WASHINGTON – As a potential add-on therapy to phenobarbital, bumetanide demonstrated acceptable safety and promising antiseizure activity in a phase 1/2 safety study presented at the annual meeting of the American Epilepsy Society.

“This is an early-phase trial, but it did associate bumetanide with an additional reduction in seizure burden relative to phenobarbital alone,” reported Janet S. Soul, MD, director of the fetal-neonatal neurology program at Boston Children’s Hospital. She added, “The adverse events observed were not substantially different in the group that received the experimental agent.”

Ted Bosworth/Frontline Medical News

SOURCE: Soul J Abstract 2.426

WASHINGTON – As a potential add-on therapy to phenobarbital, bumetanide demonstrated acceptable safety and promising antiseizure activity in a phase 1/2 safety study presented at the annual meeting of the American Epilepsy Society.

“This is an early-phase trial, but it did associate bumetanide with an additional reduction in seizure burden relative to phenobarbital alone,” reported Janet S. Soul, MD, director of the fetal-neonatal neurology program at Boston Children’s Hospital. She added, “The adverse events observed were not substantially different in the group that received the experimental agent.”

Ted Bosworth/Frontline Medical News

SOURCE: Soul J Abstract 2.426

WASHINGTON – As a potential add-on therapy to phenobarbital, bumetanide demonstrated acceptable safety and promising antiseizure activity in a phase 1/2 safety study presented at the annual meeting of the American Epilepsy Society.

“This is an early-phase trial, but it did associate bumetanide with an additional reduction in seizure burden relative to phenobarbital alone,” reported Janet S. Soul, MD, director of the fetal-neonatal neurology program at Boston Children’s Hospital. She added, “The adverse events observed were not substantially different in the group that received the experimental agent.”

Ted Bosworth/Frontline Medical News

SOURCE: Soul J Abstract 2.426

ORLANDO – Bariatric surgery significantly linked with increased levels of alcohol use and abuse in a meta-analysis of 28 studies with a total of nearly 16,000 patients.

Following any of several methods of bariatric surgery, patients showed a statistically significant 8% higher rate of new onset alcohol abuse, and a relative 50% increased rate of significant alcohol use, compared with rates before surgery, Prandeet Wander, MD, said at the World Congress of Gastroenterology at ACG 2017.

Mitchel L. Zoler/Frontline Medical News

[email protected]

SOURCE: Wander P et al. World Congress of Gastroenterology, abstract 10.
 

ORLANDO – Bariatric surgery significantly linked with increased levels of alcohol use and abuse in a meta-analysis of 28 studies with a total of nearly 16,000 patients.

Following any of several methods of bariatric surgery, patients showed a statistically significant 8% higher rate of new onset alcohol abuse, and a relative 50% increased rate of significant alcohol use, compared with rates before surgery, Prandeet Wander, MD, said at the World Congress of Gastroenterology at ACG 2017.

Mitchel L. Zoler/Frontline Medical News

[email protected]

SOURCE: Wander P et al. World Congress of Gastroenterology, abstract 10.
 

ORLANDO – Bariatric surgery significantly linked with increased levels of alcohol use and abuse in a meta-analysis of 28 studies with a total of nearly 16,000 patients.

Following any of several methods of bariatric surgery, patients showed a statistically significant 8% higher rate of new onset alcohol abuse, and a relative 50% increased rate of significant alcohol use, compared with rates before surgery, Prandeet Wander, MD, said at the World Congress of Gastroenterology at ACG 2017.

Mitchel L. Zoler/Frontline Medical News

[email protected]

SOURCE: Wander P et al. World Congress of Gastroenterology, abstract 10.
 

Levels of antiphospholipid antibodies were significantly higher in adults with celiac disease compared with healthy controls, and gluten was not a factor, according to a study published in Digestive and Liver Disease (Dig Liver Dis. 2017. doi: 10.1016/j.dld.2017.11.018).

“In inflammatory bowel diseases active prophylaxis and treatment of thromboembolic complications is considered appropriate despite the increased risk of gastrointestinal bleeding,” wrote Outi Laine, MD, of Tampere University, Finland, and colleagues.

Results from previous studies suggest that thrombophilic autoantibodies are increased in celiac disease patients, but data are limited, the researchers wrote. In this study, the researchers measured antiphospholipid antibodies (cardiolipin IgG and M, prothrombin IgG, and aPS/PT IgG) in 179 adults with celiac disease (89 untreated, 90 on long-term gluten-free diets) and 91 nonceliac controls. Demographic characteristics were similar among the groups; the average age of the patients was 48 years in the untreated celiac disease group, 58 years in the treated group, and 45 years in the control group. In addition, the presentation of disease (gastrointestinal symptoms, malabsorption or anemia, and extraintestinal symptoms or screen-detected celiac disease) was similar among the groups.

Overall, the levels of antiphospholipid antibodies were significantly higher among celiac disease patients compared with controls 4.9 U/mL vs. 2.2 U/mL respectively, for anticardiolipin; 2.9 U/mL vs. 2.1 U/mL for antiprothrombin IgG, and 6.9 U/mL vs. 2.3 U/mL for antiphosphatidylserine-prothrombin. All three were higher among the untreated celiac disease patients compared with the treated patients.

“Treated patients with the highest levels of cardiolipin IgG and prothrombin IgG antibodies and aPS/PT were older than the newly diagnosed, untreated patients. This observation suggests that the formation of antibodies is not triggered by gluten but is related to the autoimmune-based celiac disease itself,” the researchers wrote.

The study was not designed to assess the impact of antiphospholipid antibodies on thrombosis, the researchers noted. However, “To guide therapeutic decisions, the optimal predictive biomarkers for thromboembolic episodes in patients with celiac disease should be determined,” and future areas of research should include identifying patients at high risk for thromboembolic episodes, they said.

The researchers had no financial conflicts to disclose. The study was funded in part by organizations including the Competitive State Research Financing of the Expert Responsibility Area of Tampere University Hospital, the Academy of Finland, and the Finnish Association of Hematology.

Levels of antiphospholipid antibodies were significantly higher in adults with celiac disease compared with healthy controls, and gluten was not a factor, according to a study published in Digestive and Liver Disease (Dig Liver Dis. 2017. doi: 10.1016/j.dld.2017.11.018).

“In inflammatory bowel diseases active prophylaxis and treatment of thromboembolic complications is considered appropriate despite the increased risk of gastrointestinal bleeding,” wrote Outi Laine, MD, of Tampere University, Finland, and colleagues.

Results from previous studies suggest that thrombophilic autoantibodies are increased in celiac disease patients, but data are limited, the researchers wrote. In this study, the researchers measured antiphospholipid antibodies (cardiolipin IgG and M, prothrombin IgG, and aPS/PT IgG) in 179 adults with celiac disease (89 untreated, 90 on long-term gluten-free diets) and 91 nonceliac controls. Demographic characteristics were similar among the groups; the average age of the patients was 48 years in the untreated celiac disease group, 58 years in the treated group, and 45 years in the control group. In addition, the presentation of disease (gastrointestinal symptoms, malabsorption or anemia, and extraintestinal symptoms or screen-detected celiac disease) was similar among the groups.

Overall, the levels of antiphospholipid antibodies were significantly higher among celiac disease patients compared with controls 4.9 U/mL vs. 2.2 U/mL respectively, for anticardiolipin; 2.9 U/mL vs. 2.1 U/mL for antiprothrombin IgG, and 6.9 U/mL vs. 2.3 U/mL for antiphosphatidylserine-prothrombin. All three were higher among the untreated celiac disease patients compared with the treated patients.

“Treated patients with the highest levels of cardiolipin IgG and prothrombin IgG antibodies and aPS/PT were older than the newly diagnosed, untreated patients. This observation suggests that the formation of antibodies is not triggered by gluten but is related to the autoimmune-based celiac disease itself,” the researchers wrote.

The study was not designed to assess the impact of antiphospholipid antibodies on thrombosis, the researchers noted. However, “To guide therapeutic decisions, the optimal predictive biomarkers for thromboembolic episodes in patients with celiac disease should be determined,” and future areas of research should include identifying patients at high risk for thromboembolic episodes, they said.

The researchers had no financial conflicts to disclose. The study was funded in part by organizations including the Competitive State Research Financing of the Expert Responsibility Area of Tampere University Hospital, the Academy of Finland, and the Finnish Association of Hematology.

Levels of antiphospholipid antibodies were significantly higher in adults with celiac disease compared with healthy controls, and gluten was not a factor, according to a study published in Digestive and Liver Disease (Dig Liver Dis. 2017. doi: 10.1016/j.dld.2017.11.018).

“In inflammatory bowel diseases active prophylaxis and treatment of thromboembolic complications is considered appropriate despite the increased risk of gastrointestinal bleeding,” wrote Outi Laine, MD, of Tampere University, Finland, and colleagues.

Results from previous studies suggest that thrombophilic autoantibodies are increased in celiac disease patients, but data are limited, the researchers wrote. In this study, the researchers measured antiphospholipid antibodies (cardiolipin IgG and M, prothrombin IgG, and aPS/PT IgG) in 179 adults with celiac disease (89 untreated, 90 on long-term gluten-free diets) and 91 nonceliac controls. Demographic characteristics were similar among the groups; the average age of the patients was 48 years in the untreated celiac disease group, 58 years in the treated group, and 45 years in the control group. In addition, the presentation of disease (gastrointestinal symptoms, malabsorption or anemia, and extraintestinal symptoms or screen-detected celiac disease) was similar among the groups.

Overall, the levels of antiphospholipid antibodies were significantly higher among celiac disease patients compared with controls 4.9 U/mL vs. 2.2 U/mL respectively, for anticardiolipin; 2.9 U/mL vs. 2.1 U/mL for antiprothrombin IgG, and 6.9 U/mL vs. 2.3 U/mL for antiphosphatidylserine-prothrombin. All three were higher among the untreated celiac disease patients compared with the treated patients.

“Treated patients with the highest levels of cardiolipin IgG and prothrombin IgG antibodies and aPS/PT were older than the newly diagnosed, untreated patients. This observation suggests that the formation of antibodies is not triggered by gluten but is related to the autoimmune-based celiac disease itself,” the researchers wrote.

The study was not designed to assess the impact of antiphospholipid antibodies on thrombosis, the researchers noted. However, “To guide therapeutic decisions, the optimal predictive biomarkers for thromboembolic episodes in patients with celiac disease should be determined,” and future areas of research should include identifying patients at high risk for thromboembolic episodes, they said.

The researchers had no financial conflicts to disclose. The study was funded in part by organizations including the Competitive State Research Financing of the Expert Responsibility Area of Tampere University Hospital, the Academy of Finland, and the Finnish Association of Hematology.

The numbers tell a grim story. Nationwide, 43.7 million adult Americans experienced a mental health condition during 2016 – an increase of 1.2 million over the previous year. Mental health issues send almost 5.5 million people to emergency departments each year; nearly 60% of adults with a mental illness received no treatment at all.

If that massive – and growing – need is one side of the story, shrinking resources are the other. Mental health resources had already been diminishing for decades before the recession hit – and hit them especially hard. Between 2009 and 2012, states cut $5 billion in mental health services; during that time, at least 4,500 public psychiatric hospital beds nationwide disappeared – nearly 10% of the total supply. The bulk of those resources have never been restored.

Provider numbers also are falling. “Psychiatry is probably the top manpower shortage among all specialties,” said Joe Parks, MD, medical director of the National Council for Behavioral Health. “We have about a third the number of psychiatrists that most estimates say we need, and the number per capita is decreasing.” A significant percentage of psychiatrists – more than 50% – only accept cash, bypassing the low reimbursement rates even private insurance typically offers.

Providers of last resort

But much of the burden of caring for this population ends up falling on hospitals by default. At Denver Health, Melanie Rylander, MD, medical director of the inpatient psychiatric unit, reports seeing this manifest in three categories of patients. First, there is an influx of people coming into the emergency department with primary mental health issues.

“We’re also seeing an influx of people coming in with physical problems, and upon assessment it becomes very clear very quickly that the real issue is an underlying mental health issue,” she said. Then there are the people coming in for the same physical problems over and over – maybe decompensated heart failure or COPD exacerbations – because mental health issues are impeding their ability to take care of themselves.

Some hospitalists say they feel ill equipped to care for these patients. “We don’t have the facility or the resources many times to properly care for their psychiatric needs when they’re in the hospital. It’s not really part of an internist’s training to be familiar with a lot of the medications,” said Atashi Mandal, MD, a hospitalist and pediatrician in Los Angeles. “Sometimes they get improperly medicated because we don’t know what else to do and the patient’s behavioral issues are escalating, so it’s really a difficult position.”

It’s a dispiriting experience for a hospitalist. “It really bothers me when I am trying to care for a patient who has psychiatric needs, and I feel I’m not able to do it, and I can’t find resources, and I feel that this patient’s needs are being neglected – not because we don’t care, and not because of a lack of effort by the staff. It’s just set up to fail,” Dr. Mandal said.
 

Ending the silo mentality

Encouraging a more holistic view of health across health care would be an important step to begin to address the problem – after all, the mind and the body are not separate.

“We work in silos, and we really have to stop doing that because these are intertwined,” said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “A schizophrenic will become worse when they’re medically ill. That illness will be harder to treat if their psychiatric illness is active.” This is starting to happen in the outpatient setting, evidenced by the expansion of the integrated care model, where a primary care doctor is the lead physician working in combination with psychologists, psychiatrists, and social workers. Communication among providers becomes simpler, and patients don’t fall through the cracks as often while trying to navigate the system.

Hospitals and communities

It’s axiomatic to say that a better approach to mental health would be based around prevention and early intervention, rather than the less crisis-oriented system we have now. Some efforts are being made in that direction, and they involve, and require, outreach outside the hospital.

“The best hospitals doing work in mental health are going beyond the hospital walls; they’re really looking at their community,” Dr. Nguyen said. “You have hospitals, like Accountable Care Organizations, who are trying to move earlier and think about mental health from a pediatric standpoint: How can we support parents and children during critical phases of brain growth? How can we provide prevention services?” Ultimately, those efforts should help lower future admission rates to EDs and hospitals.

That forward-looking approach may be necessary, but it’s also a challenge. “As a hospital administrator, I would think that you look out at the community and see this problem is not going away – in fact, it is likely going to get worse,” Dr. McHugh said. “A health system may look at themselves and say we have to take the lead on this.” The difficulty is that thinking of it in a sense of value to the community, and making the requisite investments, will have a very long period of payout; a health system that’s struggling may not be able to do it. “It’s the large [health systems] that tend to be more integrated … that are thinking about this much differently,” he said.

Still, the reality is that’s where the root of the problem lies, Dr. Rylander said – not in the hospital, but in the larger community. “In the absence of very basic needs – stable housing, food, heating – it’s really not reasonable to expect that people are going to take care of their physical needs,” she said. “It’s a much larger social issue: how to get resources so that these people can have stable places to live, they can get to and from appointments, that type of thing.”

Those needs are ongoing, of course. Many of these patients suffer from chronic conditions, meaning people will continue to need services and support, said Ron Honberg, JD, senior policy adviser for the National Alliance on Mental Illness. Often, people need services from different systems. “There are complexities in terms of navigating those systems and getting those systems to work well together. Until we make inroads in solving those things, or at least improving those things, the burdens are going to fall on the providers of last resort, and that includes hospitals,” he said.

What a hospitalist can do

One thing hospitalists might consider is starting that practice at their own hospitals, measuring, recording, and sharing that kind of information.

“Hospitalists should measure systematically, and in a very neutral manner, the total burden and frequency of the problem and report it consistently to management, along with their assessment that this impairs the quality of care and creates patient risk,” Dr. Parks said. That information can help hospitalists lobby for access to psychiatric personnel, be that in person or through telemedicine. “We don’t have to lay hands on you. There’s no excuse for any hospital not having a contract in place for on-demand consultation in the ER and on the floors.”

Track outcomes, too, Dr. Mandal suggests. With access to the right personnel, are you getting patients out of the ED faster? Are you having fewer negative outcomes while these patients are in the hospital, such as having to use restraints or get security involved? “Hopefully you can get some data in terms of how much money you’ve saved by decreasing the length of stays and decreasing inadvertent adverse effects because the patients weren’t receiving the proper care,” he said.

As this challenge seems likely to continue to grow, hospitalists might consider finding more training in mental health issues themselves so they are more comfortable handling these issues, Dr. Parks said. “The average mini-psych rotation from medical school is only 4 weeks,” he noted. “The ob.gyn. is at least 8 weeks and often 12 weeks, and if you don’t go into ob.gyn., you’re going to see a lot more mentally ill people through the rest of your practice, no matter what you do, than you are going to see pregnant women.”

Just starting these conversations – with patients, with colleagues, with family and friends – might be the most important change of all. “Even though nobody is above these issues afflicting them, this is still something that is not part of an open dialogue, and this is something that affects our own colleagues,” Dr. Mandal said. “I don’t know how many more trainees jumping out of windows it will take, or colleagues going through depression and feeling that it’s a sign of weakness to even talk about it.

“We need to create safe harbors within our own medical communities and acknowledge that we ourselves can be prone to this,” he said. “Perhaps by doing that, we will develop more empathy and become more comfortable, not just with ourselves and our colleagues but also helping these patients. People get overwhelmed and throw their hands up because it is just such a difficult issue. I don’t want people to give up, both from the medical community and our society as a whole – we can’t give up.”
 

A med-psych unit pilot project

Med-psych units can be a good model to take on these challenges. At Long Island Jewish Medical Center, they launched a pilot project to see how one would work in their community and summarized the results in an SHM abstract.

The hospital shares a campus with a 200-bed inpatient psych hospital, and doctors were seeing a lot of back and forth between the two institutions, said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “Patients would come into the hospital because they had an active medical issue, but because of their behavioral issues, they’d have to have continuous observation. It would not be uncommon for us to have sometimes close to 30 patients who needed 24-hour continuous observation to make sure they were not hurting themselves.” These PCAs or nurse’s assistants were doing 8-hour shifts, so each patient needed three. “The math is staggering – and with not any better outcomes.”

So the hospital created a 15-bed closed med-psych unit for medically ill patients with behavioral health disorders. They staffed it with a dedicated hospitalist, a nurse practitioner, a psychologist, and a nurse manager.

The number of patients requiring continuous observation fell to single digits. Once in their own unit, these patients caused less disruption and stress on the medical units. They had a lower length of stay compared to their previous admissions in other units, and this became one of the hospital’s highest performing units in terms of patient experience.

The biggest secret of their success, Dr. Karlin-Zysman said, is cohorting. “Instead of them going to the next open bed, wherever it may be, you get the patients all in one place geographically, with a team trained to manage those patients.” Another factor: it’s a hospitalist-run unit. “You can’t have 20 different doctors taking care of the patients; it’s one or two hospitalists running this unit.”

Care models like this can be a true win-win, and her hospital is using them more and more.

“I have a care model that’s a stroke unit; I have a care model that’s an onc unit and one that’s a pulmonary unit,” she said. “We’re creating these true teams, which I think hospitalists really like being part of. What’s that thing that makes them want to come to work every day? Things like this: running a care model, becoming specialized in something.” There are research and abstract opportunities for hospitalists on these units too, which also helps keep them engaged, she said. “I’ve used this care model and things like that to reduce burnout and keep people excited.”
 

The persistent mortality gap

Patients with mental illness tend to receive worse medical care than people without, studies have shown; they die an average of 25 years earlier, largely from preventable or treatable conditions such as cardiovascular disease and diabetes. The World Health Organization has called the problem “a hidden human rights emergency.”

In one in a series of articles on mental health, Lisa Rosenbaum, MD, a cardiologist at Brigham and Women’s Hospital, Boston, raises the question: Might physician attitudes toward mentally ill people contribute to this mortality gap, and if so, can we change them?

She recognizes the many obstacles physicians face in treating these patients. “The medicines we have are good but not great and can cause obesity and diabetes, which contributes to cardiovascular morbidity and mortality,” Dr. Rosenbaum said. “We have the adherence challenge for the psychiatric medications and for medications for chronic disease. It’s hard enough for anyone to take a medicine every day, and to do that if you’re homeless or you don’t have insight into the need for it, it’s really hard.”

Also, certain behaviors that are more common among people with serious mental illness – smoking, substance abuse, physical inactivity – increase their risk for chronic diseases.

These hurdles may foster a sense of helplessness among hospitalists who have just a small amount of time to spend with a patient, and attitudes may be hard to change.

“Negotiating more effectively about care refusals, more adeptly assessing capacity, and recognizing when our efforts to orchestrate care have been inadequate seem feasible,” Dr. Rosenbaum writes. “Far harder is overcoming any collective belief that what mentally ill people truly need is not something we can offer.” That’s why a truly honest examination of attitudes and biases is a necessary place to start.

She tells the story of one mentally ill patient she learned of in her research, who, after decades as the quintessential frequent flier in the ER, was living stably in the community. “No one could have known how many tries it would take to help him get there,” she writes. His doctor told her, “Let’s say 10 attempts are necessary. Someone needs to be number 2, 3 and 7. You just never know which number you are.”
 

Education for physicians

A course created by the National Alliance on Mental Illness addresses mental illness issues from a provider perspective.

“Although the description states that the course is intended for mental health professionals, it can be and has been used to educate and inform other healthcare professionals as well,” said Ron Honberg, JD, senior policy advisor for the National Alliance on Mental Illness. The standard course takes 15 hours; there is an abbreviated 4-hour alternative as well. More information can be found at http://www.nami.org/Find-Support/NAMI-Programs/NAMI-Provider-Education.
 

Sources

1. Szabo L. Cost of Not Caring: Nowhere to Go. USA Today. https://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/. Accessed March 10, 2017.

2. Mental Health America. The State of Mental Health in America. http://www.mentalhealthamerica.net/issues/state-mental-health-america. Accessed March 30, 2017.

3. Karlin-Zysman C, Lerner K, Warner-Cohen J. Creating a Hybrid Medicine and Psychiatric Unit to Manage Medically Ill Patients with Behavioral Health Disorders [abstract]. Journal of Hospital Medicine. 2015; 10 (suppl 2). http://www.shmabstracts.com/abstract/creating-a-hybrid-medicine-and-psychiatric-unit-to-manage-medically-ill-patients-with-behavioral-health-disorders/. Accessed March 19, 2017.

4. Garey J. When Doctors Discriminate. New York Times. http://www.nytimes.com/2013/08/11/opinion/sunday/when-doctors-discriminate.html. August 10, 2013. Accessed March 15, 2017.

5. Rosenbaum L. Closing the Mortality Gap – Mental Illness and Medical Care. N Engl J Med. 2016; 375:1585-1589. doi: 10.1056/NEJMms1610125.

6. Rosenbaum L. Unlearning Our Helplessness – Coexisting Serious Mental and Medical Illness. N Engl J Med. 2016;375:1690-4. doi: 10.1056/NEJMms1610127.

The numbers tell a grim story. Nationwide, 43.7 million adult Americans experienced a mental health condition during 2016 – an increase of 1.2 million over the previous year. Mental health issues send almost 5.5 million people to emergency departments each year; nearly 60% of adults with a mental illness received no treatment at all.

If that massive – and growing – need is one side of the story, shrinking resources are the other. Mental health resources had already been diminishing for decades before the recession hit – and hit them especially hard. Between 2009 and 2012, states cut $5 billion in mental health services; during that time, at least 4,500 public psychiatric hospital beds nationwide disappeared – nearly 10% of the total supply. The bulk of those resources have never been restored.

Provider numbers also are falling. “Psychiatry is probably the top manpower shortage among all specialties,” said Joe Parks, MD, medical director of the National Council for Behavioral Health. “We have about a third the number of psychiatrists that most estimates say we need, and the number per capita is decreasing.” A significant percentage of psychiatrists – more than 50% – only accept cash, bypassing the low reimbursement rates even private insurance typically offers.

Providers of last resort

But much of the burden of caring for this population ends up falling on hospitals by default. At Denver Health, Melanie Rylander, MD, medical director of the inpatient psychiatric unit, reports seeing this manifest in three categories of patients. First, there is an influx of people coming into the emergency department with primary mental health issues.

“We’re also seeing an influx of people coming in with physical problems, and upon assessment it becomes very clear very quickly that the real issue is an underlying mental health issue,” she said. Then there are the people coming in for the same physical problems over and over – maybe decompensated heart failure or COPD exacerbations – because mental health issues are impeding their ability to take care of themselves.

Some hospitalists say they feel ill equipped to care for these patients. “We don’t have the facility or the resources many times to properly care for their psychiatric needs when they’re in the hospital. It’s not really part of an internist’s training to be familiar with a lot of the medications,” said Atashi Mandal, MD, a hospitalist and pediatrician in Los Angeles. “Sometimes they get improperly medicated because we don’t know what else to do and the patient’s behavioral issues are escalating, so it’s really a difficult position.”

It’s a dispiriting experience for a hospitalist. “It really bothers me when I am trying to care for a patient who has psychiatric needs, and I feel I’m not able to do it, and I can’t find resources, and I feel that this patient’s needs are being neglected – not because we don’t care, and not because of a lack of effort by the staff. It’s just set up to fail,” Dr. Mandal said.
 

Ending the silo mentality

Encouraging a more holistic view of health across health care would be an important step to begin to address the problem – after all, the mind and the body are not separate.

“We work in silos, and we really have to stop doing that because these are intertwined,” said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “A schizophrenic will become worse when they’re medically ill. That illness will be harder to treat if their psychiatric illness is active.” This is starting to happen in the outpatient setting, evidenced by the expansion of the integrated care model, where a primary care doctor is the lead physician working in combination with psychologists, psychiatrists, and social workers. Communication among providers becomes simpler, and patients don’t fall through the cracks as often while trying to navigate the system.

Hospitals and communities

It’s axiomatic to say that a better approach to mental health would be based around prevention and early intervention, rather than the less crisis-oriented system we have now. Some efforts are being made in that direction, and they involve, and require, outreach outside the hospital.

“The best hospitals doing work in mental health are going beyond the hospital walls; they’re really looking at their community,” Dr. Nguyen said. “You have hospitals, like Accountable Care Organizations, who are trying to move earlier and think about mental health from a pediatric standpoint: How can we support parents and children during critical phases of brain growth? How can we provide prevention services?” Ultimately, those efforts should help lower future admission rates to EDs and hospitals.

That forward-looking approach may be necessary, but it’s also a challenge. “As a hospital administrator, I would think that you look out at the community and see this problem is not going away – in fact, it is likely going to get worse,” Dr. McHugh said. “A health system may look at themselves and say we have to take the lead on this.” The difficulty is that thinking of it in a sense of value to the community, and making the requisite investments, will have a very long period of payout; a health system that’s struggling may not be able to do it. “It’s the large [health systems] that tend to be more integrated … that are thinking about this much differently,” he said.

Still, the reality is that’s where the root of the problem lies, Dr. Rylander said – not in the hospital, but in the larger community. “In the absence of very basic needs – stable housing, food, heating – it’s really not reasonable to expect that people are going to take care of their physical needs,” she said. “It’s a much larger social issue: how to get resources so that these people can have stable places to live, they can get to and from appointments, that type of thing.”

Those needs are ongoing, of course. Many of these patients suffer from chronic conditions, meaning people will continue to need services and support, said Ron Honberg, JD, senior policy adviser for the National Alliance on Mental Illness. Often, people need services from different systems. “There are complexities in terms of navigating those systems and getting those systems to work well together. Until we make inroads in solving those things, or at least improving those things, the burdens are going to fall on the providers of last resort, and that includes hospitals,” he said.

What a hospitalist can do

One thing hospitalists might consider is starting that practice at their own hospitals, measuring, recording, and sharing that kind of information.

“Hospitalists should measure systematically, and in a very neutral manner, the total burden and frequency of the problem and report it consistently to management, along with their assessment that this impairs the quality of care and creates patient risk,” Dr. Parks said. That information can help hospitalists lobby for access to psychiatric personnel, be that in person or through telemedicine. “We don’t have to lay hands on you. There’s no excuse for any hospital not having a contract in place for on-demand consultation in the ER and on the floors.”

Track outcomes, too, Dr. Mandal suggests. With access to the right personnel, are you getting patients out of the ED faster? Are you having fewer negative outcomes while these patients are in the hospital, such as having to use restraints or get security involved? “Hopefully you can get some data in terms of how much money you’ve saved by decreasing the length of stays and decreasing inadvertent adverse effects because the patients weren’t receiving the proper care,” he said.

As this challenge seems likely to continue to grow, hospitalists might consider finding more training in mental health issues themselves so they are more comfortable handling these issues, Dr. Parks said. “The average mini-psych rotation from medical school is only 4 weeks,” he noted. “The ob.gyn. is at least 8 weeks and often 12 weeks, and if you don’t go into ob.gyn., you’re going to see a lot more mentally ill people through the rest of your practice, no matter what you do, than you are going to see pregnant women.”

Just starting these conversations – with patients, with colleagues, with family and friends – might be the most important change of all. “Even though nobody is above these issues afflicting them, this is still something that is not part of an open dialogue, and this is something that affects our own colleagues,” Dr. Mandal said. “I don’t know how many more trainees jumping out of windows it will take, or colleagues going through depression and feeling that it’s a sign of weakness to even talk about it.

“We need to create safe harbors within our own medical communities and acknowledge that we ourselves can be prone to this,” he said. “Perhaps by doing that, we will develop more empathy and become more comfortable, not just with ourselves and our colleagues but also helping these patients. People get overwhelmed and throw their hands up because it is just such a difficult issue. I don’t want people to give up, both from the medical community and our society as a whole – we can’t give up.”
 

A med-psych unit pilot project

Med-psych units can be a good model to take on these challenges. At Long Island Jewish Medical Center, they launched a pilot project to see how one would work in their community and summarized the results in an SHM abstract.

The hospital shares a campus with a 200-bed inpatient psych hospital, and doctors were seeing a lot of back and forth between the two institutions, said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “Patients would come into the hospital because they had an active medical issue, but because of their behavioral issues, they’d have to have continuous observation. It would not be uncommon for us to have sometimes close to 30 patients who needed 24-hour continuous observation to make sure they were not hurting themselves.” These PCAs or nurse’s assistants were doing 8-hour shifts, so each patient needed three. “The math is staggering – and with not any better outcomes.”

So the hospital created a 15-bed closed med-psych unit for medically ill patients with behavioral health disorders. They staffed it with a dedicated hospitalist, a nurse practitioner, a psychologist, and a nurse manager.

The number of patients requiring continuous observation fell to single digits. Once in their own unit, these patients caused less disruption and stress on the medical units. They had a lower length of stay compared to their previous admissions in other units, and this became one of the hospital’s highest performing units in terms of patient experience.

The biggest secret of their success, Dr. Karlin-Zysman said, is cohorting. “Instead of them going to the next open bed, wherever it may be, you get the patients all in one place geographically, with a team trained to manage those patients.” Another factor: it’s a hospitalist-run unit. “You can’t have 20 different doctors taking care of the patients; it’s one or two hospitalists running this unit.”

Care models like this can be a true win-win, and her hospital is using them more and more.

“I have a care model that’s a stroke unit; I have a care model that’s an onc unit and one that’s a pulmonary unit,” she said. “We’re creating these true teams, which I think hospitalists really like being part of. What’s that thing that makes them want to come to work every day? Things like this: running a care model, becoming specialized in something.” There are research and abstract opportunities for hospitalists on these units too, which also helps keep them engaged, she said. “I’ve used this care model and things like that to reduce burnout and keep people excited.”
 

The persistent mortality gap

Patients with mental illness tend to receive worse medical care than people without, studies have shown; they die an average of 25 years earlier, largely from preventable or treatable conditions such as cardiovascular disease and diabetes. The World Health Organization has called the problem “a hidden human rights emergency.”

In one in a series of articles on mental health, Lisa Rosenbaum, MD, a cardiologist at Brigham and Women’s Hospital, Boston, raises the question: Might physician attitudes toward mentally ill people contribute to this mortality gap, and if so, can we change them?

She recognizes the many obstacles physicians face in treating these patients. “The medicines we have are good but not great and can cause obesity and diabetes, which contributes to cardiovascular morbidity and mortality,” Dr. Rosenbaum said. “We have the adherence challenge for the psychiatric medications and for medications for chronic disease. It’s hard enough for anyone to take a medicine every day, and to do that if you’re homeless or you don’t have insight into the need for it, it’s really hard.”

Also, certain behaviors that are more common among people with serious mental illness – smoking, substance abuse, physical inactivity – increase their risk for chronic diseases.

These hurdles may foster a sense of helplessness among hospitalists who have just a small amount of time to spend with a patient, and attitudes may be hard to change.

“Negotiating more effectively about care refusals, more adeptly assessing capacity, and recognizing when our efforts to orchestrate care have been inadequate seem feasible,” Dr. Rosenbaum writes. “Far harder is overcoming any collective belief that what mentally ill people truly need is not something we can offer.” That’s why a truly honest examination of attitudes and biases is a necessary place to start.

She tells the story of one mentally ill patient she learned of in her research, who, after decades as the quintessential frequent flier in the ER, was living stably in the community. “No one could have known how many tries it would take to help him get there,” she writes. His doctor told her, “Let’s say 10 attempts are necessary. Someone needs to be number 2, 3 and 7. You just never know which number you are.”
 

Education for physicians

A course created by the National Alliance on Mental Illness addresses mental illness issues from a provider perspective.

“Although the description states that the course is intended for mental health professionals, it can be and has been used to educate and inform other healthcare professionals as well,” said Ron Honberg, JD, senior policy advisor for the National Alliance on Mental Illness. The standard course takes 15 hours; there is an abbreviated 4-hour alternative as well. More information can be found at http://www.nami.org/Find-Support/NAMI-Programs/NAMI-Provider-Education.
 

Sources

1. Szabo L. Cost of Not Caring: Nowhere to Go. USA Today. https://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/. Accessed March 10, 2017.

2. Mental Health America. The State of Mental Health in America. http://www.mentalhealthamerica.net/issues/state-mental-health-america. Accessed March 30, 2017.

3. Karlin-Zysman C, Lerner K, Warner-Cohen J. Creating a Hybrid Medicine and Psychiatric Unit to Manage Medically Ill Patients with Behavioral Health Disorders [abstract]. Journal of Hospital Medicine. 2015; 10 (suppl 2). http://www.shmabstracts.com/abstract/creating-a-hybrid-medicine-and-psychiatric-unit-to-manage-medically-ill-patients-with-behavioral-health-disorders/. Accessed March 19, 2017.

4. Garey J. When Doctors Discriminate. New York Times. http://www.nytimes.com/2013/08/11/opinion/sunday/when-doctors-discriminate.html. August 10, 2013. Accessed March 15, 2017.

5. Rosenbaum L. Closing the Mortality Gap – Mental Illness and Medical Care. N Engl J Med. 2016; 375:1585-1589. doi: 10.1056/NEJMms1610125.

6. Rosenbaum L. Unlearning Our Helplessness – Coexisting Serious Mental and Medical Illness. N Engl J Med. 2016;375:1690-4. doi: 10.1056/NEJMms1610127.

The numbers tell a grim story. Nationwide, 43.7 million adult Americans experienced a mental health condition during 2016 – an increase of 1.2 million over the previous year. Mental health issues send almost 5.5 million people to emergency departments each year; nearly 60% of adults with a mental illness received no treatment at all.

If that massive – and growing – need is one side of the story, shrinking resources are the other. Mental health resources had already been diminishing for decades before the recession hit – and hit them especially hard. Between 2009 and 2012, states cut $5 billion in mental health services; during that time, at least 4,500 public psychiatric hospital beds nationwide disappeared – nearly 10% of the total supply. The bulk of those resources have never been restored.

Provider numbers also are falling. “Psychiatry is probably the top manpower shortage among all specialties,” said Joe Parks, MD, medical director of the National Council for Behavioral Health. “We have about a third the number of psychiatrists that most estimates say we need, and the number per capita is decreasing.” A significant percentage of psychiatrists – more than 50% – only accept cash, bypassing the low reimbursement rates even private insurance typically offers.

Providers of last resort

But much of the burden of caring for this population ends up falling on hospitals by default. At Denver Health, Melanie Rylander, MD, medical director of the inpatient psychiatric unit, reports seeing this manifest in three categories of patients. First, there is an influx of people coming into the emergency department with primary mental health issues.

“We’re also seeing an influx of people coming in with physical problems, and upon assessment it becomes very clear very quickly that the real issue is an underlying mental health issue,” she said. Then there are the people coming in for the same physical problems over and over – maybe decompensated heart failure or COPD exacerbations – because mental health issues are impeding their ability to take care of themselves.

Some hospitalists say they feel ill equipped to care for these patients. “We don’t have the facility or the resources many times to properly care for their psychiatric needs when they’re in the hospital. It’s not really part of an internist’s training to be familiar with a lot of the medications,” said Atashi Mandal, MD, a hospitalist and pediatrician in Los Angeles. “Sometimes they get improperly medicated because we don’t know what else to do and the patient’s behavioral issues are escalating, so it’s really a difficult position.”

It’s a dispiriting experience for a hospitalist. “It really bothers me when I am trying to care for a patient who has psychiatric needs, and I feel I’m not able to do it, and I can’t find resources, and I feel that this patient’s needs are being neglected – not because we don’t care, and not because of a lack of effort by the staff. It’s just set up to fail,” Dr. Mandal said.
 

Ending the silo mentality

Encouraging a more holistic view of health across health care would be an important step to begin to address the problem – after all, the mind and the body are not separate.

“We work in silos, and we really have to stop doing that because these are intertwined,” said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “A schizophrenic will become worse when they’re medically ill. That illness will be harder to treat if their psychiatric illness is active.” This is starting to happen in the outpatient setting, evidenced by the expansion of the integrated care model, where a primary care doctor is the lead physician working in combination with psychologists, psychiatrists, and social workers. Communication among providers becomes simpler, and patients don’t fall through the cracks as often while trying to navigate the system.

Hospitals and communities

It’s axiomatic to say that a better approach to mental health would be based around prevention and early intervention, rather than the less crisis-oriented system we have now. Some efforts are being made in that direction, and they involve, and require, outreach outside the hospital.

“The best hospitals doing work in mental health are going beyond the hospital walls; they’re really looking at their community,” Dr. Nguyen said. “You have hospitals, like Accountable Care Organizations, who are trying to move earlier and think about mental health from a pediatric standpoint: How can we support parents and children during critical phases of brain growth? How can we provide prevention services?” Ultimately, those efforts should help lower future admission rates to EDs and hospitals.

That forward-looking approach may be necessary, but it’s also a challenge. “As a hospital administrator, I would think that you look out at the community and see this problem is not going away – in fact, it is likely going to get worse,” Dr. McHugh said. “A health system may look at themselves and say we have to take the lead on this.” The difficulty is that thinking of it in a sense of value to the community, and making the requisite investments, will have a very long period of payout; a health system that’s struggling may not be able to do it. “It’s the large [health systems] that tend to be more integrated … that are thinking about this much differently,” he said.

Still, the reality is that’s where the root of the problem lies, Dr. Rylander said – not in the hospital, but in the larger community. “In the absence of very basic needs – stable housing, food, heating – it’s really not reasonable to expect that people are going to take care of their physical needs,” she said. “It’s a much larger social issue: how to get resources so that these people can have stable places to live, they can get to and from appointments, that type of thing.”

Those needs are ongoing, of course. Many of these patients suffer from chronic conditions, meaning people will continue to need services and support, said Ron Honberg, JD, senior policy adviser for the National Alliance on Mental Illness. Often, people need services from different systems. “There are complexities in terms of navigating those systems and getting those systems to work well together. Until we make inroads in solving those things, or at least improving those things, the burdens are going to fall on the providers of last resort, and that includes hospitals,” he said.

What a hospitalist can do

One thing hospitalists might consider is starting that practice at their own hospitals, measuring, recording, and sharing that kind of information.

“Hospitalists should measure systematically, and in a very neutral manner, the total burden and frequency of the problem and report it consistently to management, along with their assessment that this impairs the quality of care and creates patient risk,” Dr. Parks said. That information can help hospitalists lobby for access to psychiatric personnel, be that in person or through telemedicine. “We don’t have to lay hands on you. There’s no excuse for any hospital not having a contract in place for on-demand consultation in the ER and on the floors.”

Track outcomes, too, Dr. Mandal suggests. With access to the right personnel, are you getting patients out of the ED faster? Are you having fewer negative outcomes while these patients are in the hospital, such as having to use restraints or get security involved? “Hopefully you can get some data in terms of how much money you’ve saved by decreasing the length of stays and decreasing inadvertent adverse effects because the patients weren’t receiving the proper care,” he said.

As this challenge seems likely to continue to grow, hospitalists might consider finding more training in mental health issues themselves so they are more comfortable handling these issues, Dr. Parks said. “The average mini-psych rotation from medical school is only 4 weeks,” he noted. “The ob.gyn. is at least 8 weeks and often 12 weeks, and if you don’t go into ob.gyn., you’re going to see a lot more mentally ill people through the rest of your practice, no matter what you do, than you are going to see pregnant women.”

Just starting these conversations – with patients, with colleagues, with family and friends – might be the most important change of all. “Even though nobody is above these issues afflicting them, this is still something that is not part of an open dialogue, and this is something that affects our own colleagues,” Dr. Mandal said. “I don’t know how many more trainees jumping out of windows it will take, or colleagues going through depression and feeling that it’s a sign of weakness to even talk about it.

“We need to create safe harbors within our own medical communities and acknowledge that we ourselves can be prone to this,” he said. “Perhaps by doing that, we will develop more empathy and become more comfortable, not just with ourselves and our colleagues but also helping these patients. People get overwhelmed and throw their hands up because it is just such a difficult issue. I don’t want people to give up, both from the medical community and our society as a whole – we can’t give up.”
 

A med-psych unit pilot project

Med-psych units can be a good model to take on these challenges. At Long Island Jewish Medical Center, they launched a pilot project to see how one would work in their community and summarized the results in an SHM abstract.

The hospital shares a campus with a 200-bed inpatient psych hospital, and doctors were seeing a lot of back and forth between the two institutions, said Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at Northwell Health. “Patients would come into the hospital because they had an active medical issue, but because of their behavioral issues, they’d have to have continuous observation. It would not be uncommon for us to have sometimes close to 30 patients who needed 24-hour continuous observation to make sure they were not hurting themselves.” These PCAs or nurse’s assistants were doing 8-hour shifts, so each patient needed three. “The math is staggering – and with not any better outcomes.”

So the hospital created a 15-bed closed med-psych unit for medically ill patients with behavioral health disorders. They staffed it with a dedicated hospitalist, a nurse practitioner, a psychologist, and a nurse manager.

The number of patients requiring continuous observation fell to single digits. Once in their own unit, these patients caused less disruption and stress on the medical units. They had a lower length of stay compared to their previous admissions in other units, and this became one of the hospital’s highest performing units in terms of patient experience.

The biggest secret of their success, Dr. Karlin-Zysman said, is cohorting. “Instead of them going to the next open bed, wherever it may be, you get the patients all in one place geographically, with a team trained to manage those patients.” Another factor: it’s a hospitalist-run unit. “You can’t have 20 different doctors taking care of the patients; it’s one or two hospitalists running this unit.”

Care models like this can be a true win-win, and her hospital is using them more and more.

“I have a care model that’s a stroke unit; I have a care model that’s an onc unit and one that’s a pulmonary unit,” she said. “We’re creating these true teams, which I think hospitalists really like being part of. What’s that thing that makes them want to come to work every day? Things like this: running a care model, becoming specialized in something.” There are research and abstract opportunities for hospitalists on these units too, which also helps keep them engaged, she said. “I’ve used this care model and things like that to reduce burnout and keep people excited.”
 

The persistent mortality gap

Patients with mental illness tend to receive worse medical care than people without, studies have shown; they die an average of 25 years earlier, largely from preventable or treatable conditions such as cardiovascular disease and diabetes. The World Health Organization has called the problem “a hidden human rights emergency.”

In one in a series of articles on mental health, Lisa Rosenbaum, MD, a cardiologist at Brigham and Women’s Hospital, Boston, raises the question: Might physician attitudes toward mentally ill people contribute to this mortality gap, and if so, can we change them?

She recognizes the many obstacles physicians face in treating these patients. “The medicines we have are good but not great and can cause obesity and diabetes, which contributes to cardiovascular morbidity and mortality,” Dr. Rosenbaum said. “We have the adherence challenge for the psychiatric medications and for medications for chronic disease. It’s hard enough for anyone to take a medicine every day, and to do that if you’re homeless or you don’t have insight into the need for it, it’s really hard.”

Also, certain behaviors that are more common among people with serious mental illness – smoking, substance abuse, physical inactivity – increase their risk for chronic diseases.

These hurdles may foster a sense of helplessness among hospitalists who have just a small amount of time to spend with a patient, and attitudes may be hard to change.

“Negotiating more effectively about care refusals, more adeptly assessing capacity, and recognizing when our efforts to orchestrate care have been inadequate seem feasible,” Dr. Rosenbaum writes. “Far harder is overcoming any collective belief that what mentally ill people truly need is not something we can offer.” That’s why a truly honest examination of attitudes and biases is a necessary place to start.

She tells the story of one mentally ill patient she learned of in her research, who, after decades as the quintessential frequent flier in the ER, was living stably in the community. “No one could have known how many tries it would take to help him get there,” she writes. His doctor told her, “Let’s say 10 attempts are necessary. Someone needs to be number 2, 3 and 7. You just never know which number you are.”
 

Education for physicians

A course created by the National Alliance on Mental Illness addresses mental illness issues from a provider perspective.

“Although the description states that the course is intended for mental health professionals, it can be and has been used to educate and inform other healthcare professionals as well,” said Ron Honberg, JD, senior policy advisor for the National Alliance on Mental Illness. The standard course takes 15 hours; there is an abbreviated 4-hour alternative as well. More information can be found at http://www.nami.org/Find-Support/NAMI-Programs/NAMI-Provider-Education.
 

Sources

1. Szabo L. Cost of Not Caring: Nowhere to Go. USA Today. https://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/. Accessed March 10, 2017.

2. Mental Health America. The State of Mental Health in America. http://www.mentalhealthamerica.net/issues/state-mental-health-america. Accessed March 30, 2017.

3. Karlin-Zysman C, Lerner K, Warner-Cohen J. Creating a Hybrid Medicine and Psychiatric Unit to Manage Medically Ill Patients with Behavioral Health Disorders [abstract]. Journal of Hospital Medicine. 2015; 10 (suppl 2). http://www.shmabstracts.com/abstract/creating-a-hybrid-medicine-and-psychiatric-unit-to-manage-medically-ill-patients-with-behavioral-health-disorders/. Accessed March 19, 2017.

4. Garey J. When Doctors Discriminate. New York Times. http://www.nytimes.com/2013/08/11/opinion/sunday/when-doctors-discriminate.html. August 10, 2013. Accessed March 15, 2017.

5. Rosenbaum L. Closing the Mortality Gap – Mental Illness and Medical Care. N Engl J Med. 2016; 375:1585-1589. doi: 10.1056/NEJMms1610125.

6. Rosenbaum L. Unlearning Our Helplessness – Coexisting Serious Mental and Medical Illness. N Engl J Med. 2016;375:1690-4. doi: 10.1056/NEJMms1610127.

SAN DIEGO – New research into factors that predict which systemic lupus erythematosus patients are at high risk for hospitalization is beginning to identify the contribution of medication nonadherence to the problem.

Compared with others hospitalized for systemic lupus erythematosus (SLE), high-risk patients were an adjusted 10 percentage points less likely to show evidence of adherence to prescribed drugs, according to a study presented at the annual meeting of the American College of Rheumatology.

“Medication nonadherence remains an important problem among patients with SLE. It is a major modifiable cause to help decrease hospital admissions and readmissions and decrease risk for morbidity and mortality associated with SLE,” study coauthor Allen P. Anandarajah, MBBS, said in an interview after the ACR meeting.

SOURCE: C. Thirukuraman et al. ACR 2017 abstract 223.

SAN DIEGO – New research into factors that predict which systemic lupus erythematosus patients are at high risk for hospitalization is beginning to identify the contribution of medication nonadherence to the problem.

Compared with others hospitalized for systemic lupus erythematosus (SLE), high-risk patients were an adjusted 10 percentage points less likely to show evidence of adherence to prescribed drugs, according to a study presented at the annual meeting of the American College of Rheumatology.

“Medication nonadherence remains an important problem among patients with SLE. It is a major modifiable cause to help decrease hospital admissions and readmissions and decrease risk for morbidity and mortality associated with SLE,” study coauthor Allen P. Anandarajah, MBBS, said in an interview after the ACR meeting.

SOURCE: C. Thirukuraman et al. ACR 2017 abstract 223.

SAN DIEGO – New research into factors that predict which systemic lupus erythematosus patients are at high risk for hospitalization is beginning to identify the contribution of medication nonadherence to the problem.

Compared with others hospitalized for systemic lupus erythematosus (SLE), high-risk patients were an adjusted 10 percentage points less likely to show evidence of adherence to prescribed drugs, according to a study presented at the annual meeting of the American College of Rheumatology.

“Medication nonadherence remains an important problem among patients with SLE. It is a major modifiable cause to help decrease hospital admissions and readmissions and decrease risk for morbidity and mortality associated with SLE,” study coauthor Allen P. Anandarajah, MBBS, said in an interview after the ACR meeting.

SOURCE: C. Thirukuraman et al. ACR 2017 abstract 223.

SAN ANTONIO – The phase 1b/2 PANACEA trial of pembrolizumab and trastuzumab in trastuzumab-resistant HER2-positive advanced breast cancer met its primary endpoint, showing an overall response rate of 15.2% in the PD-L1-positive cohort and controlling disease for almost a year without chemotherapy, Sherene Loi, MD, PhD, of the Peter MacCallum Cancer Centre in Melbourne reported on behalf of the International Breast Cancer Study Group (IBCSG). But level of antitumor immunity was key. In an interview at the San Antonio Breast Cancer Symposium, Dr. Loi discussed the findings and possible implications for use of pembrolizumab earlier in the disease course.

[email protected]

SAN ANTONIO – The phase 1b/2 PANACEA trial of pembrolizumab and trastuzumab in trastuzumab-resistant HER2-positive advanced breast cancer met its primary endpoint, showing an overall response rate of 15.2% in the PD-L1-positive cohort and controlling disease for almost a year without chemotherapy, Sherene Loi, MD, PhD, of the Peter MacCallum Cancer Centre in Melbourne reported on behalf of the International Breast Cancer Study Group (IBCSG). But level of antitumor immunity was key. In an interview at the San Antonio Breast Cancer Symposium, Dr. Loi discussed the findings and possible implications for use of pembrolizumab earlier in the disease course.

[email protected]

SAN ANTONIO – The phase 1b/2 PANACEA trial of pembrolizumab and trastuzumab in trastuzumab-resistant HER2-positive advanced breast cancer met its primary endpoint, showing an overall response rate of 15.2% in the PD-L1-positive cohort and controlling disease for almost a year without chemotherapy, Sherene Loi, MD, PhD, of the Peter MacCallum Cancer Centre in Melbourne reported on behalf of the International Breast Cancer Study Group (IBCSG). But level of antitumor immunity was key. In an interview at the San Antonio Breast Cancer Symposium, Dr. Loi discussed the findings and possible implications for use of pembrolizumab earlier in the disease course.

[email protected]

SAN ANTONIO – Increasing the dose intensity of adjuvant chemotherapy reduced risks of breast cancer recurrence and death by about 15% in an Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) meta-analysis of individual patient data from 25 randomized trials among 34,122 women. Lead author Richard Gray, MSc, professor of medical statistics in the Nuffield Department of Population Health at University of Oxford, England, discussed the findings for various dose-intensification approaches and likely impact on clinical practice in an interview at the San Antonio Breast Cancer Symposium.

[email protected]

SAN ANTONIO – Increasing the dose intensity of adjuvant chemotherapy reduced risks of breast cancer recurrence and death by about 15% in an Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) meta-analysis of individual patient data from 25 randomized trials among 34,122 women. Lead author Richard Gray, MSc, professor of medical statistics in the Nuffield Department of Population Health at University of Oxford, England, discussed the findings for various dose-intensification approaches and likely impact on clinical practice in an interview at the San Antonio Breast Cancer Symposium.

[email protected]

SAN ANTONIO – Increasing the dose intensity of adjuvant chemotherapy reduced risks of breast cancer recurrence and death by about 15% in an Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) meta-analysis of individual patient data from 25 randomized trials among 34,122 women. Lead author Richard Gray, MSc, professor of medical statistics in the Nuffield Department of Population Health at University of Oxford, England, discussed the findings for various dose-intensification approaches and likely impact on clinical practice in an interview at the San Antonio Breast Cancer Symposium.

[email protected]

The Food and Drug Administration has approved semaglutide (OZEMPIC) injections for treatment of type 2 diabetes in adults, according to a press release from Novo Nordisk.

Semaglutide is a once-weekly injection of glucagon-like peptide (GLP-1) receptor agonist that, combined with diet and exercise, can improve glycemic control in adults with type 2 diabetes. Weekly injections are administered by health care providers in a prefilled pen subcutaneously in the stomach, abdomen, thigh, or upper arm as a 0.5-mg or 1-mg formulation. It is important that all doses be administered on the same day each week, according to the OZEMPIC package insert.

“The OZEMPIC (semaglutide) approval builds on Novo Nordisk’s commitment to offering health care professionals a range of treatments that effectively addresses the complex needs of diabetes management and fits their patients’ lifestyles,” said Todd Hobbs, vice president and U.S. chief medical officer of Novo Nordisk.

[email protected]

The Food and Drug Administration has approved semaglutide (OZEMPIC) injections for treatment of type 2 diabetes in adults, according to a press release from Novo Nordisk.

Semaglutide is a once-weekly injection of glucagon-like peptide (GLP-1) receptor agonist that, combined with diet and exercise, can improve glycemic control in adults with type 2 diabetes. Weekly injections are administered by health care providers in a prefilled pen subcutaneously in the stomach, abdomen, thigh, or upper arm as a 0.5-mg or 1-mg formulation. It is important that all doses be administered on the same day each week, according to the OZEMPIC package insert.

“The OZEMPIC (semaglutide) approval builds on Novo Nordisk’s commitment to offering health care professionals a range of treatments that effectively addresses the complex needs of diabetes management and fits their patients’ lifestyles,” said Todd Hobbs, vice president and U.S. chief medical officer of Novo Nordisk.

[email protected]

The Food and Drug Administration has approved semaglutide (OZEMPIC) injections for treatment of type 2 diabetes in adults, according to a press release from Novo Nordisk.

Semaglutide is a once-weekly injection of glucagon-like peptide (GLP-1) receptor agonist that, combined with diet and exercise, can improve glycemic control in adults with type 2 diabetes. Weekly injections are administered by health care providers in a prefilled pen subcutaneously in the stomach, abdomen, thigh, or upper arm as a 0.5-mg or 1-mg formulation. It is important that all doses be administered on the same day each week, according to the OZEMPIC package insert.

“The OZEMPIC (semaglutide) approval builds on Novo Nordisk’s commitment to offering health care professionals a range of treatments that effectively addresses the complex needs of diabetes management and fits their patients’ lifestyles,” said Todd Hobbs, vice president and U.S. chief medical officer of Novo Nordisk.

[email protected]

Pulmonary arterial hypertension (PAH) patients with moderate, stable disease can benefit from an implantable drug delivery system, based on data from a review of 60 adults with successful implantations. The findings were published in the December issue of CHEST.

“A fully implanted system offers patients the hope of returning to more normal activities such as bathing, swimming, and reduced risk of infections from externalized central venous catheter contamination or reduced subcutaneous pain from subcutaneous infusion,” wrote Aaron B. Waxman, MD, PhD, of Brigham and Women’s Hospital, Boston, and his colleagues (Chest. 2017 June 3. doi: 10.1016/j.chest.2017.04.188).

In the DelIVery Trial, clinicians at 10 locations in the United States placed a fully implantable delivery system in adults aged 18 years and older with stable PAH who were previously receiving treprostinil via an external pump at an average dose of 71 ng/kg per min.

All 60 patients were successfully implanted with a system consisting of a drug infusion pump placed in an abdominal pocket and an intravascular catheter linking the implanted pump to the superior vena cava.

“The location of the pump pocket was determined in partnership with the patient and was based on consideration of clothing styles, belt line and subcutaneous fat depth,” the researchers noted.

Procedure-related complications deemed clinically significant included one atrial fibrillation, two incidences of pneumothorax, two infections unrelated to catheter placement, and three catheter dislocations (two in the same patient). The most common patient complaints were expected implant site pain in 83% and bruising in 17%.

The findings were limited by the small number of patients, but the researchers identified several factors that contributed to the success of the procedure, including selecting patients who have shown response to treprostinil and are motivated to comply with pump refill visits, performing the procedure at centers with a high volume of PAH patients, keeping the procedure consistent for each patient, and using the same implant team in each case. “The implant procedure was successfully performed with a low complication rate by clinicians with a diverse range of specialty training,” the researchers added.

Patients reported satisfaction with the implant system at 6 weeks and 6 months, and said they spent an average of 75% less time managing their delivery system, according to previously published data on the patients’ perspective (CHEST 2016;150[1]:27-34).

Medtronic sponsored the study. The lead author, Dr. Waxman, had no financial conflicts to disclose; several coauthors reported relationships with companies including Medtronic, Actelion, Bayer, Gilead, Merck, and United Therapeutics.

[email protected]

Pulmonary arterial hypertension (PAH) patients with moderate, stable disease can benefit from an implantable drug delivery system, based on data from a review of 60 adults with successful implantations. The findings were published in the December issue of CHEST.

“A fully implanted system offers patients the hope of returning to more normal activities such as bathing, swimming, and reduced risk of infections from externalized central venous catheter contamination or reduced subcutaneous pain from subcutaneous infusion,” wrote Aaron B. Waxman, MD, PhD, of Brigham and Women’s Hospital, Boston, and his colleagues (Chest. 2017 June 3. doi: 10.1016/j.chest.2017.04.188).

In the DelIVery Trial, clinicians at 10 locations in the United States placed a fully implantable delivery system in adults aged 18 years and older with stable PAH who were previously receiving treprostinil via an external pump at an average dose of 71 ng/kg per min.

All 60 patients were successfully implanted with a system consisting of a drug infusion pump placed in an abdominal pocket and an intravascular catheter linking the implanted pump to the superior vena cava.

“The location of the pump pocket was determined in partnership with the patient and was based on consideration of clothing styles, belt line and subcutaneous fat depth,” the researchers noted.

Procedure-related complications deemed clinically significant included one atrial fibrillation, two incidences of pneumothorax, two infections unrelated to catheter placement, and three catheter dislocations (two in the same patient). The most common patient complaints were expected implant site pain in 83% and bruising in 17%.

The findings were limited by the small number of patients, but the researchers identified several factors that contributed to the success of the procedure, including selecting patients who have shown response to treprostinil and are motivated to comply with pump refill visits, performing the procedure at centers with a high volume of PAH patients, keeping the procedure consistent for each patient, and using the same implant team in each case. “The implant procedure was successfully performed with a low complication rate by clinicians with a diverse range of specialty training,” the researchers added.

Patients reported satisfaction with the implant system at 6 weeks and 6 months, and said they spent an average of 75% less time managing their delivery system, according to previously published data on the patients’ perspective (CHEST 2016;150[1]:27-34).

Medtronic sponsored the study. The lead author, Dr. Waxman, had no financial conflicts to disclose; several coauthors reported relationships with companies including Medtronic, Actelion, Bayer, Gilead, Merck, and United Therapeutics.

[email protected]

Pulmonary arterial hypertension (PAH) patients with moderate, stable disease can benefit from an implantable drug delivery system, based on data from a review of 60 adults with successful implantations. The findings were published in the December issue of CHEST.

“A fully implanted system offers patients the hope of returning to more normal activities such as bathing, swimming, and reduced risk of infections from externalized central venous catheter contamination or reduced subcutaneous pain from subcutaneous infusion,” wrote Aaron B. Waxman, MD, PhD, of Brigham and Women’s Hospital, Boston, and his colleagues (Chest. 2017 June 3. doi: 10.1016/j.chest.2017.04.188).

In the DelIVery Trial, clinicians at 10 locations in the United States placed a fully implantable delivery system in adults aged 18 years and older with stable PAH who were previously receiving treprostinil via an external pump at an average dose of 71 ng/kg per min.

All 60 patients were successfully implanted with a system consisting of a drug infusion pump placed in an abdominal pocket and an intravascular catheter linking the implanted pump to the superior vena cava.

“The location of the pump pocket was determined in partnership with the patient and was based on consideration of clothing styles, belt line and subcutaneous fat depth,” the researchers noted.

Procedure-related complications deemed clinically significant included one atrial fibrillation, two incidences of pneumothorax, two infections unrelated to catheter placement, and three catheter dislocations (two in the same patient). The most common patient complaints were expected implant site pain in 83% and bruising in 17%.

The findings were limited by the small number of patients, but the researchers identified several factors that contributed to the success of the procedure, including selecting patients who have shown response to treprostinil and are motivated to comply with pump refill visits, performing the procedure at centers with a high volume of PAH patients, keeping the procedure consistent for each patient, and using the same implant team in each case. “The implant procedure was successfully performed with a low complication rate by clinicians with a diverse range of specialty training,” the researchers added.

Patients reported satisfaction with the implant system at 6 weeks and 6 months, and said they spent an average of 75% less time managing their delivery system, according to previously published data on the patients’ perspective (CHEST 2016;150[1]:27-34).

Medtronic sponsored the study. The lead author, Dr. Waxman, had no financial conflicts to disclose; several coauthors reported relationships with companies including Medtronic, Actelion, Bayer, Gilead, Merck, and United Therapeutics.

[email protected]

The challenges of hospital discharge planning are well known and yet have not been adequately addressed by hospitalists and discharge teams. As the complexity of patient care needs has grown, so has the difficulty in developing appropriate discharge goals for post-acute and long term care (LTC), choosing the appropriate setting(s), and selecting appropriate providers. Post-acute and LTC needs may include rehabilitation, nursing care, home health, supportive services, and/or palliative care¹ in an institutional setting or at home from a wide array of providers with varying levels of quality.

Even though 52% of U.S. hospitals received penalties for having higher-than-expected readmissions between 2013 and 2017,² inadequate discharge planning for post-acute and LTC continues to contribute to high rates of all-cause 30-day rehospitalization. The discharge process sometimes is deficient in: discussion of goals; assessment of discharge needs; appropriate choice of discharge locations; and the provision of additional or different home services.³ Discharge decisions are complicated by the stressful circumstances of hospitalization and discharge deadlines.

Charlene Harrington, PhD, RN, is professor of sociology and nursing; Leslie Ross, PhD, is a research specialist and principal investigator of the Calqualitycare.org website project; and Jeffrey Newman, MD, MPH, is a professor at the Institute for Health and Aging, all at the University of California, San Francisco.

References

1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.

2. Thompson, MP, Waters, TM, Kaplan et al. Most hospitals received annual penalties for excess readmissions, but some fared better than others. Health Aff (Millwood). 36(5):893-901.

3. Auerbach AD et al. Preventability and causes of readmissions in a national cohort of general medicine patients. JAMA Intern Med. 2016;176(4):484-93.

4. Jack B et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87.

5. Hansen LO et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8)421-7.

6. Naylor MD et al. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood). 2011;30(4):746-54.

7. Coleman EA. Family caregivers as partners in care transitions: The caregiver advise record and enable act. J Hosp Med. 2016 Dec;11(12):883-5.

8. Leppin AL et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Internal Med. 2014;174(7):1095-107.

9. Mukamel DB et al. Personalizing nursing home compare and the discharge from hospitals to nursing homes. Health Serv Res. 2016;1(6):2076-2094.

10. Werner RM et al. Changes in consumer demand following public reporting of summary quality ratings: An evaluation in nursing homes. Health Serv Res. 2016;51 Suppl 2:1291-309.

11. Boccuti C et al. Reading the stars: nursing home quality star ratings, nationally and by state. Kaiser Family Foundation Issue Brief. May 2015.

12. Centers for Medicare and Medicaid Services. Nursing home compare data archives. May 2017 monthly files. Quality MSR Claims data. https://data.medicare.gov/data/archives/nursing-home-compare. Accessed July 15, 2017.

13. Harrington C et al. The need for higher minimum staffing standards in U.S. nursing homes. Health Serv Insights. 2016;9:13-9.

14. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.
 

The challenges of hospital discharge planning are well known and yet have not been adequately addressed by hospitalists and discharge teams. As the complexity of patient care needs has grown, so has the difficulty in developing appropriate discharge goals for post-acute and long term care (LTC), choosing the appropriate setting(s), and selecting appropriate providers. Post-acute and LTC needs may include rehabilitation, nursing care, home health, supportive services, and/or palliative care¹ in an institutional setting or at home from a wide array of providers with varying levels of quality.

Even though 52% of U.S. hospitals received penalties for having higher-than-expected readmissions between 2013 and 2017,² inadequate discharge planning for post-acute and LTC continues to contribute to high rates of all-cause 30-day rehospitalization. The discharge process sometimes is deficient in: discussion of goals; assessment of discharge needs; appropriate choice of discharge locations; and the provision of additional or different home services.³ Discharge decisions are complicated by the stressful circumstances of hospitalization and discharge deadlines.

Charlene Harrington, PhD, RN, is professor of sociology and nursing; Leslie Ross, PhD, is a research specialist and principal investigator of the Calqualitycare.org website project; and Jeffrey Newman, MD, MPH, is a professor at the Institute for Health and Aging, all at the University of California, San Francisco.

References

1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.

2. Thompson, MP, Waters, TM, Kaplan et al. Most hospitals received annual penalties for excess readmissions, but some fared better than others. Health Aff (Millwood). 36(5):893-901.

3. Auerbach AD et al. Preventability and causes of readmissions in a national cohort of general medicine patients. JAMA Intern Med. 2016;176(4):484-93.

4. Jack B et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87.

5. Hansen LO et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8)421-7.

6. Naylor MD et al. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood). 2011;30(4):746-54.

7. Coleman EA. Family caregivers as partners in care transitions: The caregiver advise record and enable act. J Hosp Med. 2016 Dec;11(12):883-5.

8. Leppin AL et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Internal Med. 2014;174(7):1095-107.

9. Mukamel DB et al. Personalizing nursing home compare and the discharge from hospitals to nursing homes. Health Serv Res. 2016;1(6):2076-2094.

10. Werner RM et al. Changes in consumer demand following public reporting of summary quality ratings: An evaluation in nursing homes. Health Serv Res. 2016;51 Suppl 2:1291-309.

11. Boccuti C et al. Reading the stars: nursing home quality star ratings, nationally and by state. Kaiser Family Foundation Issue Brief. May 2015.

12. Centers for Medicare and Medicaid Services. Nursing home compare data archives. May 2017 monthly files. Quality MSR Claims data. https://data.medicare.gov/data/archives/nursing-home-compare. Accessed July 15, 2017.

13. Harrington C et al. The need for higher minimum staffing standards in U.S. nursing homes. Health Serv Insights. 2016;9:13-9.

14. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.
 

The challenges of hospital discharge planning are well known and yet have not been adequately addressed by hospitalists and discharge teams. As the complexity of patient care needs has grown, so has the difficulty in developing appropriate discharge goals for post-acute and long term care (LTC), choosing the appropriate setting(s), and selecting appropriate providers. Post-acute and LTC needs may include rehabilitation, nursing care, home health, supportive services, and/or palliative care¹ in an institutional setting or at home from a wide array of providers with varying levels of quality.

Even though 52% of U.S. hospitals received penalties for having higher-than-expected readmissions between 2013 and 2017,² inadequate discharge planning for post-acute and LTC continues to contribute to high rates of all-cause 30-day rehospitalization. The discharge process sometimes is deficient in: discussion of goals; assessment of discharge needs; appropriate choice of discharge locations; and the provision of additional or different home services.³ Discharge decisions are complicated by the stressful circumstances of hospitalization and discharge deadlines.

Charlene Harrington, PhD, RN, is professor of sociology and nursing; Leslie Ross, PhD, is a research specialist and principal investigator of the Calqualitycare.org website project; and Jeffrey Newman, MD, MPH, is a professor at the Institute for Health and Aging, all at the University of California, San Francisco.

References

1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.

2. Thompson, MP, Waters, TM, Kaplan et al. Most hospitals received annual penalties for excess readmissions, but some fared better than others. Health Aff (Millwood). 36(5):893-901.

3. Auerbach AD et al. Preventability and causes of readmissions in a national cohort of general medicine patients. JAMA Intern Med. 2016;176(4):484-93.

4. Jack B et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87.

5. Hansen LO et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8)421-7.

6. Naylor MD et al. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood). 2011;30(4):746-54.

7. Coleman EA. Family caregivers as partners in care transitions: The caregiver advise record and enable act. J Hosp Med. 2016 Dec;11(12):883-5.

8. Leppin AL et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Internal Med. 2014;174(7):1095-107.

9. Mukamel DB et al. Personalizing nursing home compare and the discharge from hospitals to nursing homes. Health Serv Res. 2016;1(6):2076-2094.

10. Werner RM et al. Changes in consumer demand following public reporting of summary quality ratings: An evaluation in nursing homes. Health Serv Res. 2016;51 Suppl 2:1291-309.

11. Boccuti C et al. Reading the stars: nursing home quality star ratings, nationally and by state. Kaiser Family Foundation Issue Brief. May 2015.

12. Centers for Medicare and Medicaid Services. Nursing home compare data archives. May 2017 monthly files. Quality MSR Claims data. https://data.medicare.gov/data/archives/nursing-home-compare. Accessed July 15, 2017.

13. Harrington C et al. The need for higher minimum staffing standards in U.S. nursing homes. Health Serv Insights. 2016;9:13-9.

14. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.