SAN DIEGO – Assessing the risk of kidney disease in diabetes requires estimating the glomerular filtration rate.

“One of the big campaigns is Know Your Numbers, and we think of ABC,” also known as hemoglobin A_1c, blood pressure, and cholesterol levels, noted Andrew Bzowyckyj, PharmD, BCPS, CDE. “Now we have eGFR, which measures kidney function. It’s something quantifiable that patients can follow.”

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SAN DIEGO – Assessing the risk of kidney disease in diabetes requires estimating the glomerular filtration rate.

“One of the big campaigns is Know Your Numbers, and we think of ABC,” also known as hemoglobin A_1c, blood pressure, and cholesterol levels, noted Andrew Bzowyckyj, PharmD, BCPS, CDE. “Now we have eGFR, which measures kidney function. It’s something quantifiable that patients can follow.”

[email protected]

SAN DIEGO – Assessing the risk of kidney disease in diabetes requires estimating the glomerular filtration rate.

“One of the big campaigns is Know Your Numbers, and we think of ABC,” also known as hemoglobin A_1c, blood pressure, and cholesterol levels, noted Andrew Bzowyckyj, PharmD, BCPS, CDE. “Now we have eGFR, which measures kidney function. It’s something quantifiable that patients can follow.”

[email protected]

Imatinib discontinuation is safe in patients with chronic myeloid leukemia (CML) who have sustained deep molecular response with no late molecular recurrence, according to long-term follow-up of the French Stop Imatinib Study (STIM1).

Over a median follow-up of 77 months after treatment discontinuation in 100 patients with CML who had undetectable minimal residual disease (UMRD) for at least 2 years, 61 lost UMRD after a median of 2.5 months, and 1 died with UMRD at 10 months, Gabriel Etienne, MD, of Institut Bergonie, Bordeaux, France, and colleagues reported online in the Journal of Clinical Oncology.

Of the 61 patients who lost UMRD, 57 restarted treatment and 55 achieved a second UMRD at a median of 4.3 months. The median time to second UMRD in patients with molecular recurrence with or without loss of major molecular response at the time of relapse was 4.2 months and 5 months, respectively. At a median of 73 months, none of the patients with molecular recurrence experienced CML progression. The rate of molecular recurrence-free survival overall was 43% at 6 months, 40% at 18 months, and 38% at 60 months, the investigators reported (2016 Oct. 3. doi: 10.1200/JCO.2016.68.2914).

These final long-term results of the STIM1 trial confirm the safety of imatinib discontinuation in CML patients with deep molecular response, and “make treatment-free remission legitimate as a criterion of treatment evaluation in the future,” the investigators concluded, noting that the possibility of improved results in patients treated with second-generation tyrosine kinase inhibitors as first- or second-line therapy is currently being evaluated in ongoing discontinuation trials.
 

[email protected]

Imatinib discontinuation is safe in patients with chronic myeloid leukemia (CML) who have sustained deep molecular response with no late molecular recurrence, according to long-term follow-up of the French Stop Imatinib Study (STIM1).

Over a median follow-up of 77 months after treatment discontinuation in 100 patients with CML who had undetectable minimal residual disease (UMRD) for at least 2 years, 61 lost UMRD after a median of 2.5 months, and 1 died with UMRD at 10 months, Gabriel Etienne, MD, of Institut Bergonie, Bordeaux, France, and colleagues reported online in the Journal of Clinical Oncology.

Of the 61 patients who lost UMRD, 57 restarted treatment and 55 achieved a second UMRD at a median of 4.3 months. The median time to second UMRD in patients with molecular recurrence with or without loss of major molecular response at the time of relapse was 4.2 months and 5 months, respectively. At a median of 73 months, none of the patients with molecular recurrence experienced CML progression. The rate of molecular recurrence-free survival overall was 43% at 6 months, 40% at 18 months, and 38% at 60 months, the investigators reported (2016 Oct. 3. doi: 10.1200/JCO.2016.68.2914).

These final long-term results of the STIM1 trial confirm the safety of imatinib discontinuation in CML patients with deep molecular response, and “make treatment-free remission legitimate as a criterion of treatment evaluation in the future,” the investigators concluded, noting that the possibility of improved results in patients treated with second-generation tyrosine kinase inhibitors as first- or second-line therapy is currently being evaluated in ongoing discontinuation trials.
 

[email protected]

Imatinib discontinuation is safe in patients with chronic myeloid leukemia (CML) who have sustained deep molecular response with no late molecular recurrence, according to long-term follow-up of the French Stop Imatinib Study (STIM1).

Over a median follow-up of 77 months after treatment discontinuation in 100 patients with CML who had undetectable minimal residual disease (UMRD) for at least 2 years, 61 lost UMRD after a median of 2.5 months, and 1 died with UMRD at 10 months, Gabriel Etienne, MD, of Institut Bergonie, Bordeaux, France, and colleagues reported online in the Journal of Clinical Oncology.

Of the 61 patients who lost UMRD, 57 restarted treatment and 55 achieved a second UMRD at a median of 4.3 months. The median time to second UMRD in patients with molecular recurrence with or without loss of major molecular response at the time of relapse was 4.2 months and 5 months, respectively. At a median of 73 months, none of the patients with molecular recurrence experienced CML progression. The rate of molecular recurrence-free survival overall was 43% at 6 months, 40% at 18 months, and 38% at 60 months, the investigators reported (2016 Oct. 3. doi: 10.1200/JCO.2016.68.2914).

These final long-term results of the STIM1 trial confirm the safety of imatinib discontinuation in CML patients with deep molecular response, and “make treatment-free remission legitimate as a criterion of treatment evaluation in the future,” the investigators concluded, noting that the possibility of improved results in patients treated with second-generation tyrosine kinase inhibitors as first- or second-line therapy is currently being evaluated in ongoing discontinuation trials.
 

[email protected]

Congratulations to the recipients of the 2016 Pediatric Hospital Medicine Awards, who were recently recognized at the 2016 Pediatric Hospital Medicine meeting in Chicago. The awards are presented to pediatric hospitalists who make exemplary contributions to hospital medicine, quality improvement, and patient care.

The awards are presented in four categories:

Safety and Quality Improvement

Recipient: Kavita Parikh, MD, Children’s National Medical Center, Washington, D.C.

Dr. Parikh is a member of the Value in Inpatient Pediatrics Network and has worked with the group to improve the care of community-acquired pneumonia. The group has enrolled more than 50 hospitals around the country and one international site to standardize care so that all children hospitalized with pneumonia can receive the same high-quality care, including the use of narrow-spectrum antibiotics.

Educational Achievement and Innovation

Recipient: H. Barrett Fromme, MD, University of Chicago

Dr. Fromme is well known as a leader in pediatric medical education and was instrumental in establishing the Pediatric National Nighttime Curriculum, which includes approximately 75 percent of all residency programs across the U.S. She also led the Advancing Pediatric Educator Excellence Teaching Program for hospitalists, which helps develop their teaching skills. Dr. Fromme has also been named a Master Educator at the University of Chicago Academy of Distinguished Medical Educators.

Research Excellence

Recipient: Derek Williams, MD, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville

Dr. Williams is a pediatric hospitalist whose research activities have focused on respiratory infections in hospitalized children. He has received multiple grants and awards from the Centers for Disease Control and Prevention, National Institutes of Health, and Patient-Centered Outcomes Research Institute and has served as the lead investigator at his institution for the CDC-sponsored study entitled Etiology of Pneumonia in the Community (EPIC), which has generated several publications, including in The New England Journal of Medicine.

Lifetime Achievement

Recipient: Ken Roberts, MD, chairman emeritus, University of North Carolina, Chapel Hill

While he is now retired, Dr. Roberts has served as a mentor to many pediatric hospitalists throughout his storied career and has more than 200 publications, including one in Pediatrics called “A Hospitalist Movement? Where to?”

Congratulations to the recipients of the 2016 Pediatric Hospital Medicine Awards, who were recently recognized at the 2016 Pediatric Hospital Medicine meeting in Chicago. The awards are presented to pediatric hospitalists who make exemplary contributions to hospital medicine, quality improvement, and patient care.

The awards are presented in four categories:

Safety and Quality Improvement

Recipient: Kavita Parikh, MD, Children’s National Medical Center, Washington, D.C.

Dr. Parikh is a member of the Value in Inpatient Pediatrics Network and has worked with the group to improve the care of community-acquired pneumonia. The group has enrolled more than 50 hospitals around the country and one international site to standardize care so that all children hospitalized with pneumonia can receive the same high-quality care, including the use of narrow-spectrum antibiotics.

Educational Achievement and Innovation

Recipient: H. Barrett Fromme, MD, University of Chicago

Dr. Fromme is well known as a leader in pediatric medical education and was instrumental in establishing the Pediatric National Nighttime Curriculum, which includes approximately 75 percent of all residency programs across the U.S. She also led the Advancing Pediatric Educator Excellence Teaching Program for hospitalists, which helps develop their teaching skills. Dr. Fromme has also been named a Master Educator at the University of Chicago Academy of Distinguished Medical Educators.

Research Excellence

Recipient: Derek Williams, MD, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville

Dr. Williams is a pediatric hospitalist whose research activities have focused on respiratory infections in hospitalized children. He has received multiple grants and awards from the Centers for Disease Control and Prevention, National Institutes of Health, and Patient-Centered Outcomes Research Institute and has served as the lead investigator at his institution for the CDC-sponsored study entitled Etiology of Pneumonia in the Community (EPIC), which has generated several publications, including in The New England Journal of Medicine.

Lifetime Achievement

Recipient: Ken Roberts, MD, chairman emeritus, University of North Carolina, Chapel Hill

While he is now retired, Dr. Roberts has served as a mentor to many pediatric hospitalists throughout his storied career and has more than 200 publications, including one in Pediatrics called “A Hospitalist Movement? Where to?”

Congratulations to the recipients of the 2016 Pediatric Hospital Medicine Awards, who were recently recognized at the 2016 Pediatric Hospital Medicine meeting in Chicago. The awards are presented to pediatric hospitalists who make exemplary contributions to hospital medicine, quality improvement, and patient care.

The awards are presented in four categories:

Safety and Quality Improvement

Recipient: Kavita Parikh, MD, Children’s National Medical Center, Washington, D.C.

Dr. Parikh is a member of the Value in Inpatient Pediatrics Network and has worked with the group to improve the care of community-acquired pneumonia. The group has enrolled more than 50 hospitals around the country and one international site to standardize care so that all children hospitalized with pneumonia can receive the same high-quality care, including the use of narrow-spectrum antibiotics.

Educational Achievement and Innovation

Recipient: H. Barrett Fromme, MD, University of Chicago

Dr. Fromme is well known as a leader in pediatric medical education and was instrumental in establishing the Pediatric National Nighttime Curriculum, which includes approximately 75 percent of all residency programs across the U.S. She also led the Advancing Pediatric Educator Excellence Teaching Program for hospitalists, which helps develop their teaching skills. Dr. Fromme has also been named a Master Educator at the University of Chicago Academy of Distinguished Medical Educators.

Research Excellence

Recipient: Derek Williams, MD, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville

Dr. Williams is a pediatric hospitalist whose research activities have focused on respiratory infections in hospitalized children. He has received multiple grants and awards from the Centers for Disease Control and Prevention, National Institutes of Health, and Patient-Centered Outcomes Research Institute and has served as the lead investigator at his institution for the CDC-sponsored study entitled Etiology of Pneumonia in the Community (EPIC), which has generated several publications, including in The New England Journal of Medicine.

Lifetime Achievement

Recipient: Ken Roberts, MD, chairman emeritus, University of North Carolina, Chapel Hill

While he is now retired, Dr. Roberts has served as a mentor to many pediatric hospitalists throughout his storied career and has more than 200 publications, including one in Pediatrics called “A Hospitalist Movement? Where to?”

Selective serotonin reuptake inhibitors taken during pregnancy are linked to a 37% increased risk of speech and language disorders in the children prenatally exposed to them, according to a prospective birth cohort study.

That risk occurs when children exposed prenatally are compared with children whose mothers did not take SSRIs but who had a diagnosis for which the antidepressants are indicated.

“The finding was observed only in offspring of mothers who purchased at least two SSRI prescriptions during pregnancy,” reported Alan S. Brown, MD, of New York State Psychiatric Institute in New York City, and his associates (JAMA Psychiatry. 2016 Oct 12. doi: 10.1001/jamapsychiatry.2016.2594). “This finding is particularly noteworthy because these women were more likely to have taken these medications and were exposed for a longer period and to larger amounts of SSRIs during pregnancy, compared with women who filled only one prescription.”

From among an initial cohort of 845,345 pregnant women in Finland, the researchers followed a final cohort of 56,340 offspring. Most of the children (86.6%) were 9 years old or younger at the end of study follow-up, running from 1996 to 2010, and the oldest children were aged 14 years. The researchers used Finland’s national registries to determine the children’s and mothers’ diagnoses and the mothers’ history of prescriptions from 30 days before pregnancy through delivery.

Among all children, 15,596 children were born to women who took SSRIs for depression or another SSRI-indicated psychiatric condition, and 31,207 children were born to mothers who had neither a psychiatric diagnosis nor a history of taking SSRIs during pregnancy. The remaining 9,537 children had mothers with a psychiatric diagnosis but who did not take SSRIs during pregnancy.

The average ages of the children at diagnosis were 4.4 years for speech or language disorders, 3.6 years for scholastic problems, and 7.7 years for motor disorders. When the researchers compared the children prenatally exposed to SSRIs to the children of mothers with a depression-related diagnosis but not taking SSRIs during pregnancy, the rates of scholastic or motor disorders did not differ.

For language and speech disorders, however, children whose mothers purchased two SSRI prescriptions had a 37% increased risk of a disorder, compared with children whose mothers had a diagnosis but did not purchase SSRIs. Without the requirement of at least two prescriptions, the statistical difference did not exist.

That increased risk occurred after adjustment for sex, mother’s parity, marital status, socioeconomic status, place of residence, both parents’ ages, the children’s gestational age at birth, prenatal exposure to antiepileptic drugs, exposure to anxiolytics/sedatives, history of chronic diseases, death of the child’s parent, mother’s country of birth, maternal smoking or substance abuse, and the psychiatric history of both parents. Data on maternal alcohol consumption were unavailable. Both the children exposed to SSRIs and the children of unmedicated mothers with a psychiatric condition had a higher risk of speech and language disorders.

The research was funded by the National Institutes of Health; the Sackler Foundation of Columbia University, New York; and the University of Turku (Finland). One of the researchers, David Gyllenberg, MD, reported receiving research funding from the Sigrid Juselius Foundation, the Foundation for Pediatric Research in Finland, and the Finnish Medical Foundation. No other conflicts of interest were disclosed.

[email protected]

Selective serotonin reuptake inhibitors taken during pregnancy are linked to a 37% increased risk of speech and language disorders in the children prenatally exposed to them, according to a prospective birth cohort study.

That risk occurs when children exposed prenatally are compared with children whose mothers did not take SSRIs but who had a diagnosis for which the antidepressants are indicated.

“The finding was observed only in offspring of mothers who purchased at least two SSRI prescriptions during pregnancy,” reported Alan S. Brown, MD, of New York State Psychiatric Institute in New York City, and his associates (JAMA Psychiatry. 2016 Oct 12. doi: 10.1001/jamapsychiatry.2016.2594). “This finding is particularly noteworthy because these women were more likely to have taken these medications and were exposed for a longer period and to larger amounts of SSRIs during pregnancy, compared with women who filled only one prescription.”

From among an initial cohort of 845,345 pregnant women in Finland, the researchers followed a final cohort of 56,340 offspring. Most of the children (86.6%) were 9 years old or younger at the end of study follow-up, running from 1996 to 2010, and the oldest children were aged 14 years. The researchers used Finland’s national registries to determine the children’s and mothers’ diagnoses and the mothers’ history of prescriptions from 30 days before pregnancy through delivery.

Among all children, 15,596 children were born to women who took SSRIs for depression or another SSRI-indicated psychiatric condition, and 31,207 children were born to mothers who had neither a psychiatric diagnosis nor a history of taking SSRIs during pregnancy. The remaining 9,537 children had mothers with a psychiatric diagnosis but who did not take SSRIs during pregnancy.

The average ages of the children at diagnosis were 4.4 years for speech or language disorders, 3.6 years for scholastic problems, and 7.7 years for motor disorders. When the researchers compared the children prenatally exposed to SSRIs to the children of mothers with a depression-related diagnosis but not taking SSRIs during pregnancy, the rates of scholastic or motor disorders did not differ.

For language and speech disorders, however, children whose mothers purchased two SSRI prescriptions had a 37% increased risk of a disorder, compared with children whose mothers had a diagnosis but did not purchase SSRIs. Without the requirement of at least two prescriptions, the statistical difference did not exist.

That increased risk occurred after adjustment for sex, mother’s parity, marital status, socioeconomic status, place of residence, both parents’ ages, the children’s gestational age at birth, prenatal exposure to antiepileptic drugs, exposure to anxiolytics/sedatives, history of chronic diseases, death of the child’s parent, mother’s country of birth, maternal smoking or substance abuse, and the psychiatric history of both parents. Data on maternal alcohol consumption were unavailable. Both the children exposed to SSRIs and the children of unmedicated mothers with a psychiatric condition had a higher risk of speech and language disorders.

The research was funded by the National Institutes of Health; the Sackler Foundation of Columbia University, New York; and the University of Turku (Finland). One of the researchers, David Gyllenberg, MD, reported receiving research funding from the Sigrid Juselius Foundation, the Foundation for Pediatric Research in Finland, and the Finnish Medical Foundation. No other conflicts of interest were disclosed.

[email protected]

Selective serotonin reuptake inhibitors taken during pregnancy are linked to a 37% increased risk of speech and language disorders in the children prenatally exposed to them, according to a prospective birth cohort study.

That risk occurs when children exposed prenatally are compared with children whose mothers did not take SSRIs but who had a diagnosis for which the antidepressants are indicated.

“The finding was observed only in offspring of mothers who purchased at least two SSRI prescriptions during pregnancy,” reported Alan S. Brown, MD, of New York State Psychiatric Institute in New York City, and his associates (JAMA Psychiatry. 2016 Oct 12. doi: 10.1001/jamapsychiatry.2016.2594). “This finding is particularly noteworthy because these women were more likely to have taken these medications and were exposed for a longer period and to larger amounts of SSRIs during pregnancy, compared with women who filled only one prescription.”

From among an initial cohort of 845,345 pregnant women in Finland, the researchers followed a final cohort of 56,340 offspring. Most of the children (86.6%) were 9 years old or younger at the end of study follow-up, running from 1996 to 2010, and the oldest children were aged 14 years. The researchers used Finland’s national registries to determine the children’s and mothers’ diagnoses and the mothers’ history of prescriptions from 30 days before pregnancy through delivery.

Among all children, 15,596 children were born to women who took SSRIs for depression or another SSRI-indicated psychiatric condition, and 31,207 children were born to mothers who had neither a psychiatric diagnosis nor a history of taking SSRIs during pregnancy. The remaining 9,537 children had mothers with a psychiatric diagnosis but who did not take SSRIs during pregnancy.

The average ages of the children at diagnosis were 4.4 years for speech or language disorders, 3.6 years for scholastic problems, and 7.7 years for motor disorders. When the researchers compared the children prenatally exposed to SSRIs to the children of mothers with a depression-related diagnosis but not taking SSRIs during pregnancy, the rates of scholastic or motor disorders did not differ.

For language and speech disorders, however, children whose mothers purchased two SSRI prescriptions had a 37% increased risk of a disorder, compared with children whose mothers had a diagnosis but did not purchase SSRIs. Without the requirement of at least two prescriptions, the statistical difference did not exist.

That increased risk occurred after adjustment for sex, mother’s parity, marital status, socioeconomic status, place of residence, both parents’ ages, the children’s gestational age at birth, prenatal exposure to antiepileptic drugs, exposure to anxiolytics/sedatives, history of chronic diseases, death of the child’s parent, mother’s country of birth, maternal smoking or substance abuse, and the psychiatric history of both parents. Data on maternal alcohol consumption were unavailable. Both the children exposed to SSRIs and the children of unmedicated mothers with a psychiatric condition had a higher risk of speech and language disorders.

The research was funded by the National Institutes of Health; the Sackler Foundation of Columbia University, New York; and the University of Turku (Finland). One of the researchers, David Gyllenberg, MD, reported receiving research funding from the Sigrid Juselius Foundation, the Foundation for Pediatric Research in Finland, and the Finnish Medical Foundation. No other conflicts of interest were disclosed.

[email protected]

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Chronic pain that typically follows primary inguinal hernia repair can be significantly reduced by adopting procedures that use underlay mesh rather than overlay mesh, according to a new study published in the Journal of Surgical Research.

“Although chronic pain and discomfort is still one of the greatest problems after inguinal hernia repair due to the fact that it interferes with patients’ quality of life, there are very little data available from previous studies concerning presentation, diagnosis, and modes of treatment of this issue. In particular, the data in the literature concerning the cause of chronic pain are very limited,” wrote the authors, led by Hideyuki Takata, MD, of Nippon Medical School, Tokyo.

Dr. Takata and his coinvestigators looked at patients who underwent a mesh repair operation for primary inguinal hernia at a single institution – Nippon Medical School – between May 2011 and May 2014. All patients were aged 40 years or older, and the overwhelming majority were male. A total of 334 patients were identified, with 378 lesions among them; all patients’ operations were performed via the Lichtenstein (onlay mesh only), Ultrapro Plug (onlay and plug mesh), modified Kugel Patch (onlay and underlay mesh), or laparoscopic transabdominal preperitoneal (underlay mesh only, TAPP) surgical routes.

Forty-four patients had bilateral lesions, 152 had lesions on the right, and 138 on the left; 76 patients received Lichtenstein operations, 85 received Ultrapro Plug, 156 received modified Kugel Patch, and 61 received TAPP. (J Surg Res 2016 Aug 11. doi: 10.1016/j.jss.2016.08.027).

Patients received questionnaires at 2-3 weeks, 3 months, and 6 months after the operation to determine their pain and discomfort levels. Responses for all 378 lesions (100%) were received at the first follow-up, with questionnaires received for 229 lesions (60.5%) at the 3-month follow-up and 249 lesions (65.9%) at the 6-month follow-up. Of those who responded at the 6-month follow-up, 46 received Lichtenstein, 59 received Ultrapro Plug, 101 received modified Kugel Patch, and 61 received TAPP.

No patients reported moderate or severe pain while at rest. Mild pain was reported by 11 (4.4%) of all respondents; 0 of those who received Lichtenstein, 4 (6.8%) of those who received Ultrapro Plug, 7 (6.9%) of those who received modified Kugel Patch, and 0 of those who received TAPP (P less than .01).

Pain with movement was reported in 35 (14.1%) of respondents: 6 (13.0%) of those who received Lichtenstein, 7 (11.9%) of those who received Ultrapro Plug, 20 (19.8%) of those who received modified Kugel Patch, and 2 (4.7%) of those who received TAPP (P less than .05). One respondent reported experiencing moderate pain with movement, and that individual received Ultrapro Plug (1.7%). No patients reported experiencing severe pain with movement.

“We conclude that the sensory nerves in the inguinal region should be kept away from the mesh to prevent the development of chronic pain and discomfort,” the investigators concluded. “Further study is required to determine the mechanism involved in the generation of chronic pain and discomfort to improve the patient’s quality of life after primary inguinal hernia repair.”

No funding source was disclosed for this study. Dr. Takata and his coauthors did not report any relevant financial disclosures.

[email protected]

Chronic pain that typically follows primary inguinal hernia repair can be significantly reduced by adopting procedures that use underlay mesh rather than overlay mesh, according to a new study published in the Journal of Surgical Research.

“Although chronic pain and discomfort is still one of the greatest problems after inguinal hernia repair due to the fact that it interferes with patients’ quality of life, there are very little data available from previous studies concerning presentation, diagnosis, and modes of treatment of this issue. In particular, the data in the literature concerning the cause of chronic pain are very limited,” wrote the authors, led by Hideyuki Takata, MD, of Nippon Medical School, Tokyo.

Dr. Takata and his coinvestigators looked at patients who underwent a mesh repair operation for primary inguinal hernia at a single institution – Nippon Medical School – between May 2011 and May 2014. All patients were aged 40 years or older, and the overwhelming majority were male. A total of 334 patients were identified, with 378 lesions among them; all patients’ operations were performed via the Lichtenstein (onlay mesh only), Ultrapro Plug (onlay and plug mesh), modified Kugel Patch (onlay and underlay mesh), or laparoscopic transabdominal preperitoneal (underlay mesh only, TAPP) surgical routes.

Forty-four patients had bilateral lesions, 152 had lesions on the right, and 138 on the left; 76 patients received Lichtenstein operations, 85 received Ultrapro Plug, 156 received modified Kugel Patch, and 61 received TAPP. (J Surg Res 2016 Aug 11. doi: 10.1016/j.jss.2016.08.027).

Patients received questionnaires at 2-3 weeks, 3 months, and 6 months after the operation to determine their pain and discomfort levels. Responses for all 378 lesions (100%) were received at the first follow-up, with questionnaires received for 229 lesions (60.5%) at the 3-month follow-up and 249 lesions (65.9%) at the 6-month follow-up. Of those who responded at the 6-month follow-up, 46 received Lichtenstein, 59 received Ultrapro Plug, 101 received modified Kugel Patch, and 61 received TAPP.

No patients reported moderate or severe pain while at rest. Mild pain was reported by 11 (4.4%) of all respondents; 0 of those who received Lichtenstein, 4 (6.8%) of those who received Ultrapro Plug, 7 (6.9%) of those who received modified Kugel Patch, and 0 of those who received TAPP (P less than .01).

Pain with movement was reported in 35 (14.1%) of respondents: 6 (13.0%) of those who received Lichtenstein, 7 (11.9%) of those who received Ultrapro Plug, 20 (19.8%) of those who received modified Kugel Patch, and 2 (4.7%) of those who received TAPP (P less than .05). One respondent reported experiencing moderate pain with movement, and that individual received Ultrapro Plug (1.7%). No patients reported experiencing severe pain with movement.

“We conclude that the sensory nerves in the inguinal region should be kept away from the mesh to prevent the development of chronic pain and discomfort,” the investigators concluded. “Further study is required to determine the mechanism involved in the generation of chronic pain and discomfort to improve the patient’s quality of life after primary inguinal hernia repair.”

No funding source was disclosed for this study. Dr. Takata and his coauthors did not report any relevant financial disclosures.

[email protected]

Chronic pain that typically follows primary inguinal hernia repair can be significantly reduced by adopting procedures that use underlay mesh rather than overlay mesh, according to a new study published in the Journal of Surgical Research.

“Although chronic pain and discomfort is still one of the greatest problems after inguinal hernia repair due to the fact that it interferes with patients’ quality of life, there are very little data available from previous studies concerning presentation, diagnosis, and modes of treatment of this issue. In particular, the data in the literature concerning the cause of chronic pain are very limited,” wrote the authors, led by Hideyuki Takata, MD, of Nippon Medical School, Tokyo.

Dr. Takata and his coinvestigators looked at patients who underwent a mesh repair operation for primary inguinal hernia at a single institution – Nippon Medical School – between May 2011 and May 2014. All patients were aged 40 years or older, and the overwhelming majority were male. A total of 334 patients were identified, with 378 lesions among them; all patients’ operations were performed via the Lichtenstein (onlay mesh only), Ultrapro Plug (onlay and plug mesh), modified Kugel Patch (onlay and underlay mesh), or laparoscopic transabdominal preperitoneal (underlay mesh only, TAPP) surgical routes.

Forty-four patients had bilateral lesions, 152 had lesions on the right, and 138 on the left; 76 patients received Lichtenstein operations, 85 received Ultrapro Plug, 156 received modified Kugel Patch, and 61 received TAPP. (J Surg Res 2016 Aug 11. doi: 10.1016/j.jss.2016.08.027).

Patients received questionnaires at 2-3 weeks, 3 months, and 6 months after the operation to determine their pain and discomfort levels. Responses for all 378 lesions (100%) were received at the first follow-up, with questionnaires received for 229 lesions (60.5%) at the 3-month follow-up and 249 lesions (65.9%) at the 6-month follow-up. Of those who responded at the 6-month follow-up, 46 received Lichtenstein, 59 received Ultrapro Plug, 101 received modified Kugel Patch, and 61 received TAPP.

No patients reported moderate or severe pain while at rest. Mild pain was reported by 11 (4.4%) of all respondents; 0 of those who received Lichtenstein, 4 (6.8%) of those who received Ultrapro Plug, 7 (6.9%) of those who received modified Kugel Patch, and 0 of those who received TAPP (P less than .01).

Pain with movement was reported in 35 (14.1%) of respondents: 6 (13.0%) of those who received Lichtenstein, 7 (11.9%) of those who received Ultrapro Plug, 20 (19.8%) of those who received modified Kugel Patch, and 2 (4.7%) of those who received TAPP (P less than .05). One respondent reported experiencing moderate pain with movement, and that individual received Ultrapro Plug (1.7%). No patients reported experiencing severe pain with movement.

“We conclude that the sensory nerves in the inguinal region should be kept away from the mesh to prevent the development of chronic pain and discomfort,” the investigators concluded. “Further study is required to determine the mechanism involved in the generation of chronic pain and discomfort to improve the patient’s quality of life after primary inguinal hernia repair.”

No funding source was disclosed for this study. Dr. Takata and his coauthors did not report any relevant financial disclosures.

[email protected]

Patients who have chronic lymphocytic leukemia and achieve minimal residual disease negativity have a high probability of long-term progression-free and overall survival, irrespective of the type of therapy they receive, reported Marwan Kwok, MD, of Queen Elizabeth Hospital Birmingham (England) and colleagues.

Minimal residual disease (MRD) negativity, defined as less than 1 chronic lymphocytic leukemic (CLL) cell detectable per 10,000 leukocytes, has been shown to independently predict clinical outcome in the front line setting, but the long-term prognostic value of MRD status in other therapeutic settings remains unclear. “Our results demonstrate the long-term benefit of achieving MRD negativity regardless of the therapeutic setting and treatment modality, and support its use as a prognostic marker for long-term PFS (progression-free survival) and as a potential therapeutic goal in CLL,” the authors wrote (Blood. 2016 Oct 3. doi: 10.1182/blood-2016-05-714162).

The researchers retrospectively analyzed, with up to 18 years of follow-up, all 133 CLL patients at St. James’s University Hospital in Leeds, England, who achieved at least a partial response with various therapies between 1996 and 2007 and who received a bone marrow MRD assessment at the end of treatment, according to the international harmonized approach.

MRD negativity correlated with progression-free and overall survival, and the association was independent of the type and line of treatment, as well as adverse cytogenetic findings, the investigators said.

For those who achieved MRD negativity in front-line treatment, the 10-year progression-free survival was 65%; survival in patients who did not achieve MRD negativity was 10%. Overall survival at 10 years was 70% for those who achieved MRD negativity and 30% for MRD-positive patients.

The authors had no relevant financial disclosures.

[email protected]

Patients who have chronic lymphocytic leukemia and achieve minimal residual disease negativity have a high probability of long-term progression-free and overall survival, irrespective of the type of therapy they receive, reported Marwan Kwok, MD, of Queen Elizabeth Hospital Birmingham (England) and colleagues.

Minimal residual disease (MRD) negativity, defined as less than 1 chronic lymphocytic leukemic (CLL) cell detectable per 10,000 leukocytes, has been shown to independently predict clinical outcome in the front line setting, but the long-term prognostic value of MRD status in other therapeutic settings remains unclear. “Our results demonstrate the long-term benefit of achieving MRD negativity regardless of the therapeutic setting and treatment modality, and support its use as a prognostic marker for long-term PFS (progression-free survival) and as a potential therapeutic goal in CLL,” the authors wrote (Blood. 2016 Oct 3. doi: 10.1182/blood-2016-05-714162).

The researchers retrospectively analyzed, with up to 18 years of follow-up, all 133 CLL patients at St. James’s University Hospital in Leeds, England, who achieved at least a partial response with various therapies between 1996 and 2007 and who received a bone marrow MRD assessment at the end of treatment, according to the international harmonized approach.

MRD negativity correlated with progression-free and overall survival, and the association was independent of the type and line of treatment, as well as adverse cytogenetic findings, the investigators said.

For those who achieved MRD negativity in front-line treatment, the 10-year progression-free survival was 65%; survival in patients who did not achieve MRD negativity was 10%. Overall survival at 10 years was 70% for those who achieved MRD negativity and 30% for MRD-positive patients.

The authors had no relevant financial disclosures.

[email protected]

Patients who have chronic lymphocytic leukemia and achieve minimal residual disease negativity have a high probability of long-term progression-free and overall survival, irrespective of the type of therapy they receive, reported Marwan Kwok, MD, of Queen Elizabeth Hospital Birmingham (England) and colleagues.

Minimal residual disease (MRD) negativity, defined as less than 1 chronic lymphocytic leukemic (CLL) cell detectable per 10,000 leukocytes, has been shown to independently predict clinical outcome in the front line setting, but the long-term prognostic value of MRD status in other therapeutic settings remains unclear. “Our results demonstrate the long-term benefit of achieving MRD negativity regardless of the therapeutic setting and treatment modality, and support its use as a prognostic marker for long-term PFS (progression-free survival) and as a potential therapeutic goal in CLL,” the authors wrote (Blood. 2016 Oct 3. doi: 10.1182/blood-2016-05-714162).

The researchers retrospectively analyzed, with up to 18 years of follow-up, all 133 CLL patients at St. James’s University Hospital in Leeds, England, who achieved at least a partial response with various therapies between 1996 and 2007 and who received a bone marrow MRD assessment at the end of treatment, according to the international harmonized approach.

MRD negativity correlated with progression-free and overall survival, and the association was independent of the type and line of treatment, as well as adverse cytogenetic findings, the investigators said.

For those who achieved MRD negativity in front-line treatment, the 10-year progression-free survival was 65%; survival in patients who did not achieve MRD negativity was 10%. Overall survival at 10 years was 70% for those who achieved MRD negativity and 30% for MRD-positive patients.

The authors had no relevant financial disclosures.

[email protected]

CD49d was a strong predictor of overall survival in a cohort of 778 unselected patients with chronic lymphocytic leukemia, reported Michele Dal Bo, MD, of Centro di Riferimento Oncologico, in Aviano, Italy, and colleagues.

©Ed Uthman/Flickr

[email protected]

CD49d was a strong predictor of overall survival in a cohort of 778 unselected patients with chronic lymphocytic leukemia, reported Michele Dal Bo, MD, of Centro di Riferimento Oncologico, in Aviano, Italy, and colleagues.

©Ed Uthman/Flickr

[email protected]

CD49d was a strong predictor of overall survival in a cohort of 778 unselected patients with chronic lymphocytic leukemia, reported Michele Dal Bo, MD, of Centro di Riferimento Oncologico, in Aviano, Italy, and colleagues.

©Ed Uthman/Flickr

[email protected]

Nearly half of all intensive care unit hospitalizations among terminal oncology patients in a retrospective case review were identified as potentially avoidable.

The findings suggest a need for strategies to prospectively identify patients at risk for ICU admission and to formulate interventions to improve end-of-life care, wrote Bobby Daly, MD, and colleagues at the University of Chicago. The report was published in the Journal of Oncology Practice.

[email protected]

Nearly half of all intensive care unit hospitalizations among terminal oncology patients in a retrospective case review were identified as potentially avoidable.

The findings suggest a need for strategies to prospectively identify patients at risk for ICU admission and to formulate interventions to improve end-of-life care, wrote Bobby Daly, MD, and colleagues at the University of Chicago. The report was published in the Journal of Oncology Practice.

[email protected]

Nearly half of all intensive care unit hospitalizations among terminal oncology patients in a retrospective case review were identified as potentially avoidable.

The findings suggest a need for strategies to prospectively identify patients at risk for ICU admission and to formulate interventions to improve end-of-life care, wrote Bobby Daly, MD, and colleagues at the University of Chicago. The report was published in the Journal of Oncology Practice.

[email protected]

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.