Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

Despite a 30% decline in heart disease mortality from 2001 to 2011, heart disease prevalence is on the rise, responsible for 1 of every 3 deaths in the U.S.¹ Cardiac rehabilitation (CR) is an evidence-based, secondary prevention strategy that has been proven effective in preventing future cardiovascular events and decreasing heart disease mortality.^2-4 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is the leading authority on CR and provides guidelines for CR programs. The AACVPR and the American Heart Association (AHA) published core components for CR programs deemed essential for all CR/secondary prevention programs, including evaluations, interventions, and expected outcomes.⁵ These core components are aimed at promoting a healthy lifestyle and increasing function and well-being while reducing injury, death, and the reoccurrence of disease.⁶

In a meta-analysis of 47 trials with 10,794 participants, CR reduced cardiovascular disease (CVD) mortality and hospital admissions by 26% and 18%, respectively.² Performance measures (Class 1, Level A) recommend the following types of patients should be referred from the inpatient setting: “all patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina, or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation.”⁷ However, despite overwhelming evidence and widespread endorsement (Class 1, Level A), service utilization, uptake, and patient adherence to CR programs remain suboptimal. In a U.S. study of claims from > 250,000 Medicare beneficiaries, < 30% of eligible patients participated in some type of CR program.⁸ In response to poor participation, a presidential advisory from the AHA in 2011 stated, “the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.”⁹

This treatment gap is echoed throughout the VHA. Schopfer and colleagues found that only 28% of the 124 VAMCs that provide inpatient care also offer a supervised, facility-based CR program.¹⁰ Furthermore, only 10.3% of eligible veterans participated in at least 1 CR session (VA or non-VA). On a systemic level, low patient referral rates and inadequate third-party reimbursement were the most common barriers to participation in CR.^10,11 On a patient level, distance was by far the largest barrier to veterans receiving CR. Currently, 74% of the 9.3 million VA-enrolled veterans live at least 1 hour by car from a VA facility that offers CR.⁹ Within some regions of the VHA, there are no VA facility-based CR programs. For example, VISN 21 has no facility-based CR programs. At the same time, referral of eligible veterans to facility-based CR outside the VA remains low. Prior to April 2013, < 2% of qualified patients residing in VISN 21 were being referred to Non-VA CR programs, making it the VISN with the lowest participation rate for CR.

One potential solution that addresses both systemic and patient barriers to CR utilization is home-based CR. Veterans within the wide geographic area of VISN 21 are referred to San Francisco VAMC (SFVAMC) for ischemic heart disease, cardiovascular revascularization, and cardiac valve surgeries. In 2013, a comprehensive home-based CR program named The Healthy Heart Program was developed based on a successful evidence-based CVD secondary prevention program. The Healthy Heart Program is designed to be a physician-directed, nurse case-managed, customized exercise and lifestyle program that provides a safe and convenient way for veterans to participate in CR. Exercise and disease self-management education are the cornerstones of the Healthy Heart Program. The program’s multidisciplinary team includes physicians, nurses, a dietician, an exercise physiologist, and a health behavior psychologist.

An Alternative Approach

DeBusk and colleagues demonstrated that a physician-directed, nurse-managed, home-based cardiac risk-factor modification program improved smoking cessation, reduced low-density lipoprotein cholesterol, and increased exercise capacity compared with usual care.¹² The results of this study helped pave the way for one of the first CR programs with a strong home-based element. The MULTIFIT program was jointly developed by the Stanford Coronary Rehabilitation Program and Kaiser Permanente (Oakland, CA) in 1995. MULTIFIT is a nurse-based care model for CVD prevention.

Further research that evaluated other home-based programs showed similar promise. A Cochrane review demonstrated that home- and facility-based CR programs were equal in cardiac risk factor reduction, reduced hospital readmissions and mortality rates, and improved quality of life (QOL).¹³ Cost-effectiveness also seemed to be similar in both home- and hospital-based CR programs.¹⁴ A meta-analysis of telephone support interventions for coronary artery disease demonstrated a 38% decrease in rehospitalizations and a 32% increase in the number of participants who stopped smoking.¹⁵ In addition, patients with time constraints (eg, work, family obligations) preferred home-based CR programs for the convenience and accessibility that these programs offer.¹⁶ Home-based CR programs may have better completion rates compared with that of facility-based programs.¹⁷ The American College of Cardiology and AHA updated guidelines for CR include home-based CR as a substitute for facility-based CR for low-risk patients (Class 1, Level A).¹⁸

Referrals

To address the problems with referrals that plague other CR programs, staff of the Healthy Heart Program worked closely with interventional cardiology and the cardiothoracic team, including the clinical informatics coordinators, to develop an automatic referral system for CR evaluation. Consults for CR evaluation were embedded within the post-CABG and PCI order sets in the electronic health record. Laboratory troponin alerts were created to alert CR staff of patients with elevated troponins, which identified patients admitted for acute MI. Healthy Heart Program staff members received the referrals once a patient was admitted to the unit following their heart procedure. Early referrals for evaluation allowed staff to begin a chart review of all eligible patients and to follow the patient’s course of recovery. Most consults were generated during hospitalization for one of the indications; however, a minority of consults come from both the cardiology and primary care clinics.

Three Phases of CR

The AACVPR describes the challenges and opportunities found throughout the CR continuum.⁵ Over the past several decades, the continuum of care was more program centered and service utilization was more isolated. Today, CR is viewed as more process oriented and coordinates care across many professionals and services. Phase 1 inpatient CR begins in the hospital and is a shared responsibility between several services. Shortened hospital stays have led to innovative solutions for early ambulation, risk factor education, and discharge planning, including enrollment into phase 2 CR. Phase 2, also known as early outpatient, should begin within 1 to 2 weeks postevent in healthier patients and can last between 6 and 12 weeks postdischarge. Phase 3 (maintenance phase) should begin immediately at the conclusion of phase 2.

Phase 1

Prior to the advent of the Healthy Heart Program, secondary prevention education was not done at the bedside for SFVAMC patients following cardiac revascularization. The AACVPR recommends patient assessment, mobilization, risk-factor identification and education, and facilitation into outpatient CR as essential components of phase 1 CR.⁵ The Healthy Heart Program clinician initiates phase 1 CR by examining cardiac risk factor management for all referred patients. Physical and cardiac risk factor assessments are accomplished by completing a detailed chart review and interview with the patient. During this interview with the patient, the clinician evaluates cognitive function and readiness to learn. Staff will interview the patient further to assess the overall patient needs, including availability of social support, resources to maintain optimal health, and the need for secondary preventive education. For the PCI patient, the interview may occur in the hours following their procedure; for the surgical patient, this bedside visit typically occurs postoperative day 3 or 4.

A standardized cardiac risk factor evaluation tool was designed, which also serves as an education form to help guide the conversation on risk factor management. The interactive, patient-centered form includes opportunities to review risk, discuss current laboratory values (eg, lipids and hemoglobin A_1c), and establish individualized goals based on patient preference and recommended guidelines. Healthy Heart Program staff assist the patient in formulating achievable goals using the SMART (specific, measurable, attainable, realistic, and time-related) criteria.¹⁹ Immediately after a heart event or procedure, patients often feel highly motivated to initiate lifestyle changes.²⁰ However, PCI patients may have a short window of opportunity for learning between their readiness to learn state and before the activities of discharge. Staff use these opportunities as a teachable moment and to increase enrollment into outpatient CR (phase 2).

The provider performs a thorough chart review and bedside consultation to determine whether home-based CR is indicated, feasible, and appropriate. Not every patient that is referred will be enrolled in CR. Patients have the option to opt out. In addition, clinical staff adhere to the program protocol’s exclusion criteria.

Absolute contraindications for home enrollment include unstable angina, staged cardiac procedure (PCI and surgery), complex ventricular arrhythmias, severe or symptomatic aortic stenosis, decompensated heart failure, and uncontrolled hypertension (Table). Patients deemed high risk for home-based CR may be referred to a non-VA facility-based CR program. Risk stratification, using the Canadian Cardiovascular Society Grading of Angina Pectoris, is a continuous process that is used to identify patients who may move from moderate to high risk, both before and during the program.^21,22

Phases 2 and 3

Phase 2 of the Healthy Heart Program CR includes physical activity, risk-factor modification, nutritional guidance, psychosocial modification, a return to previous activities, and an improved QOL. Prior to entry into the program, a submaximal exercise test, the 6-minute walk test (6MWT), is used as both a qualifying test and for developing the initial exercise prescription.²² The minimum 6MWT distance needed to qualify is 75 m for postoperative and 150 m for nonsurgical patients. The 6MWT is performed in-hospital for patients who were admitted for stable angina, PCI, and are > 4 days following acute MI.²³ Cardiothoracic surgery patients are tested at their first follow-up clinic visit (typically 2-3 weeks postoperatively). The clinician monitors the heart rate with either a wearable device or via inpatient telemetry monitors. This exercise testing also serves as a motivational tool for patients to gain confidence in their ability to begin to exercise at home.

Each participant receives a workbook and a DVD titled An Active Partnership for the Health of Your Heart. A personal health journal is provided for documenting vital signs, activity, and dietary intake. In addition, each participant receives equipment on an as-needed basis, including resistance bands, a weight scale, a blood pressure cuff, a pedometer/heart rate monitoring device, an exercise peddler or stationary bike, and a dietary video. Baseline assessments include the General Anxiety Disorder (GAD-7), Personal Health Questionnaire (PHQ-9) and a nutrition (Rate Your Plate) questionnaire. A cognitive function test (Montreal Cognitive Assessment) is used on an as-needed basis.

Nine 30-minute telephone follow-up sessions are scheduled within a 12-week period (weekly for the first 6 weeks, then biweekly). Topics covered are customized and include exercise; nutrition; medications; smoking cessation; and diabetes, hypertension, and weight management. Via a telephone follow-up session, the program nurses and patients codevelop an electronic individualized treatment plan that is tailored to the patient’s diagnosis, individual goals, and preferences. Clinicians teach participants how to self-monitor exercise, using a continuous heart rate monitoring device (Mio Alpha II or Fuse) and the 6-20 Borg dyspnea rating scale.²⁴ Initially, moderate intensity exercise is prescribed with a target heart rate that is 60% to 75% of the 6MWT peak heart rate and an initial Borg scale target (11-14 on 20 point scale). The program physicians approve the treatment plan at the first patient visit and every 30 days until phase 2 is complete.

Patients who have completed early outpatient phase 2 CR can benefit from continuing to a phase 3 CR program.²⁵ Participants of the Healthy Heart Program automatically are enrolled in phase 3, which is a long-term maintenance program that includes monthly or bimonthly phone calls for up to 1-year posthospital discharge. The goal is to support each veteran’s transition to a long-term healthy lifestyle that includes regular exercise.

Client-Clinician Partnership

The Healthy Heart Program establishes the client-clinician partnership prior to discharge for hospitalized patients. The nurse who initiates phase 1 at the bedside is the primary clinician throughout phases 2 and 3 with the exception of a dietician, psychologist, and/or exercise physiologist who provide follow-up calls as needed. Throughout these weekly follow-up phone sessions, the clinician gains an appreciation of the patient’s understanding of his or her disease, patterns of behavior, desire to change, confidence in being able to change, potential barriers, and responses to obstacles. Clinicians in this setting are empathetic, supportive, and nonjudgmental. They encourage positive changes no matter how small and express concern when the patient is having difficulty.

Tailored Behavioral Change

The clinician’s responsibility is to listen to the patient’s concerns, assess their level of commitment for changing health behaviors, and provide guidance and support at the patient’s current level. The clinician applies the Transtheoretical Model founded on the Stages of Change principals to help understand and provide guidance based on the patient’s feelings about health behavior change.²⁶ People are actively open to changing behaviors by only 20% at any given time.²⁷ Therefore, action-oriented guidance for patients who are in the contemplative stage would not be helpful. This patient-centered approach promotes patients’ self-awareness, participation, and understanding of their decision-making role in their health management. Ultimately, individuals must take ownership of their health care maintenance for sustained behavioral change and medication management, and clinicians should facilitate that process.

Discussion

Secondary prevention strategies for heart disease continue to be underutilized. The Healthy Heart Program aims to improve participation in CR, improve QOL, help patients understand their heart disease, and support these patients psychologically. An advantage of this program is that it begins inpatient CR immediately following the heart event, when many patients often are more receptive to behavioral change support and guidance. Another advantage is that the program breaks down barriers to access, which is especially important in the veteran population. The Healthy Heart Program provides support and guidance for exercise and cardiac risk factor management to patients who otherwise would have not participated in any type of CR program.

A home-based CR program can be adopted independently or in conjunction with a facility-based program to which patients lack access. Furthermore, home-based CR programs function well as a phase 3 maintenance program at the completion of a traditional CR program. Since its inception, the Healthy Heart Program has increased the number of veterans enrolled in cardiac rehabilitation at the SFVAMC dramatically, from < 1% in FY 2012 to > 40% in FY 2015.

Program Limitations

One potential disadvantage of a home-based CR program is patients’ fear of returning to an exercise routine following a cardiac event. In addition, a lack of in-person supervision in home-based CR can lead patients to engage in less intensive activity than in facility-based CR. Other disadvantages include a lack of social support, less patient accountability, and safety concerns for sicker patients. Staff have consulted on several patients who expressed a lack of confidence in their ability to do well in this type of program, where accountability for exercising is self-reported. Staff referred these patients, who had the means to travel, to a non-VA facility-based CR program of their choice. Ideally, patients would have the choice between facility- or home-based programs or be able to choose a hybrid program that would best meet their needs.

Another identified limitation of this program was the lack of group support and in-person interactions with rehabilitation staff. Finally, although this program uses mobile devices with heart rate monitoring technology, these devices currently lack the capability to remotely share data with clinicians. Clinicians are reliant on the patient’s use of a personal health journal and memory. Subjective patient reporting has been found to be overestimated; therefore, more objective methods to measure important clinical outcomes are necessary^.28

Conclusion

Facility-based CR is effective but underutilized. Alternative secondary programs are needed to help meet patient needs and overcome patient barriers. One promising approach to increase participation is home-based CR. Home-based CR programs have the potential to increase CR uptake and adherence. Home-based CR optimizes enrollment through evidence-based alternative models due to improved access. The future of CR will become highly individualized and multifaceted as a result of available mobile technologies and Internet-based tools, which will help increase the number of participants and expand the reach of cardiac risk factor management programs beyond the facility-based setting. A home-based program will be a valuable addition to facility-based programs as a stand-alone program or adopted into a hybrid program.

Acknowledgments
This work was funded by the VA Quality Enhancement Research Initiative.

Despite a 30% decline in heart disease mortality from 2001 to 2011, heart disease prevalence is on the rise, responsible for 1 of every 3 deaths in the U.S.¹ Cardiac rehabilitation (CR) is an evidence-based, secondary prevention strategy that has been proven effective in preventing future cardiovascular events and decreasing heart disease mortality.^2-4 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is the leading authority on CR and provides guidelines for CR programs. The AACVPR and the American Heart Association (AHA) published core components for CR programs deemed essential for all CR/secondary prevention programs, including evaluations, interventions, and expected outcomes.⁵ These core components are aimed at promoting a healthy lifestyle and increasing function and well-being while reducing injury, death, and the reoccurrence of disease.⁶

In a meta-analysis of 47 trials with 10,794 participants, CR reduced cardiovascular disease (CVD) mortality and hospital admissions by 26% and 18%, respectively.² Performance measures (Class 1, Level A) recommend the following types of patients should be referred from the inpatient setting: “all patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina, or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation.”⁷ However, despite overwhelming evidence and widespread endorsement (Class 1, Level A), service utilization, uptake, and patient adherence to CR programs remain suboptimal. In a U.S. study of claims from > 250,000 Medicare beneficiaries, < 30% of eligible patients participated in some type of CR program.⁸ In response to poor participation, a presidential advisory from the AHA in 2011 stated, “the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.”⁹

This treatment gap is echoed throughout the VHA. Schopfer and colleagues found that only 28% of the 124 VAMCs that provide inpatient care also offer a supervised, facility-based CR program.¹⁰ Furthermore, only 10.3% of eligible veterans participated in at least 1 CR session (VA or non-VA). On a systemic level, low patient referral rates and inadequate third-party reimbursement were the most common barriers to participation in CR.^10,11 On a patient level, distance was by far the largest barrier to veterans receiving CR. Currently, 74% of the 9.3 million VA-enrolled veterans live at least 1 hour by car from a VA facility that offers CR.⁹ Within some regions of the VHA, there are no VA facility-based CR programs. For example, VISN 21 has no facility-based CR programs. At the same time, referral of eligible veterans to facility-based CR outside the VA remains low. Prior to April 2013, < 2% of qualified patients residing in VISN 21 were being referred to Non-VA CR programs, making it the VISN with the lowest participation rate for CR.

One potential solution that addresses both systemic and patient barriers to CR utilization is home-based CR. Veterans within the wide geographic area of VISN 21 are referred to San Francisco VAMC (SFVAMC) for ischemic heart disease, cardiovascular revascularization, and cardiac valve surgeries. In 2013, a comprehensive home-based CR program named The Healthy Heart Program was developed based on a successful evidence-based CVD secondary prevention program. The Healthy Heart Program is designed to be a physician-directed, nurse case-managed, customized exercise and lifestyle program that provides a safe and convenient way for veterans to participate in CR. Exercise and disease self-management education are the cornerstones of the Healthy Heart Program. The program’s multidisciplinary team includes physicians, nurses, a dietician, an exercise physiologist, and a health behavior psychologist.

An Alternative Approach

DeBusk and colleagues demonstrated that a physician-directed, nurse-managed, home-based cardiac risk-factor modification program improved smoking cessation, reduced low-density lipoprotein cholesterol, and increased exercise capacity compared with usual care.¹² The results of this study helped pave the way for one of the first CR programs with a strong home-based element. The MULTIFIT program was jointly developed by the Stanford Coronary Rehabilitation Program and Kaiser Permanente (Oakland, CA) in 1995. MULTIFIT is a nurse-based care model for CVD prevention.

Further research that evaluated other home-based programs showed similar promise. A Cochrane review demonstrated that home- and facility-based CR programs were equal in cardiac risk factor reduction, reduced hospital readmissions and mortality rates, and improved quality of life (QOL).¹³ Cost-effectiveness also seemed to be similar in both home- and hospital-based CR programs.¹⁴ A meta-analysis of telephone support interventions for coronary artery disease demonstrated a 38% decrease in rehospitalizations and a 32% increase in the number of participants who stopped smoking.¹⁵ In addition, patients with time constraints (eg, work, family obligations) preferred home-based CR programs for the convenience and accessibility that these programs offer.¹⁶ Home-based CR programs may have better completion rates compared with that of facility-based programs.¹⁷ The American College of Cardiology and AHA updated guidelines for CR include home-based CR as a substitute for facility-based CR for low-risk patients (Class 1, Level A).¹⁸

Referrals

To address the problems with referrals that plague other CR programs, staff of the Healthy Heart Program worked closely with interventional cardiology and the cardiothoracic team, including the clinical informatics coordinators, to develop an automatic referral system for CR evaluation. Consults for CR evaluation were embedded within the post-CABG and PCI order sets in the electronic health record. Laboratory troponin alerts were created to alert CR staff of patients with elevated troponins, which identified patients admitted for acute MI. Healthy Heart Program staff members received the referrals once a patient was admitted to the unit following their heart procedure. Early referrals for evaluation allowed staff to begin a chart review of all eligible patients and to follow the patient’s course of recovery. Most consults were generated during hospitalization for one of the indications; however, a minority of consults come from both the cardiology and primary care clinics.

Three Phases of CR

The AACVPR describes the challenges and opportunities found throughout the CR continuum.⁵ Over the past several decades, the continuum of care was more program centered and service utilization was more isolated. Today, CR is viewed as more process oriented and coordinates care across many professionals and services. Phase 1 inpatient CR begins in the hospital and is a shared responsibility between several services. Shortened hospital stays have led to innovative solutions for early ambulation, risk factor education, and discharge planning, including enrollment into phase 2 CR. Phase 2, also known as early outpatient, should begin within 1 to 2 weeks postevent in healthier patients and can last between 6 and 12 weeks postdischarge. Phase 3 (maintenance phase) should begin immediately at the conclusion of phase 2.

Phase 1

Prior to the advent of the Healthy Heart Program, secondary prevention education was not done at the bedside for SFVAMC patients following cardiac revascularization. The AACVPR recommends patient assessment, mobilization, risk-factor identification and education, and facilitation into outpatient CR as essential components of phase 1 CR.⁵ The Healthy Heart Program clinician initiates phase 1 CR by examining cardiac risk factor management for all referred patients. Physical and cardiac risk factor assessments are accomplished by completing a detailed chart review and interview with the patient. During this interview with the patient, the clinician evaluates cognitive function and readiness to learn. Staff will interview the patient further to assess the overall patient needs, including availability of social support, resources to maintain optimal health, and the need for secondary preventive education. For the PCI patient, the interview may occur in the hours following their procedure; for the surgical patient, this bedside visit typically occurs postoperative day 3 or 4.

A standardized cardiac risk factor evaluation tool was designed, which also serves as an education form to help guide the conversation on risk factor management. The interactive, patient-centered form includes opportunities to review risk, discuss current laboratory values (eg, lipids and hemoglobin A_1c), and establish individualized goals based on patient preference and recommended guidelines. Healthy Heart Program staff assist the patient in formulating achievable goals using the SMART (specific, measurable, attainable, realistic, and time-related) criteria.¹⁹ Immediately after a heart event or procedure, patients often feel highly motivated to initiate lifestyle changes.²⁰ However, PCI patients may have a short window of opportunity for learning between their readiness to learn state and before the activities of discharge. Staff use these opportunities as a teachable moment and to increase enrollment into outpatient CR (phase 2).

The provider performs a thorough chart review and bedside consultation to determine whether home-based CR is indicated, feasible, and appropriate. Not every patient that is referred will be enrolled in CR. Patients have the option to opt out. In addition, clinical staff adhere to the program protocol’s exclusion criteria.

Absolute contraindications for home enrollment include unstable angina, staged cardiac procedure (PCI and surgery), complex ventricular arrhythmias, severe or symptomatic aortic stenosis, decompensated heart failure, and uncontrolled hypertension (Table). Patients deemed high risk for home-based CR may be referred to a non-VA facility-based CR program. Risk stratification, using the Canadian Cardiovascular Society Grading of Angina Pectoris, is a continuous process that is used to identify patients who may move from moderate to high risk, both before and during the program.^21,22

Phases 2 and 3

Phase 2 of the Healthy Heart Program CR includes physical activity, risk-factor modification, nutritional guidance, psychosocial modification, a return to previous activities, and an improved QOL. Prior to entry into the program, a submaximal exercise test, the 6-minute walk test (6MWT), is used as both a qualifying test and for developing the initial exercise prescription.²² The minimum 6MWT distance needed to qualify is 75 m for postoperative and 150 m for nonsurgical patients. The 6MWT is performed in-hospital for patients who were admitted for stable angina, PCI, and are > 4 days following acute MI.²³ Cardiothoracic surgery patients are tested at their first follow-up clinic visit (typically 2-3 weeks postoperatively). The clinician monitors the heart rate with either a wearable device or via inpatient telemetry monitors. This exercise testing also serves as a motivational tool for patients to gain confidence in their ability to begin to exercise at home.

Each participant receives a workbook and a DVD titled An Active Partnership for the Health of Your Heart. A personal health journal is provided for documenting vital signs, activity, and dietary intake. In addition, each participant receives equipment on an as-needed basis, including resistance bands, a weight scale, a blood pressure cuff, a pedometer/heart rate monitoring device, an exercise peddler or stationary bike, and a dietary video. Baseline assessments include the General Anxiety Disorder (GAD-7), Personal Health Questionnaire (PHQ-9) and a nutrition (Rate Your Plate) questionnaire. A cognitive function test (Montreal Cognitive Assessment) is used on an as-needed basis.

Nine 30-minute telephone follow-up sessions are scheduled within a 12-week period (weekly for the first 6 weeks, then biweekly). Topics covered are customized and include exercise; nutrition; medications; smoking cessation; and diabetes, hypertension, and weight management. Via a telephone follow-up session, the program nurses and patients codevelop an electronic individualized treatment plan that is tailored to the patient’s diagnosis, individual goals, and preferences. Clinicians teach participants how to self-monitor exercise, using a continuous heart rate monitoring device (Mio Alpha II or Fuse) and the 6-20 Borg dyspnea rating scale.²⁴ Initially, moderate intensity exercise is prescribed with a target heart rate that is 60% to 75% of the 6MWT peak heart rate and an initial Borg scale target (11-14 on 20 point scale). The program physicians approve the treatment plan at the first patient visit and every 30 days until phase 2 is complete.

Patients who have completed early outpatient phase 2 CR can benefit from continuing to a phase 3 CR program.²⁵ Participants of the Healthy Heart Program automatically are enrolled in phase 3, which is a long-term maintenance program that includes monthly or bimonthly phone calls for up to 1-year posthospital discharge. The goal is to support each veteran’s transition to a long-term healthy lifestyle that includes regular exercise.

Client-Clinician Partnership

The Healthy Heart Program establishes the client-clinician partnership prior to discharge for hospitalized patients. The nurse who initiates phase 1 at the bedside is the primary clinician throughout phases 2 and 3 with the exception of a dietician, psychologist, and/or exercise physiologist who provide follow-up calls as needed. Throughout these weekly follow-up phone sessions, the clinician gains an appreciation of the patient’s understanding of his or her disease, patterns of behavior, desire to change, confidence in being able to change, potential barriers, and responses to obstacles. Clinicians in this setting are empathetic, supportive, and nonjudgmental. They encourage positive changes no matter how small and express concern when the patient is having difficulty.

Tailored Behavioral Change

The clinician’s responsibility is to listen to the patient’s concerns, assess their level of commitment for changing health behaviors, and provide guidance and support at the patient’s current level. The clinician applies the Transtheoretical Model founded on the Stages of Change principals to help understand and provide guidance based on the patient’s feelings about health behavior change.²⁶ People are actively open to changing behaviors by only 20% at any given time.²⁷ Therefore, action-oriented guidance for patients who are in the contemplative stage would not be helpful. This patient-centered approach promotes patients’ self-awareness, participation, and understanding of their decision-making role in their health management. Ultimately, individuals must take ownership of their health care maintenance for sustained behavioral change and medication management, and clinicians should facilitate that process.

Discussion

Secondary prevention strategies for heart disease continue to be underutilized. The Healthy Heart Program aims to improve participation in CR, improve QOL, help patients understand their heart disease, and support these patients psychologically. An advantage of this program is that it begins inpatient CR immediately following the heart event, when many patients often are more receptive to behavioral change support and guidance. Another advantage is that the program breaks down barriers to access, which is especially important in the veteran population. The Healthy Heart Program provides support and guidance for exercise and cardiac risk factor management to patients who otherwise would have not participated in any type of CR program.

A home-based CR program can be adopted independently or in conjunction with a facility-based program to which patients lack access. Furthermore, home-based CR programs function well as a phase 3 maintenance program at the completion of a traditional CR program. Since its inception, the Healthy Heart Program has increased the number of veterans enrolled in cardiac rehabilitation at the SFVAMC dramatically, from < 1% in FY 2012 to > 40% in FY 2015.

Program Limitations

One potential disadvantage of a home-based CR program is patients’ fear of returning to an exercise routine following a cardiac event. In addition, a lack of in-person supervision in home-based CR can lead patients to engage in less intensive activity than in facility-based CR. Other disadvantages include a lack of social support, less patient accountability, and safety concerns for sicker patients. Staff have consulted on several patients who expressed a lack of confidence in their ability to do well in this type of program, where accountability for exercising is self-reported. Staff referred these patients, who had the means to travel, to a non-VA facility-based CR program of their choice. Ideally, patients would have the choice between facility- or home-based programs or be able to choose a hybrid program that would best meet their needs.

Another identified limitation of this program was the lack of group support and in-person interactions with rehabilitation staff. Finally, although this program uses mobile devices with heart rate monitoring technology, these devices currently lack the capability to remotely share data with clinicians. Clinicians are reliant on the patient’s use of a personal health journal and memory. Subjective patient reporting has been found to be overestimated; therefore, more objective methods to measure important clinical outcomes are necessary^.28

Conclusion

Facility-based CR is effective but underutilized. Alternative secondary programs are needed to help meet patient needs and overcome patient barriers. One promising approach to increase participation is home-based CR. Home-based CR programs have the potential to increase CR uptake and adherence. Home-based CR optimizes enrollment through evidence-based alternative models due to improved access. The future of CR will become highly individualized and multifaceted as a result of available mobile technologies and Internet-based tools, which will help increase the number of participants and expand the reach of cardiac risk factor management programs beyond the facility-based setting. A home-based program will be a valuable addition to facility-based programs as a stand-alone program or adopted into a hybrid program.

Acknowledgments
This work was funded by the VA Quality Enhancement Research Initiative.

Despite a 30% decline in heart disease mortality from 2001 to 2011, heart disease prevalence is on the rise, responsible for 1 of every 3 deaths in the U.S.¹ Cardiac rehabilitation (CR) is an evidence-based, secondary prevention strategy that has been proven effective in preventing future cardiovascular events and decreasing heart disease mortality.^2-4 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is the leading authority on CR and provides guidelines for CR programs. The AACVPR and the American Heart Association (AHA) published core components for CR programs deemed essential for all CR/secondary prevention programs, including evaluations, interventions, and expected outcomes.⁵ These core components are aimed at promoting a healthy lifestyle and increasing function and well-being while reducing injury, death, and the reoccurrence of disease.⁶

In a meta-analysis of 47 trials with 10,794 participants, CR reduced cardiovascular disease (CVD) mortality and hospital admissions by 26% and 18%, respectively.² Performance measures (Class 1, Level A) recommend the following types of patients should be referred from the inpatient setting: “all patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina, or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation.”⁷ However, despite overwhelming evidence and widespread endorsement (Class 1, Level A), service utilization, uptake, and patient adherence to CR programs remain suboptimal. In a U.S. study of claims from > 250,000 Medicare beneficiaries, < 30% of eligible patients participated in some type of CR program.⁸ In response to poor participation, a presidential advisory from the AHA in 2011 stated, “the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.”⁹

This treatment gap is echoed throughout the VHA. Schopfer and colleagues found that only 28% of the 124 VAMCs that provide inpatient care also offer a supervised, facility-based CR program.¹⁰ Furthermore, only 10.3% of eligible veterans participated in at least 1 CR session (VA or non-VA). On a systemic level, low patient referral rates and inadequate third-party reimbursement were the most common barriers to participation in CR.^10,11 On a patient level, distance was by far the largest barrier to veterans receiving CR. Currently, 74% of the 9.3 million VA-enrolled veterans live at least 1 hour by car from a VA facility that offers CR.⁹ Within some regions of the VHA, there are no VA facility-based CR programs. For example, VISN 21 has no facility-based CR programs. At the same time, referral of eligible veterans to facility-based CR outside the VA remains low. Prior to April 2013, < 2% of qualified patients residing in VISN 21 were being referred to Non-VA CR programs, making it the VISN with the lowest participation rate for CR.

One potential solution that addresses both systemic and patient barriers to CR utilization is home-based CR. Veterans within the wide geographic area of VISN 21 are referred to San Francisco VAMC (SFVAMC) for ischemic heart disease, cardiovascular revascularization, and cardiac valve surgeries. In 2013, a comprehensive home-based CR program named The Healthy Heart Program was developed based on a successful evidence-based CVD secondary prevention program. The Healthy Heart Program is designed to be a physician-directed, nurse case-managed, customized exercise and lifestyle program that provides a safe and convenient way for veterans to participate in CR. Exercise and disease self-management education are the cornerstones of the Healthy Heart Program. The program’s multidisciplinary team includes physicians, nurses, a dietician, an exercise physiologist, and a health behavior psychologist.

An Alternative Approach

DeBusk and colleagues demonstrated that a physician-directed, nurse-managed, home-based cardiac risk-factor modification program improved smoking cessation, reduced low-density lipoprotein cholesterol, and increased exercise capacity compared with usual care.¹² The results of this study helped pave the way for one of the first CR programs with a strong home-based element. The MULTIFIT program was jointly developed by the Stanford Coronary Rehabilitation Program and Kaiser Permanente (Oakland, CA) in 1995. MULTIFIT is a nurse-based care model for CVD prevention.

Further research that evaluated other home-based programs showed similar promise. A Cochrane review demonstrated that home- and facility-based CR programs were equal in cardiac risk factor reduction, reduced hospital readmissions and mortality rates, and improved quality of life (QOL).¹³ Cost-effectiveness also seemed to be similar in both home- and hospital-based CR programs.¹⁴ A meta-analysis of telephone support interventions for coronary artery disease demonstrated a 38% decrease in rehospitalizations and a 32% increase in the number of participants who stopped smoking.¹⁵ In addition, patients with time constraints (eg, work, family obligations) preferred home-based CR programs for the convenience and accessibility that these programs offer.¹⁶ Home-based CR programs may have better completion rates compared with that of facility-based programs.¹⁷ The American College of Cardiology and AHA updated guidelines for CR include home-based CR as a substitute for facility-based CR for low-risk patients (Class 1, Level A).¹⁸

Referrals

To address the problems with referrals that plague other CR programs, staff of the Healthy Heart Program worked closely with interventional cardiology and the cardiothoracic team, including the clinical informatics coordinators, to develop an automatic referral system for CR evaluation. Consults for CR evaluation were embedded within the post-CABG and PCI order sets in the electronic health record. Laboratory troponin alerts were created to alert CR staff of patients with elevated troponins, which identified patients admitted for acute MI. Healthy Heart Program staff members received the referrals once a patient was admitted to the unit following their heart procedure. Early referrals for evaluation allowed staff to begin a chart review of all eligible patients and to follow the patient’s course of recovery. Most consults were generated during hospitalization for one of the indications; however, a minority of consults come from both the cardiology and primary care clinics.

Three Phases of CR

The AACVPR describes the challenges and opportunities found throughout the CR continuum.⁵ Over the past several decades, the continuum of care was more program centered and service utilization was more isolated. Today, CR is viewed as more process oriented and coordinates care across many professionals and services. Phase 1 inpatient CR begins in the hospital and is a shared responsibility between several services. Shortened hospital stays have led to innovative solutions for early ambulation, risk factor education, and discharge planning, including enrollment into phase 2 CR. Phase 2, also known as early outpatient, should begin within 1 to 2 weeks postevent in healthier patients and can last between 6 and 12 weeks postdischarge. Phase 3 (maintenance phase) should begin immediately at the conclusion of phase 2.

Phase 1

Prior to the advent of the Healthy Heart Program, secondary prevention education was not done at the bedside for SFVAMC patients following cardiac revascularization. The AACVPR recommends patient assessment, mobilization, risk-factor identification and education, and facilitation into outpatient CR as essential components of phase 1 CR.⁵ The Healthy Heart Program clinician initiates phase 1 CR by examining cardiac risk factor management for all referred patients. Physical and cardiac risk factor assessments are accomplished by completing a detailed chart review and interview with the patient. During this interview with the patient, the clinician evaluates cognitive function and readiness to learn. Staff will interview the patient further to assess the overall patient needs, including availability of social support, resources to maintain optimal health, and the need for secondary preventive education. For the PCI patient, the interview may occur in the hours following their procedure; for the surgical patient, this bedside visit typically occurs postoperative day 3 or 4.

A standardized cardiac risk factor evaluation tool was designed, which also serves as an education form to help guide the conversation on risk factor management. The interactive, patient-centered form includes opportunities to review risk, discuss current laboratory values (eg, lipids and hemoglobin A_1c), and establish individualized goals based on patient preference and recommended guidelines. Healthy Heart Program staff assist the patient in formulating achievable goals using the SMART (specific, measurable, attainable, realistic, and time-related) criteria.¹⁹ Immediately after a heart event or procedure, patients often feel highly motivated to initiate lifestyle changes.²⁰ However, PCI patients may have a short window of opportunity for learning between their readiness to learn state and before the activities of discharge. Staff use these opportunities as a teachable moment and to increase enrollment into outpatient CR (phase 2).

The provider performs a thorough chart review and bedside consultation to determine whether home-based CR is indicated, feasible, and appropriate. Not every patient that is referred will be enrolled in CR. Patients have the option to opt out. In addition, clinical staff adhere to the program protocol’s exclusion criteria.

Absolute contraindications for home enrollment include unstable angina, staged cardiac procedure (PCI and surgery), complex ventricular arrhythmias, severe or symptomatic aortic stenosis, decompensated heart failure, and uncontrolled hypertension (Table). Patients deemed high risk for home-based CR may be referred to a non-VA facility-based CR program. Risk stratification, using the Canadian Cardiovascular Society Grading of Angina Pectoris, is a continuous process that is used to identify patients who may move from moderate to high risk, both before and during the program.^21,22

Phases 2 and 3

Phase 2 of the Healthy Heart Program CR includes physical activity, risk-factor modification, nutritional guidance, psychosocial modification, a return to previous activities, and an improved QOL. Prior to entry into the program, a submaximal exercise test, the 6-minute walk test (6MWT), is used as both a qualifying test and for developing the initial exercise prescription.²² The minimum 6MWT distance needed to qualify is 75 m for postoperative and 150 m for nonsurgical patients. The 6MWT is performed in-hospital for patients who were admitted for stable angina, PCI, and are > 4 days following acute MI.²³ Cardiothoracic surgery patients are tested at their first follow-up clinic visit (typically 2-3 weeks postoperatively). The clinician monitors the heart rate with either a wearable device or via inpatient telemetry monitors. This exercise testing also serves as a motivational tool for patients to gain confidence in their ability to begin to exercise at home.

Each participant receives a workbook and a DVD titled An Active Partnership for the Health of Your Heart. A personal health journal is provided for documenting vital signs, activity, and dietary intake. In addition, each participant receives equipment on an as-needed basis, including resistance bands, a weight scale, a blood pressure cuff, a pedometer/heart rate monitoring device, an exercise peddler or stationary bike, and a dietary video. Baseline assessments include the General Anxiety Disorder (GAD-7), Personal Health Questionnaire (PHQ-9) and a nutrition (Rate Your Plate) questionnaire. A cognitive function test (Montreal Cognitive Assessment) is used on an as-needed basis.

Nine 30-minute telephone follow-up sessions are scheduled within a 12-week period (weekly for the first 6 weeks, then biweekly). Topics covered are customized and include exercise; nutrition; medications; smoking cessation; and diabetes, hypertension, and weight management. Via a telephone follow-up session, the program nurses and patients codevelop an electronic individualized treatment plan that is tailored to the patient’s diagnosis, individual goals, and preferences. Clinicians teach participants how to self-monitor exercise, using a continuous heart rate monitoring device (Mio Alpha II or Fuse) and the 6-20 Borg dyspnea rating scale.²⁴ Initially, moderate intensity exercise is prescribed with a target heart rate that is 60% to 75% of the 6MWT peak heart rate and an initial Borg scale target (11-14 on 20 point scale). The program physicians approve the treatment plan at the first patient visit and every 30 days until phase 2 is complete.

Patients who have completed early outpatient phase 2 CR can benefit from continuing to a phase 3 CR program.²⁵ Participants of the Healthy Heart Program automatically are enrolled in phase 3, which is a long-term maintenance program that includes monthly or bimonthly phone calls for up to 1-year posthospital discharge. The goal is to support each veteran’s transition to a long-term healthy lifestyle that includes regular exercise.

Client-Clinician Partnership

The Healthy Heart Program establishes the client-clinician partnership prior to discharge for hospitalized patients. The nurse who initiates phase 1 at the bedside is the primary clinician throughout phases 2 and 3 with the exception of a dietician, psychologist, and/or exercise physiologist who provide follow-up calls as needed. Throughout these weekly follow-up phone sessions, the clinician gains an appreciation of the patient’s understanding of his or her disease, patterns of behavior, desire to change, confidence in being able to change, potential barriers, and responses to obstacles. Clinicians in this setting are empathetic, supportive, and nonjudgmental. They encourage positive changes no matter how small and express concern when the patient is having difficulty.

Tailored Behavioral Change

The clinician’s responsibility is to listen to the patient’s concerns, assess their level of commitment for changing health behaviors, and provide guidance and support at the patient’s current level. The clinician applies the Transtheoretical Model founded on the Stages of Change principals to help understand and provide guidance based on the patient’s feelings about health behavior change.²⁶ People are actively open to changing behaviors by only 20% at any given time.²⁷ Therefore, action-oriented guidance for patients who are in the contemplative stage would not be helpful. This patient-centered approach promotes patients’ self-awareness, participation, and understanding of their decision-making role in their health management. Ultimately, individuals must take ownership of their health care maintenance for sustained behavioral change and medication management, and clinicians should facilitate that process.

Discussion

Secondary prevention strategies for heart disease continue to be underutilized. The Healthy Heart Program aims to improve participation in CR, improve QOL, help patients understand their heart disease, and support these patients psychologically. An advantage of this program is that it begins inpatient CR immediately following the heart event, when many patients often are more receptive to behavioral change support and guidance. Another advantage is that the program breaks down barriers to access, which is especially important in the veteran population. The Healthy Heart Program provides support and guidance for exercise and cardiac risk factor management to patients who otherwise would have not participated in any type of CR program.

A home-based CR program can be adopted independently or in conjunction with a facility-based program to which patients lack access. Furthermore, home-based CR programs function well as a phase 3 maintenance program at the completion of a traditional CR program. Since its inception, the Healthy Heart Program has increased the number of veterans enrolled in cardiac rehabilitation at the SFVAMC dramatically, from < 1% in FY 2012 to > 40% in FY 2015.

Program Limitations

One potential disadvantage of a home-based CR program is patients’ fear of returning to an exercise routine following a cardiac event. In addition, a lack of in-person supervision in home-based CR can lead patients to engage in less intensive activity than in facility-based CR. Other disadvantages include a lack of social support, less patient accountability, and safety concerns for sicker patients. Staff have consulted on several patients who expressed a lack of confidence in their ability to do well in this type of program, where accountability for exercising is self-reported. Staff referred these patients, who had the means to travel, to a non-VA facility-based CR program of their choice. Ideally, patients would have the choice between facility- or home-based programs or be able to choose a hybrid program that would best meet their needs.

Another identified limitation of this program was the lack of group support and in-person interactions with rehabilitation staff. Finally, although this program uses mobile devices with heart rate monitoring technology, these devices currently lack the capability to remotely share data with clinicians. Clinicians are reliant on the patient’s use of a personal health journal and memory. Subjective patient reporting has been found to be overestimated; therefore, more objective methods to measure important clinical outcomes are necessary^.28

Conclusion

Facility-based CR is effective but underutilized. Alternative secondary programs are needed to help meet patient needs and overcome patient barriers. One promising approach to increase participation is home-based CR. Home-based CR programs have the potential to increase CR uptake and adherence. Home-based CR optimizes enrollment through evidence-based alternative models due to improved access. The future of CR will become highly individualized and multifaceted as a result of available mobile technologies and Internet-based tools, which will help increase the number of participants and expand the reach of cardiac risk factor management programs beyond the facility-based setting. A home-based program will be a valuable addition to facility-based programs as a stand-alone program or adopted into a hybrid program.

Acknowledgments
This work was funded by the VA Quality Enhancement Research Initiative.

Photo courtesy of CDC

Severe hospital-acquired anemia (HAA) may increase a person’s risk of hospital readmission and death, a new study suggests.

Researchers studied more than 11,000 patients admitted to 6 Texas hospitals and found that a third of the patients developed HAA.

The team also found that severe HAA was associated with a higher risk of death or readmission, even after the researchers adjusted for other factors.

They reported these findings in the Journal of Hospital Medicine.

“This study shines a spotlight on a very common but underappreciated risk of hospitalization, hospital-acquired anemia, which has traditionally been viewed as an incidental change in the red blood count of no significance,” said study author Ethan Halm, MD, of the University of Texas Southwestern Medical Center in Dallas.

“However, our results showed that hospital-acquired anemia was associated with worse clinical outcomes after leaving the hospital, so it needs to be taken more seriously.”

Dr Halm and his colleagues looked at consecutive medicine discharges between November 1, 2009, and October 30, 2010, from 6 hospitals in Texas (safety-net, teaching, and nonteaching).

Of the 11,309 patients studied, 33.1% developed HAA. Most (21.6%) had mild HAA, followed by moderate HAA (10.1%), and severe HAA (1.4%).

The study’s primary outcome was a composite of 30-day mortality and nonelective readmission. This occurred in 9.7% of patients without HAA and 16.4% of those with severe HAA.

The researchers found that severe HAA was independently associated with a 39% increase in the odds of meeting the primary outcome (readmission or 30-day mortality).

The team noted that 85% of patients with severe HAA underwent a major procedure, had a discharge diagnosis of hemorrhage, and/or a discharge diagnosis of hemorrhagic disorder.

The researchers identified 2 potentially modifiable predictors of moderate or severe HAA. These were length of hospital stay (adjusted odds ratio=1.26 per day) and undergoing a major procedure (adjusted odds ratio=5.09).

“Our findings suggest that reducing blood loss during major surgeries and reducing unnecessary testing during hospital stays may lower a patient’s risk of developing severe hospital-acquired anemia, and potentially improve their recovery,” said Anil N. Makam, MD, of the University of Texas Southwestern Medical Center.

In the future, the researchers hope to examine other patient-centered outcomes that may be related to HAA, such as fatigue, functional impairment, and the trajectory of post-hospital recovery. 

Photo courtesy of CDC

Severe hospital-acquired anemia (HAA) may increase a person’s risk of hospital readmission and death, a new study suggests.

Researchers studied more than 11,000 patients admitted to 6 Texas hospitals and found that a third of the patients developed HAA.

The team also found that severe HAA was associated with a higher risk of death or readmission, even after the researchers adjusted for other factors.

They reported these findings in the Journal of Hospital Medicine.

“This study shines a spotlight on a very common but underappreciated risk of hospitalization, hospital-acquired anemia, which has traditionally been viewed as an incidental change in the red blood count of no significance,” said study author Ethan Halm, MD, of the University of Texas Southwestern Medical Center in Dallas.

“However, our results showed that hospital-acquired anemia was associated with worse clinical outcomes after leaving the hospital, so it needs to be taken more seriously.”

Dr Halm and his colleagues looked at consecutive medicine discharges between November 1, 2009, and October 30, 2010, from 6 hospitals in Texas (safety-net, teaching, and nonteaching).

Of the 11,309 patients studied, 33.1% developed HAA. Most (21.6%) had mild HAA, followed by moderate HAA (10.1%), and severe HAA (1.4%).

The study’s primary outcome was a composite of 30-day mortality and nonelective readmission. This occurred in 9.7% of patients without HAA and 16.4% of those with severe HAA.

The researchers found that severe HAA was independently associated with a 39% increase in the odds of meeting the primary outcome (readmission or 30-day mortality).

The team noted that 85% of patients with severe HAA underwent a major procedure, had a discharge diagnosis of hemorrhage, and/or a discharge diagnosis of hemorrhagic disorder.

The researchers identified 2 potentially modifiable predictors of moderate or severe HAA. These were length of hospital stay (adjusted odds ratio=1.26 per day) and undergoing a major procedure (adjusted odds ratio=5.09).

“Our findings suggest that reducing blood loss during major surgeries and reducing unnecessary testing during hospital stays may lower a patient’s risk of developing severe hospital-acquired anemia, and potentially improve their recovery,” said Anil N. Makam, MD, of the University of Texas Southwestern Medical Center.

In the future, the researchers hope to examine other patient-centered outcomes that may be related to HAA, such as fatigue, functional impairment, and the trajectory of post-hospital recovery. 

Photo courtesy of CDC

Severe hospital-acquired anemia (HAA) may increase a person’s risk of hospital readmission and death, a new study suggests.

Researchers studied more than 11,000 patients admitted to 6 Texas hospitals and found that a third of the patients developed HAA.

The team also found that severe HAA was associated with a higher risk of death or readmission, even after the researchers adjusted for other factors.

They reported these findings in the Journal of Hospital Medicine.

“This study shines a spotlight on a very common but underappreciated risk of hospitalization, hospital-acquired anemia, which has traditionally been viewed as an incidental change in the red blood count of no significance,” said study author Ethan Halm, MD, of the University of Texas Southwestern Medical Center in Dallas.

“However, our results showed that hospital-acquired anemia was associated with worse clinical outcomes after leaving the hospital, so it needs to be taken more seriously.”

Dr Halm and his colleagues looked at consecutive medicine discharges between November 1, 2009, and October 30, 2010, from 6 hospitals in Texas (safety-net, teaching, and nonteaching).

Of the 11,309 patients studied, 33.1% developed HAA. Most (21.6%) had mild HAA, followed by moderate HAA (10.1%), and severe HAA (1.4%).

The study’s primary outcome was a composite of 30-day mortality and nonelective readmission. This occurred in 9.7% of patients without HAA and 16.4% of those with severe HAA.

The researchers found that severe HAA was independently associated with a 39% increase in the odds of meeting the primary outcome (readmission or 30-day mortality).

The team noted that 85% of patients with severe HAA underwent a major procedure, had a discharge diagnosis of hemorrhage, and/or a discharge diagnosis of hemorrhagic disorder.

The researchers identified 2 potentially modifiable predictors of moderate or severe HAA. These were length of hospital stay (adjusted odds ratio=1.26 per day) and undergoing a major procedure (adjusted odds ratio=5.09).

“Our findings suggest that reducing blood loss during major surgeries and reducing unnecessary testing during hospital stays may lower a patient’s risk of developing severe hospital-acquired anemia, and potentially improve their recovery,” said Anil N. Makam, MD, of the University of Texas Southwestern Medical Center.

In the future, the researchers hope to examine other patient-centered outcomes that may be related to HAA, such as fatigue, functional impairment, and the trajectory of post-hospital recovery. 

The drop in frequent binge drinking (FBD) among adolescents can be attributed to age, period, and cohort effects, but there are variations in certain subgroups of teens, said Joy Bohyun Jang, PhD, and her associates.

The decline in FBD is not as great in teen girls, African American youth, and youth from low socioeconomic backgrounds, so those groups deserve close attention by researchers and clinicians, they said.

Galina Barskaya/Fotolia

The drop in frequent binge drinking (FBD) among adolescents can be attributed to age, period, and cohort effects, but there are variations in certain subgroups of teens, said Joy Bohyun Jang, PhD, and her associates.

The decline in FBD is not as great in teen girls, African American youth, and youth from low socioeconomic backgrounds, so those groups deserve close attention by researchers and clinicians, they said.

Galina Barskaya/Fotolia

The drop in frequent binge drinking (FBD) among adolescents can be attributed to age, period, and cohort effects, but there are variations in certain subgroups of teens, said Joy Bohyun Jang, PhD, and her associates.

The decline in FBD is not as great in teen girls, African American youth, and youth from low socioeconomic backgrounds, so those groups deserve close attention by researchers and clinicians, they said.

Galina Barskaya/Fotolia

Once a month in my department, we focus on a case with challenging ethical considerations for part of the discussion at the M & M conference.

Earlier this week, my colleagues and I heard about an unfortunate 87-year-old man, who had been living independently when he developed a partial bowel obstruction. His wife had died over 10 years earlier and, although he lived alone, he had two sons and a daughter who lived close to him and regularly looked in on him and helped him to keep up his small home.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Once a month in my department, we focus on a case with challenging ethical considerations for part of the discussion at the M & M conference.

Earlier this week, my colleagues and I heard about an unfortunate 87-year-old man, who had been living independently when he developed a partial bowel obstruction. His wife had died over 10 years earlier and, although he lived alone, he had two sons and a daughter who lived close to him and regularly looked in on him and helped him to keep up his small home.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Once a month in my department, we focus on a case with challenging ethical considerations for part of the discussion at the M & M conference.

Earlier this week, my colleagues and I heard about an unfortunate 87-year-old man, who had been living independently when he developed a partial bowel obstruction. His wife had died over 10 years earlier and, although he lived alone, he had two sons and a daughter who lived close to him and regularly looked in on him and helped him to keep up his small home.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Although Cuba lies less than 100 miles from the United States, we Americans tend to know far less about the island nation than about almost any other country in our hemisphere. Only since 2014 has the United States begun to allow its citizens to travel directly to Cuba and has opened official diplomatic relations, although direct trade still remains blocked.

Cuba’s health care system has been touted as providing universal access to primary care services, whose goals are promoting health and preventing disease as well as providing free medical education to a veritable army of health care workers. Less well known are the quality and standards of their surgical services.

Dr. Deveney

Photo Dr. Deveney

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

Although Cuba lies less than 100 miles from the United States, we Americans tend to know far less about the island nation than about almost any other country in our hemisphere. Only since 2014 has the United States begun to allow its citizens to travel directly to Cuba and has opened official diplomatic relations, although direct trade still remains blocked.

Cuba’s health care system has been touted as providing universal access to primary care services, whose goals are promoting health and preventing disease as well as providing free medical education to a veritable army of health care workers. Less well known are the quality and standards of their surgical services.

Dr. Deveney

Photo Dr. Deveney

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

Although Cuba lies less than 100 miles from the United States, we Americans tend to know far less about the island nation than about almost any other country in our hemisphere. Only since 2014 has the United States begun to allow its citizens to travel directly to Cuba and has opened official diplomatic relations, although direct trade still remains blocked.

Cuba’s health care system has been touted as providing universal access to primary care services, whose goals are promoting health and preventing disease as well as providing free medical education to a veritable army of health care workers. Less well known are the quality and standards of their surgical services.

Dr. Deveney

Photo Dr. Deveney

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

On July 1, 2017, the Centers for Medicare and Medicaid Services (CMS) will begin requiring practitioners in nine states who are part of groups of 10 or more to report data on the services that they provide for select 10- and 90-day global surgical codes. The data collected will be used to improve the accuracy of global codes starting in 2019.

Which states are impacted by the requirement to report global codes data?

What data must be reported?

Health care practitioners who meet claims-based data collection requirements will be required to report American Medical Association Current Procedure Terminology (CPT)* code 99024, Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure, for every postoperative visit they provide within the global period of a select list of 10- or 90-day global codes. CMS selected 293 services, which are provided to Medicare patients by more than 100 practitioners per year and are either furnished more than 10,000 times or have allowed charges of more than $10 million annually. The agency estimates that these 293 codes describe approximately 87 percent of all furnished 10- and 90-day global services, and approximately 77 percent of all Medicare expenditures for 10- and 90-day global services under the physician fee schedule.

Is claims-based data reporting mandatory? Is there a penalty for failure to report?

Reporting is mandatory. CMS’ goal is to gather data on postoperative visits as part of its effort to improve the accuracy of global code values starting in 2019. CMS has the authority to implement a 5 percent withhold in payment for global services for health care professionals who fail to report but has not implemented the withhold at this time. Although there is no penalty or withhold of payment for failure to report, ACS urges all surgeons required to report data to comply. Failure to report will result in incomplete data and should data analysis of both inpatient and outpatient postsurgical visits not reflect existing global code definitions, new assumptions may be created to redefine postoperative care.

Why is CMS requiring the reporting of global codes data?

For several years, CMS has communicated its concerns about the accuracy of the values assigned to 10- and 90-day global codes. In 2014, CMS proposed to transition all 10- and 90-day global codes to 0-day, with the requirement that postoperative visits would be reported separately. The ACS argued against this transition because it would have resulted in a reduction in surgeons’ reimbursement for 10- and 90-day global services.
 

Dr. Bailey is a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

On July 1, 2017, the Centers for Medicare and Medicaid Services (CMS) will begin requiring practitioners in nine states who are part of groups of 10 or more to report data on the services that they provide for select 10- and 90-day global surgical codes. The data collected will be used to improve the accuracy of global codes starting in 2019.

Which states are impacted by the requirement to report global codes data?

What data must be reported?

Health care practitioners who meet claims-based data collection requirements will be required to report American Medical Association Current Procedure Terminology (CPT)* code 99024, Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure, for every postoperative visit they provide within the global period of a select list of 10- or 90-day global codes. CMS selected 293 services, which are provided to Medicare patients by more than 100 practitioners per year and are either furnished more than 10,000 times or have allowed charges of more than $10 million annually. The agency estimates that these 293 codes describe approximately 87 percent of all furnished 10- and 90-day global services, and approximately 77 percent of all Medicare expenditures for 10- and 90-day global services under the physician fee schedule.

Is claims-based data reporting mandatory? Is there a penalty for failure to report?

Reporting is mandatory. CMS’ goal is to gather data on postoperative visits as part of its effort to improve the accuracy of global code values starting in 2019. CMS has the authority to implement a 5 percent withhold in payment for global services for health care professionals who fail to report but has not implemented the withhold at this time. Although there is no penalty or withhold of payment for failure to report, ACS urges all surgeons required to report data to comply. Failure to report will result in incomplete data and should data analysis of both inpatient and outpatient postsurgical visits not reflect existing global code definitions, new assumptions may be created to redefine postoperative care.

Why is CMS requiring the reporting of global codes data?

For several years, CMS has communicated its concerns about the accuracy of the values assigned to 10- and 90-day global codes. In 2014, CMS proposed to transition all 10- and 90-day global codes to 0-day, with the requirement that postoperative visits would be reported separately. The ACS argued against this transition because it would have resulted in a reduction in surgeons’ reimbursement for 10- and 90-day global services.
 

Dr. Bailey is a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

On July 1, 2017, the Centers for Medicare and Medicaid Services (CMS) will begin requiring practitioners in nine states who are part of groups of 10 or more to report data on the services that they provide for select 10- and 90-day global surgical codes. The data collected will be used to improve the accuracy of global codes starting in 2019.

Which states are impacted by the requirement to report global codes data?

What data must be reported?

Health care practitioners who meet claims-based data collection requirements will be required to report American Medical Association Current Procedure Terminology (CPT)* code 99024, Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure, for every postoperative visit they provide within the global period of a select list of 10- or 90-day global codes. CMS selected 293 services, which are provided to Medicare patients by more than 100 practitioners per year and are either furnished more than 10,000 times or have allowed charges of more than $10 million annually. The agency estimates that these 293 codes describe approximately 87 percent of all furnished 10- and 90-day global services, and approximately 77 percent of all Medicare expenditures for 10- and 90-day global services under the physician fee schedule.

Is claims-based data reporting mandatory? Is there a penalty for failure to report?

Reporting is mandatory. CMS’ goal is to gather data on postoperative visits as part of its effort to improve the accuracy of global code values starting in 2019. CMS has the authority to implement a 5 percent withhold in payment for global services for health care professionals who fail to report but has not implemented the withhold at this time. Although there is no penalty or withhold of payment for failure to report, ACS urges all surgeons required to report data to comply. Failure to report will result in incomplete data and should data analysis of both inpatient and outpatient postsurgical visits not reflect existing global code definitions, new assumptions may be created to redefine postoperative care.

Why is CMS requiring the reporting of global codes data?

For several years, CMS has communicated its concerns about the accuracy of the values assigned to 10- and 90-day global codes. In 2014, CMS proposed to transition all 10- and 90-day global codes to 0-day, with the requirement that postoperative visits would be reported separately. The ACS argued against this transition because it would have resulted in a reduction in surgeons’ reimbursement for 10- and 90-day global services.
 

Dr. Bailey is a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

The American College of Surgeons (ACS) Board of Regents approved new officers of the ACS Foundation Board of Directors at the Regents’ February meeting in Chicago, IL. The new officers, who began their two-year terms in February, are Chair Mary H. McGrath, MD, MPH, FACS, professor of surgery, University of California, San Francisco (UCSF); Vice-Chair Charles E. Lucas, MD, FACS, professor of surgery, Wayne State University, Detroit, MI; and Secretary Ruth L. Bush, MD, JD, MPH, FACS, deputy director, the Center for Innovations in Quality, Effectiveness and Safety, a partnership between the Baylor College of Medicine and the Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, TX.

Mary H. McGrath, MD, MPH, FACS

Dr. McGrath is a graduate of St. Louis University School of Medicine, MO, and completed her general surgery residency at the University of Colorado Medical Center, Denver. She then trained in plastic surgery at Yale University School of Medicine, New Haven, CT, and has made outstanding clinical and academic contributions to the field of plastic surgery, especially in the areas of breast and hand surgery, wound healing, introduction of new technology, and workforce issues.

Charles E. Lucas, MD, FACS

A native of Detroit, Dr. Lucas has dedicated his surgical career to his hometown. He earned his undergraduate degree from the University of Detroit and his doctor of medicine degree from Wayne State University (WSU). After completing his residency at WSU, he accepted a position on the WSU surgical faculty, specializing in trauma and surgical critical care.

Ruth L. Bush, MD, JD, MPH, FACS

Dr. Bush received her doctor of medicine degree from the University of North Carolina School of Medicine, Chapel Hill, in 1992. She completed her general surgery residency at the University of California, Davis, Medical Center, where she also spent two additional years as a vascular research fellow. She then finished her vascular surgery fellowship at Emory University Hospital, Atlanta, GA. Serving in several academic positions over her career, Dr. Bush was most recently vice-dean and professor of surgery at Texas A&M College of Medicine, Bryan, TX.

Ms. Klein is Director, Donor Relations and Communications, ACS Foundation, Chicago, IL.

The American College of Surgeons (ACS) Board of Regents approved new officers of the ACS Foundation Board of Directors at the Regents’ February meeting in Chicago, IL. The new officers, who began their two-year terms in February, are Chair Mary H. McGrath, MD, MPH, FACS, professor of surgery, University of California, San Francisco (UCSF); Vice-Chair Charles E. Lucas, MD, FACS, professor of surgery, Wayne State University, Detroit, MI; and Secretary Ruth L. Bush, MD, JD, MPH, FACS, deputy director, the Center for Innovations in Quality, Effectiveness and Safety, a partnership between the Baylor College of Medicine and the Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, TX.

Mary H. McGrath, MD, MPH, FACS

Dr. McGrath is a graduate of St. Louis University School of Medicine, MO, and completed her general surgery residency at the University of Colorado Medical Center, Denver. She then trained in plastic surgery at Yale University School of Medicine, New Haven, CT, and has made outstanding clinical and academic contributions to the field of plastic surgery, especially in the areas of breast and hand surgery, wound healing, introduction of new technology, and workforce issues.

Charles E. Lucas, MD, FACS

A native of Detroit, Dr. Lucas has dedicated his surgical career to his hometown. He earned his undergraduate degree from the University of Detroit and his doctor of medicine degree from Wayne State University (WSU). After completing his residency at WSU, he accepted a position on the WSU surgical faculty, specializing in trauma and surgical critical care.

Ruth L. Bush, MD, JD, MPH, FACS

Dr. Bush received her doctor of medicine degree from the University of North Carolina School of Medicine, Chapel Hill, in 1992. She completed her general surgery residency at the University of California, Davis, Medical Center, where she also spent two additional years as a vascular research fellow. She then finished her vascular surgery fellowship at Emory University Hospital, Atlanta, GA. Serving in several academic positions over her career, Dr. Bush was most recently vice-dean and professor of surgery at Texas A&M College of Medicine, Bryan, TX.

Ms. Klein is Director, Donor Relations and Communications, ACS Foundation, Chicago, IL.

The American College of Surgeons (ACS) Board of Regents approved new officers of the ACS Foundation Board of Directors at the Regents’ February meeting in Chicago, IL. The new officers, who began their two-year terms in February, are Chair Mary H. McGrath, MD, MPH, FACS, professor of surgery, University of California, San Francisco (UCSF); Vice-Chair Charles E. Lucas, MD, FACS, professor of surgery, Wayne State University, Detroit, MI; and Secretary Ruth L. Bush, MD, JD, MPH, FACS, deputy director, the Center for Innovations in Quality, Effectiveness and Safety, a partnership between the Baylor College of Medicine and the Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, TX.

Mary H. McGrath, MD, MPH, FACS

Dr. McGrath is a graduate of St. Louis University School of Medicine, MO, and completed her general surgery residency at the University of Colorado Medical Center, Denver. She then trained in plastic surgery at Yale University School of Medicine, New Haven, CT, and has made outstanding clinical and academic contributions to the field of plastic surgery, especially in the areas of breast and hand surgery, wound healing, introduction of new technology, and workforce issues.

Charles E. Lucas, MD, FACS

A native of Detroit, Dr. Lucas has dedicated his surgical career to his hometown. He earned his undergraduate degree from the University of Detroit and his doctor of medicine degree from Wayne State University (WSU). After completing his residency at WSU, he accepted a position on the WSU surgical faculty, specializing in trauma and surgical critical care.

Ruth L. Bush, MD, JD, MPH, FACS

Dr. Bush received her doctor of medicine degree from the University of North Carolina School of Medicine, Chapel Hill, in 1992. She completed her general surgery residency at the University of California, Davis, Medical Center, where she also spent two additional years as a vascular research fellow. She then finished her vascular surgery fellowship at Emory University Hospital, Atlanta, GA. Serving in several academic positions over her career, Dr. Bush was most recently vice-dean and professor of surgery at Texas A&M College of Medicine, Bryan, TX.

Ms. Klein is Director, Donor Relations and Communications, ACS Foundation, Chicago, IL.

The Coalition for Quality in Geriatric Surgery (CQGS), a multidisciplinary coalition representing the ACS and 58 other stakeholder organizations, has released the first comprehensive set of hospital-level surgical care standards for older adults.

The Coalition for Quality in Geriatric Surgery (CQGS), a multidisciplinary coalition representing the American College of Surgeons (ACS) and 58 other stakeholder organizations, has released the first comprehensive set of hospital-level surgical care standards for older adults. The standards have been published on the Annals of Surgery website ahead of print publication in a report titled “Hospital Standards to Promote Optimal Surgical Care of the Older Adult.” (See the article at bit.ly/2p1TmNC.)

These preliminary standards reflect the shift toward interdisciplinary care of surgical patients, while taking into account the unique physiologic changes related to aging and chronic diseases that can leave older patients at risk for postoperative complications. The standards build upon existing quality indicators, National Quality Forum-endorsed quality measures, and previous work by the ACS, American Geriatrics Society, and John A. Hartford Foundation, which have previously collaborated to develop and release two sets of perioperative guidelines. Standards, however, differ from guidelines, as Julia Berian, MD, lead author and ACS Clinical Scholar, notes. “Standards, as they exist in ACS Quality Programs, are more than recommendations—they are elevated to the level of care practices that are expected to be completed,” Dr. Berian said.

The standards are divided into four categories—continuum of care, clinical care, program management, and patient outcomes and follow-up. CQGS stakeholders rated 308 proposed standards of care for whether they are validated means of improving quality of geriatric surgery and can feasibly be implemented. The reviewers rated 306 of the standards as valid and 304 as feasible.

The preliminary standards are undergoing a two-phase pilot process. The alpha phase, which involved engaging 15 end-user hospitals to gain their insight on the possibility of implementing these standards, is nearing completion. The beta phase, which involves actual implementation of the standards in six hospitals, will occur later this year.

Read the full ACS press release at facs.org/media/press-releases/2017/olderadults040617.

The Coalition for Quality in Geriatric Surgery (CQGS), a multidisciplinary coalition representing the ACS and 58 other stakeholder organizations, has released the first comprehensive set of hospital-level surgical care standards for older adults.

The Coalition for Quality in Geriatric Surgery (CQGS), a multidisciplinary coalition representing the American College of Surgeons (ACS) and 58 other stakeholder organizations, has released the first comprehensive set of hospital-level surgical care standards for older adults. The standards have been published on the Annals of Surgery website ahead of print publication in a report titled “Hospital Standards to Promote Optimal Surgical Care of the Older Adult.” (See the article at bit.ly/2p1TmNC.)

These preliminary standards reflect the shift toward interdisciplinary care of surgical patients, while taking into account the unique physiologic changes related to aging and chronic diseases that can leave older patients at risk for postoperative complications. The standards build upon existing quality indicators, National Quality Forum-endorsed quality measures, and previous work by the ACS, American Geriatrics Society, and John A. Hartford Foundation, which have previously collaborated to develop and release two sets of perioperative guidelines. Standards, however, differ from guidelines, as Julia Berian, MD, lead author and ACS Clinical Scholar, notes. “Standards, as they exist in ACS Quality Programs, are more than recommendations—they are elevated to the level of care practices that are expected to be completed,” Dr. Berian said.

The standards are divided into four categories—continuum of care, clinical care, program management, and patient outcomes and follow-up. CQGS stakeholders rated 308 proposed standards of care for whether they are validated means of improving quality of geriatric surgery and can feasibly be implemented. The reviewers rated 306 of the standards as valid and 304 as feasible.

The preliminary standards are undergoing a two-phase pilot process. The alpha phase, which involved engaging 15 end-user hospitals to gain their insight on the possibility of implementing these standards, is nearing completion. The beta phase, which involves actual implementation of the standards in six hospitals, will occur later this year.

Read the full ACS press release at facs.org/media/press-releases/2017/olderadults040617.

The Coalition for Quality in Geriatric Surgery (CQGS), a multidisciplinary coalition representing the ACS and 58 other stakeholder organizations, has released the first comprehensive set of hospital-level surgical care standards for older adults.

The Coalition for Quality in Geriatric Surgery (CQGS), a multidisciplinary coalition representing the American College of Surgeons (ACS) and 58 other stakeholder organizations, has released the first comprehensive set of hospital-level surgical care standards for older adults. The standards have been published on the Annals of Surgery website ahead of print publication in a report titled “Hospital Standards to Promote Optimal Surgical Care of the Older Adult.” (See the article at bit.ly/2p1TmNC.)

These preliminary standards reflect the shift toward interdisciplinary care of surgical patients, while taking into account the unique physiologic changes related to aging and chronic diseases that can leave older patients at risk for postoperative complications. The standards build upon existing quality indicators, National Quality Forum-endorsed quality measures, and previous work by the ACS, American Geriatrics Society, and John A. Hartford Foundation, which have previously collaborated to develop and release two sets of perioperative guidelines. Standards, however, differ from guidelines, as Julia Berian, MD, lead author and ACS Clinical Scholar, notes. “Standards, as they exist in ACS Quality Programs, are more than recommendations—they are elevated to the level of care practices that are expected to be completed,” Dr. Berian said.

The standards are divided into four categories—continuum of care, clinical care, program management, and patient outcomes and follow-up. CQGS stakeholders rated 308 proposed standards of care for whether they are validated means of improving quality of geriatric surgery and can feasibly be implemented. The reviewers rated 306 of the standards as valid and 304 as feasible.

The preliminary standards are undergoing a two-phase pilot process. The alpha phase, which involved engaging 15 end-user hospitals to gain their insight on the possibility of implementing these standards, is nearing completion. The beta phase, which involves actual implementation of the standards in six hospitals, will occur later this year.

Read the full ACS press release at facs.org/media/press-releases/2017/olderadults040617.

The American College of Surgeons (ACS) International Relations Committee has announced the availability of the following scholarships for 2018.

Community Surgeon Travel Awards

The International Relations Committee of the ACS has announced the availability of Community Surgeon Travel Awards. This new program provides a stipend of $4,000 to enable international surgeons ages 30–50 in regional or community hospitals/clinics or financially challenged surgical departments to attend the ACS Clinical Congress 2018.

The complete requirements and the online application form are posted on the College website at facs.org/member-services/scholarships/international/communitytravel. Applications and all related documents are due July 3. For more information, contact [email protected].

International Guest Scholarships

The International Relations Committee of the ACS has announced the availability of International Guest Scholarships for 2018 to young surgeons from countries other than the U.S. or Canada. The scholarships, in the amount of $10,000 each, provide the scholars with an opportunity to visit clinical, teaching, and research activities in the U.S. or Canada, and to attend and participate fully in the educational opportunities and activities of the ACS Clinical Congress.

The complete requirements and the link to the direct online application form appear online on the College’s website at facs.org/member-services/scholarships/international/igs. Applications and all related documents are due July 3. For more information, contact [email protected].

The American College of Surgeons (ACS) International Relations Committee has announced the availability of the following scholarships for 2018.

Community Surgeon Travel Awards

The International Relations Committee of the ACS has announced the availability of Community Surgeon Travel Awards. This new program provides a stipend of $4,000 to enable international surgeons ages 30–50 in regional or community hospitals/clinics or financially challenged surgical departments to attend the ACS Clinical Congress 2018.

The complete requirements and the online application form are posted on the College website at facs.org/member-services/scholarships/international/communitytravel. Applications and all related documents are due July 3. For more information, contact [email protected].

International Guest Scholarships

The International Relations Committee of the ACS has announced the availability of International Guest Scholarships for 2018 to young surgeons from countries other than the U.S. or Canada. The scholarships, in the amount of $10,000 each, provide the scholars with an opportunity to visit clinical, teaching, and research activities in the U.S. or Canada, and to attend and participate fully in the educational opportunities and activities of the ACS Clinical Congress.

The complete requirements and the link to the direct online application form appear online on the College’s website at facs.org/member-services/scholarships/international/igs. Applications and all related documents are due July 3. For more information, contact [email protected].

The American College of Surgeons (ACS) International Relations Committee has announced the availability of the following scholarships for 2018.

Community Surgeon Travel Awards

The International Relations Committee of the ACS has announced the availability of Community Surgeon Travel Awards. This new program provides a stipend of $4,000 to enable international surgeons ages 30–50 in regional or community hospitals/clinics or financially challenged surgical departments to attend the ACS Clinical Congress 2018.

The complete requirements and the online application form are posted on the College website at facs.org/member-services/scholarships/international/communitytravel. Applications and all related documents are due July 3. For more information, contact [email protected].

International Guest Scholarships

The International Relations Committee of the ACS has announced the availability of International Guest Scholarships for 2018 to young surgeons from countries other than the U.S. or Canada. The scholarships, in the amount of $10,000 each, provide the scholars with an opportunity to visit clinical, teaching, and research activities in the U.S. or Canada, and to attend and participate fully in the educational opportunities and activities of the ACS Clinical Congress.

The complete requirements and the link to the direct online application form appear online on the College’s website at facs.org/member-services/scholarships/international/igs. Applications and all related documents are due July 3. For more information, contact [email protected].