single biggest focus should be on reducing highly processed foods rich in refined grains, starch, added sugars and salt; and increasing minimally processed healthful foods such as fruits, non-starchy vegetables, nuts, seeds, beans, fish and yogurt," Mozaffarian added by email.

Researchers looked at trends in eating habits for almost 34,000 adults aged 20 or older who participated in seven nationally representative surveys from 1999 to 2012.

The study team scored diets based, among other things, on how well people followed recommendations from the American Heart Association (AHA) that are designed to help prevent chronic health problems like cardiovascular disease.

Under these guidelines, a healthy diet includes at least 4.5 cups a day of fruits and vegetables, at least three ounces a day of fiber-rich whole grains and at least seven ounces a week of fish. It also caps sodium intake at 1,500 mg a day, the amount in three quarters of a teaspoon (3.75 g) of salt, and limits sodas and sugary juices at 36 ounces (1 liter) a week.

Overall, the percentage of Americans with poor diets based on these AHA standards dropped from 56 percent to 46 percent during the study period. The proportion of people with ideal diets was low but inched up to 1.5 percent from less than 1 percent.

Racial disparities in eating habits persisted throughout the study period. The proportion of white people with poor diets declined, while remaining little changed among black and Hispanic adults.

More affluent adults saw greater improvements in diet than lower-income people, the study also found.

For some eating patterns - including consumption of total vegetables, whole grains, unprocessed red meat and milk - trends over time were similar regardless of race, ethnicity, income or education levels. Intake of these things was consistently higher for more affluent people and white people and lower for poor people and black and Hispanic adults.

At the same time, salt intake was unchanged for white people but increased for black and Hispanic people during the study period.

Refined grain consumption dropped for white and black adults while increasing for Hispanics.

Limitations of the study include its reliance on survey participants to accurately recall and report what they ate and drank, as well as the potential for diet fads or food trends in popular culture to influence how people described their diets, the authors note.

Even so, the findings suggest that doctors need to do a better job educating patients about how to eat and how food choices influence their health, Dr. Margo Denke, a former researcher at the University of Texas Southwestern Medical Center in Dallas noted in an accompanying editorial.

Physicians also have to recognize that improving diets may be not be just a question of education, but of access and affordability, Denke added by email. While it's possible some people are confused about what to eat, the bigger problem is that they aren't sure what to do when fresh produce isn't at their local store.

"The import of less expensive fruits and vegetables I believe drove improved intake among those who have higher incomes," Denke said. "How can we pass this on to those who are financially struggling?"

SOURCE: http://bit.ly/28LE2ye JAMA 2016.

It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.

When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.

I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.

Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.

Most important, he listened and didn’t judge.

Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.

As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.

But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.

We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.

So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.

As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.

Happy July, everyone! TH

It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.

When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.

I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.

Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.

Most important, he listened and didn’t judge.

Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.

As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.

But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.

We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.

So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.

As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.

Happy July, everyone! TH

It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.

When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.

I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.

Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.

Most important, he listened and didn’t judge.

Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.

As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.

But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.

We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.

So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.

As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.

Happy July, everyone! TH