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Perceived core competency achievements of fellowship and non‐fellowship‐trained early career pediatric hospitalists

Author(s)

Pediatric hospital medicine (PHM) has established itself as a well‐defined field of pediatrics dedicated to improving the care of hospitalized children.[1] In 2010, the PHM core competencies were established to identify a specific knowledge base and skill set needed to provide the highest quality care for hospitalized children.[2] With these competencies, many are re‐evaluating training needs, particularly given the rapid advancement of the field.[1, 3] Previous workforce evaluations estimated that less than half of hospitalists surveyed had any specific hospitalist training.[4] In 2004 and 2008, studies of the current roles and training needs of pediatric hospitalists revealed advanced training needs in administration, research, quality improvement (QI), and education.[5, 6] Currently, there are 27 US PHM fellowship programs, but the majority of hospitalists are entering the field without PHM‐specific training. There is little evidence regarding our current residency and fellowship training models' abilities to help participants achieve proficiency in the PHM core competencies.

The objectives of this study were to compare the perceived PHM core competency achievements of fellowship and non‐fellowship‐trained early career pediatric hospitalists and identify perceived knowledge gaps in our current training models.

METHODS

Study Design

An anonymous Web‐based survey was conducted in November 2013. The survey was electronically distributed to the American Academy of Pediatrics (AAP) Section on Hospital Medicine (SOHM) Listserv, current PHM fellows present at the annual PHM Fellows Conference, as well as PHM division directors and fellowship directors to distribute to eligible hospitalists. The AAP SOHM Listserv functions as a convenience sample, representing the single largest listing of pediatric hospitalists, currently with over 2100 subscribers (email communication with Nicole Alexander, AAP Manager of the Division of Hospital and Surgical Services). An email announcing the survey was distributed to the aforementioned parties with 1 reminder email sent to the SOHM Listserv encouraging participation.

Inclusion criteria were current practicing hospitalists who had graduated from a US Accreditation Council for Graduate Medical Education‐approved residency program within the last 5 years. Recruiting individuals within 5 years of residency graduation was chosen in an effort to capture the experience of our current training models. Practicing hospitalists included current PHM fellows, PHM fellowship graduates (both defined as fellowship‐trained), and non‐fellowship‐trained individuals.

Survey Development

The survey obtained demographic data including type of residency training, chief residency, postresidency training, advanced degrees, practice environment, and professional positions. Competency was self‐assessed using an interactive sliding scale where participants could indicate their perceived competency by placing the cursor along a continuum with the anchors novice, competent, and expert. Each anchor was defined as follows: novice is the inability to perform the skill or require supervision/assistance to complete the activity; competent is the ability to perform unsupervised execution of a task, not requiring substantial mastery or advanced ability; and expert is demonstrating initiative and adaptability to special problem situations and can lead others in performing the skill.[7] Cursor position along the sliding scale was converted by the survey tool to a value from 0 to 100 for data analysis. Within each group, a mean score below 50 was considered an area respondents perceived themselves less than competent. Select PHM core competencies were chosen in consultation with the authors of the PHM core competencies to provide a representative sample from each of the 4 domains (Table 1) as well as restrict the survey to a reasonable length. The survey was pilot tested in small groups and revised for content and readability based on the feedback received.

Table 1.Pediatric Hospital Medicine Core Competencies
Clinical Diagnosis	Core Skills	Specialized Clinical Skills	Healthcare Systems
Abbreviations: ALTE, apparent life‐threatening event; CNS, central nervous system; ECG, electrocardiogram; IV, intravenous; PALS, pediatric advanced life support; UTI, urinary tract infection. *Competency assessed in the survey.
Abdominal pain	Bladder catheterization	Child abuse*	Advocacy*
ALTE	ECG interpretation	Hospice and palliative care	Business practice*
Asthma	Feeding tubes	Leading healthcare team*	Communication
Bone and joint infection	Fluid/electrolytes	Newborn care*	Quality improvement*
Bronchiolitis	IV access/ phlebotomy*	Technology‐dependent children*	Cost‐effective care*
CNS infections	Lumbar puncture*	Transport of the critically ill	Education*
Diabetes	Noninvasive monitoring		Evidence‐based medicine*
Failure to thrive	Nutrition*		Health information systems
Fever unknown origin	Oxygen delivery and airway management		Legal, risk management
Gastroenteritis	Pain management*		Patient safety*
Kawasaki disease	PALS		Research*
Neonatal fever	Procedural sedation*		Transitions of care*
Neonatal jaundice	Radiographic interpretation
Pneumonia
Respiratory failure
Seizures
Shock
Sickle cell disease
Skin and soft tissue infection
Upper airway infections
UTI
Single summative question included in the survey.

Data Collection

Study data were collected and managed using the Research Electronic Data Capture (REDcap) tool hosted at Children's National Health System. REDcap is a secure, Web‐based application designed to support data capture for research studies.[8]

Data Analysis

Analysis was performed using SPSS version 22 (IBM, Armonk, NY). Demographic data comparing fellowship‐trained and non‐fellowship‐trained individuals were analyzed by [2] testing for categorical variables. Mean competency values between non‐fellows and those who have completed or are in the process of completing fellowship were analyzed using multiprobit regression. Values were adjusted for years since residency graduation (regardless of whether the individual was a current fellow, a fellowship graduate, or non‐fellowship‐trained), type of residency, and chief residency. P values were calculated based on the estimate and standard error of the slope term within the probit model. The effect of fellowship was qualitatively analyzed by comparing the values between the groups at different years since residency graduation. Incomplete data were excluded only for responses missing.

Institutional review board approval was obtained from Children's National Medical Center in Washington, DC.

RESULTS

One hundred ninety‐seven pediatric hospitalists responded to the survey. All were included in the analysis. One hundred forty‐seven respondents were non‐fellowship‐trained and 50 were PHM fellowship graduates or current PHM fellows. Demographic characteristics are listed in Table 2. Current and former PHM fellows were on average 2.1 years from residency graduation, whereas non‐fellowship‐trained hospitalists were 2.6 years from residency graduation (P=0.05). A significantly higher proportion of fellowship‐trained hospitalists reported working at a university‐affiliated free‐standing children's hospital, whereas a higher proportion of non‐fellowship‐trained hospitalists reported working at a non‐university‐affiliated community hospital. The majority of practice domains included hospitalists worked were similar between the 2 groups. A significantly higher proportion of fellowship‐trained hospitalists reported working in research and QI/safety. Surgical comanagement and newborn nursery were domains a significantly higher proportion of non‐fellowship‐trained hospitalists reported working.

Table 2.Demographics
	Fellowship Trained, n=50	Non‐Fellowship‐Trained, n=147	P Value
NOTE: Abbreviations: NICU, neonatal intensive care unit; PICU, pediatric intensive care unit, ED, emergency department.
Average years experience (since residency graduation)	2.1	2.6	0.05
Type of residency			0.82
Pediatric	48 (96%)	140 (95%)
Medicine‐pediatric	2 (4%)	7 (5%)
Family medicine	0	0
Chief residency	17 (34%)	37 (25%)	0.23
Advanced degree obtained			0.12
Master's Public Health	2 (4%)	8 (5.5%)
Master's of Education	0	1 (0.7%)
Master's Clinical and Translational Research	1 (2%)	0
Master's Business Administration	1 (2%)	0
PhD	0	1 (0.7%)
Other	3 (6%)	8 (5.5%)
Currently pursuing	14 (28%)	6 (4.1%)
Practice environment
University‐affiliated free‐standing children's hospital	40 (80%)	68 (46.3%)	<0.001
University‐affiliated pediatric ward	7 (14%)	37 (25.2%)	0.1
University‐affiliated community hospital	2 (4%)	25 (17%)	0.02
Non‐university affiliated community hospital	2 (4%)	35 (23.8%)	0.002
Practice domain
General pediatrics inpatient unit	49/49 (100%)	139/143 (97.2%)	0.24
Subspecialty wards	19/46 (41.3%)	47/130 (36.1%)	0.54
Surgical comanagement	36/46 (78.3%)	119/133 (89.5%)	0.05
NICU	8/47 (17.0%)	36/128 (28.1%)	0.13
PICU	11/47 (17.0%)	16/126 (12.0%)	0.08
Intermediate care unit	17/47 (36.2%)	36/128 (28.1%)	0.09
ED	16/47 (34.0%)	55/128 (43.0%)	0.42
Newborn nursery	11/45 (24.4%)	68/132 (51.5%)	0.002
Sedation	20/48 (41.7%)	48/133 (36.1%)	0.49
Medical education	47/48 (97.9%)	123/137 (89.8%)	0.08
Hospital committee work	42/48 (87.5%)	109/138 (79.0%)	0.3
Research	44/49 (90.0%)	72/137 (52.6%)	<0.001
Quality improvement/safety	44/48 (91.7%)	103/134 (76.9%)	0.003
Advocacy	23/47 (47.9%)	49/128 (38.2%)	0.19

The adjusted mean perceived competency scores for fellowship and non‐fellowship‐trained hospitalists are shown in Table 3. Reported competency scores for management of common acute inpatient medical conditions in an otherwise healthy child were similar between the 2 groups. Both fellowship and non‐fellowship‐trained hospitalists reported feeling less than competent (scores <50) in sedation, understanding basic components of PHM business practice, and defining a relative value unit. Fellowship‐trained hospitalists indicated perceived competency (scores >50) in the remainder of the competencies surveyed. Non‐fellowship‐trained hospitalists additionally had average scores <50 with statistically significant lower reported competency scores than fellowship‐trained hospitalists in IV access/phlebotomy, managing emergencies in technology‐dependent children, performing Plan‐Do‐Study‐Act (PDSA) cycles to achieve QI, performing root‐cause analysis (RCA), defining basic statistical terms, and identifying resources required to conduct research. Non‐fellowship‐trained hospitalists reported statistically significant higher mean competency scores in pain management, newborn care, and transitions in care. In each of these competencies, though, mean scores for both groups were in the competent range.

Table 3.Adjusted Mean Competency Scores by Training
Core Competency	Fellowship Trained, n=50	Non‐Fellowship‐Trained, n=147	P Value
NOTE: Scale: 0=novice, 50=competent, 100=expert. Abbreviations: FCR, family‐centered rounds; IV, intravenous; PDSA, Plan‐Do‐Study‐Act; RCA, root‐cause analysis; RVU, relative value unit.
Common diagnoses	78.4	78.6	0.717
Core skills
IV access/phlebotomy	52.9	30.6	0.012
Lumbar puncture	76.2	77.0	0.245
Sedation	30.9	28.3	0.001
Pain management	70.7	72.6	0.014
Nutrition	68.0	66.1	0.026
Specialized clinical skills
Leading a health care team
Team leadership	74.9	72.0	<0.001
FCR	75.3	72.6	<0.001
Technology‐dependent patient
General management	71.4	65.9	<0.001
Emergencies	53.2	49.4	<0.001
Newborn care	56.6	61.6	<0.001
Child abuse
Diagnosing	68.6	68.7	0.925
Reporting	68.9	68.5	0.630
Healthcare systems
Transitions in care	77.4	79.6	0.002
Advocacy	57.4	53.5	<0.001
Business practice
Basic components	36.4	32.0	<0.001
Concept of RVU	30.2	30.2	0.972
Billing/coding	61.4	63.9	0.004
Quality Improvement
PDSA cycles	63.7	42.8	<0.001
Best practice guidelines	64.7	51.8	<0.001
Safety
Identify and address harm	65.9	59.1	<0.001
Perform RCA	56.7	36.0	<0.001
Cost‐effective care	58.4	51.6	<0.001
Medical education
Needs assessment	69.4	65.6	<0.001
Large group teaching	67.6	60.6	<0.001
Small group teaching	74.2	72.6	0.040
Feedback	73.8	68.9	<0.001
Evidence‐based medicine
Literature search	75.9	69.0	<0.001
Literature appraisal	63.4	57.2	<0.001
Apply study results	70.2	64.8	<0.001
Research
Comparing study design	62.6	54.1	<0.001
Basic statistics	57.2	41.7	<0.001
Identifying resources	56.0	36.1	<0.001

The mean adjusted competency scores in areas with some of the largest differences between the 2 groups were plotted by time since residency graduation and depicted in Figure 1. This does not represent a single cohort of hospitalists over time, rather individual hospitalists at different post‐graduate years from their residency graduation. In performing PDSA cycles, fellowship‐trained hospitalists 1 year postresidency graduation reported a mean score indicating competency (57.3), whereas only non‐fellowship‐trained hospitalists 3 to 5 years postresidency graduation reported a mean score approaching competency (49.1) (Figure 1A). For development of best practice guidelines, fellowship‐trained hospitalists 1 year postresidency graduation reported a mean competency score (61.8), similar to non‐fellowship‐trained hospitalists 3 to 5 years postresidency graduation (60.8) (Figure 1B). Competency in performing RCA was reported by fellowship‐trained hospitalists 2 years postresidency (72.1), whereas non‐fellowship‐trained hospitalists up to 5 years post‐residency report a mean score below competency (Figure 1C). Regarding research competencies, fellowship‐trained hospitalists reported increased perceived competency at each year postresidency graduation, whereas non‐fellowship‐trained hospitalists reported lower mean competency scores with each year post‐residency (Figure 1D,E).

Mean perceived competency by experience.

DISCUSSION

Our study results reveal significant differences in perceived competency between fellowship‐trained and non‐fellowship‐trained hospitalists, identifying several perceived knowledge gaps. Early career hospitalists, regardless of their training, perceive they have not achieved competency in sedation and aspects of PHM business practice. Early career hospitalists who did not pursue PHM fellowship training reported also feeling less than competent in intravenous access/phlebotomy, managing emergencies in technology‐dependent children, performing PDSA cycles to achieve QI, performing RCA, defining basic statistical terms, and identifying resources required to conduct research. Although both groups perceived themselves as competent in newborn care, pain management, and transitions in care, non‐fellowship‐trained hospitalists did report statistically significant higher competency scores compared to fellowship‐trained hospitalists in these skills.

Our findings support previous studies on the roles and training needs of pediatric hospitalists. In 2004, Ottolini et al. conducted a survey of pediatric hospitalists through Pediatric Research in Inpatient Settings, finding additional training needs in program/division management, practice guidelines, QI, safety, teaching, evidence‐based medicine (EBM), and research. The majority of hospitalists surveyed did not believe their pediatric residency training provided all of the skills necessary to practice as pediatric hospitalists.[5] Maniscalco et al. repeated the study in 2008 with similar findings.[6] In the field of adult internal medicine, Plauth et al. surveyed practicing hospitalists regarding the adequacy of their residency training, and found that systems issues (ie, QI, health economics, practice guidelines development) were reported as important to their current practice and not adequately emphasized in residency training.[9] Collectively, these findings highlight the need to critically evaluate our current training models' ability to prepare an individual for a career in hospital medicine. There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified,[1] but it is important to identify where the current knowledge gaps exist to optimize this process.

Not surprisingly, the majority of the hospitalists surveyed self‐reported competency in most of the clinical skills included. Residency training is heavily weighted toward acquisition of clinical skills, with a significant amount of time spent on inpatient clinical rotations.[10] The exception was sedation, which had some of the lowest mean perceived competency scores for all early career hospitalists surveyed. There is growing demand for safe and effective procedural sedation nationally, and pediatric hospitalists have been recognized as well poised to augment sedation services provided by anesthesiologists.[11, 12] This study demonstrates that current residency and PHM fellowship training may not adequately address this skill set to produce hospitalists prepared to take on this potential role.

Significant findings in the non‐clinical domains were the healthcare systems competencies. It is increasingly evident that a hospitalist's job description includes addressing communication, coordination of care, quality of care, and patient safety.[13] Yet, our findings indicate that non‐fellowship‐trained early career hospitalists do not feel competent in several of these aspects of hospital medicine practice. Our findings suggest that residency training alone may not provide adequate instruction for perceived competency, as no hospitalists with <1 year since residency graduation reported competency in PDSA cycles, best practice guidelines, and RCA. Interestingly, examining these competencies at different years following residency graduation, experience alone also does not ensure perceived competency early in one's career. Hospitalists are establishing themselves as a catalyst for change and the driving forces behind healthcare systems improvements within the hospital setting, often as our value added to an institution.[14, 15, 16, 17] Therefore, every pediatric hospitalist will need to acquire competency in these skills in a timely manner to effectively deliver high‐quality care to hospitalized children.

Finally, research was another area in which non‐fellowship‐trained hospitalists had low self‐perceived competency. When evaluating competency at different years postresidency graduation, non‐fellowship‐trained individuals appeared to lose a sense of competency each year, whereas fellowship‐trained hospitalists reported escalating competency with each year post‐residency. This finding may be due to the fellowship training itself, mentorship established in fellowship, or resources available in their chosen practice environment following fellowship. In 2011, Bekmezian et al. found that the majority of pediatric hospitalists wanted to conduct research but cited lack of dedicated time and mentorship as barriers to their productivity.[18] High‐quality studies including clinical, QI, and comparative effectiveness research are necessary to allow practicing hospitalists to make better decisions regarding patient care and to advance the field. This need transcends practice environment evidenced by the latest movement to transition away from the more traditional academic and non‐academic nomenclature. Even if one is not planning to conduct research, a basic foundation of research knowledge is required to critically appraise literature and apply EBM principles to clinical practice. This study suggests these skills are not being adequately obtained in residency for perceived competency or acquired with experience alone early in one's career.

There are several limitations of this study that should be considered. Most notably, the competency scores are based on self‐perceived assessments and therefore are not validated with objective measures of an individual's knowledge and skill, risking bias based on an individual's level of personal insight. We also did not quantify differences in training experience based on specific institutions, residency size, patient volume, and exposure to a hospitalist service, which could influence perceived competency and generalizability. Similarly, there is wide variation in current PHM fellowship curriculums, which is not accounted for in this study. Professional competency is challenging to define as well as measure.[19] Although this study is based on subjective measures, one can postulate that self‐perceived competency may impact an individual's approach to clinical practice, projects pursued, and career aspirations.

A second significant limitation was our inability to accurately determine a response rate. Other pediatric hospitalist surveys have faced similar limitations utilizing the AAP SOHM Listserv, because there is no centralized database of practicing hospitalists.[18, 20, 21] Attempts to collect workforce data from the American Board of Pediatrics (ABP) regarding estimates of the number of hospitalists within 5 years of their residency graduation revealed that they changed their data collection methods during our study period, therefore direct comparisons could not be made before and after 2012 (email communication with Cathy Koenig, Psychometric Data Analyst, ABP). Additionally, the AAP SOHM Listserv does not collect demographic data on subscribers, therefore we were unable to determine how many of the 2100 subscribers are within 5 years of their residency graduation. Nevertheless, it is the largest listserv of pediatric hospitalists and enabled us to attempt to collect data from the most representative population. PHM fellowship programs have also rapidly expanded, and only recently has there been a more centralized, comprehensive database of programs and fellows. With the available information, we could not accurately estimate a response rate. Despite the potential for response bias and small sample size, we feel the information collected is a valuable first look at important and timely data that can inform future studies.

Overall, this study provides important information regarding the perceived competency of early career pediatric hospitalists. Although different practice environments may afford different experiences and influence competency over time, we believe the majority of the PHM core competencies transcend practice environment and are ones all early career hospitalists should strive to achieve. To ensure the ongoing advancement of our field, we must guarantee that hospitalists are provided the resources and training to attain these competencies. This may include developing hospital medicine residency tracks, continuing medical education offerings, and/or PHM fellowships whose objectives are aligned with the established core competencies. Although this study was not designed to determine which of these options are optimal, the results can help identify the existing gaps to inform curriculum development in the future. As our field continues to evolve and advance, it will be important to continuously re‐evaluate our training programs' abilities to produce pediatric hospitalists with clinical, quality, scholarly, and leadership skills that meet our field's core competency standards.

CONCLUSIONS

Early career pediatric hospitalists report deficits in several of the PHM core competencies, which should be considered when designing PHM‐specific training in the future. PHM fellowship‐trained hospitalists report higher levels of self‐perceived competency in many core areas.

Disclosure: Nothing to report.

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References

Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7(4):329–334.
Stucky ER, Maniscalco J, Ottolini MC, et al. The Pediatric Hospital Medicine Core Competencies Supplement: a Framework for Curriculum Development by the Society of Hospital Medicine with acknowledgement to pediatric hospitalists from the American Academy of Pediatrics and the Academic Pediatric Association. J Hosp Med. 2010;5(suppl 2):i–xv, 1–114.
Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can't stand still. JAMA Pediatr. 2013;167(5):412–413.
Freed GL, Dunham KM, Research Advisory Committee of the American Board of Pediatrics. Pediatric hospitalists: training, current practice, and career goals. J Hosp Med. 2009;4(3):179–186.
Ottolini MC, Landrigan CP, Chiang VW, Stucky ER. PRIS Survey: pediatric hospitalist roles and training needs. Pediatr Res. 2004;55:360A.
Maniscalco J, Ottolini M, Stucky E, Landrigan C, Dhepyasuwan N. Current roles and training needs of pediatric hospitalists: a study from the Pediatric Research in Inpatient Settings (PRIS) Network. Paper presented at: Pediatric Academic Societies; 2008; Honolulu, HI.
Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills. Acad Med. 2008;83(8):761–767.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research Electronic Data Capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.
Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247–254.
Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Pediatrics. 2012. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/320_pediatrics_07012013.pdf. Accessed August 14, 2014.
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Bekmezian A, Teufel RJ, Wilson KM. Research needs of pediatric hospitalists. Hosp Pediatr. 2011;1(1):38–44.
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METHODS

Study Design

Survey Development

Table 1.Pediatric Hospital Medicine Core Competencies
Clinical Diagnosis	Core Skills	Specialized Clinical Skills	Healthcare Systems
Abbreviations: ALTE, apparent life‐threatening event; CNS, central nervous system; ECG, electrocardiogram; IV, intravenous; PALS, pediatric advanced life support; UTI, urinary tract infection. *Competency assessed in the survey.
Abdominal pain	Bladder catheterization	Child abuse*	Advocacy*
ALTE	ECG interpretation	Hospice and palliative care	Business practice*
Asthma	Feeding tubes	Leading healthcare team*	Communication
Bone and joint infection	Fluid/electrolytes	Newborn care*	Quality improvement*
Bronchiolitis	IV access/ phlebotomy*	Technology‐dependent children*	Cost‐effective care*
CNS infections	Lumbar puncture*	Transport of the critically ill	Education*
Diabetes	Noninvasive monitoring		Evidence‐based medicine*
Failure to thrive	Nutrition*		Health information systems
Fever unknown origin	Oxygen delivery and airway management		Legal, risk management
Gastroenteritis	Pain management*		Patient safety*
Kawasaki disease	PALS		Research*
Neonatal fever	Procedural sedation*		Transitions of care*
Neonatal jaundice	Radiographic interpretation
Pneumonia
Respiratory failure
Seizures
Shock
Sickle cell disease
Skin and soft tissue infection
Upper airway infections
UTI
Single summative question included in the survey.

Data Collection

Data Analysis

Institutional review board approval was obtained from Children's National Medical Center in Washington, DC.

RESULTS

Table 2.Demographics
	Fellowship Trained, n=50	Non‐Fellowship‐Trained, n=147	P Value
NOTE: Abbreviations: NICU, neonatal intensive care unit; PICU, pediatric intensive care unit, ED, emergency department.
Average years experience (since residency graduation)	2.1	2.6	0.05
Type of residency			0.82
Pediatric	48 (96%)	140 (95%)
Medicine‐pediatric	2 (4%)	7 (5%)
Family medicine	0	0
Chief residency	17 (34%)	37 (25%)	0.23
Advanced degree obtained			0.12
Master's Public Health	2 (4%)	8 (5.5%)
Master's of Education	0	1 (0.7%)
Master's Clinical and Translational Research	1 (2%)	0
Master's Business Administration	1 (2%)	0
PhD	0	1 (0.7%)
Other	3 (6%)	8 (5.5%)
Currently pursuing	14 (28%)	6 (4.1%)
Practice environment
University‐affiliated free‐standing children's hospital	40 (80%)	68 (46.3%)	<0.001
University‐affiliated pediatric ward	7 (14%)	37 (25.2%)	0.1
University‐affiliated community hospital	2 (4%)	25 (17%)	0.02
Non‐university affiliated community hospital	2 (4%)	35 (23.8%)	0.002
Practice domain
General pediatrics inpatient unit	49/49 (100%)	139/143 (97.2%)	0.24
Subspecialty wards	19/46 (41.3%)	47/130 (36.1%)	0.54
Surgical comanagement	36/46 (78.3%)	119/133 (89.5%)	0.05
NICU	8/47 (17.0%)	36/128 (28.1%)	0.13
PICU	11/47 (17.0%)	16/126 (12.0%)	0.08
Intermediate care unit	17/47 (36.2%)	36/128 (28.1%)	0.09
ED	16/47 (34.0%)	55/128 (43.0%)	0.42
Newborn nursery	11/45 (24.4%)	68/132 (51.5%)	0.002
Sedation	20/48 (41.7%)	48/133 (36.1%)	0.49
Medical education	47/48 (97.9%)	123/137 (89.8%)	0.08
Hospital committee work	42/48 (87.5%)	109/138 (79.0%)	0.3
Research	44/49 (90.0%)	72/137 (52.6%)	<0.001
Quality improvement/safety	44/48 (91.7%)	103/134 (76.9%)	0.003
Advocacy	23/47 (47.9%)	49/128 (38.2%)	0.19

Table 3.Adjusted Mean Competency Scores by Training
Core Competency	Fellowship Trained, n=50	Non‐Fellowship‐Trained, n=147	P Value
NOTE: Scale: 0=novice, 50=competent, 100=expert. Abbreviations: FCR, family‐centered rounds; IV, intravenous; PDSA, Plan‐Do‐Study‐Act; RCA, root‐cause analysis; RVU, relative value unit.
Common diagnoses	78.4	78.6	0.717
Core skills
IV access/phlebotomy	52.9	30.6	0.012
Lumbar puncture	76.2	77.0	0.245
Sedation	30.9	28.3	0.001
Pain management	70.7	72.6	0.014
Nutrition	68.0	66.1	0.026
Specialized clinical skills
Leading a health care team
Team leadership	74.9	72.0	<0.001
FCR	75.3	72.6	<0.001
Technology‐dependent patient
General management	71.4	65.9	<0.001
Emergencies	53.2	49.4	<0.001
Newborn care	56.6	61.6	<0.001
Child abuse
Diagnosing	68.6	68.7	0.925
Reporting	68.9	68.5	0.630
Healthcare systems
Transitions in care	77.4	79.6	0.002
Advocacy	57.4	53.5	<0.001
Business practice
Basic components	36.4	32.0	<0.001
Concept of RVU	30.2	30.2	0.972
Billing/coding	61.4	63.9	0.004
Quality Improvement
PDSA cycles	63.7	42.8	<0.001
Best practice guidelines	64.7	51.8	<0.001
Safety
Identify and address harm	65.9	59.1	<0.001
Perform RCA	56.7	36.0	<0.001
Cost‐effective care	58.4	51.6	<0.001
Medical education
Needs assessment	69.4	65.6	<0.001
Large group teaching	67.6	60.6	<0.001
Small group teaching	74.2	72.6	0.040
Feedback	73.8	68.9	<0.001
Evidence‐based medicine
Literature search	75.9	69.0	<0.001
Literature appraisal	63.4	57.2	<0.001
Apply study results	70.2	64.8	<0.001
Research
Comparing study design	62.6	54.1	<0.001
Basic statistics	57.2	41.7	<0.001
Identifying resources	56.0	36.1	<0.001

DISCUSSION

CONCLUSIONS

Disclosure: Nothing to report.

METHODS

Study Design

Survey Development

Table 1.Pediatric Hospital Medicine Core Competencies
Clinical Diagnosis	Core Skills	Specialized Clinical Skills	Healthcare Systems
Abbreviations: ALTE, apparent life‐threatening event; CNS, central nervous system; ECG, electrocardiogram; IV, intravenous; PALS, pediatric advanced life support; UTI, urinary tract infection. *Competency assessed in the survey.
Abdominal pain	Bladder catheterization	Child abuse*	Advocacy*
ALTE	ECG interpretation	Hospice and palliative care	Business practice*
Asthma	Feeding tubes	Leading healthcare team*	Communication
Bone and joint infection	Fluid/electrolytes	Newborn care*	Quality improvement*
Bronchiolitis	IV access/ phlebotomy*	Technology‐dependent children*	Cost‐effective care*
CNS infections	Lumbar puncture*	Transport of the critically ill	Education*
Diabetes	Noninvasive monitoring		Evidence‐based medicine*
Failure to thrive	Nutrition*		Health information systems
Fever unknown origin	Oxygen delivery and airway management		Legal, risk management
Gastroenteritis	Pain management*		Patient safety*
Kawasaki disease	PALS		Research*
Neonatal fever	Procedural sedation*		Transitions of care*
Neonatal jaundice	Radiographic interpretation
Pneumonia
Respiratory failure
Seizures
Shock
Sickle cell disease
Skin and soft tissue infection
Upper airway infections
UTI
Single summative question included in the survey.

Data Collection

Data Analysis

Institutional review board approval was obtained from Children's National Medical Center in Washington, DC.

RESULTS

Table 2.Demographics
	Fellowship Trained, n=50	Non‐Fellowship‐Trained, n=147	P Value
NOTE: Abbreviations: NICU, neonatal intensive care unit; PICU, pediatric intensive care unit, ED, emergency department.
Average years experience (since residency graduation)	2.1	2.6	0.05
Type of residency			0.82
Pediatric	48 (96%)	140 (95%)
Medicine‐pediatric	2 (4%)	7 (5%)
Family medicine	0	0
Chief residency	17 (34%)	37 (25%)	0.23
Advanced degree obtained			0.12
Master's Public Health	2 (4%)	8 (5.5%)
Master's of Education	0	1 (0.7%)
Master's Clinical and Translational Research	1 (2%)	0
Master's Business Administration	1 (2%)	0
PhD	0	1 (0.7%)
Other	3 (6%)	8 (5.5%)
Currently pursuing	14 (28%)	6 (4.1%)
Practice environment
University‐affiliated free‐standing children's hospital	40 (80%)	68 (46.3%)	<0.001
University‐affiliated pediatric ward	7 (14%)	37 (25.2%)	0.1
University‐affiliated community hospital	2 (4%)	25 (17%)	0.02
Non‐university affiliated community hospital	2 (4%)	35 (23.8%)	0.002
Practice domain
General pediatrics inpatient unit	49/49 (100%)	139/143 (97.2%)	0.24
Subspecialty wards	19/46 (41.3%)	47/130 (36.1%)	0.54
Surgical comanagement	36/46 (78.3%)	119/133 (89.5%)	0.05
NICU	8/47 (17.0%)	36/128 (28.1%)	0.13
PICU	11/47 (17.0%)	16/126 (12.0%)	0.08
Intermediate care unit	17/47 (36.2%)	36/128 (28.1%)	0.09
ED	16/47 (34.0%)	55/128 (43.0%)	0.42
Newborn nursery	11/45 (24.4%)	68/132 (51.5%)	0.002
Sedation	20/48 (41.7%)	48/133 (36.1%)	0.49
Medical education	47/48 (97.9%)	123/137 (89.8%)	0.08
Hospital committee work	42/48 (87.5%)	109/138 (79.0%)	0.3
Research	44/49 (90.0%)	72/137 (52.6%)	<0.001
Quality improvement/safety	44/48 (91.7%)	103/134 (76.9%)	0.003
Advocacy	23/47 (47.9%)	49/128 (38.2%)	0.19

Table 3.Adjusted Mean Competency Scores by Training
Core Competency	Fellowship Trained, n=50	Non‐Fellowship‐Trained, n=147	P Value
NOTE: Scale: 0=novice, 50=competent, 100=expert. Abbreviations: FCR, family‐centered rounds; IV, intravenous; PDSA, Plan‐Do‐Study‐Act; RCA, root‐cause analysis; RVU, relative value unit.
Common diagnoses	78.4	78.6	0.717
Core skills
IV access/phlebotomy	52.9	30.6	0.012
Lumbar puncture	76.2	77.0	0.245
Sedation	30.9	28.3	0.001
Pain management	70.7	72.6	0.014
Nutrition	68.0	66.1	0.026
Specialized clinical skills
Leading a health care team
Team leadership	74.9	72.0	<0.001
FCR	75.3	72.6	<0.001
Technology‐dependent patient
General management	71.4	65.9	<0.001
Emergencies	53.2	49.4	<0.001
Newborn care	56.6	61.6	<0.001
Child abuse
Diagnosing	68.6	68.7	0.925
Reporting	68.9	68.5	0.630
Healthcare systems
Transitions in care	77.4	79.6	0.002
Advocacy	57.4	53.5	<0.001
Business practice
Basic components	36.4	32.0	<0.001
Concept of RVU	30.2	30.2	0.972
Billing/coding	61.4	63.9	0.004
Quality Improvement
PDSA cycles	63.7	42.8	<0.001
Best practice guidelines	64.7	51.8	<0.001
Safety
Identify and address harm	65.9	59.1	<0.001
Perform RCA	56.7	36.0	<0.001
Cost‐effective care	58.4	51.6	<0.001
Medical education
Needs assessment	69.4	65.6	<0.001
Large group teaching	67.6	60.6	<0.001
Small group teaching	74.2	72.6	0.040
Feedback	73.8	68.9	<0.001
Evidence‐based medicine
Literature search	75.9	69.0	<0.001
Literature appraisal	63.4	57.2	<0.001
Apply study results	70.2	64.8	<0.001
Research
Comparing study design	62.6	54.1	<0.001
Basic statistics	57.2	41.7	<0.001
Identifying resources	56.0	36.1	<0.001

DISCUSSION

CONCLUSIONS

Disclosure: Nothing to report.

References

Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7(4):329–334.
Stucky ER, Maniscalco J, Ottolini MC, et al. The Pediatric Hospital Medicine Core Competencies Supplement: a Framework for Curriculum Development by the Society of Hospital Medicine with acknowledgement to pediatric hospitalists from the American Academy of Pediatrics and the Academic Pediatric Association. J Hosp Med. 2010;5(suppl 2):i–xv, 1–114.
Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can't stand still. JAMA Pediatr. 2013;167(5):412–413.
Freed GL, Dunham KM, Research Advisory Committee of the American Board of Pediatrics. Pediatric hospitalists: training, current practice, and career goals. J Hosp Med. 2009;4(3):179–186.
Ottolini MC, Landrigan CP, Chiang VW, Stucky ER. PRIS Survey: pediatric hospitalist roles and training needs. Pediatr Res. 2004;55:360A.
Maniscalco J, Ottolini M, Stucky E, Landrigan C, Dhepyasuwan N. Current roles and training needs of pediatric hospitalists: a study from the Pediatric Research in Inpatient Settings (PRIS) Network. Paper presented at: Pediatric Academic Societies; 2008; Honolulu, HI.
Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills. Acad Med. 2008;83(8):761–767.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research Electronic Data Capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.
Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247–254.
Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Pediatrics. 2012. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/320_pediatrics_07012013.pdf. Accessed August 14, 2014.
Daud YN, Carlson DW. Pediatric sedation. Pediatr Clin North Am. 2014;61(4):703–717.
Turmelle M, Moscoso LM, Hamlin KP, Daud YN, Carlson DW. Development of a pediatric hospitalist sedation service: training and implementation. J Hosp Med. 2012;7(4):335–339.
Mirkinson LJ, Daru JA, Fisher ERS, et al. Guiding principles for pediatric hospital medicine programs. Pediatrics. 2013;132(4):782–786.
Landrigan CP, Conway PH, Edwards S, Srivastava R. Pediatric hospitalists: a systematic review of the literature. Pediatrics. 2006;117(5):1736–1744.
Mussman GM, Conway PH. Pediatric hospitalist systems versus traditional models of care: effect on quality and cost outcomes. J Hosp Med. 2012;7(4):350–357.
Fisher ES. Pediatric hospital medicine: historical perspectives, inspired future. Curr Probl Pediatr Adolesc Health Care. 2012;42(5):107–112.
Percelay JM. Pediatric hospitalists working in community hospitals. Pediatr Clin North Am. 2014;61(4):681–691.
Bekmezian A, Teufel RJ, Wilson KM. Research needs of pediatric hospitalists. Hosp Pediatr. 2011;1(1):38–44.
Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226–235.
Collins SW, Reiss J, Saidi A. Transition of care: what Is the pediatric hospitalist's role? An exploratory survey of current attitudes. J Hosp Med. 2012;7(4):277–281.
Pane LA, Davis AB, Ottolini MC. Association between practice setting and pediatric hospitalist career satisfaction. Hosp Pediatr. 2013;3(3):285–291.

References

Rauch DA, Lye PS, Carlson D, et al. Pediatric hospital medicine: a strategic planning roundtable to chart the future. J Hosp Med. 2012;7(4):329–334.
Stucky ER, Maniscalco J, Ottolini MC, et al. The Pediatric Hospital Medicine Core Competencies Supplement: a Framework for Curriculum Development by the Society of Hospital Medicine with acknowledgement to pediatric hospitalists from the American Academy of Pediatrics and the Academic Pediatric Association. J Hosp Med. 2010;5(suppl 2):i–xv, 1–114.
Maniscalco J, Fisher ES. Pediatric hospital medicine and education: why we can't stand still. JAMA Pediatr. 2013;167(5):412–413.
Freed GL, Dunham KM, Research Advisory Committee of the American Board of Pediatrics. Pediatric hospitalists: training, current practice, and career goals. J Hosp Med. 2009;4(3):179–186.
Ottolini MC, Landrigan CP, Chiang VW, Stucky ER. PRIS Survey: pediatric hospitalist roles and training needs. Pediatr Res. 2004;55:360A.
Maniscalco J, Ottolini M, Stucky E, Landrigan C, Dhepyasuwan N. Current roles and training needs of pediatric hospitalists: a study from the Pediatric Research in Inpatient Settings (PRIS) Network. Paper presented at: Pediatric Academic Societies; 2008; Honolulu, HI.
Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills. Acad Med. 2008;83(8):761–767.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research Electronic Data Capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.
Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247–254.
Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Pediatrics. 2012. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/320_pediatrics_07012013.pdf. Accessed August 14, 2014.
Daud YN, Carlson DW. Pediatric sedation. Pediatr Clin North Am. 2014;61(4):703–717.
Turmelle M, Moscoso LM, Hamlin KP, Daud YN, Carlson DW. Development of a pediatric hospitalist sedation service: training and implementation. J Hosp Med. 2012;7(4):335–339.
Mirkinson LJ, Daru JA, Fisher ERS, et al. Guiding principles for pediatric hospital medicine programs. Pediatrics. 2013;132(4):782–786.
Landrigan CP, Conway PH, Edwards S, Srivastava R. Pediatric hospitalists: a systematic review of the literature. Pediatrics. 2006;117(5):1736–1744.
Mussman GM, Conway PH. Pediatric hospitalist systems versus traditional models of care: effect on quality and cost outcomes. J Hosp Med. 2012;7(4):350–357.
Fisher ES. Pediatric hospital medicine: historical perspectives, inspired future. Curr Probl Pediatr Adolesc Health Care. 2012;42(5):107–112.
Percelay JM. Pediatric hospitalists working in community hospitals. Pediatr Clin North Am. 2014;61(4):681–691.
Bekmezian A, Teufel RJ, Wilson KM. Research needs of pediatric hospitalists. Hosp Pediatr. 2011;1(1):38–44.
Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226–235.
Collins SW, Reiss J, Saidi A. Transition of care: what Is the pediatric hospitalist's role? An exploratory survey of current attitudes. J Hosp Med. 2012;7(4):277–281.
Pane LA, Davis AB, Ottolini MC. Association between practice setting and pediatric hospitalist career satisfaction. Hosp Pediatr. 2013;3(3):285–291.

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Perceived core competency achievements of fellowship and non‐fellowship‐trained early career pediatric hospitalists

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Perceived core competency achievements of fellowship and non‐fellowship‐trained early career pediatric hospitalists

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Jamie Librizzi, MD

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Address for correspondence and reprint requests: Jamie Librizzi, MD, Children's National Health Systems, Department of Hospital Medicine, 111 Michigan Ave. NW, Suite 4800, Washington, DC 20010; Telephone: 202‐476‐3044; Fax: 202‐476‐3732; E‐mail: [email protected]

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PCP Communication at Discharge

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We need to talk: Primary care provider communication at discharge in the era of a shared electronic medical record

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Transitions of care from hospital to home are high‐risk times for patients.[1, 2] Increasing complexity of hospital admissions and shorter lengths of stay demand more effective coordination of care between hospitalists and outpatient clinicians.[3, 4, 5] Inaccurate, delayed, or incomplete clinical handoversthat is, transfer of information and professional responsibility and accountability[6]can lead to patient harm, and has been recognized as a key cause of preventable morbidity by the World Health Organization and The Joint Commission.[6, 7, 8] Conversely, when done effectively, transitions can result in improved patient health outcomes, reduced readmission rates, and higher patient and provider satisfaction.³

Previous studies note deficits in communication at discharge and primary care provider (PCP) dissatisfaction with discharge practices.[4, 9, 10, 11, 12, 13] In studies at academic medical centers, there were low rates of direct communication between inpatient and outpatient providers, mainly because of providers' belief that the discharge summary was adequate and the presence of significant barriers to direct communication.[14, 15] However, studies have shown that discharge summaries often omit critical information, and often are not available to PCPs in a timely manner.[10, 11, 12, 16] In response, the Society of Hospital Medicine developed a discharge checklist to aide in standardization of safe discharge practices.[1, 5] Discharge summary templates further attempt to improve documentation of patients' hospital courses. An electronic medical record (EMR) system shared by both inpatient and outpatient clinicians should impart several advantages: (1) automated alerts provide timely notification to PCPs regarding admission and discharge, (2) discharge summaries are available to the PCP as soon as they are written, and (3) all patient information pertaining to the hospitalization is available to the PCP.

Although it is plausible that shared EMRs should facilitate transitions of care by streamlining communication between hospitalists and PCPs, guidelines on format and content of PCP communication at discharge in the era of a shared EMR have yet to be defined. In this study, we sought to understand current discharge communication practices and PCP satisfaction within a shared EMR at our institution, and to identify key areas in which communication can be improved.

METHODS

Participants and Setting

We surveyed all resident and attending PCPs (n=124) working in the Division of General Internal Medicine (DGIM) Outpatient Practice at the University of California, San Francisco (UCSF). In June 2012, the outpatient and inpatient practices of UCSF transitioned from having separate medical record systems to a shared EMR (Epic Systems Corp., Verona, WI) where all informationboth inpatient and outpatientis accessible among healthcare professionals. The EMR provides automated notifications of admission and discharge to PCPs, allows for review of inpatient notes, labs, and studies, and immediate access to templated discharge summaries (see Supporting Information, Appendix 1, in the online version of this article). The EMR also enables secure communication between clinicians. At our institution, over 90% of discharge summaries are completed within 24 hours of discharge.[17]

Study Design and Analysis

We developed a survey about the discharge communication practices of inpatient medicine patients based on a previously described survey in the literature (see Supporting Information, Appendix 2, in the online version of this article).[9] The anonymous, 17‐question survey was electronically distributed to resident and attending PCPs at the DGIM practice. The survey was designed to determine: (1) overall PCP satisfaction with current communication practices from the inpatient team at patient discharge, (2) perceived adequacy of automatic discharge notifications, and (3) perception of the types of patients and hospitalizations requiring additional high‐touch communication at discharge.

We analyzed results of our survey using descriptive statistics. Differences in resident and attending responses were analyzed by ²tests.

RESULTS

Seventy‐five of 124 (60%) clinicians (46% residents, 54% attendings) completed the survey. Thirty‐nine (52%) PCPs were satisfied or very satisfied with communication at patient discharge. Although most reported receiving automated discharge notifications (71%), only 39% felt that the notifications plus the discharge summaries were adequate communication for safe transition of care from hospital to community. Fifty‐one percent desired direct contact beyond a discharge summary. There were no differences in preferences on discharge communication between resident and attending PCPs (P>0.05).

Over three‐fourths of PCPs surveyed preferred that for patients with complex hospitalizations (multiple readmissions, multiple active comorbidities, goals of care changes, high‐risk medication changes, time‐sensitive follow‐up needs), an additional e‐mail or verbal communication was needed to augment the information in the discharge summary (Figure 1). Only 31% reported receiving such communication.

Primary care physicians' (PCPs') preferred mode of discharge communication based on patient characteristics. Definitions of patient characteristics: Known patients = patients who have been previously seen by the PCP and will need standard follow up after discharge; New patients = new hospital referrals who have not been previously seen by the PCP; Multiple active comorbidities = patients with 2 or more chronic conditions that require active monitoring/medication changes; Multiple readmissions = patients who have had at least 1 readmission in the past year; Changes in goals of care = changes in code status during hospitalization; New or changed high risk medications = anticoagulants, hypoglycemics, antibiotics; Time sensitive follow‐up = patients requiring time‐sensitive follow‐up, left to interpretation.

When asked about important items to communicate for safer transitions of care, PCPs reported finding the following elements most critical: (1) medication changes (93%), (2) follow‐up actions for the PCP (88%), and (3) active medical issues (84%) (Figure 2).

Important factors identified for discharge communication for all discharges. Definitions of patient characteristics: Known patients = patients who have been previously seen by the primary care physician (PCP) and will need standard follow up after discharge; New patients = new hospital referrals who have not been previously seen by the PCP; Multiple active comorbidities = patients with 2 or more chronic conditions that require active monitoring/medication changes; Multiple readmissions patients who have had at least 1 readmission in the past year; Changes in goals of care = changes in code status during hospitalization; New or changed high risk medications = anticoagulants, hypoglycemics, antibiotics; Time sensitive follow‐up = patients requiring time‐sensitive follow‐up, left to interpretation.

CONCLUSIONS

In the era of shared EMRs, real‐time access to medication lists, pending test results, and discharge summaries should facilitate care transitions at discharge.[18, 19] We conducted a study to determine PCP perceptions of discharge communication after implementation of a shared EMR. We found that although PCPs largely acknowledged timely receipt of automated discharge notifications and discharge summaries, the majority of PCPs felt that most discharges required additional communication to ensure safe transition of care.

Guidelines for discharge communication emphasize timely communication with the PCP, primarily through discharge summaries containing key safety elements.[1, 5, 10] At our institution, we have improved the timeliness and quality of discharge summaries according to guideline recommendations,[17] and conducted quality improvement projects to improve rates of direct communication with PCPs.[9] In addition, the shared EMR provides automated notifications to PCPs when their patients are discharged. Despite these interventions, our survey shows that PCP satisfaction with discharge communication is still inadequate. PCPs desired direct communication that highlights active medical issues, medication changes, and specific follow‐up actions. Although all of these topics are included in our discharge summary template (see Supporting Information, Appendix 1, in the online version of this article), it is possible that the templated discharge summaries lend themselves to longer documents and information overload, as prior studies have documented the desire for more succinct discharge summaries.[18] We also found that automated notifications of discharge were less reliable and useful for PCPs than anticipated. There were several reasons for this: (1) discharge summaries sometimes were sent to PCPs uncoupled from the discharge notification, (2) there were errors with the generation and delivery of automated messages at the rollout of the new system, and (3) PCPs received many other automated system messages, meaning that discharge notifications could be easily missed. These factors all likely contribute to PCPs' desire for high‐touch communication that highlights the most salient aspects of each patient's hospitalization. It is also possible that automated notifications and depersonalized discharge summaries create distance and a less‐collaborative feeling to patient care. PCPs want more direct communication, and desire to play a more active role in inpatient management, especially for complex hospitalizations.[18] This emphasis on direct communication resonates with previous studies conducted before shared EMRs existed.[9, 12, 19]

Our study had several limitations. First, because this is a single‐institution study at a tertiary care academic setting, the results may not be generalizable to all shared EMR settings, and may not reflect all the challenges of communication with the wider community of outpatient providers. One can postulate that inpatient and outpatient clinician relationships are stronger in an academic setting than in other more disparate environments, where direct communication may happen even less frequently. Of note, our low rates of direct communication are consistent with other single‐ and multi‐institution studies, suggesting that our findings are generalizable.[14, 15] Second, our survey is limited in its ability to distinguish those patients who require high‐touch communication and those who do not. Third, although we have used the survey to assess PCP satisfaction in previous studies, it is not a validated instrument, and therefore we cannot reliably say that increasing direct PCP communication would increase their satisfaction around discharge. Last, the PCP‐reported rates of discharge communication are subjective and may be influenced by recall bias. We did not have a systematic way to confirm the actual rates of communication at discharge, which could have occurred through EMR messages, e‐mails, phone calls, or pages.

Although a shared EMR allows for real‐time access to patient data, it does not eliminate PCPs' desire for direct 2‐way dialogue at discharge, especially for complex patients. Key information desired in such communication should include active medical issues, medication changes, and follow‐up needs, which is consistent with prior studies. Standardizing this direct communication process in an efficient way can be challenging. Further elucidation of PCP preferences around which patients necessitate higher‐level communication and preferred methods and timing of communication is needed, as well as determining the most efficient and effective method for hospitalists to provide such communication. Improving communication between hospitalists and PCPs requires not just the presence of a shared EMR, but additional, systematic efforts to engage both inpatient and outpatient clinicians in collaborative care.

Disclosure

Nothing to report.

Files

References

Soong C, Daub S, Lee J, et al. Development of a checklist of safe discharge practices for hospital patients. J Hosp Med. 2013;8(8):444–449.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167.
Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157(6):417–428.
Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. “Did I do as best as the system would let me?” Healthcare professional views on hospital to home care transitions. J Gen Intern Med. 2012;27(12):1649–1656.
Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists. J Hosp Med. 2006;1(6):354−660.
Jeffcott SA, Evans SM, Cameron PA, Chin SM, Ibrahim JE. Improving measurement in clinical handover. Qual Saf Health Care. 2009;18:272–277.
World Health Organization. Patient safety: action on patient safety: high 5s. 2007. Available at: http://www.who.int/patientsafety/implementation/solutions/high5s/en/index.html. Accessed January 28, 2015.
The Joint Commission Center for Transforming Healthcare. Hand‐off communications. 2012. Available at: http://www.centerfortransforminghealthcare.org/projects/detail.aspx?Project=1. Accessed January 28, 2015.
Kalanithi L, Coffey CH, Mourad M, et al. The effect of a resident‐led quality improvement project on improving communication between hospital‐based and outpatient physicians. Am J Med Qual. 2013;28(6):472–479.
Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–323.
Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital‐based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–841.
Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(9B):15S–20S.
Johnson JK, Farman JM, Barach P, et al. Searching for the missing pieces between the hospital and primary care: mapping the patient process during care transitions. BMJ Qual Saf. 2012;21:i97–i105.
Oduyebo I, Lehmann CU, Pollack CE, et al. Association of self‐reported hospital discharge handoffs with 30‐day readmissions. JAMA. 2013;173(8):624–629.
Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital‐based physicians and primary care providers with patient outcomes. J Gen Intern Med. 2009;24(3):381–386.
Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post‐discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186–192.
Bischoff K, Goel A, Hollander H, Ranji SR, Mourad M. The Housestaff Incentive Program: improving the timeliness and quality of discharge summaries by engaging residents in quality improvement. BMJ Qual Saf. 2013;22(9):768–774.
Jones CD, Vu MB, O'Donnell CM, et al. A Failure to communicate: a qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations [published online ahead of print October 15, 2014]. J Gen Intern Med. doi: 10.1007/s11606-014-3056-x.
Harlan G, Srivastava R, Harrison L, et al. Pediatric hospitalists and primary care providers: a communication needs assessment. J Hosp Med. 2009;4(3):187–193.

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Journal of Hospital Medicine - 10(5)

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307-310

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METHODS

Participants and Setting

Study Design and Analysis

We analyzed results of our survey using descriptive statistics. Differences in resident and attending responses were analyzed by ²tests.

RESULTS

CONCLUSIONS

Disclosure

Nothing to report.

METHODS

Participants and Setting

Study Design and Analysis

We analyzed results of our survey using descriptive statistics. Differences in resident and attending responses were analyzed by ²tests.

RESULTS

CONCLUSIONS

Disclosure

Nothing to report.

References

Soong C, Daub S, Lee J, et al. Development of a checklist of safe discharge practices for hospital patients. J Hosp Med. 2013;8(8):444–449.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167.
Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157(6):417–428.
Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. “Did I do as best as the system would let me?” Healthcare professional views on hospital to home care transitions. J Gen Intern Med. 2012;27(12):1649–1656.
Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists. J Hosp Med. 2006;1(6):354−660.
Jeffcott SA, Evans SM, Cameron PA, Chin SM, Ibrahim JE. Improving measurement in clinical handover. Qual Saf Health Care. 2009;18:272–277.
World Health Organization. Patient safety: action on patient safety: high 5s. 2007. Available at: http://www.who.int/patientsafety/implementation/solutions/high5s/en/index.html. Accessed January 28, 2015.
The Joint Commission Center for Transforming Healthcare. Hand‐off communications. 2012. Available at: http://www.centerfortransforminghealthcare.org/projects/detail.aspx?Project=1. Accessed January 28, 2015.
Kalanithi L, Coffey CH, Mourad M, et al. The effect of a resident‐led quality improvement project on improving communication between hospital‐based and outpatient physicians. Am J Med Qual. 2013;28(6):472–479.
Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–323.
Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital‐based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–841.
Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(9B):15S–20S.
Johnson JK, Farman JM, Barach P, et al. Searching for the missing pieces between the hospital and primary care: mapping the patient process during care transitions. BMJ Qual Saf. 2012;21:i97–i105.
Oduyebo I, Lehmann CU, Pollack CE, et al. Association of self‐reported hospital discharge handoffs with 30‐day readmissions. JAMA. 2013;173(8):624–629.
Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital‐based physicians and primary care providers with patient outcomes. J Gen Intern Med. 2009;24(3):381–386.
Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post‐discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186–192.
Bischoff K, Goel A, Hollander H, Ranji SR, Mourad M. The Housestaff Incentive Program: improving the timeliness and quality of discharge summaries by engaging residents in quality improvement. BMJ Qual Saf. 2013;22(9):768–774.
Jones CD, Vu MB, O'Donnell CM, et al. A Failure to communicate: a qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations [published online ahead of print October 15, 2014]. J Gen Intern Med. doi: 10.1007/s11606-014-3056-x.
Harlan G, Srivastava R, Harrison L, et al. Pediatric hospitalists and primary care providers: a communication needs assessment. J Hosp Med. 2009;4(3):187–193.

References

Soong C, Daub S, Lee J, et al. Development of a checklist of safe discharge practices for hospital patients. J Hosp Med. 2013;8(8):444–449.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167.
Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157(6):417–428.
Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. “Did I do as best as the system would let me?” Healthcare professional views on hospital to home care transitions. J Gen Intern Med. 2012;27(12):1649–1656.
Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists. J Hosp Med. 2006;1(6):354−660.
Jeffcott SA, Evans SM, Cameron PA, Chin SM, Ibrahim JE. Improving measurement in clinical handover. Qual Saf Health Care. 2009;18:272–277.
World Health Organization. Patient safety: action on patient safety: high 5s. 2007. Available at: http://www.who.int/patientsafety/implementation/solutions/high5s/en/index.html. Accessed January 28, 2015.
The Joint Commission Center for Transforming Healthcare. Hand‐off communications. 2012. Available at: http://www.centerfortransforminghealthcare.org/projects/detail.aspx?Project=1. Accessed January 28, 2015.
Kalanithi L, Coffey CH, Mourad M, et al. The effect of a resident‐led quality improvement project on improving communication between hospital‐based and outpatient physicians. Am J Med Qual. 2013;28(6):472–479.
Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–323.
Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital‐based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–841.
Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(9B):15S–20S.
Johnson JK, Farman JM, Barach P, et al. Searching for the missing pieces between the hospital and primary care: mapping the patient process during care transitions. BMJ Qual Saf. 2012;21:i97–i105.
Oduyebo I, Lehmann CU, Pollack CE, et al. Association of self‐reported hospital discharge handoffs with 30‐day readmissions. JAMA. 2013;173(8):624–629.
Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital‐based physicians and primary care providers with patient outcomes. J Gen Intern Med. 2009;24(3):381–386.
Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post‐discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186–192.
Bischoff K, Goel A, Hollander H, Ranji SR, Mourad M. The Housestaff Incentive Program: improving the timeliness and quality of discharge summaries by engaging residents in quality improvement. BMJ Qual Saf. 2013;22(9):768–774.
Jones CD, Vu MB, O'Donnell CM, et al. A Failure to communicate: a qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations [published online ahead of print October 15, 2014]. J Gen Intern Med. doi: 10.1007/s11606-014-3056-x.
Harlan G, Srivastava R, Harrison L, et al. Pediatric hospitalists and primary care providers: a communication needs assessment. J Hosp Med. 2009;4(3):187–193.

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Address for correspondence and reprint requests: Ethel Wu, MD, Assistant Clinical Professor, Department of Medicine, Division of Hospital Medicine, University of California San Francisco, 533 Parnassus Ave., Room U149, Box 0131, San Francisco, CA 94143; Telephone: 415‐502‐1413; Fax: 415‐476‐4818; E‐mail: [email protected]

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Minimal residual disease could signify worse outcomes in acute myeloid leukemia treatment

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Minimal residual disease could signify worse outcomes in acute myeloid leukemia treatment

Although peripheral count recovery and minimal residual disease level following induction therapy are linked, each is an independent prognostic factor for relapse and overall survival in patients with acute myeloid leukemia, investigators say in a report published online March 2 in Journal of Clinical Oncology. “Information about these post-treatment factors is likely more important than information about several traditional pretreatment prognostic factors and should play a major – and perhaps the dominant – role in planning postinduction therapy,” wrote Dr. Xueyan Chen and her associates.

The investigators retrospectively analyzed data from 245 adults with newly diagnosed, relapsed, or refractory acute myeloid leukemia (AML) who achieved either complete remission (CR), complete remission with incomplete platelet recovery (CRp), or complete remission with incomplete blood count recovery (CRi), after induction therapy. The 71% of patients who achieved CR had minimal residual disease (MRD) less frequently and had lower levels of MRD than the 19.6% of patients achieving CRp and 9.4% achieving CRi, suggesting that failure of blood count recovery may result from inadequate treatment of AML.

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Studies of anesthesia’s effect on upper airway are limited

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CORONADO, CALIF. – Studies of the most appropriate anesthetic agents for drug-induced sleep endoscopy are limited, but according to the best available evidence, local anesthetics appear to affect airway reflexes while inhalation anesthetics and opioids exaggerate dynamic airway collapse, so they may not be ideal.

Those are key conclusions from a systematic review of literature on the effects of commonly used anesthetic agents and opioids on the upper airway presented at the Triological Society’s Combined Sections meeting. Drug-induced sleep endoscopy (DISE) “is a great tool to assess upper airway dynamics in order to determine optimal surgical therapy for obstructive sleep apnea,” said Dr. Zarmina Ehsan, a pediatric pulmonary medicine fellow at Cincinnati Children’s Hospital Medical Center. “There’s a lack of understanding regarding how upper airway dynamics are altered by anesthetic agents, compared with normal sleep. This is important because this hinders the development of universal guidelines and protocols for the use of DISE.”

Using PubMed, EMBASE, and other sources, she and her associates conducted a qualitative systematic review of studies related to common anesthetic agents and opioids in the medical literature through September 2014. To be eligible for inclusion, a study must have evaluated the agent’s effect on the upper airway, must have contained an abstract, and must have been published in English. Studies with fewer than seven subjects, no original data, review articles, and those involving animals were excluded. The researchers reviewed 180 abstracts and included 56 full text articles in the final analysis, for a total study population of 8,540 patients. At the meeting Dr. Ehsan summarized the following findings by agent:

• Lidocaine. This agent is safe for topical use, has a rapid onset of action, and an intermediate duration of efficacy. Lidocaine acts on muscles “which are potent dilators and tensors of the pharyngeal and laryngeal structures,” she said. Of 10 studies included in the analysis, 7 assessed the impact of lidocaine on upper airway obstruction. Of these, three showed increased airway obstruction while four showed no significant effects. There were two studies on sleep parameters with conflicting results: One showed an increase in mean apnea duration with lidocaine use while the other did not. From this the researchers concluded that lidocaine does affect upper airway dynamics.

• Propofol. This lipophilic intravenous agent has a quick onset of action and acts by global central nervous system depression. Of 12 studies included in the analysis, 4 examined dose-response characteristics and showed a dose-dependent decrease in airway cross-sectional area with increased dosing of propofol. “So increasing your dose makes airway obstruction more likely,” Dr. Ehsan said. “The levels of obstruction were greatest at the base of tongue, and the closure was primarily in the anterior-posterior direction.” Three studies found that propofol caused a decrease in genioglossus electromyogram activity, while the remaining five studies assessed heterogeneous outcomes. “Overall, the studies showed that propofol had a dose-dependent effect on the upper airway with increasing doses making airway obstruction more likely,” she said.

• Dexmedetomidine (DEX). This agent is an alpha-2 adrenergic agonist with sedative, anxiolytic, and analgesic effects. It’s typically given as a 10-minute loading dose followed by a continuous infusion, and is recommended when you want to preserve spontaneous respiration. Of the four DEX-related studies that were included in the analysis, all demonstrated a minimal effect on upper airway cross-sectional area. “One of the studies looked at sleep parameters and concluded that DEX does approximate non-REM sleep without causing respiratory depression,” Dr. Ehsan added. “So overall, DEX was less likely to result in upper airway obstruction, compared with propofol.”

• Midazolam. This agent is commonly used for procedural sedation, with an onset of action within 1-3 minutes and a duration of 15-60 minutes. Of the six studies involving midazolam, two evaluated sleep staging. One reported lack of REM sleep and increased duration of stage N3 sleep, while the other study found that all sleep stages were observed at a lower dosage. The remaining four studies had heterogeneous outcomes. This led the researchers to conclude that midazolam “may lead to upper airway obstruction,” Dr. Ehsan said. “It’s unclear if this is dose dependent.”

• Pentobarbital. Of the two studies involving this short-acting barbiturate, one showed no effect on pharyngeal critical pressure or respiratory muscle function, while the other found that pentobarbital can increase the upper airway cross-sectional area. “So the effect of pentobarbital is unclear,” she said.

• Ketamine. This N-methyl-D-aspartate receptor has a rapid onset and a minimal effect on the central respiratory drive. Of the three studies involving ketamine, one found a 10% incidence of transient laryngospasm, one found that the incidence of transient laryngospasm was higher when it was delivered intramuscularly vs. intravenously, and one found that ketamine was safe in infants undergoing upper airway endoscopy. The researchers concluded that overall, ketamine “could be useful during DISE.”

• Inhalation anesthetics. There were 11 studies of these agents. Of these, six found that inhalation anesthetics caused upper airway collapse while five had heterogeneous outcomes. “Overall, a majority of studies found that inhalation anesthetics exaggerate dynamic airway collapse,” Dr. Ehsan said.

• Opioids. Of the nine studies involving these agents, six found that opioids caused upper airway obstruction; two found that they caused depression of upper airway reflexes, and one found that they caused a decrease in respiratory compliance. “Overall, opioids increase upper airway obstruction,” she said.

Dr. Ehsan acknowledged certain limitations of the analysis, including the fact that there was little information on sleep state approximated by many of these agents, “which makes it difficult to determine the ideal anesthetic protocol. There was substantial heterogeneity in outcomes, and few prospective studies comparing the ability of anesthetics to approximate natural sleep.” She recommended that future efforts focus on comparative effectiveness studies between the agents, as well as evaluate the impact of combining anesthetic agents. “This is important, because most DISE protocols use a combination of agents,” she said.

The meeting was jointly sponsored by the Triological Society and the American College of Surgeons

Dr. Ehsan reported having no relevant financial conflicts.

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Key clinical point: Choice of an appropriate anesthetic protocol for drug-induced sleep endoscopy must be based on a limited number of comparative studies.

Major finding: Local anesthetics appear to affect upper airway reflexes while inhalation anesthetics and opioids exaggerate dynamic airway collapse.

Data source: A qualitative systematic review of 56 studies related to common anesthetic agents and opioids published in the medical literature through September 2014.

Disclosures: Dr. Ehsan reported having no financial disclosures.

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Smart diet remains potent cardiovascular medicine

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Bruce Jancin

SNOWMASS, COLO. – Cutting dietary fat intake remains a highly effective strategy for reducing coronary heart disease risk – but only so long as the replacement nutrients aren’t even bigger offenders, Dr. Robert A. Vogel said at the Annual Cardiovascular Conference at Snowmass.

In the face of decades of public health admonitions to reduce saturated fat intake, most Americans have increased their consumption of trans fats and simple carbohydrates, especially sugar. And therein lies a problem. Trans fats are far more harmful than saturated fats in terms of cardiovascular risk. And excessive sugar consumption is a major contributor to abdominal obesity, metabolic syndrome, hypertension, and endothelial dysfunction.

“In the United States, sugar is a bigger source of hypertension than is salt,” asserted Dr. Vogel, a cardiologist at the University of Colorado, Denver.

The editors of Time magazine ignited a public controversy last year with a cover story arrestingly titled, “Eat Butter – Scientists labelled fat the enemy. Why they were wrong.” The editors were picking up on a British meta-analysis of 32 observational studies that concluded there is no clear evidence to support the notion that saturated fats are harmful to cardiovascular health and that swapping them out for consumption of polyunsaturated fatty acids (PUFAs) is beneficial (Ann. Intern. Med. 2014;160:398-406).

Dr. Vogel said those investigators are in fact correct: Many of the observational studies – going all the way back to the pioneering work by Dr. Ancel Keys in the 1950s – are flawed. They don’t convincingly prove the case for PUFAs as a healthier alternative. But there is persuasive evidence from well-conducted, randomized, controlled trials that this is indeed so, he added.

Several of these studies were done in an earlier era when it was possible to slip around the challenges and limitations of dietary studies in free-living populations. These trials wouldn’t be possible today for ethical reasons involving lack of informed consent.

©Digital Vision/Thinkstock

For example, in the Finnish Mental Hospital Study conducted during 1959-1971, the food served at two mental institutions was altered. Patients at one hospital got 6 years of a diet high in PUFAs, then were crossed over to a typical Finnish diet. At the other mental hospital, patients were fed a normal Finnish diet for 6 years, then crossed over to the high-PUFA diet for 6 years. During the experimental-diet years, the coronary heart disease event rate was reduced by nearly 60% (Int. J. Epidemiol. 1979;8:99-118).

Similarly, in a prospective randomized trial conducted at a Los Angeles Veterans Affairs institution for older, cognitively impaired men, a no-choice shift to a diet high in PUFAs with reduced saturated fats resulted in roughly a 30% reduction in CHD events compared to the usual institutional diet (Lancet 1968;2:1060-2). A similar magnitude of CHD event reduction was seen with a high-PUFA dietary intervention in the Oslo Diet-Heart Study, a prospective secondary prevention trial (Circulation 1970;42:935-42).

In the contemporary era, the standout randomized dietary intervention trial is the Lyon Diet Heart Study, a 46-month prospective secondary prevention trial in which a Mediterranean diet low in saturated fat and high in alpha-linoleic acid, a PUFA, reduced the combined endpoint of cardiac death and nonfatal MI by 70%, compared with the usual post-MI prudent diet recommended at that time. Yet total cholesterol levels in the two study arms did not differ (Circulation 1999;99:779-85).

To put these results into context, Dr. Vogel noted that the Cholesterol Treatment Trialists Collaboration headquartered at the University of Oxford (England) has shown that for every 40 mg/dL of LDL-lowering achieved with statin therapy, the result is roughly a 20% reduction in CHD. In contrast, the classic nonpharmacologic diet studies resulted in 30%-70% relative risk reductions.

“Heart disease is a dietary disease,” the cardiologist emphasized. “When you compare diet intervention to LDL lowering with statins, you see that diet is very, very effective. But you have to know the details of the diet. You can’t take something out and put just anything in. It doesn’t work like that.”

For example, an analysis of data from the National Health and Nutrition Examination Survey concluded that individuals who consumed 25% of their calories from added sugar – that’s the equivalent of three 12-oz cans of a sugary cola per day – had a 175% increased risk of cardiovascular mortality during a median 14.6 years of follow-up, compared with those who got less than 10% of their calories from added sugar (JAMA Intern. Med. 2014;174:516-24).

And as for the impact of the trans fat that’s liberally present in many processed foods, the Nurses Health Study showed that for every 5% increase in energy intake from saturated fat – that’s equivalent to one 8-oz steak per day – the relative risk for CHD rose by a relatively modest 17%, while for a 5% increase in energy intake from trans fat – the equivalent of 4 oz of butter – CHD risk shot up by 382% (N. Engl. J. Med. 1997;337:1491-9).

Dr. Vogel reported serving as a paid consultant to the National Football League and the Pritikin Longevity Center and receiving a research grant from Sanofi.

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“In the United States, sugar is a bigger source of hypertension than is salt,” asserted Dr. Vogel, a cardiologist at the University of Colorado, Denver.

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Dr. Vogel reported serving as a paid consultant to the National Football League and the Pritikin Longevity Center and receiving a research grant from Sanofi.

“In the United States, sugar is a bigger source of hypertension than is salt,” asserted Dr. Vogel, a cardiologist at the University of Colorado, Denver.

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Dr. Vogel reported serving as a paid consultant to the National Football League and the Pritikin Longevity Center and receiving a research grant from Sanofi.

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Experimental vaccine may have worked on Ebola-exposed physician

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A U.S. physician exposed to Ebola virus received an investigational vaccine afterward and didn’t contract the disease, but the vaccine’s effectiveness remains unknown, according to report published online March 5 in JAMA.

The vaccine, VSV[Delta]G-ZEBOV, is based on a vesicular stomatitis virus with the glycoprotein gene replaced by a Zaire Ebola glycoprotein gene.

The physician received the vaccine slightly less than 2 days after Ebola exposure. After 12 hours, symptoms appeared that are associated with vesicular stomatitis virus. Those dissipated after 3-4 days, noted Dr. Lilin Lai of Emory University, Atlanta, and her colleagues.

No Ebola symptoms were detected, but the patient tested positive for Ebola virus glycoprotein-specific antibodies and T cells, which was an intended effect of the vaccine.

A single case report cannot provide a definitive answer to the effectiveness of VSV[Delta]G-ZEBOV, noted Thomas W. Geisbert, Ph.D. of the Galveston National Laboratory, University of Texas Medical Branch, in a related editorial. However, “this incident serves as an example of how important it is to have safe and effective countermeasures available in sufficient quantities that can be rapidly deployed for emergency use for both medical workers and affected populations.”

Find the full study and editorial in JAMA: (doi: 10.1001/jama.2015.1995) and (doi: 10.1001/jama.2015.2057).

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The vaccine, VSV[Delta]G-ZEBOV, is based on a vesicular stomatitis virus with the glycoprotein gene replaced by a Zaire Ebola glycoprotein gene.

No Ebola symptoms were detected, but the patient tested positive for Ebola virus glycoprotein-specific antibodies and T cells, which was an intended effect of the vaccine.

Find the full study and editorial in JAMA: (doi: 10.1001/jama.2015.1995) and (doi: 10.1001/jama.2015.2057).

The vaccine, VSV[Delta]G-ZEBOV, is based on a vesicular stomatitis virus with the glycoprotein gene replaced by a Zaire Ebola glycoprotein gene.

No Ebola symptoms were detected, but the patient tested positive for Ebola virus glycoprotein-specific antibodies and T cells, which was an intended effect of the vaccine.

Find the full study and editorial in JAMA: (doi: 10.1001/jama.2015.1995) and (doi: 10.1001/jama.2015.2057).

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Regimen prolongs PFS, increases AEs in MCL

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Results of a phase 3 study suggest the VR-CAP regimen is more effective but less safe than R-CHOP in patients with newly diagnosed mantle cell lymphoma (MCL).

Patients who received VR-CAP (bortezomib, rituximab, cyclophosphamide, doxorubicin, and prednisone) had superior progression-free survival (PFS) when compared to patients who received R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone).

But VR-CAP was also associated with more adverse events (AEs), particularly hematologic toxicities.

Tadeusz Robak, MD, of the Medical University of Lodz in Poland, and his colleagues reported results from this trial, known as LYM-3002, in NEJM. The study was funded by Janssen Research and Development and Millennium Pharmaceuticals.

LYM-3002 included 487 patients newly diagnosed with MCL who were not eligible for stem cell transplant.

Patients were randomized to receive six to eight 21-day cycles of R-CHOP intravenously on day 1 (with prednisone administered orally on days 1 to 5) or VR-CAP (similar to the R-CHOP regimen, but replacing vincristine with bortezomib at a dose of 1.3 mg per square meter of body-surface area on days 1, 4, 8, and 11).

The median follow-up was 40 months. The VR-CAP regimen significantly improved PFS, the primary endpoint, when compared to R-CHOP.

According to an independent review committee, there was a 59% improvement in PFS for the VR-CAP arm compared to the R-CHOP arm, with median PFS times of 24.7 months and 14.4 months, respectively (hazard ratio [HR]=0.63, P<0.001).

Study investigators reported a 96% increase in PFS with VR-CAP compared to R-CHOP, with median PFS times of 30.7 months and 16.1 months, respectively (HR=0.51, P<0.001).

Patients in the VR-CAP arm also fared better with regard to some secondary endpoints. The complete response rate was higher in the VR-CAP arm than the R-CHOP arm—53% and 42%, respectively (HR=1.29, P=0.007).

And patients in the VR-CAP arm had a longer median treatment-free interval—40.6 months and 20.5 months, respectively (HR=0.50, P<0.001).

However, there was no significant difference in overall survival between the treatment arms. The median overall survival was not reached in the VR-CAP arm and was 56.3 months in the R-CHOP arm (HR=0.80, P=0.17). The 4-year overall survival rate was 64% and 54%, respectively.

The investigators said VR-CAP was associated with additional, but manageable, toxicity when compared to R-CHOP. Serious AEs were reported in 38% and 30% of patients, respectively. And grade 3 or higher AEs were reported in 93% and 85% of patients, respectively.

Hematologic toxicity was more common in the VR-CAP arm than the R-CHOP arm. This included thrombocytopenia (72% vs 19%), neutropenia (88% vs 74%), anemia (51% vs 37%), leukopenia (50% vs 38%), lymphocytopenia (31% vs 13%), and febrile neutropenia (17% vs 14%).

Treatment discontinuation due to AEs occurred in 8% of patients in the VR-CAP arm and 6% in the R-CHOP arm. On-treatment, drug-related deaths occurred in 2% and 3% of patients, respectively.

It was based on these results that bortezomib was approved for use in patients with newly diagnosed MCL in the Europe Union and the US.

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