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Identifying high-value care practices
A new tool can help where hospitalists need it most: at the bedside.
The focus on providing high-value care (HVC) continues to grow and expand in health care today. Still, most education around HVC currently happens in a formalized setting – lectures, modules, and so on, says Carolyn D. Sy, MD, interim director of the Hospital Medicine Service at the University of Washington, Seattle, and coauthor of a recent abstract about a new tool to address this shortcoming. “There are no instruments for measuring HVC discussions or practices at the bedside, confounding efforts to assess behavior changes associated with curricular interventions,” she said.
So she and other doctors undertook a study to identify 10 HVC topics in three domains (quality, cost, patient values), then measured their reliability with the goal of designing an HVC Rounding Tool and showing that it is an effective tool to measure observable markers of HVC at the bedside. “This is critical as it addresses an important educational gap in translating HVC from theoretical knowledge to bedside practice,” Dr. Sy said.
The tool is designed to capture multidisciplinary participation, she says, including involvement from not only faculty, fellows, or trainees, but also nursing, pharmacists, families, and other members of the health care team. The tool can be used as a peer feedback instrument to help physicians integrate HVC topics during bedside rounds or as a metric to assess the educational efficacy of future curriculum.
“The HVC Rounding Tool provides an opportunity for faculty development through peer observation and feedback on the integration and role modeling of HVC at the bedside,” Dr. Sy said. “It also is an instrument to help assess the educational efficacy of formal HVC curriculum and translation into bedside practice. Lastly, it is a tool that could be used to measure the relationship between HVC behaviors and actual patient outcomes such as length of stay, readmissions, cost of hospitalization – a feature with increasing importance given our move toward value-based health care.”
Reference
Sy CD, McDaniel C, Bradford M, et al. The Development and Validation of a High Value Care Rounding Tool Using the Delphi Method [abstract]. J Hosp Med. 2017; 12 (suppl 2). http://www.shmabstracts.com/abstract/the-development-and-validation-of-a-high-value-care-rounding-tool-using-the-delphi-method/. Accessed June 6, 2017.
A new tool can help where hospitalists need it most: at the bedside.
The focus on providing high-value care (HVC) continues to grow and expand in health care today. Still, most education around HVC currently happens in a formalized setting – lectures, modules, and so on, says Carolyn D. Sy, MD, interim director of the Hospital Medicine Service at the University of Washington, Seattle, and coauthor of a recent abstract about a new tool to address this shortcoming. “There are no instruments for measuring HVC discussions or practices at the bedside, confounding efforts to assess behavior changes associated with curricular interventions,” she said.
So she and other doctors undertook a study to identify 10 HVC topics in three domains (quality, cost, patient values), then measured their reliability with the goal of designing an HVC Rounding Tool and showing that it is an effective tool to measure observable markers of HVC at the bedside. “This is critical as it addresses an important educational gap in translating HVC from theoretical knowledge to bedside practice,” Dr. Sy said.
The tool is designed to capture multidisciplinary participation, she says, including involvement from not only faculty, fellows, or trainees, but also nursing, pharmacists, families, and other members of the health care team. The tool can be used as a peer feedback instrument to help physicians integrate HVC topics during bedside rounds or as a metric to assess the educational efficacy of future curriculum.
“The HVC Rounding Tool provides an opportunity for faculty development through peer observation and feedback on the integration and role modeling of HVC at the bedside,” Dr. Sy said. “It also is an instrument to help assess the educational efficacy of formal HVC curriculum and translation into bedside practice. Lastly, it is a tool that could be used to measure the relationship between HVC behaviors and actual patient outcomes such as length of stay, readmissions, cost of hospitalization – a feature with increasing importance given our move toward value-based health care.”
Reference
Sy CD, McDaniel C, Bradford M, et al. The Development and Validation of a High Value Care Rounding Tool Using the Delphi Method [abstract]. J Hosp Med. 2017; 12 (suppl 2). http://www.shmabstracts.com/abstract/the-development-and-validation-of-a-high-value-care-rounding-tool-using-the-delphi-method/. Accessed June 6, 2017.
A new tool can help where hospitalists need it most: at the bedside.
The focus on providing high-value care (HVC) continues to grow and expand in health care today. Still, most education around HVC currently happens in a formalized setting – lectures, modules, and so on, says Carolyn D. Sy, MD, interim director of the Hospital Medicine Service at the University of Washington, Seattle, and coauthor of a recent abstract about a new tool to address this shortcoming. “There are no instruments for measuring HVC discussions or practices at the bedside, confounding efforts to assess behavior changes associated with curricular interventions,” she said.
So she and other doctors undertook a study to identify 10 HVC topics in three domains (quality, cost, patient values), then measured their reliability with the goal of designing an HVC Rounding Tool and showing that it is an effective tool to measure observable markers of HVC at the bedside. “This is critical as it addresses an important educational gap in translating HVC from theoretical knowledge to bedside practice,” Dr. Sy said.
The tool is designed to capture multidisciplinary participation, she says, including involvement from not only faculty, fellows, or trainees, but also nursing, pharmacists, families, and other members of the health care team. The tool can be used as a peer feedback instrument to help physicians integrate HVC topics during bedside rounds or as a metric to assess the educational efficacy of future curriculum.
“The HVC Rounding Tool provides an opportunity for faculty development through peer observation and feedback on the integration and role modeling of HVC at the bedside,” Dr. Sy said. “It also is an instrument to help assess the educational efficacy of formal HVC curriculum and translation into bedside practice. Lastly, it is a tool that could be used to measure the relationship between HVC behaviors and actual patient outcomes such as length of stay, readmissions, cost of hospitalization – a feature with increasing importance given our move toward value-based health care.”
Reference
Sy CD, McDaniel C, Bradford M, et al. The Development and Validation of a High Value Care Rounding Tool Using the Delphi Method [abstract]. J Hosp Med. 2017; 12 (suppl 2). http://www.shmabstracts.com/abstract/the-development-and-validation-of-a-high-value-care-rounding-tool-using-the-delphi-method/. Accessed June 6, 2017.
Obesity linked to pain, fatigue in SLE
SAN DIEGO – A new study offers a double message about the potential impact of obesity on systemic lupus erythematosus (SLE) in women: Excess pounds are linked to a higher risk of patient-reported outcomes such as pain and fatigue, and body mass index may be an appropriate tool to study weight issues in this population.
Researchers found “a strong relationship between body composition and worse outcomes,” Sarah Patterson, MD, a fellow in rheumatology at the University of California, San Francisco, and the lead study author, said at the annual meeting of the American College of Rheumatology.
For the new study, Dr. Patterson and her colleagues analyzed findings from surveys of 148 participants in the Arthritis Body Composition and Disability study. All participants were women with a verified SLE diagnosis.
About two-thirds of the sample were white, 14% were Asian, and 13% were African American. The average age was 48 years, the average disease duration was 16 years, and 45% took glucocorticoids.
Researchers used two measurements of obesity: BMI of 30 kg/m2 or greater and fat mass index (FMI) of 13 kg/m2 or greater.
They calculated FMI with data collected via whole dual x-ray absorptiometry. Of the participants, 32% and 30% met criteria for obesity under FMI and BMI definitions, respectively.
Researchers also collected survey data regarding measurements of disease activity, depressive symptoms, pain and fatigue.
The study authors controlled their results to account for factors such as age, race, and prednisone use. They found that those defined as obese via FMI had more disease activity and depression than did nonobese women: 14.8 versus 11.5, P = .010, on the Systemic Lupus Activity Questionnaire scale, and 19.8 versus 13.1, P = .004, on the Center for Epidemiologic Studies Depression scale.
On two other scales of pain and fatigue, obese patients scored lower – a sign of worse status – compared with nonobese women: 38.7 versus 44.2, P = .004, on the Short Form 36 (SF-36) Health Survey pain subscale and 39.6 versus 45.2, P = .010, on the SF-36 vitality subscale. The researchers reported similar findings when using BMI to assess obesity.
It’s not clear why obesity and lupus may be linked, Dr. Patterson said, though she noted that inflammation is a shared factor. “People with lupus have arthritis and chronic pain, so there may be this vicious feedback cycle with hindrances to be able to live healthy lifestyles,” she added.
The study has limitations, including that the sample is largely white, while lupus is more common among minority women. In addition, the study does not include underweight patients or track patients over time. “It will be important to look at obesity and patient-reported outcomes to determine whether weight loss results in better outcomes,” Dr. Patterson said.
The study does provide an extra benefit by suggesting that BMI is not an inferior tool to measure the effects of obesity in the SLE population, Dr. Patterson said. BMI has been criticized as a misleading measurement of obesity. But the BMI and FMI measures produced similar results in this study. “That’s really good news in a way for the practicalities of using this information,” she said.
But FMI may still be a better measurement of obesity in the general population, where BMI may be more likely to be thrown off by high muscle mass.
It may seem obvious that obesity is linked to worse lupus outcomes, but rheumatologist Bryant England, MD, of the University of Nebraska, Omaha, said that this research is noteworthy because it highlights the importance of focusing on obesity in the clinic.
Rheumatologists shouldn’t leave obesity to primary care physicians but instead confront it themselves, said Dr. England, who moderated a discussion of new research at an ACR annual meeting press conference. But he cautioned that prudence is especially important when talking about obesity with lupus patients because they may be sensitive about medication-related weight gain.
Dr. Patterson and the other study authors reported having no relevant disclosures. Dr. England also reported no relevant disclosures. The study was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
SAN DIEGO – A new study offers a double message about the potential impact of obesity on systemic lupus erythematosus (SLE) in women: Excess pounds are linked to a higher risk of patient-reported outcomes such as pain and fatigue, and body mass index may be an appropriate tool to study weight issues in this population.
Researchers found “a strong relationship between body composition and worse outcomes,” Sarah Patterson, MD, a fellow in rheumatology at the University of California, San Francisco, and the lead study author, said at the annual meeting of the American College of Rheumatology.
For the new study, Dr. Patterson and her colleagues analyzed findings from surveys of 148 participants in the Arthritis Body Composition and Disability study. All participants were women with a verified SLE diagnosis.
About two-thirds of the sample were white, 14% were Asian, and 13% were African American. The average age was 48 years, the average disease duration was 16 years, and 45% took glucocorticoids.
Researchers used two measurements of obesity: BMI of 30 kg/m2 or greater and fat mass index (FMI) of 13 kg/m2 or greater.
They calculated FMI with data collected via whole dual x-ray absorptiometry. Of the participants, 32% and 30% met criteria for obesity under FMI and BMI definitions, respectively.
Researchers also collected survey data regarding measurements of disease activity, depressive symptoms, pain and fatigue.
The study authors controlled their results to account for factors such as age, race, and prednisone use. They found that those defined as obese via FMI had more disease activity and depression than did nonobese women: 14.8 versus 11.5, P = .010, on the Systemic Lupus Activity Questionnaire scale, and 19.8 versus 13.1, P = .004, on the Center for Epidemiologic Studies Depression scale.
On two other scales of pain and fatigue, obese patients scored lower – a sign of worse status – compared with nonobese women: 38.7 versus 44.2, P = .004, on the Short Form 36 (SF-36) Health Survey pain subscale and 39.6 versus 45.2, P = .010, on the SF-36 vitality subscale. The researchers reported similar findings when using BMI to assess obesity.
It’s not clear why obesity and lupus may be linked, Dr. Patterson said, though she noted that inflammation is a shared factor. “People with lupus have arthritis and chronic pain, so there may be this vicious feedback cycle with hindrances to be able to live healthy lifestyles,” she added.
The study has limitations, including that the sample is largely white, while lupus is more common among minority women. In addition, the study does not include underweight patients or track patients over time. “It will be important to look at obesity and patient-reported outcomes to determine whether weight loss results in better outcomes,” Dr. Patterson said.
The study does provide an extra benefit by suggesting that BMI is not an inferior tool to measure the effects of obesity in the SLE population, Dr. Patterson said. BMI has been criticized as a misleading measurement of obesity. But the BMI and FMI measures produced similar results in this study. “That’s really good news in a way for the practicalities of using this information,” she said.
But FMI may still be a better measurement of obesity in the general population, where BMI may be more likely to be thrown off by high muscle mass.
It may seem obvious that obesity is linked to worse lupus outcomes, but rheumatologist Bryant England, MD, of the University of Nebraska, Omaha, said that this research is noteworthy because it highlights the importance of focusing on obesity in the clinic.
Rheumatologists shouldn’t leave obesity to primary care physicians but instead confront it themselves, said Dr. England, who moderated a discussion of new research at an ACR annual meeting press conference. But he cautioned that prudence is especially important when talking about obesity with lupus patients because they may be sensitive about medication-related weight gain.
Dr. Patterson and the other study authors reported having no relevant disclosures. Dr. England also reported no relevant disclosures. The study was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
SAN DIEGO – A new study offers a double message about the potential impact of obesity on systemic lupus erythematosus (SLE) in women: Excess pounds are linked to a higher risk of patient-reported outcomes such as pain and fatigue, and body mass index may be an appropriate tool to study weight issues in this population.
Researchers found “a strong relationship between body composition and worse outcomes,” Sarah Patterson, MD, a fellow in rheumatology at the University of California, San Francisco, and the lead study author, said at the annual meeting of the American College of Rheumatology.
For the new study, Dr. Patterson and her colleagues analyzed findings from surveys of 148 participants in the Arthritis Body Composition and Disability study. All participants were women with a verified SLE diagnosis.
About two-thirds of the sample were white, 14% were Asian, and 13% were African American. The average age was 48 years, the average disease duration was 16 years, and 45% took glucocorticoids.
Researchers used two measurements of obesity: BMI of 30 kg/m2 or greater and fat mass index (FMI) of 13 kg/m2 or greater.
They calculated FMI with data collected via whole dual x-ray absorptiometry. Of the participants, 32% and 30% met criteria for obesity under FMI and BMI definitions, respectively.
Researchers also collected survey data regarding measurements of disease activity, depressive symptoms, pain and fatigue.
The study authors controlled their results to account for factors such as age, race, and prednisone use. They found that those defined as obese via FMI had more disease activity and depression than did nonobese women: 14.8 versus 11.5, P = .010, on the Systemic Lupus Activity Questionnaire scale, and 19.8 versus 13.1, P = .004, on the Center for Epidemiologic Studies Depression scale.
On two other scales of pain and fatigue, obese patients scored lower – a sign of worse status – compared with nonobese women: 38.7 versus 44.2, P = .004, on the Short Form 36 (SF-36) Health Survey pain subscale and 39.6 versus 45.2, P = .010, on the SF-36 vitality subscale. The researchers reported similar findings when using BMI to assess obesity.
It’s not clear why obesity and lupus may be linked, Dr. Patterson said, though she noted that inflammation is a shared factor. “People with lupus have arthritis and chronic pain, so there may be this vicious feedback cycle with hindrances to be able to live healthy lifestyles,” she added.
The study has limitations, including that the sample is largely white, while lupus is more common among minority women. In addition, the study does not include underweight patients or track patients over time. “It will be important to look at obesity and patient-reported outcomes to determine whether weight loss results in better outcomes,” Dr. Patterson said.
The study does provide an extra benefit by suggesting that BMI is not an inferior tool to measure the effects of obesity in the SLE population, Dr. Patterson said. BMI has been criticized as a misleading measurement of obesity. But the BMI and FMI measures produced similar results in this study. “That’s really good news in a way for the practicalities of using this information,” she said.
But FMI may still be a better measurement of obesity in the general population, where BMI may be more likely to be thrown off by high muscle mass.
It may seem obvious that obesity is linked to worse lupus outcomes, but rheumatologist Bryant England, MD, of the University of Nebraska, Omaha, said that this research is noteworthy because it highlights the importance of focusing on obesity in the clinic.
Rheumatologists shouldn’t leave obesity to primary care physicians but instead confront it themselves, said Dr. England, who moderated a discussion of new research at an ACR annual meeting press conference. But he cautioned that prudence is especially important when talking about obesity with lupus patients because they may be sensitive about medication-related weight gain.
Dr. Patterson and the other study authors reported having no relevant disclosures. Dr. England also reported no relevant disclosures. The study was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
AT ACR 2017
Key clinical point:
Major finding: Obese women with SLE had more disease activity than did nonobese women (14.8 versus 11.5, P = .010).
Data source: An analysis of 148 SLE patients (65% white, mean age 48, about 31% obese) with obesity measured by body mass index or fat mass index.
Disclosures: The study authors reported having no relevant disclosures. The National Institute of Arthritis and Musculoskeletal and Skin Diseases funded the study.
Gout incidence is intertwined with serum urate, but only up to a point
SAN DIEGO – The incidence of gout is strongly linked to patients’ concentration of serum uric acid over time, but even so, less than half of patients with levels of 10 mg/dL or above develop the condition by 15 years, according to the largest individual person-level analysis to examine the relationship.
The incidence of gout rose from about 1% after 15 years in patients with a serum uric acid (sUA) level of less than 6 mg/dL to almost 49% in those with 10 mg/dL or higher in the study, which implies “a long period of hyperuricemia preceding the onset of clinical gout” and also “supports a role for additional factors in the pathogenesis of gout,” Nicola Dalbeth, MD, said in her presentation of the results at the annual meeting of the American College of Rheumatology.
Dr. Dalbeth and her associates found four studies in a search of PubMed and the Database of Genotype and Phenotype from Jan. 1, 1980, to June 11, 2016, that met the inclusion criteria of containing publicly available participant level data, recorded incident gout (via classification criteria, doctor’s diagnosis, or self report of disease), and had a minimum of 3 years of follow-up. The four studies were the Atherosclerosis Risk in Communities study, the Coronary Artery Risk Development in Young Adults study, the original cohort of the Framingham Heart Study, and the offspring cohort of the Framingham Heart Study, comprising 18,889 individuals who were gout free at the beginning of follow-up, which lasted a mean of 11.2 years.
In all studies combined, the incidence of gout at an sUA level of less than 6 mg/dL steadily increased from 0.21% at 3 years of follow-up to 1.12% at 15 years. In contrast, sUA at 10 mg/dL or higher led to gout in 10.00% at 3 years and in 48.57% at 15 years.
The same general pattern held for the incidence of gout in both men and women, although men had a higher incidence across nearly all sUA concentration ranges.
Female sex provided a 30% reduced risk of gout, and European ethnicity nearly halved the risk for gout, compared with non-Europeans, The risk for gout rose across decades of age, starting at 40-49 years, and also increased significantly for each 1-mg/dL interval of sUA starting at 6 mg/dL.
The study’s conclusions are limited by the use of variable definitions of gout and how it was ascertained. In addition, the study did not analyze other endpoints that are associated with hyperuricemia and may be relevant to discuss in counseling people with elevated sUA levels, such as hypertension, chronic kidney disease, and cardiovascular disease, Dr. Dalbeth said.
Audience member Daniel H. Solomon, MD, of Brigham and Women’s Hospital, Boston, said after the presentation that it is possible that age might not be independent of sUA level because it’s unknown when patients first had hyperuricemia, and so it could just serve as a marker of the duration of the effect of hyperuricemia. “You showed us that the longer you wait for people who have higher [sUA] levels, the more likely you are to observe gout. So it’s probably some mixture of duration [of hyperuricemia] and age,” he said.
Dr. Dalbeth agreed, saying that it could also help to explain why the incidence of gout is lower at younger ages in women but then subsequently becomes higher.
The Health Research Council of New Zealand supported the research. Dr. Dalbeth reported receiving consulting fees, grants, or speaking fees from Takeda, Horizon, Menarini, AstraZeneca, Ardea Biosciences, Pfizer, and Cymabay, but none are related to this study. Two other authors also had several financial disclosures, but none of the others did.
SAN DIEGO – The incidence of gout is strongly linked to patients’ concentration of serum uric acid over time, but even so, less than half of patients with levels of 10 mg/dL or above develop the condition by 15 years, according to the largest individual person-level analysis to examine the relationship.
The incidence of gout rose from about 1% after 15 years in patients with a serum uric acid (sUA) level of less than 6 mg/dL to almost 49% in those with 10 mg/dL or higher in the study, which implies “a long period of hyperuricemia preceding the onset of clinical gout” and also “supports a role for additional factors in the pathogenesis of gout,” Nicola Dalbeth, MD, said in her presentation of the results at the annual meeting of the American College of Rheumatology.
Dr. Dalbeth and her associates found four studies in a search of PubMed and the Database of Genotype and Phenotype from Jan. 1, 1980, to June 11, 2016, that met the inclusion criteria of containing publicly available participant level data, recorded incident gout (via classification criteria, doctor’s diagnosis, or self report of disease), and had a minimum of 3 years of follow-up. The four studies were the Atherosclerosis Risk in Communities study, the Coronary Artery Risk Development in Young Adults study, the original cohort of the Framingham Heart Study, and the offspring cohort of the Framingham Heart Study, comprising 18,889 individuals who were gout free at the beginning of follow-up, which lasted a mean of 11.2 years.
In all studies combined, the incidence of gout at an sUA level of less than 6 mg/dL steadily increased from 0.21% at 3 years of follow-up to 1.12% at 15 years. In contrast, sUA at 10 mg/dL or higher led to gout in 10.00% at 3 years and in 48.57% at 15 years.
The same general pattern held for the incidence of gout in both men and women, although men had a higher incidence across nearly all sUA concentration ranges.
Female sex provided a 30% reduced risk of gout, and European ethnicity nearly halved the risk for gout, compared with non-Europeans, The risk for gout rose across decades of age, starting at 40-49 years, and also increased significantly for each 1-mg/dL interval of sUA starting at 6 mg/dL.
The study’s conclusions are limited by the use of variable definitions of gout and how it was ascertained. In addition, the study did not analyze other endpoints that are associated with hyperuricemia and may be relevant to discuss in counseling people with elevated sUA levels, such as hypertension, chronic kidney disease, and cardiovascular disease, Dr. Dalbeth said.
Audience member Daniel H. Solomon, MD, of Brigham and Women’s Hospital, Boston, said after the presentation that it is possible that age might not be independent of sUA level because it’s unknown when patients first had hyperuricemia, and so it could just serve as a marker of the duration of the effect of hyperuricemia. “You showed us that the longer you wait for people who have higher [sUA] levels, the more likely you are to observe gout. So it’s probably some mixture of duration [of hyperuricemia] and age,” he said.
Dr. Dalbeth agreed, saying that it could also help to explain why the incidence of gout is lower at younger ages in women but then subsequently becomes higher.
The Health Research Council of New Zealand supported the research. Dr. Dalbeth reported receiving consulting fees, grants, or speaking fees from Takeda, Horizon, Menarini, AstraZeneca, Ardea Biosciences, Pfizer, and Cymabay, but none are related to this study. Two other authors also had several financial disclosures, but none of the others did.
SAN DIEGO – The incidence of gout is strongly linked to patients’ concentration of serum uric acid over time, but even so, less than half of patients with levels of 10 mg/dL or above develop the condition by 15 years, according to the largest individual person-level analysis to examine the relationship.
The incidence of gout rose from about 1% after 15 years in patients with a serum uric acid (sUA) level of less than 6 mg/dL to almost 49% in those with 10 mg/dL or higher in the study, which implies “a long period of hyperuricemia preceding the onset of clinical gout” and also “supports a role for additional factors in the pathogenesis of gout,” Nicola Dalbeth, MD, said in her presentation of the results at the annual meeting of the American College of Rheumatology.
Dr. Dalbeth and her associates found four studies in a search of PubMed and the Database of Genotype and Phenotype from Jan. 1, 1980, to June 11, 2016, that met the inclusion criteria of containing publicly available participant level data, recorded incident gout (via classification criteria, doctor’s diagnosis, or self report of disease), and had a minimum of 3 years of follow-up. The four studies were the Atherosclerosis Risk in Communities study, the Coronary Artery Risk Development in Young Adults study, the original cohort of the Framingham Heart Study, and the offspring cohort of the Framingham Heart Study, comprising 18,889 individuals who were gout free at the beginning of follow-up, which lasted a mean of 11.2 years.
In all studies combined, the incidence of gout at an sUA level of less than 6 mg/dL steadily increased from 0.21% at 3 years of follow-up to 1.12% at 15 years. In contrast, sUA at 10 mg/dL or higher led to gout in 10.00% at 3 years and in 48.57% at 15 years.
The same general pattern held for the incidence of gout in both men and women, although men had a higher incidence across nearly all sUA concentration ranges.
Female sex provided a 30% reduced risk of gout, and European ethnicity nearly halved the risk for gout, compared with non-Europeans, The risk for gout rose across decades of age, starting at 40-49 years, and also increased significantly for each 1-mg/dL interval of sUA starting at 6 mg/dL.
The study’s conclusions are limited by the use of variable definitions of gout and how it was ascertained. In addition, the study did not analyze other endpoints that are associated with hyperuricemia and may be relevant to discuss in counseling people with elevated sUA levels, such as hypertension, chronic kidney disease, and cardiovascular disease, Dr. Dalbeth said.
Audience member Daniel H. Solomon, MD, of Brigham and Women’s Hospital, Boston, said after the presentation that it is possible that age might not be independent of sUA level because it’s unknown when patients first had hyperuricemia, and so it could just serve as a marker of the duration of the effect of hyperuricemia. “You showed us that the longer you wait for people who have higher [sUA] levels, the more likely you are to observe gout. So it’s probably some mixture of duration [of hyperuricemia] and age,” he said.
Dr. Dalbeth agreed, saying that it could also help to explain why the incidence of gout is lower at younger ages in women but then subsequently becomes higher.
The Health Research Council of New Zealand supported the research. Dr. Dalbeth reported receiving consulting fees, grants, or speaking fees from Takeda, Horizon, Menarini, AstraZeneca, Ardea Biosciences, Pfizer, and Cymabay, but none are related to this study. Two other authors also had several financial disclosures, but none of the others did.
AT ACR 2017
Key clinical point:
Major finding: The incidence of gout rose to about 1% after 15 years in patients with a serum uric acid (sUA) level of less than 6 mg/dL to almost 49% in those with 10 mg/dL or higher.
Data source: An analysis of 18,889 participants in four longitudinal observational cohort studies for whom baseline serum uric acid levels were available.
Disclosures: The Health Research Council of New Zealand supported the research. Dr. Dalbeth reported receiving consulting fees, grants, or speaking fees from Takeda, Horizon, Menarini, AstraZeneca, Ardea Biosciences, Pfizer, and Cymabay, but none are related to this study. Two other authors also had several financial disclosures, but none of the others did.
ACOG updates guidance on pelvic organ prolapse
Using polypropylene mesh to augment surgical repair of anterior vaginal wall prolapse improves anatomic and some subjective outcomes, compared with native tissue repair, but it also comes with increased morbidity, according to new guidance from the American College of Obstetricians and Gynecologists.
(POP) to incorporate recent systematic review evidence.
When using polypropylene mesh for anterior POP repair, 11% of patients develop mesh erosion, of which 7% require surgical correction, according to the updated practice bulletin (Obstet Gynecol. 2017;130:e234-50).
“Referral to an obstetrician-gynecologist with appropriate training and experience, such as a female pelvic medicine and reconstructive surgery specialist, is recommended for surgical treatment of prolapse mesh complications,” ACOG and AUGS wrote.
The practice bulletin updates the recommendations on mesh based on a recent systematic review and meta-analysis that concluded that biological graft repair and absorbable mesh offered minimal benefits compared with native tissue repair, and did not significantly reduce rates of prolapse awareness or repeat surgery (Cochrane Database Syst Rev. 2016 Nov 30;11:CD004014).
Porcine dermis graft, which was used in most of the studies, did not significantly reduce rates of anterior prolapse recurrence compared with native tissue repair. Use of polypropylene mesh also tends to prolong operating times and causes more blood loss than native tissue anterior repair, and is associated with an elevated combined risk of stress urinary incontinence, mesh erosion, and repeat surgery for prolapse, the review concluded.
“Uterosacral and sacrospinous ligament suspension for apical POP with native tissue are equally effective surgical treatments of POP, with comparable anatomic, functional, and adverse outcomes,” the authors wrote in the practice bulletin.
Neither synthetic mesh nor biologic grafts improve outcomes of transvaginal repair of posterior vaginal wall prolapse, they added. As an alternative to surgery, most women can be successfully fitted with a pessary and clinicians should offer them this option, the practice bulletin stated. In up to 9% of cases, pessaries cause local devascularization or erosion, in which case they should be removed for 2-4 weeks while the patient undergoes local estrogen therapy.
Although POP is common and benign, symptomatic cases undermine quality of life by causing vaginal bulge and pressure and problems voiding, defecating, and during sexual activity. Consequently, about 300,000 women in the United States undergo surgery for POP every year. By 2050, population aging in the United States will lead to about a 50% rise in the number of women with POP, according to the practice bulletin.
Using polypropylene mesh to augment surgical repair of anterior vaginal wall prolapse improves anatomic and some subjective outcomes, compared with native tissue repair, but it also comes with increased morbidity, according to new guidance from the American College of Obstetricians and Gynecologists.
(POP) to incorporate recent systematic review evidence.
When using polypropylene mesh for anterior POP repair, 11% of patients develop mesh erosion, of which 7% require surgical correction, according to the updated practice bulletin (Obstet Gynecol. 2017;130:e234-50).
“Referral to an obstetrician-gynecologist with appropriate training and experience, such as a female pelvic medicine and reconstructive surgery specialist, is recommended for surgical treatment of prolapse mesh complications,” ACOG and AUGS wrote.
The practice bulletin updates the recommendations on mesh based on a recent systematic review and meta-analysis that concluded that biological graft repair and absorbable mesh offered minimal benefits compared with native tissue repair, and did not significantly reduce rates of prolapse awareness or repeat surgery (Cochrane Database Syst Rev. 2016 Nov 30;11:CD004014).
Porcine dermis graft, which was used in most of the studies, did not significantly reduce rates of anterior prolapse recurrence compared with native tissue repair. Use of polypropylene mesh also tends to prolong operating times and causes more blood loss than native tissue anterior repair, and is associated with an elevated combined risk of stress urinary incontinence, mesh erosion, and repeat surgery for prolapse, the review concluded.
“Uterosacral and sacrospinous ligament suspension for apical POP with native tissue are equally effective surgical treatments of POP, with comparable anatomic, functional, and adverse outcomes,” the authors wrote in the practice bulletin.
Neither synthetic mesh nor biologic grafts improve outcomes of transvaginal repair of posterior vaginal wall prolapse, they added. As an alternative to surgery, most women can be successfully fitted with a pessary and clinicians should offer them this option, the practice bulletin stated. In up to 9% of cases, pessaries cause local devascularization or erosion, in which case they should be removed for 2-4 weeks while the patient undergoes local estrogen therapy.
Although POP is common and benign, symptomatic cases undermine quality of life by causing vaginal bulge and pressure and problems voiding, defecating, and during sexual activity. Consequently, about 300,000 women in the United States undergo surgery for POP every year. By 2050, population aging in the United States will lead to about a 50% rise in the number of women with POP, according to the practice bulletin.
Using polypropylene mesh to augment surgical repair of anterior vaginal wall prolapse improves anatomic and some subjective outcomes, compared with native tissue repair, but it also comes with increased morbidity, according to new guidance from the American College of Obstetricians and Gynecologists.
(POP) to incorporate recent systematic review evidence.
When using polypropylene mesh for anterior POP repair, 11% of patients develop mesh erosion, of which 7% require surgical correction, according to the updated practice bulletin (Obstet Gynecol. 2017;130:e234-50).
“Referral to an obstetrician-gynecologist with appropriate training and experience, such as a female pelvic medicine and reconstructive surgery specialist, is recommended for surgical treatment of prolapse mesh complications,” ACOG and AUGS wrote.
The practice bulletin updates the recommendations on mesh based on a recent systematic review and meta-analysis that concluded that biological graft repair and absorbable mesh offered minimal benefits compared with native tissue repair, and did not significantly reduce rates of prolapse awareness or repeat surgery (Cochrane Database Syst Rev. 2016 Nov 30;11:CD004014).
Porcine dermis graft, which was used in most of the studies, did not significantly reduce rates of anterior prolapse recurrence compared with native tissue repair. Use of polypropylene mesh also tends to prolong operating times and causes more blood loss than native tissue anterior repair, and is associated with an elevated combined risk of stress urinary incontinence, mesh erosion, and repeat surgery for prolapse, the review concluded.
“Uterosacral and sacrospinous ligament suspension for apical POP with native tissue are equally effective surgical treatments of POP, with comparable anatomic, functional, and adverse outcomes,” the authors wrote in the practice bulletin.
Neither synthetic mesh nor biologic grafts improve outcomes of transvaginal repair of posterior vaginal wall prolapse, they added. As an alternative to surgery, most women can be successfully fitted with a pessary and clinicians should offer them this option, the practice bulletin stated. In up to 9% of cases, pessaries cause local devascularization or erosion, in which case they should be removed for 2-4 weeks while the patient undergoes local estrogen therapy.
Although POP is common and benign, symptomatic cases undermine quality of life by causing vaginal bulge and pressure and problems voiding, defecating, and during sexual activity. Consequently, about 300,000 women in the United States undergo surgery for POP every year. By 2050, population aging in the United States will lead to about a 50% rise in the number of women with POP, according to the practice bulletin.
FROM OBSTETRICS & GYNECOLOGY
Topical timolol improved chronic leg ulcer healing
The use of topical timolol maleate as a treatment for chronic diabetic and chronic venous ulcers showed increased wound healing compared with controls, according to the results of a prospective observational study of 60 patients.
In the treatment group, 30 patients with chronic leg ulcer (15 diabetic ulcers; 15 venous) received topical application of 0.5% timolol maleate (a beta-blocker) plus conventional antibiotic and wound dressing therapy. In the control group, 30 patients (identical split between diabetic and venous ulcers) were treated with conventional therapy alone, according to a report published in the November issue of the Journal of Vascular Surgery: Venous and Lymphatic Disorders.
The researchers found no significant difference in healing rates due to sex, between smokers and nonsmokers, or alcohol consumers vs. nonconsumers and they saw no major adverse effects due to timolol application (J Vasc Surg: Venous and Lym Dis 2017;5:844-50).
They reported that the limitations of their study included the lack of randomization and a formal power assessment.
“Topical application of timolol maleate is an effective therapeutic option for the treatment of chronic diabetic ulcer and chronic venous ulcer patients to improve ulcer healing by promoting keratinocyte migration,” the researchers concluded.
They reported having no relevant conflicts.
The use of topical timolol maleate as a treatment for chronic diabetic and chronic venous ulcers showed increased wound healing compared with controls, according to the results of a prospective observational study of 60 patients.
In the treatment group, 30 patients with chronic leg ulcer (15 diabetic ulcers; 15 venous) received topical application of 0.5% timolol maleate (a beta-blocker) plus conventional antibiotic and wound dressing therapy. In the control group, 30 patients (identical split between diabetic and venous ulcers) were treated with conventional therapy alone, according to a report published in the November issue of the Journal of Vascular Surgery: Venous and Lymphatic Disorders.
The researchers found no significant difference in healing rates due to sex, between smokers and nonsmokers, or alcohol consumers vs. nonconsumers and they saw no major adverse effects due to timolol application (J Vasc Surg: Venous and Lym Dis 2017;5:844-50).
They reported that the limitations of their study included the lack of randomization and a formal power assessment.
“Topical application of timolol maleate is an effective therapeutic option for the treatment of chronic diabetic ulcer and chronic venous ulcer patients to improve ulcer healing by promoting keratinocyte migration,” the researchers concluded.
They reported having no relevant conflicts.
The use of topical timolol maleate as a treatment for chronic diabetic and chronic venous ulcers showed increased wound healing compared with controls, according to the results of a prospective observational study of 60 patients.
In the treatment group, 30 patients with chronic leg ulcer (15 diabetic ulcers; 15 venous) received topical application of 0.5% timolol maleate (a beta-blocker) plus conventional antibiotic and wound dressing therapy. In the control group, 30 patients (identical split between diabetic and venous ulcers) were treated with conventional therapy alone, according to a report published in the November issue of the Journal of Vascular Surgery: Venous and Lymphatic Disorders.
The researchers found no significant difference in healing rates due to sex, between smokers and nonsmokers, or alcohol consumers vs. nonconsumers and they saw no major adverse effects due to timolol application (J Vasc Surg: Venous and Lym Dis 2017;5:844-50).
They reported that the limitations of their study included the lack of randomization and a formal power assessment.
“Topical application of timolol maleate is an effective therapeutic option for the treatment of chronic diabetic ulcer and chronic venous ulcer patients to improve ulcer healing by promoting keratinocyte migration,” the researchers concluded.
They reported having no relevant conflicts.
FROM THE JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS
Clozapine, olanzapine, risperidone fare best on more outcomes for schizophrenia
Clozapine, olanzapine, and oral and long-acting injectable formulations of risperidone proved superior on more schizophrenia outcomes that did other second-generation antipsychotics, according to a review of the effectiveness of treatments for adults with the illness. Meanwhile, psychosocial interventions were found to be more effective than “usual care” in “improving two or more outcomes.”
Those were some of the findings of Marian S. McDonagh, PharmD, and her associates in the review of hundreds of studies on the effectiveness of first-generation antipsychotics (FGAs), second-generation antipsychotics (SGAs), and psychosocial treatments in outpatient adults with schizophrenia. The researchers, who are affiliated with the Pacific Northwest Evidence-based Practice Center and worked on behalf of the Agency for Healthcare Research and Quality, asked two key questions: What did head-to-head comparisons show in terms of SGAs vs. SGAs and FGAs vs. SGAs, and what did trials show for usual care, which they defined as “elements of medication treatment ... rehabilitation services, and psychotherapy.” They reported the findings in a recent Comparative Effectiveness Review.
Dr. McDonagh and her associates conducted a literature search of the evidence on antipsychotics and found one systematic review (SR) of 138 trials (n = 47,189); 24 trials (n = 6,672) for SGAs vs. SGAs; one SR of 111 trials (n = 118,503); and five trials (n = 1,055) for FGAs vs. SGAs. For psychosocial interventions, they found 13 SRs of 271 trials (n = 25,050) and looked at 27 trials that were not included in the reviews (n = 6,404).
They found no evidence showing newer SGAs as superior to older SGAs on any outcomes. When FGAs were compared with SGAs, the reviewers found that olanzapine, risperidone, ziprasidone, and aripiprazole were similar to haloperidol “on some outcomes of benefit, and were superior on overall adverse events and withdrawal due to adverse events.”
Most of the findings were consistent with previous reviews that compared SGAs, and SGAs vs. FGAs. However, a new finding is that risperidone long-acting injectables and olanzapine are associated with significantly lower withdrawals tied to adverse events than are “most other SGAs.” In addition, Dr. McDonagh and her associates found that clozapine proved superior to other SGAs in preventing self-harm and suicides. Two SGAs, olanzapine and risperidone, were more likely to lead to improved scores on the Positive and Negative Syndrome Scale than was quetiapine.
When the reviewers looked at psychosocial interventions and compared them with usual care, the researchers found results that were consistent with some previous findings and different from others. For family interventions, they found the strongest evidence for interventions that last 7 to 12 months. The team also found that “the number of sessions was more predictive of relapse than was duration of treatment.” Their findings also showed that supported employment led to better outcomes for work over 2 years, compared with usual care. “More patients either gained employment (competitive or any job), had more hours worked, were employed longer, or earned more money than those receiving usual care,” the authors wrote. Also, patients who received assertive community treatment “were more likely to be living independently and to be employed, and they were less likely to be homeless or to discontinue treatment, compared with patients assigned to usual care.”
Dr. McDonagh and her associates said future review research should evaluate the comparative effectiveness of psychosocial interventions and compare them with one another. They also said future research should evaluate other nonpharmacologic, deviced-based treatments, such as electroconvulsive therapy and transcranial magnetic stimulation.
Clozapine, olanzapine, and oral and long-acting injectable formulations of risperidone proved superior on more schizophrenia outcomes that did other second-generation antipsychotics, according to a review of the effectiveness of treatments for adults with the illness. Meanwhile, psychosocial interventions were found to be more effective than “usual care” in “improving two or more outcomes.”
Those were some of the findings of Marian S. McDonagh, PharmD, and her associates in the review of hundreds of studies on the effectiveness of first-generation antipsychotics (FGAs), second-generation antipsychotics (SGAs), and psychosocial treatments in outpatient adults with schizophrenia. The researchers, who are affiliated with the Pacific Northwest Evidence-based Practice Center and worked on behalf of the Agency for Healthcare Research and Quality, asked two key questions: What did head-to-head comparisons show in terms of SGAs vs. SGAs and FGAs vs. SGAs, and what did trials show for usual care, which they defined as “elements of medication treatment ... rehabilitation services, and psychotherapy.” They reported the findings in a recent Comparative Effectiveness Review.
Dr. McDonagh and her associates conducted a literature search of the evidence on antipsychotics and found one systematic review (SR) of 138 trials (n = 47,189); 24 trials (n = 6,672) for SGAs vs. SGAs; one SR of 111 trials (n = 118,503); and five trials (n = 1,055) for FGAs vs. SGAs. For psychosocial interventions, they found 13 SRs of 271 trials (n = 25,050) and looked at 27 trials that were not included in the reviews (n = 6,404).
They found no evidence showing newer SGAs as superior to older SGAs on any outcomes. When FGAs were compared with SGAs, the reviewers found that olanzapine, risperidone, ziprasidone, and aripiprazole were similar to haloperidol “on some outcomes of benefit, and were superior on overall adverse events and withdrawal due to adverse events.”
Most of the findings were consistent with previous reviews that compared SGAs, and SGAs vs. FGAs. However, a new finding is that risperidone long-acting injectables and olanzapine are associated with significantly lower withdrawals tied to adverse events than are “most other SGAs.” In addition, Dr. McDonagh and her associates found that clozapine proved superior to other SGAs in preventing self-harm and suicides. Two SGAs, olanzapine and risperidone, were more likely to lead to improved scores on the Positive and Negative Syndrome Scale than was quetiapine.
When the reviewers looked at psychosocial interventions and compared them with usual care, the researchers found results that were consistent with some previous findings and different from others. For family interventions, they found the strongest evidence for interventions that last 7 to 12 months. The team also found that “the number of sessions was more predictive of relapse than was duration of treatment.” Their findings also showed that supported employment led to better outcomes for work over 2 years, compared with usual care. “More patients either gained employment (competitive or any job), had more hours worked, were employed longer, or earned more money than those receiving usual care,” the authors wrote. Also, patients who received assertive community treatment “were more likely to be living independently and to be employed, and they were less likely to be homeless or to discontinue treatment, compared with patients assigned to usual care.”
Dr. McDonagh and her associates said future review research should evaluate the comparative effectiveness of psychosocial interventions and compare them with one another. They also said future research should evaluate other nonpharmacologic, deviced-based treatments, such as electroconvulsive therapy and transcranial magnetic stimulation.
Clozapine, olanzapine, and oral and long-acting injectable formulations of risperidone proved superior on more schizophrenia outcomes that did other second-generation antipsychotics, according to a review of the effectiveness of treatments for adults with the illness. Meanwhile, psychosocial interventions were found to be more effective than “usual care” in “improving two or more outcomes.”
Those were some of the findings of Marian S. McDonagh, PharmD, and her associates in the review of hundreds of studies on the effectiveness of first-generation antipsychotics (FGAs), second-generation antipsychotics (SGAs), and psychosocial treatments in outpatient adults with schizophrenia. The researchers, who are affiliated with the Pacific Northwest Evidence-based Practice Center and worked on behalf of the Agency for Healthcare Research and Quality, asked two key questions: What did head-to-head comparisons show in terms of SGAs vs. SGAs and FGAs vs. SGAs, and what did trials show for usual care, which they defined as “elements of medication treatment ... rehabilitation services, and psychotherapy.” They reported the findings in a recent Comparative Effectiveness Review.
Dr. McDonagh and her associates conducted a literature search of the evidence on antipsychotics and found one systematic review (SR) of 138 trials (n = 47,189); 24 trials (n = 6,672) for SGAs vs. SGAs; one SR of 111 trials (n = 118,503); and five trials (n = 1,055) for FGAs vs. SGAs. For psychosocial interventions, they found 13 SRs of 271 trials (n = 25,050) and looked at 27 trials that were not included in the reviews (n = 6,404).
They found no evidence showing newer SGAs as superior to older SGAs on any outcomes. When FGAs were compared with SGAs, the reviewers found that olanzapine, risperidone, ziprasidone, and aripiprazole were similar to haloperidol “on some outcomes of benefit, and were superior on overall adverse events and withdrawal due to adverse events.”
Most of the findings were consistent with previous reviews that compared SGAs, and SGAs vs. FGAs. However, a new finding is that risperidone long-acting injectables and olanzapine are associated with significantly lower withdrawals tied to adverse events than are “most other SGAs.” In addition, Dr. McDonagh and her associates found that clozapine proved superior to other SGAs in preventing self-harm and suicides. Two SGAs, olanzapine and risperidone, were more likely to lead to improved scores on the Positive and Negative Syndrome Scale than was quetiapine.
When the reviewers looked at psychosocial interventions and compared them with usual care, the researchers found results that were consistent with some previous findings and different from others. For family interventions, they found the strongest evidence for interventions that last 7 to 12 months. The team also found that “the number of sessions was more predictive of relapse than was duration of treatment.” Their findings also showed that supported employment led to better outcomes for work over 2 years, compared with usual care. “More patients either gained employment (competitive or any job), had more hours worked, were employed longer, or earned more money than those receiving usual care,” the authors wrote. Also, patients who received assertive community treatment “were more likely to be living independently and to be employed, and they were less likely to be homeless or to discontinue treatment, compared with patients assigned to usual care.”
Dr. McDonagh and her associates said future review research should evaluate the comparative effectiveness of psychosocial interventions and compare them with one another. They also said future research should evaluate other nonpharmacologic, deviced-based treatments, such as electroconvulsive therapy and transcranial magnetic stimulation.
Key clinical point:
Major finding: “Olanzapine, risperidone, ziprasidone, and aripiprazole were similar to haloperidol on some outcomes of benefit.”
Data source: One systematic review (SR) of 138 trials (n = 47,189) and 24 trials (n = 6,672) for SGAs vs. SGAs; one SR of 111 trials (n = 118,503) and 5 trials (n = 1,055) for first-generation antipsychotics (FGAs) vs. SGAs; 13 SRs of 271 trials (n = 25,050); and 27 trials (n = 6,404) for psychosocial interventions.
Disclosures: Dr. McDonagh is affiliated with the Pacific Northwest Evidence-based Practice Center, and worked on behalf of the Agency for Healthcare Research and Quality.
Chlamydia infection: Common, and consequential to women's health
SHORT TAKES
Cardiac testing of Emergency Department patients with chest pain leads to increased revascularization without reduction in admissions for acute MI
Retrospective cohort study of ED patients presenting with chest pain but without evidence of ischemia, shows that non-invasive cardiac testing of these patients lead to more coronary angiograms (92.1 per 1,000 patients) within 30 days, but no significant reduction of admissions for acute MI at 1 year (remained 7.8 per 1,000 patients tested).
Citation: Sandhu AT, Heidenreich PA, Bhattacharya J, Bundorf MK. Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain. JAMA Intern Med. Published online 2017 June 26. doi: 10.1001/jamainternmed.2017.2432.
Facebook star ratings and “likes” correlate with patient satisfaction scores
In a cross-sectional analysis of 136 New York State hospitals, the study found increased Facebook star ratings correlated (P less than .003) with overall increased HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) score (21/23 HCAHPS). HCAHPS measures also positively correlated (P less than .05) with adjusted number of “likes” on Facebook but to a lesser degree (3/21 HCAHPS). Neither star ratings nor number of “likes” correlate with Medicare spending or 30-day all-cause readmission rate.
Citation: Campbell L, Yue L. Are Facebook user ratings associated with hospital cost, quality, and patient satisfaction? BMJ Qual Saf. 2017 July 19. doi:10.1136/bmjqs-2016-006291.
Candida auris remains an ongoing health care facility transmission risk
Multidrug-resistant fungus Candida auris is an emerging pathogen and a transmission risk across health care facilities. From June 2016 through May 2017, 77 cases of clinical infection have been reported to the Centers for Disease Control and Prevention from seven states, though most (90%) cases are clustered in the New York City metropolitan area. Most patients had multiple medical conditions and extensive health care facility exposure. The CDC recommends contact precautions, private rooming, daily and terminal cleaning with disinfectant active against Clostridium difficile spores, and notification to receiving health care facilities about C. auris colonization or infection on transfer to help reduce the spread of C. auris throughout the United States.
Citation: Tsay S, Welsh RM, Adams EH, et al. Notes from the Field: Ongoing Transmission of Candida auris in Health Care Facilities – United States, June 2016–May 2017. MMWR Morb Mortal Wkly Rep. 2017;66:51415.
Cardiac testing of Emergency Department patients with chest pain leads to increased revascularization without reduction in admissions for acute MI
Retrospective cohort study of ED patients presenting with chest pain but without evidence of ischemia, shows that non-invasive cardiac testing of these patients lead to more coronary angiograms (92.1 per 1,000 patients) within 30 days, but no significant reduction of admissions for acute MI at 1 year (remained 7.8 per 1,000 patients tested).
Citation: Sandhu AT, Heidenreich PA, Bhattacharya J, Bundorf MK. Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain. JAMA Intern Med. Published online 2017 June 26. doi: 10.1001/jamainternmed.2017.2432.
Facebook star ratings and “likes” correlate with patient satisfaction scores
In a cross-sectional analysis of 136 New York State hospitals, the study found increased Facebook star ratings correlated (P less than .003) with overall increased HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) score (21/23 HCAHPS). HCAHPS measures also positively correlated (P less than .05) with adjusted number of “likes” on Facebook but to a lesser degree (3/21 HCAHPS). Neither star ratings nor number of “likes” correlate with Medicare spending or 30-day all-cause readmission rate.
Citation: Campbell L, Yue L. Are Facebook user ratings associated with hospital cost, quality, and patient satisfaction? BMJ Qual Saf. 2017 July 19. doi:10.1136/bmjqs-2016-006291.
Candida auris remains an ongoing health care facility transmission risk
Multidrug-resistant fungus Candida auris is an emerging pathogen and a transmission risk across health care facilities. From June 2016 through May 2017, 77 cases of clinical infection have been reported to the Centers for Disease Control and Prevention from seven states, though most (90%) cases are clustered in the New York City metropolitan area. Most patients had multiple medical conditions and extensive health care facility exposure. The CDC recommends contact precautions, private rooming, daily and terminal cleaning with disinfectant active against Clostridium difficile spores, and notification to receiving health care facilities about C. auris colonization or infection on transfer to help reduce the spread of C. auris throughout the United States.
Citation: Tsay S, Welsh RM, Adams EH, et al. Notes from the Field: Ongoing Transmission of Candida auris in Health Care Facilities – United States, June 2016–May 2017. MMWR Morb Mortal Wkly Rep. 2017;66:51415.
Cardiac testing of Emergency Department patients with chest pain leads to increased revascularization without reduction in admissions for acute MI
Retrospective cohort study of ED patients presenting with chest pain but without evidence of ischemia, shows that non-invasive cardiac testing of these patients lead to more coronary angiograms (92.1 per 1,000 patients) within 30 days, but no significant reduction of admissions for acute MI at 1 year (remained 7.8 per 1,000 patients tested).
Citation: Sandhu AT, Heidenreich PA, Bhattacharya J, Bundorf MK. Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain. JAMA Intern Med. Published online 2017 June 26. doi: 10.1001/jamainternmed.2017.2432.
Facebook star ratings and “likes” correlate with patient satisfaction scores
In a cross-sectional analysis of 136 New York State hospitals, the study found increased Facebook star ratings correlated (P less than .003) with overall increased HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) score (21/23 HCAHPS). HCAHPS measures also positively correlated (P less than .05) with adjusted number of “likes” on Facebook but to a lesser degree (3/21 HCAHPS). Neither star ratings nor number of “likes” correlate with Medicare spending or 30-day all-cause readmission rate.
Citation: Campbell L, Yue L. Are Facebook user ratings associated with hospital cost, quality, and patient satisfaction? BMJ Qual Saf. 2017 July 19. doi:10.1136/bmjqs-2016-006291.
Candida auris remains an ongoing health care facility transmission risk
Multidrug-resistant fungus Candida auris is an emerging pathogen and a transmission risk across health care facilities. From June 2016 through May 2017, 77 cases of clinical infection have been reported to the Centers for Disease Control and Prevention from seven states, though most (90%) cases are clustered in the New York City metropolitan area. Most patients had multiple medical conditions and extensive health care facility exposure. The CDC recommends contact precautions, private rooming, daily and terminal cleaning with disinfectant active against Clostridium difficile spores, and notification to receiving health care facilities about C. auris colonization or infection on transfer to help reduce the spread of C. auris throughout the United States.
Citation: Tsay S, Welsh RM, Adams EH, et al. Notes from the Field: Ongoing Transmission of Candida auris in Health Care Facilities – United States, June 2016–May 2017. MMWR Morb Mortal Wkly Rep. 2017;66:51415.
Don’t let GDM history limit contraception choices
WASHINGTON – Women with a history of gestational diabetes can use any contraceptive method safely, and those with uncomplicated pregestational diabetes can also consider all methods, said Anne Burke, MD, director of the family planning division at Johns Hopkins University, Baltimore.
“The real cautions, and some red lights,” apply to those with vascular sequelae, diabetes of 20 years’ duration or more, and patients with other vascular disease in addition to diabetes, she said at the biennial meeting of the Diabetes in Pregnancy Study Group of North America.
“The contraception options for women with diabetes aren’t necessarily terribly limited compared to the options for other women,” Dr. Burke said. “And the big take home is that, across the board, .”
The U.S. Medical Eligibility Criteria for Contraceptive Use issued by the Centers for Disease Control and Prevention assign a 1-4 rating for each method for women with certain characteristics or medical conditions. Category 1 indicates no restrictions, and category 2 means that the advantages generally outweigh theoretical or proven risks. Category 3 indicates that such risks usually outweigh the advantages, and category 4 means there is an unacceptable risk.
The assignment to category 2 instead of category 1 can reflect either limitations in the overall amount of data available or the lack of strong randomized studies “whereas the data [otherwise] seem to support safety,” Dr. Burke said. “And sometimes, it relates to most studies saying one thing and another being a little inconsistent.”
Uncomplicated pregestational diabetes
This is important to understand because all the methods for women with uncomplicated pregestational diabetes (no evidence of vascular disease or end-organ damage) are classified as category 2, except for the copper IUD and emergency contraception, which are in category 1. The document distinguishes between insulin-dependent and non–insulin-dependent diabetes, but the recommendations do not differ between the two categories, she said.
Progestin-only contraceptives appear to have little effect on short- or long-term diabetes control, hemostatic markers, or the lipid profile in women with uncomplicated diabetes. Combined hormonal contraception appears to have no effect on long-term diabetes control or progression to retinopathy; there may be changes in the lipid profile and hemostatic markers, but “mostly within normal values, and in some cases, in a favorable direction,” said Dr. Burke of the department of gynecology and obstetrics at the university.
GDM history
In women who have had gestational diabetes, all methods are in category 1 of the Medical Eligibility Criteria (MEC). While “there have been a couple of question marks” with progestin-only contraceptives and the later development of diabetes, “it seems that there’s really not an increased risk,” she said. Nor does there seem to be an increased risk of developing later diabetes with combined hormonal contraception.
In general, the data backing the MEC come from a limited number of studies, and “few that are rigorously done,” she said. “So the recommendations reflect consensus [that is] based on the best available information.”
Severe or long-standing disease
Data are especially limited for women with more severe and/or long-standing disease, as these women have been excluded from studies. There is enough knowledge, however, to make the hypoestrogenic effects of the depot medroxyprogesterone acetate (DMPA) injectable (Depo-Provera) concerning. “It has a pretty hefty dose of a particular type of progestin that significantly suppresses the hypothalamic-pituitary-ovarian axis – more than other progestin-only methods,” she said. “And we may see some unfavorable lipid changes and changes in carbohydrate metabolism.”
The effects of the DMPA injectable, which is in category 3 for these women, may persist for several months – or longer – after discontinuation, Dr. Burke said. The levonorgestrel IUD, on the other hand, has little effect on diabetes control, hemostatic markers, or lipids; it is in category 2 for these women.
A recently published database analysis found that diabetic users of the DMPA injectable had a hazard ratio for venous thromboembolism of 4.6, compared with IUD users, Dr. Burke said. The study included patients with type 1 and type 2 diabetes (Diabetes Care 2017;40:233-8).
Combined hormonal contraception is assigned to categories 3 and 4 for women with complicated or long-standing diabetes, in part because of thrombosis risk, which “as we know, is slightly elevated even for healthy women,” Dr. Burke said. “There are still quite a few methods that are safe to use without reservation, so here is where we start to move away from combined hormonal methods.”
In addition to the Medical Eligibility Criteria, the CDC has another document, the U.S. Selected Practice Recommendations for Contraceptive Use, also last updated in 2016, which offers “helpful” advice on precontraception tests to perform, timing after pregnancy for starting contraceptive methods, and other issues, Dr. Burke said.
Dr. Burke reported receiving research funding from Bayer, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Ibis Reproductive Health.
WASHINGTON – Women with a history of gestational diabetes can use any contraceptive method safely, and those with uncomplicated pregestational diabetes can also consider all methods, said Anne Burke, MD, director of the family planning division at Johns Hopkins University, Baltimore.
“The real cautions, and some red lights,” apply to those with vascular sequelae, diabetes of 20 years’ duration or more, and patients with other vascular disease in addition to diabetes, she said at the biennial meeting of the Diabetes in Pregnancy Study Group of North America.
“The contraception options for women with diabetes aren’t necessarily terribly limited compared to the options for other women,” Dr. Burke said. “And the big take home is that, across the board, .”
The U.S. Medical Eligibility Criteria for Contraceptive Use issued by the Centers for Disease Control and Prevention assign a 1-4 rating for each method for women with certain characteristics or medical conditions. Category 1 indicates no restrictions, and category 2 means that the advantages generally outweigh theoretical or proven risks. Category 3 indicates that such risks usually outweigh the advantages, and category 4 means there is an unacceptable risk.
The assignment to category 2 instead of category 1 can reflect either limitations in the overall amount of data available or the lack of strong randomized studies “whereas the data [otherwise] seem to support safety,” Dr. Burke said. “And sometimes, it relates to most studies saying one thing and another being a little inconsistent.”
Uncomplicated pregestational diabetes
This is important to understand because all the methods for women with uncomplicated pregestational diabetes (no evidence of vascular disease or end-organ damage) are classified as category 2, except for the copper IUD and emergency contraception, which are in category 1. The document distinguishes between insulin-dependent and non–insulin-dependent diabetes, but the recommendations do not differ between the two categories, she said.
Progestin-only contraceptives appear to have little effect on short- or long-term diabetes control, hemostatic markers, or the lipid profile in women with uncomplicated diabetes. Combined hormonal contraception appears to have no effect on long-term diabetes control or progression to retinopathy; there may be changes in the lipid profile and hemostatic markers, but “mostly within normal values, and in some cases, in a favorable direction,” said Dr. Burke of the department of gynecology and obstetrics at the university.
GDM history
In women who have had gestational diabetes, all methods are in category 1 of the Medical Eligibility Criteria (MEC). While “there have been a couple of question marks” with progestin-only contraceptives and the later development of diabetes, “it seems that there’s really not an increased risk,” she said. Nor does there seem to be an increased risk of developing later diabetes with combined hormonal contraception.
In general, the data backing the MEC come from a limited number of studies, and “few that are rigorously done,” she said. “So the recommendations reflect consensus [that is] based on the best available information.”
Severe or long-standing disease
Data are especially limited for women with more severe and/or long-standing disease, as these women have been excluded from studies. There is enough knowledge, however, to make the hypoestrogenic effects of the depot medroxyprogesterone acetate (DMPA) injectable (Depo-Provera) concerning. “It has a pretty hefty dose of a particular type of progestin that significantly suppresses the hypothalamic-pituitary-ovarian axis – more than other progestin-only methods,” she said. “And we may see some unfavorable lipid changes and changes in carbohydrate metabolism.”
The effects of the DMPA injectable, which is in category 3 for these women, may persist for several months – or longer – after discontinuation, Dr. Burke said. The levonorgestrel IUD, on the other hand, has little effect on diabetes control, hemostatic markers, or lipids; it is in category 2 for these women.
A recently published database analysis found that diabetic users of the DMPA injectable had a hazard ratio for venous thromboembolism of 4.6, compared with IUD users, Dr. Burke said. The study included patients with type 1 and type 2 diabetes (Diabetes Care 2017;40:233-8).
Combined hormonal contraception is assigned to categories 3 and 4 for women with complicated or long-standing diabetes, in part because of thrombosis risk, which “as we know, is slightly elevated even for healthy women,” Dr. Burke said. “There are still quite a few methods that are safe to use without reservation, so here is where we start to move away from combined hormonal methods.”
In addition to the Medical Eligibility Criteria, the CDC has another document, the U.S. Selected Practice Recommendations for Contraceptive Use, also last updated in 2016, which offers “helpful” advice on precontraception tests to perform, timing after pregnancy for starting contraceptive methods, and other issues, Dr. Burke said.
Dr. Burke reported receiving research funding from Bayer, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Ibis Reproductive Health.
WASHINGTON – Women with a history of gestational diabetes can use any contraceptive method safely, and those with uncomplicated pregestational diabetes can also consider all methods, said Anne Burke, MD, director of the family planning division at Johns Hopkins University, Baltimore.
“The real cautions, and some red lights,” apply to those with vascular sequelae, diabetes of 20 years’ duration or more, and patients with other vascular disease in addition to diabetes, she said at the biennial meeting of the Diabetes in Pregnancy Study Group of North America.
“The contraception options for women with diabetes aren’t necessarily terribly limited compared to the options for other women,” Dr. Burke said. “And the big take home is that, across the board, .”
The U.S. Medical Eligibility Criteria for Contraceptive Use issued by the Centers for Disease Control and Prevention assign a 1-4 rating for each method for women with certain characteristics or medical conditions. Category 1 indicates no restrictions, and category 2 means that the advantages generally outweigh theoretical or proven risks. Category 3 indicates that such risks usually outweigh the advantages, and category 4 means there is an unacceptable risk.
The assignment to category 2 instead of category 1 can reflect either limitations in the overall amount of data available or the lack of strong randomized studies “whereas the data [otherwise] seem to support safety,” Dr. Burke said. “And sometimes, it relates to most studies saying one thing and another being a little inconsistent.”
Uncomplicated pregestational diabetes
This is important to understand because all the methods for women with uncomplicated pregestational diabetes (no evidence of vascular disease or end-organ damage) are classified as category 2, except for the copper IUD and emergency contraception, which are in category 1. The document distinguishes between insulin-dependent and non–insulin-dependent diabetes, but the recommendations do not differ between the two categories, she said.
Progestin-only contraceptives appear to have little effect on short- or long-term diabetes control, hemostatic markers, or the lipid profile in women with uncomplicated diabetes. Combined hormonal contraception appears to have no effect on long-term diabetes control or progression to retinopathy; there may be changes in the lipid profile and hemostatic markers, but “mostly within normal values, and in some cases, in a favorable direction,” said Dr. Burke of the department of gynecology and obstetrics at the university.
GDM history
In women who have had gestational diabetes, all methods are in category 1 of the Medical Eligibility Criteria (MEC). While “there have been a couple of question marks” with progestin-only contraceptives and the later development of diabetes, “it seems that there’s really not an increased risk,” she said. Nor does there seem to be an increased risk of developing later diabetes with combined hormonal contraception.
In general, the data backing the MEC come from a limited number of studies, and “few that are rigorously done,” she said. “So the recommendations reflect consensus [that is] based on the best available information.”
Severe or long-standing disease
Data are especially limited for women with more severe and/or long-standing disease, as these women have been excluded from studies. There is enough knowledge, however, to make the hypoestrogenic effects of the depot medroxyprogesterone acetate (DMPA) injectable (Depo-Provera) concerning. “It has a pretty hefty dose of a particular type of progestin that significantly suppresses the hypothalamic-pituitary-ovarian axis – more than other progestin-only methods,” she said. “And we may see some unfavorable lipid changes and changes in carbohydrate metabolism.”
The effects of the DMPA injectable, which is in category 3 for these women, may persist for several months – or longer – after discontinuation, Dr. Burke said. The levonorgestrel IUD, on the other hand, has little effect on diabetes control, hemostatic markers, or lipids; it is in category 2 for these women.
A recently published database analysis found that diabetic users of the DMPA injectable had a hazard ratio for venous thromboembolism of 4.6, compared with IUD users, Dr. Burke said. The study included patients with type 1 and type 2 diabetes (Diabetes Care 2017;40:233-8).
Combined hormonal contraception is assigned to categories 3 and 4 for women with complicated or long-standing diabetes, in part because of thrombosis risk, which “as we know, is slightly elevated even for healthy women,” Dr. Burke said. “There are still quite a few methods that are safe to use without reservation, so here is where we start to move away from combined hormonal methods.”
In addition to the Medical Eligibility Criteria, the CDC has another document, the U.S. Selected Practice Recommendations for Contraceptive Use, also last updated in 2016, which offers “helpful” advice on precontraception tests to perform, timing after pregnancy for starting contraceptive methods, and other issues, Dr. Burke said.
Dr. Burke reported receiving research funding from Bayer, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Ibis Reproductive Health.
EXPERT ANALYSIS FROM DPSG-NA 2017
Infections increase risk of idiopathic VTE
Infection and infection sites have been found to be associated with a significant increased risk of venous thromboembolism, according to results of a population-based, matched, case-control analysis of medical records covering the 13-year period 1988-2000.
Dr. Kevin P. Cohoon and his colleagues at the Mayo Clinic, Rochester, Minn., developed models using conditional logistic regression analysis to stratify the risk associated with specific infections and infection sites.
Five hundred thirteen (39.4%) cases and 189 (12.7%) controls had an infection within the previous 92 days (odds ratio, 4.5; P less than .0001). Known VTE risk factors and potentially confounding variables were used in the adjusted univariate and multivariate models, as reported in the American Journal of Medicine (2017. doi: 10.1016/j.amjmed.2017.09.015).
Dr. Cohoon and his colleagues reported that univariate analysis showed “most infection sites were strongly associated with venous thromboembolism” and the adjusted multivariate model resulted in 2.4-fold (P less than .0001) higher odds for VTE incidence, compared with uninfected controls.
Adjusted multivariate analysis ranked the odds of VTE according to specific infections. Dr. Cohoon and his colleagues reported that this modeling showed that the “highest magnitude of risk, compared with no infection, was imparted by intra-abdominal infection (OR, 18) followed by oral infection (OR, 12), systematic blood stream infection (OR, 11), lower respiratory infection such as pneumonia (OR, 3.6), and symptomatic urinary tract infection (OR, 2.2).”
The researchers concluded that their findings may allow for further refinement of inpatient VTE risk-prediction models such as the Padua prediction score and “future studies are required to assess the utility of venous thromboembolism prophylaxis among outpatients with high venous thromboembolism risk infections.”
The authors reported that they had no conflicts of interest.
Infection and infection sites have been found to be associated with a significant increased risk of venous thromboembolism, according to results of a population-based, matched, case-control analysis of medical records covering the 13-year period 1988-2000.
Dr. Kevin P. Cohoon and his colleagues at the Mayo Clinic, Rochester, Minn., developed models using conditional logistic regression analysis to stratify the risk associated with specific infections and infection sites.
Five hundred thirteen (39.4%) cases and 189 (12.7%) controls had an infection within the previous 92 days (odds ratio, 4.5; P less than .0001). Known VTE risk factors and potentially confounding variables were used in the adjusted univariate and multivariate models, as reported in the American Journal of Medicine (2017. doi: 10.1016/j.amjmed.2017.09.015).
Dr. Cohoon and his colleagues reported that univariate analysis showed “most infection sites were strongly associated with venous thromboembolism” and the adjusted multivariate model resulted in 2.4-fold (P less than .0001) higher odds for VTE incidence, compared with uninfected controls.
Adjusted multivariate analysis ranked the odds of VTE according to specific infections. Dr. Cohoon and his colleagues reported that this modeling showed that the “highest magnitude of risk, compared with no infection, was imparted by intra-abdominal infection (OR, 18) followed by oral infection (OR, 12), systematic blood stream infection (OR, 11), lower respiratory infection such as pneumonia (OR, 3.6), and symptomatic urinary tract infection (OR, 2.2).”
The researchers concluded that their findings may allow for further refinement of inpatient VTE risk-prediction models such as the Padua prediction score and “future studies are required to assess the utility of venous thromboembolism prophylaxis among outpatients with high venous thromboembolism risk infections.”
The authors reported that they had no conflicts of interest.
Infection and infection sites have been found to be associated with a significant increased risk of venous thromboembolism, according to results of a population-based, matched, case-control analysis of medical records covering the 13-year period 1988-2000.
Dr. Kevin P. Cohoon and his colleagues at the Mayo Clinic, Rochester, Minn., developed models using conditional logistic regression analysis to stratify the risk associated with specific infections and infection sites.
Five hundred thirteen (39.4%) cases and 189 (12.7%) controls had an infection within the previous 92 days (odds ratio, 4.5; P less than .0001). Known VTE risk factors and potentially confounding variables were used in the adjusted univariate and multivariate models, as reported in the American Journal of Medicine (2017. doi: 10.1016/j.amjmed.2017.09.015).
Dr. Cohoon and his colleagues reported that univariate analysis showed “most infection sites were strongly associated with venous thromboembolism” and the adjusted multivariate model resulted in 2.4-fold (P less than .0001) higher odds for VTE incidence, compared with uninfected controls.
Adjusted multivariate analysis ranked the odds of VTE according to specific infections. Dr. Cohoon and his colleagues reported that this modeling showed that the “highest magnitude of risk, compared with no infection, was imparted by intra-abdominal infection (OR, 18) followed by oral infection (OR, 12), systematic blood stream infection (OR, 11), lower respiratory infection such as pneumonia (OR, 3.6), and symptomatic urinary tract infection (OR, 2.2).”
The researchers concluded that their findings may allow for further refinement of inpatient VTE risk-prediction models such as the Padua prediction score and “future studies are required to assess the utility of venous thromboembolism prophylaxis among outpatients with high venous thromboembolism risk infections.”
The authors reported that they had no conflicts of interest.
FROM THE AMERICAN JOURNAL OF MEDICINE
Key clinical point:
Major finding: A significantly greater number of patients with infections developed VTE as compared with uninfected controls (OR, 4.5; P less than .0001).
Data source: Study was a retrospective database analysis of 1,303 VTE patients and 1,494 paired controls.
Disclosures: The authors reported that they had no conflicts of interest.