DNA repair

Credit: Tom Ellenberger

Understanding the interaction between 2 genes may be the key to better treatment of Fanconi anemia, according to a paper published in Cell Cycle.

Researchers investigated the relationship between FANCD2 and DNA2, 2 genes known to play roles in DNA repair.

A defective version of FANCD2 can result in Fanconi anemia. And although DNA2 has not been associated with a Fanconi anemia family

yet, genetic studies have implicated DNA2 in the Fanconi anemia DNA repair pathway.

With the current study, the researchers found that deleting either FANCD2 or DNA2 alone makes cells susceptible to DNA damage. But the deletion of both genes enables DNA repair.

“A key implication of this finding is the potential to manipulate DNA2 to improve the survival of FANCD2-deficient cells, and hopefully, by extension, the survival of [Fanconi anemia] patients,” said study author Kenneth Karanja, PhD, a former postdoctoral scholar at the California Institute of Technology in Pasadena.

To uncover the relationship between the genes, Dr Karanja and his colleagues applied DNA-damaging substances—formaldehyde and cisplatin—to 3 types of cells: those lacking FANCD2, those lacking DNA2, and cells lacking both genes.

The groups of cells in which only 1 of the 2 genes had been deleted quickly succumbed to the substance-induced DNA damage. However, the cells lacking both FANCD2 and DNA2 were able to repair the DNA damage and survive.

So the researchers concluded that depletion of DNA2 in FANCD2-deficient cells reverses the cells’ sensitivity to DNA-damaging substances. And this finding may have implications for Fanconi anemia treatment.

“DNA2 is a well-studied gene, and this recent discovery could potentially become the basis for ameliorating the symptoms of this incurable disorder,” said study author Judith Campbell, PhD, of the California Institute of Technology.

“Since much is known about the mechanism of action of DNA2, it is an attractive target for future drug treatments—like small-molecule inhibitors that could reduce [a Fanconi anemia] patient’s cancer predisposition—as well as a possible gene therapy for aiding a patient’s blood cell development.”

DNA repair

Credit: Tom Ellenberger

Understanding the interaction between 2 genes may be the key to better treatment of Fanconi anemia, according to a paper published in Cell Cycle.

Researchers investigated the relationship between FANCD2 and DNA2, 2 genes known to play roles in DNA repair.

A defective version of FANCD2 can result in Fanconi anemia. And although DNA2 has not been associated with a Fanconi anemia family

yet, genetic studies have implicated DNA2 in the Fanconi anemia DNA repair pathway.

With the current study, the researchers found that deleting either FANCD2 or DNA2 alone makes cells susceptible to DNA damage. But the deletion of both genes enables DNA repair.

“A key implication of this finding is the potential to manipulate DNA2 to improve the survival of FANCD2-deficient cells, and hopefully, by extension, the survival of [Fanconi anemia] patients,” said study author Kenneth Karanja, PhD, a former postdoctoral scholar at the California Institute of Technology in Pasadena.

To uncover the relationship between the genes, Dr Karanja and his colleagues applied DNA-damaging substances—formaldehyde and cisplatin—to 3 types of cells: those lacking FANCD2, those lacking DNA2, and cells lacking both genes.

The groups of cells in which only 1 of the 2 genes had been deleted quickly succumbed to the substance-induced DNA damage. However, the cells lacking both FANCD2 and DNA2 were able to repair the DNA damage and survive.

So the researchers concluded that depletion of DNA2 in FANCD2-deficient cells reverses the cells’ sensitivity to DNA-damaging substances. And this finding may have implications for Fanconi anemia treatment.

“DNA2 is a well-studied gene, and this recent discovery could potentially become the basis for ameliorating the symptoms of this incurable disorder,” said study author Judith Campbell, PhD, of the California Institute of Technology.

“Since much is known about the mechanism of action of DNA2, it is an attractive target for future drug treatments—like small-molecule inhibitors that could reduce [a Fanconi anemia] patient’s cancer predisposition—as well as a possible gene therapy for aiding a patient’s blood cell development.”

DNA repair

Credit: Tom Ellenberger

Understanding the interaction between 2 genes may be the key to better treatment of Fanconi anemia, according to a paper published in Cell Cycle.

Researchers investigated the relationship between FANCD2 and DNA2, 2 genes known to play roles in DNA repair.

A defective version of FANCD2 can result in Fanconi anemia. And although DNA2 has not been associated with a Fanconi anemia family

yet, genetic studies have implicated DNA2 in the Fanconi anemia DNA repair pathway.

With the current study, the researchers found that deleting either FANCD2 or DNA2 alone makes cells susceptible to DNA damage. But the deletion of both genes enables DNA repair.

“A key implication of this finding is the potential to manipulate DNA2 to improve the survival of FANCD2-deficient cells, and hopefully, by extension, the survival of [Fanconi anemia] patients,” said study author Kenneth Karanja, PhD, a former postdoctoral scholar at the California Institute of Technology in Pasadena.

To uncover the relationship between the genes, Dr Karanja and his colleagues applied DNA-damaging substances—formaldehyde and cisplatin—to 3 types of cells: those lacking FANCD2, those lacking DNA2, and cells lacking both genes.

The groups of cells in which only 1 of the 2 genes had been deleted quickly succumbed to the substance-induced DNA damage. However, the cells lacking both FANCD2 and DNA2 were able to repair the DNA damage and survive.

So the researchers concluded that depletion of DNA2 in FANCD2-deficient cells reverses the cells’ sensitivity to DNA-damaging substances. And this finding may have implications for Fanconi anemia treatment.

“DNA2 is a well-studied gene, and this recent discovery could potentially become the basis for ameliorating the symptoms of this incurable disorder,” said study author Judith Campbell, PhD, of the California Institute of Technology.

“Since much is known about the mechanism of action of DNA2, it is an attractive target for future drug treatments—like small-molecule inhibitors that could reduce [a Fanconi anemia] patient’s cancer predisposition—as well as a possible gene therapy for aiding a patient’s blood cell development.”

Vials of drug

Credit: Bill Branson

The antitumor agent bleomycin can treat a range of cancers, but its disease-fighting properties have been poorly understood.

Now, a pair of researchers have characterized bleomycin’s ability to cut through double-stranded DNA in cancerous cells.

The duo believe their research could help inform efforts to fine-tune the drug, improving its cancer-killing properties and limiting toxicity to healthy cells.

The research appears in the Journal of the American Chemical Society.

Bleomycin is part of a family of structurally related antibiotics produced by the bacterium Streptomyces verticillus. Three potent versions of the drug—labeled A2, A5, and B2—are the primary forms in clinical use against cancers.

Previous research has shown that bleomycin can cause death in aberrant cells by migrating to the cell nucleus, binding with DNA, and subsequently causing breaks in the DNA sequence. Following a binding event, a molecule of bleomycin can effectively slice through one or both strands of DNA.

Cleavage of DNA is believed to be the primary mechanism by which bleomycin kills cancer cells, particularly through double-strand cleavages, which are more challenging for the cellular machinery to repair.

“There are several mechanisms for repairing both single-strand and double-strand breaks in DNA, but double-strand breaks are a more potent form of DNA lesion,” explained study author Basab Roy, a graduate student at Arizona State University in Tempe.

For this study, Roy and Sidney Hecht, PhD, used bleomycin A5, which has similar DNA binding and cleaving properties as bleomycin A2 and B2.

Previous research revealed that bleomycin binds with highly specific regions of the DNA strand, typically G-C sites, where a guanosine base pairs with a cytidine. The strength of this binding is closely associated with the degree of double-strand DNA cleavage.

From a pool of random DNA sequences, the researchers selected a library of 10 hairpin DNAs, based on their strong binding affinity for bleomycin A5. Hairpin DNAs are looped structures that form when a segment of a DNA strand base-pairs with another portion of the same strand. These hairpin DNAs were used to investigate double-strand cleavage.

Each of the 10 DNA samples underwent double-strand cleavage at more than one site. All of the observed cleavage sites were found within or in close proximity to an 8-base-pair-variable region.

Examination of the 10 DNA samples exposed to bleomycin revealed a total of 31 double-strand cleavage sites. Earlier research had described the form of double-strand DNA cleavage bleomycin induced at 14 of these sites. But the remaining 17 cases of double-stranded cleavage occurred through a different mechanism, described for the first time by Roy and Dr Hecht.

The pair used iron (FeII) as a cofactor for bleomycin in the binding events, and they observed 2 types of bleomycin binding and cleavage activity.

In the first, bleomycin and its iron cofactor (Fe.BLM) bind with hairpin DNA at a primary site. Typically, this is a site with a particular sequence: 5´-G-Py-B-3´. (Here, 5´ refers to one end of the DNA hairpin, G refers to the base guanosine, Py refers to a pyrimidinic base—either cytidine or thymidine, B refers to any nucleobase, and 3´ refers to the other DNA end.)

The result of this binding is the abstraction of a hydrogen atom at the primary site. Two results are possible following the primary binding event, one causing a single-strand break in the primary site and the other, failing to produce full cleavage of the strand, producing instead a site lacking either a purine or pyrimidine base. This is known as an AP site.

In the first case—where bleomycin achieves single strand cleavage—the bleomycin molecule can then become reactivated, once more abstracting a hydrogen atom from the opposing DNA strand.

The opposite strand can again follow 1 of 2 pathways, (a) full cleavage of the opposing strand, yielding a double-strand cleavage or (b) formation of an AP site. The researchers noted that this AP site can lead to strand cleavage through the opposing DNA strand with the addition of a mild base like n-butylamine.

The results of this study emphasize the correlation between the strength of bleomycin binding to DNA and the frequency of double-strand cleavage. Of the 10 sample hairpin DNAs, the 2 most tightly bound to bleomycin each showed 5 double-strand cleavages, whereas the least tightly bound samples exhibited just 2 double-strand cleavages.

This suggests a plausible mechanism for DNA cleavage by bleomycin that may lead to tumor cell killing, as well as identifying the most common sequences involved in DNA site binding and subsequent strand breakage.

Roy noted, however, that more research is needed to elucidate the biochemical causes of tight binding by bleomycin. Furthermore, bleomycin’s specificity for cancer cells remains enigmatic.

“Cancer is still a black hole,” Roy said. “We’re trying to make this particular molecule better. There is still so much to learn.”

Vials of drug

Credit: Bill Branson

The antitumor agent bleomycin can treat a range of cancers, but its disease-fighting properties have been poorly understood.

Now, a pair of researchers have characterized bleomycin’s ability to cut through double-stranded DNA in cancerous cells.

The duo believe their research could help inform efforts to fine-tune the drug, improving its cancer-killing properties and limiting toxicity to healthy cells.

The research appears in the Journal of the American Chemical Society.

Bleomycin is part of a family of structurally related antibiotics produced by the bacterium Streptomyces verticillus. Three potent versions of the drug—labeled A2, A5, and B2—are the primary forms in clinical use against cancers.

Previous research has shown that bleomycin can cause death in aberrant cells by migrating to the cell nucleus, binding with DNA, and subsequently causing breaks in the DNA sequence. Following a binding event, a molecule of bleomycin can effectively slice through one or both strands of DNA.

Cleavage of DNA is believed to be the primary mechanism by which bleomycin kills cancer cells, particularly through double-strand cleavages, which are more challenging for the cellular machinery to repair.

“There are several mechanisms for repairing both single-strand and double-strand breaks in DNA, but double-strand breaks are a more potent form of DNA lesion,” explained study author Basab Roy, a graduate student at Arizona State University in Tempe.

For this study, Roy and Sidney Hecht, PhD, used bleomycin A5, which has similar DNA binding and cleaving properties as bleomycin A2 and B2.

Previous research revealed that bleomycin binds with highly specific regions of the DNA strand, typically G-C sites, where a guanosine base pairs with a cytidine. The strength of this binding is closely associated with the degree of double-strand DNA cleavage.

From a pool of random DNA sequences, the researchers selected a library of 10 hairpin DNAs, based on their strong binding affinity for bleomycin A5. Hairpin DNAs are looped structures that form when a segment of a DNA strand base-pairs with another portion of the same strand. These hairpin DNAs were used to investigate double-strand cleavage.

Each of the 10 DNA samples underwent double-strand cleavage at more than one site. All of the observed cleavage sites were found within or in close proximity to an 8-base-pair-variable region.

Examination of the 10 DNA samples exposed to bleomycin revealed a total of 31 double-strand cleavage sites. Earlier research had described the form of double-strand DNA cleavage bleomycin induced at 14 of these sites. But the remaining 17 cases of double-stranded cleavage occurred through a different mechanism, described for the first time by Roy and Dr Hecht.

The pair used iron (FeII) as a cofactor for bleomycin in the binding events, and they observed 2 types of bleomycin binding and cleavage activity.

In the first, bleomycin and its iron cofactor (Fe.BLM) bind with hairpin DNA at a primary site. Typically, this is a site with a particular sequence: 5´-G-Py-B-3´. (Here, 5´ refers to one end of the DNA hairpin, G refers to the base guanosine, Py refers to a pyrimidinic base—either cytidine or thymidine, B refers to any nucleobase, and 3´ refers to the other DNA end.)

The result of this binding is the abstraction of a hydrogen atom at the primary site. Two results are possible following the primary binding event, one causing a single-strand break in the primary site and the other, failing to produce full cleavage of the strand, producing instead a site lacking either a purine or pyrimidine base. This is known as an AP site.

In the first case—where bleomycin achieves single strand cleavage—the bleomycin molecule can then become reactivated, once more abstracting a hydrogen atom from the opposing DNA strand.

The opposite strand can again follow 1 of 2 pathways, (a) full cleavage of the opposing strand, yielding a double-strand cleavage or (b) formation of an AP site. The researchers noted that this AP site can lead to strand cleavage through the opposing DNA strand with the addition of a mild base like n-butylamine.

The results of this study emphasize the correlation between the strength of bleomycin binding to DNA and the frequency of double-strand cleavage. Of the 10 sample hairpin DNAs, the 2 most tightly bound to bleomycin each showed 5 double-strand cleavages, whereas the least tightly bound samples exhibited just 2 double-strand cleavages.

This suggests a plausible mechanism for DNA cleavage by bleomycin that may lead to tumor cell killing, as well as identifying the most common sequences involved in DNA site binding and subsequent strand breakage.

Roy noted, however, that more research is needed to elucidate the biochemical causes of tight binding by bleomycin. Furthermore, bleomycin’s specificity for cancer cells remains enigmatic.

“Cancer is still a black hole,” Roy said. “We’re trying to make this particular molecule better. There is still so much to learn.”

Vials of drug

Credit: Bill Branson

The antitumor agent bleomycin can treat a range of cancers, but its disease-fighting properties have been poorly understood.

Now, a pair of researchers have characterized bleomycin’s ability to cut through double-stranded DNA in cancerous cells.

The duo believe their research could help inform efforts to fine-tune the drug, improving its cancer-killing properties and limiting toxicity to healthy cells.

The research appears in the Journal of the American Chemical Society.

Bleomycin is part of a family of structurally related antibiotics produced by the bacterium Streptomyces verticillus. Three potent versions of the drug—labeled A2, A5, and B2—are the primary forms in clinical use against cancers.

Previous research has shown that bleomycin can cause death in aberrant cells by migrating to the cell nucleus, binding with DNA, and subsequently causing breaks in the DNA sequence. Following a binding event, a molecule of bleomycin can effectively slice through one or both strands of DNA.

Cleavage of DNA is believed to be the primary mechanism by which bleomycin kills cancer cells, particularly through double-strand cleavages, which are more challenging for the cellular machinery to repair.

“There are several mechanisms for repairing both single-strand and double-strand breaks in DNA, but double-strand breaks are a more potent form of DNA lesion,” explained study author Basab Roy, a graduate student at Arizona State University in Tempe.

For this study, Roy and Sidney Hecht, PhD, used bleomycin A5, which has similar DNA binding and cleaving properties as bleomycin A2 and B2.

Previous research revealed that bleomycin binds with highly specific regions of the DNA strand, typically G-C sites, where a guanosine base pairs with a cytidine. The strength of this binding is closely associated with the degree of double-strand DNA cleavage.

From a pool of random DNA sequences, the researchers selected a library of 10 hairpin DNAs, based on their strong binding affinity for bleomycin A5. Hairpin DNAs are looped structures that form when a segment of a DNA strand base-pairs with another portion of the same strand. These hairpin DNAs were used to investigate double-strand cleavage.

Each of the 10 DNA samples underwent double-strand cleavage at more than one site. All of the observed cleavage sites were found within or in close proximity to an 8-base-pair-variable region.

Examination of the 10 DNA samples exposed to bleomycin revealed a total of 31 double-strand cleavage sites. Earlier research had described the form of double-strand DNA cleavage bleomycin induced at 14 of these sites. But the remaining 17 cases of double-stranded cleavage occurred through a different mechanism, described for the first time by Roy and Dr Hecht.

The pair used iron (FeII) as a cofactor for bleomycin in the binding events, and they observed 2 types of bleomycin binding and cleavage activity.

In the first, bleomycin and its iron cofactor (Fe.BLM) bind with hairpin DNA at a primary site. Typically, this is a site with a particular sequence: 5´-G-Py-B-3´. (Here, 5´ refers to one end of the DNA hairpin, G refers to the base guanosine, Py refers to a pyrimidinic base—either cytidine or thymidine, B refers to any nucleobase, and 3´ refers to the other DNA end.)

The result of this binding is the abstraction of a hydrogen atom at the primary site. Two results are possible following the primary binding event, one causing a single-strand break in the primary site and the other, failing to produce full cleavage of the strand, producing instead a site lacking either a purine or pyrimidine base. This is known as an AP site.

In the first case—where bleomycin achieves single strand cleavage—the bleomycin molecule can then become reactivated, once more abstracting a hydrogen atom from the opposing DNA strand.

The opposite strand can again follow 1 of 2 pathways, (a) full cleavage of the opposing strand, yielding a double-strand cleavage or (b) formation of an AP site. The researchers noted that this AP site can lead to strand cleavage through the opposing DNA strand with the addition of a mild base like n-butylamine.

The results of this study emphasize the correlation between the strength of bleomycin binding to DNA and the frequency of double-strand cleavage. Of the 10 sample hairpin DNAs, the 2 most tightly bound to bleomycin each showed 5 double-strand cleavages, whereas the least tightly bound samples exhibited just 2 double-strand cleavages.

This suggests a plausible mechanism for DNA cleavage by bleomycin that may lead to tumor cell killing, as well as identifying the most common sequences involved in DNA site binding and subsequent strand breakage.

Roy noted, however, that more research is needed to elucidate the biochemical causes of tight binding by bleomycin. Furthermore, bleomycin’s specificity for cancer cells remains enigmatic.

“Cancer is still a black hole,” Roy said. “We’re trying to make this particular molecule better. There is still so much to learn.”

SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.

The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.

“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.

“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”

Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.

Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.

“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”

HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.

“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.

She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”

Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.

As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.

“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”

SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.

The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.

“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.

“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”

Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.

Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.

“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”

HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.

“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.

She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”

Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.

As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.

“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”

SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.

The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.

“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.

“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”

Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.

Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.

“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”

HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.

“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.

She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”

Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.

As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.

“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”

Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.

Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.

SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.

Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.

The Medication Safety Collaborative consists of three meetings:

• ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
• The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
• Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.

Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.

Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.

SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.

Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.

The Medication Safety Collaborative consists of three meetings:

• ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
• The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
• Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.

Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.

Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.

SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.

Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.

The Medication Safety Collaborative consists of three meetings:

• ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
• The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
• Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.

SHM estimates that there are more than 44,000 hospitalists in 2014. Here are some other facts and figures about the specialty:

• In 2014, it is estimated that hospitalists have a presence at 72% of U.S. hospitals, with an average group size of 12.3 physicians.
• In the 10-year period between 2003 and 2012, the percentage of hospitals with hospitalists has more than doubled. The overall penetration of hospitals with HM groups grew from 29% to 66%.
• In same 10-year period, the number of hospitalists grew from 11,159 to 38,114.
• Since the development of SHM’s award-winning mentored implementation program, 423 hospitals nationwide have adopted the model to address some of the most pressing hospital-based healthcare issues, such as readmissions, VTE, and glycemic control. SHM’s implementation guides on these issues have been downloaded more than 9,500 times.
• Research published in the Journal of Hospital Medicine in 2013 showed that SHM’s Project BOOST has helped reduce readmissions among hospitals collecting and reporting data.

SHM estimates that there are more than 44,000 hospitalists in 2014. Here are some other facts and figures about the specialty:

• In 2014, it is estimated that hospitalists have a presence at 72% of U.S. hospitals, with an average group size of 12.3 physicians.
• In the 10-year period between 2003 and 2012, the percentage of hospitals with hospitalists has more than doubled. The overall penetration of hospitals with HM groups grew from 29% to 66%.
• In same 10-year period, the number of hospitalists grew from 11,159 to 38,114.
• Since the development of SHM’s award-winning mentored implementation program, 423 hospitals nationwide have adopted the model to address some of the most pressing hospital-based healthcare issues, such as readmissions, VTE, and glycemic control. SHM’s implementation guides on these issues have been downloaded more than 9,500 times.
• Research published in the Journal of Hospital Medicine in 2013 showed that SHM’s Project BOOST has helped reduce readmissions among hospitals collecting and reporting data.

SHM estimates that there are more than 44,000 hospitalists in 2014. Here are some other facts and figures about the specialty:

• In 2014, it is estimated that hospitalists have a presence at 72% of U.S. hospitals, with an average group size of 12.3 physicians.
• In the 10-year period between 2003 and 2012, the percentage of hospitals with hospitalists has more than doubled. The overall penetration of hospitals with HM groups grew from 29% to 66%.
• In same 10-year period, the number of hospitalists grew from 11,159 to 38,114.
• Since the development of SHM’s award-winning mentored implementation program, 423 hospitals nationwide have adopted the model to address some of the most pressing hospital-based healthcare issues, such as readmissions, VTE, and glycemic control. SHM’s implementation guides on these issues have been downloaded more than 9,500 times.
• Research published in the Journal of Hospital Medicine in 2013 showed that SHM’s Project BOOST has helped reduce readmissions among hospitals collecting and reporting data.

Editor’s note: Originally posted to SHM’s blog, The Hospital Leader, on February 25. Visit www.hospitalleader.org for more insight from leaders in the specialty.

Imagine for a second that, instead of being defined by what you are at work, you were defined by what you aren’t. What if hospitalists were called “non-executive caregivers” or “non-janitorial staff?” Confusing, at best—and potentially even demeaning, depending on the context.

That’s what happens to many nurse practitioners, physician assistants, pharmacists, and other valuable members of the hospital care team all the time. Instead of being called by the titles that they’ve worked hard to earn, some in the hospital use terms that define them by what they aren’t, like “non-physician provider,” “allied health provider,” “physician extender,” or “mid-level.” More to the point, nurse practitioners (NP), physician assistants (PA), and pharmacists are a critical part of the hospitalist teams working to deliver exceptional care to hospitalized patients.

This is not a fringe issue. Today, nearly 800 SHM members identify themselves as NPs, PAs, pharmacists, pharmacy technicians, registered nurses, registered dietitians, physical therapists, research managers, or program coordinators.

That’s why, effective this month, SHM has begun to phase out the following terms in its future materials:

• “Allied health”;
• “Non-physician provider”;
• “Physician extender”; and
• “Mid-level.”

Instead, we plan to use the names for individual groups, like “physician assistants,” “nurse practitioners,” or “pharmacists.”

For a firsthand perspective on how deeply these kinds of terms are felt by NPs and PAs, please read SHM NP/PA Committee Chair Tracy Cardin’s recent blog post on The Hospital Leader.

Admittedly, there may be times when terms like “allied health” are more expedient, and it will take some time for us to fully adjust some of our internal nomenclature (in things like our databases and meeting registration systems) to the change, but the potential for alienating members of the hospitalist family outweighs the need for convenience.

SHM is committed to properly identifying all of SHM’s members. Identity is important in medicine, to the caregivers and their patients. Just 18 years ago, Bob Wachter, MD, coined the word “hospitalist”; the term now applies to more than 44,000 in healthcare.

Today, we’re taking one step toward helping everyone in healthcare better describe the value and expertise of the members of the hospitalist team.

How do you use your titles to convey your contribution to patient care? Let us know in the comments, or join the conversation on HMX (http://connect.hospitalmedicine.org/home).

Blog post author Brendon Shank is SHM’s associate vice president of communications.

Editor’s note: Originally posted to SHM’s blog, The Hospital Leader, on February 25. Visit www.hospitalleader.org for more insight from leaders in the specialty.

Imagine for a second that, instead of being defined by what you are at work, you were defined by what you aren’t. What if hospitalists were called “non-executive caregivers” or “non-janitorial staff?” Confusing, at best—and potentially even demeaning, depending on the context.

That’s what happens to many nurse practitioners, physician assistants, pharmacists, and other valuable members of the hospital care team all the time. Instead of being called by the titles that they’ve worked hard to earn, some in the hospital use terms that define them by what they aren’t, like “non-physician provider,” “allied health provider,” “physician extender,” or “mid-level.” More to the point, nurse practitioners (NP), physician assistants (PA), and pharmacists are a critical part of the hospitalist teams working to deliver exceptional care to hospitalized patients.

This is not a fringe issue. Today, nearly 800 SHM members identify themselves as NPs, PAs, pharmacists, pharmacy technicians, registered nurses, registered dietitians, physical therapists, research managers, or program coordinators.

That’s why, effective this month, SHM has begun to phase out the following terms in its future materials:

• “Allied health”;
• “Non-physician provider”;
• “Physician extender”; and
• “Mid-level.”

Instead, we plan to use the names for individual groups, like “physician assistants,” “nurse practitioners,” or “pharmacists.”

For a firsthand perspective on how deeply these kinds of terms are felt by NPs and PAs, please read SHM NP/PA Committee Chair Tracy Cardin’s recent blog post on The Hospital Leader.

Admittedly, there may be times when terms like “allied health” are more expedient, and it will take some time for us to fully adjust some of our internal nomenclature (in things like our databases and meeting registration systems) to the change, but the potential for alienating members of the hospitalist family outweighs the need for convenience.

SHM is committed to properly identifying all of SHM’s members. Identity is important in medicine, to the caregivers and their patients. Just 18 years ago, Bob Wachter, MD, coined the word “hospitalist”; the term now applies to more than 44,000 in healthcare.

Today, we’re taking one step toward helping everyone in healthcare better describe the value and expertise of the members of the hospitalist team.

How do you use your titles to convey your contribution to patient care? Let us know in the comments, or join the conversation on HMX (http://connect.hospitalmedicine.org/home).

Blog post author Brendon Shank is SHM’s associate vice president of communications.

Editor’s note: Originally posted to SHM’s blog, The Hospital Leader, on February 25. Visit www.hospitalleader.org for more insight from leaders in the specialty.

Imagine for a second that, instead of being defined by what you are at work, you were defined by what you aren’t. What if hospitalists were called “non-executive caregivers” or “non-janitorial staff?” Confusing, at best—and potentially even demeaning, depending on the context.

That’s what happens to many nurse practitioners, physician assistants, pharmacists, and other valuable members of the hospital care team all the time. Instead of being called by the titles that they’ve worked hard to earn, some in the hospital use terms that define them by what they aren’t, like “non-physician provider,” “allied health provider,” “physician extender,” or “mid-level.” More to the point, nurse practitioners (NP), physician assistants (PA), and pharmacists are a critical part of the hospitalist teams working to deliver exceptional care to hospitalized patients.

This is not a fringe issue. Today, nearly 800 SHM members identify themselves as NPs, PAs, pharmacists, pharmacy technicians, registered nurses, registered dietitians, physical therapists, research managers, or program coordinators.

That’s why, effective this month, SHM has begun to phase out the following terms in its future materials:

• “Allied health”;
• “Non-physician provider”;
• “Physician extender”; and
• “Mid-level.”

Instead, we plan to use the names for individual groups, like “physician assistants,” “nurse practitioners,” or “pharmacists.”

For a firsthand perspective on how deeply these kinds of terms are felt by NPs and PAs, please read SHM NP/PA Committee Chair Tracy Cardin’s recent blog post on The Hospital Leader.

Admittedly, there may be times when terms like “allied health” are more expedient, and it will take some time for us to fully adjust some of our internal nomenclature (in things like our databases and meeting registration systems) to the change, but the potential for alienating members of the hospitalist family outweighs the need for convenience.

SHM is committed to properly identifying all of SHM’s members. Identity is important in medicine, to the caregivers and their patients. Just 18 years ago, Bob Wachter, MD, coined the word “hospitalist”; the term now applies to more than 44,000 in healthcare.

Today, we’re taking one step toward helping everyone in healthcare better describe the value and expertise of the members of the hospitalist team.

How do you use your titles to convey your contribution to patient care? Let us know in the comments, or join the conversation on HMX (http://connect.hospitalmedicine.org/home).

Blog post author Brendon Shank is SHM’s associate vice president of communications.

The changes launched by the Affordable Care Act are upon us and have created considerable trepidation among many in healthcare, particularly our chief financial officers (CFOs). The CFOs’ core responsibilities include financial planning, contracting, and setting budgets. Although finance teams and clinical leaders sometimes feel like they are speaking different languages—and, in fact, many physicians couldn’t pick their hospital’s CFO out of a police lineup—successful healthcare systems bridge that gap, enabling clinical and finance leaders to work together toward common goals.

It’s easy for us doctor types to be leery of our hospital’s financial team. If you’ve ever been in direct conversation with your CFO, you may have found the discussion was packed with terms like “EBIDA,” “capital allocation,” and “operating margin,” and seemed to imply that the organization is prioritizing its bond rating over its composite PSI [patient safety indicators] performance. But the truth is that our finance teams are frustrated, too. In fact, they are more than frustrated—they are scared.

They really haven’t been sleeping well lately. They’d feel better if doctors could try to see the world that they see. A CFO’s core responsibility is ensuring a responsible, long-range financial plan that meets the needs of their hospital stakeholders—to paraphrase Tom Wolfe paraphrasing astronaut Gus Grissom, “no bucks, no Buck Rogers”—and that responsibility got a lot harder in 2014. By understanding their perspective, we clinicians should be able to take actions that result in better care of our patients today—and ensure a sustainable hospital that can take care of patients tomorrow. So that we can better empathize with our green-visored colleagues, here are a few of the thoughts going through their heads as they toss and turn at 3 a.m.

Change Is All Around

There are many urgent pressures on hospital, physician, and healthcare revenues. Keep in mind that a hospital’s costs in terms of pharmaceuticals, equipment, and labor (the average hospital has nearly 60% of its cost in labor) are not really going down to offset that revenue loss. While we’ve become uncomfortably familiar with RAC audits, value-based purchasing, the sustainable growth rate, and sequestration, I’d suggest that these revenue challenges pale in comparison to the insomnia created by the rapid rise of healthcare consumerism. Lost, or at least buried, in the stories about ACA politics, coverage of the uninsured, website malfunctions, and dropped insurance plans is the fact that the nature of insurance is changing.

Although offerings like medical savings accounts and high-deductible plans have been around for years, they are increasingly mainstream, because the plans offered through the insurance exchanges, which have surpassed the seven million mark in enrollment as of the time of this writing, all carry substantial patient commitments. The great majority of these plans—81% through February—are either “bronze” or “silver” level—and keep in mind that the average “gold” plan, in covering 80% of anticipated expenses, leaves patients with higher commitments than most large-employer group plans probably do. From that standpoint, they require patients, doctors, and hospitals to manage healthcare differently than they have in the past: We have to be mindful that patients are paying more of the “first dollar.”

The problem, from a CFO’s perspective, is at least twofold: First, a lot of patients don’t pay the portion of their bill for which they are responsible. Many doctors, hospitals, and healthcare systems are moving toward more assertive and up-front collections for non-emergency care; unfortunately, at best, we don’t do a very good job and, at worst, we create an uncomfortable space where we either channel the practices of collection agencies or leave much-needed funds on the table. As the deductibles, co-pays, and co-insurance obligations rise, so do the uncollected accounts. Our advocacy for patients increasingly requires us to be better stewards of their resources.

The second insomnia-inducing aspect of consumerism is transparency of pricing. As the exchanges move to create a “Priceline.com”-like approach to selecting an insurance plan, a similar transformation is occurring in how payers—and, with the spread of plans with higher patient obligations, patients themselves—are looking at how we set prices for everything from MRIs and laboratory services to hospitalization and physician charges. While we as individuals are used to price transparency in purchasing consumer goods, the third-party payment system in healthcare has insulated us, and our hospitals, from the consequences of the market system. (Please note, dear reader: I’m not defending either the past practices or current policy. I’m simply diagnosing why your CFO has black circles under his or her eyes.)

So, prices are increasingly published and available for comparison shopping by both insurers and individuals with those high deductibles or co-insurance amounts. As charges hit their pocketbooks, there is good reason to believe that patients will be “brand loyal” only to the point where they stop appreciating value. Systems with a reliable advantage in pricing (think: academic medical centers) run a great risk of losing business quickly if they cannot demonstrate value for those prices. Hospital-based physicians have been in the position of being the “translators” of value-based care—by always advocating for measurably better care, we help both our patients and our organizations.

Variation in Care

Perhaps most befuddling to our CFO friends are the variations in costs, outcomes, and clinical processes that seemingly similar patients with seemingly similar problems incur. Wide variations might occur based on just about any parameter, from the name of the attending physician to the day of the week of admission. Of course, at times, this variation could be explainable by, say, clinically relevant features that are simply not adjusted for, or the absence of literature to guide decisions. But, all too often, no reasonable explanation exists, and underneath that is a simmering concern that wide variations reflect failure to adhere to known guidelines, uneven distribution of resources, and “waste” deeply embedded in the healthcare value stream.

Less widely understood to clinicians is that, from the CFO’s perspective, the movement toward “value over volume” and risk-bearing systems such as accountable care organizations (ACOs) requires healthcare organizations to think like insurance companies. They must be able to accurately predict clinical outcomes within a population so that they can assess their actuarial risk and manage appropriately. Wide variations in care make those predictions less valid and outcomes more unpredictable, greatly raising the stakes for an ACO or other risk-bearing model.

From the CFO’s perspective, a key advantage to the move toward systems directly employing physicians is that a management structure can be created to decrease this variation; however, I’d question whether many physician groups, much less employed-group practices, have the appropriate management culture or the sophistication with data to do this effectively.

The Cost of Recapitalization

Most of the hospitals I’ve worked in are a jumble of incrementally newer additions built on a decades-old core facility. Clinicians tend to see the consequences as patients see them: not enough private rooms, outdated technology and equipment, poorly integrated computer and health IT systems, and inadequate storage for equipment. Your CFO certainly sees these same things, but has the additional challenge of trying to keep up with the demands for new facilities and capital purchases while maintaining the older physical plant and preserving the long-term financial strength of the organization. Even though roofing, HVAC, and new flooring are rarely as sexy as a new surgical robot, it won’t do much good to invest in that new OR equipment if the roof is leaking. And healthcare construction is really expensive, even more so because of entirely appropriate requirements that renovations bring older structures up to modern codes.

In the healthcare world, these expenses are formidable. Hospitals, like other businesses, sometimes borrow money to fund projects—particularly new construction projects. Nonprofit hospitals can be attractive to lenders because of their tax-advantaged nature. But, like our personal credit ratings, a healthcare system that enters into the bond market has specific metrics at which lenders look carefully to determine the cost of such lending, such as payer mix, income margin, debt ratios, and earnings before interest, depreciation, and amortization (EBIDA). And that’s where we come full circle to that latest conversation with the CFO.

So in order to preserve the ability to meet the needs of stakeholders, our friends in finance need to make sure a long-range plan is in place that continues to fund operations, growth, and ongoing maintenance, including the ability to borrow money when appropriate. Going forward, thriving healthcare organizations will have to be consumer-minded and successful in managing the risks of population health. The uncertainty created by the exchanges and transparency, and the inability to accurately gauge and manage the risk of adverse outcomes, has our CFO colleagues pleading with us for a prescription that will ease their restless nights. Here’s how we can help:

• Focus on working with your group to measure and minimize variations in care processes and outcomes among patients and doctors;
• Be mindful that in a value-based world, CMS and insurers now look at both inpatient and outpatient utilization and costs, and we need to do the same in our transitional care planning; and
• Be conscious that our prescriptions for care are increasingly impacting patients’ wallets, so we need to articulate and demonstrate the clinical value that underlies each decision.

In Sum

The next time you or your nocturnist is admitting that nth patient at 3 a.m., consider that your CFO may also be wide awake, struggling with his or her own version of a management challenge. As physicians who practice in hospitals, which are perhaps the most costly environments in the healthcare world, you and your colleagues may be well positioned to help make your hospitals more efficient, to better manage and improve those outcomes, and to help identify and prioritize the most pressing capital needs.

In short, just what the doctor ordered for your CFO to finally get a good night’s sleep.

Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.

The changes launched by the Affordable Care Act are upon us and have created considerable trepidation among many in healthcare, particularly our chief financial officers (CFOs). The CFOs’ core responsibilities include financial planning, contracting, and setting budgets. Although finance teams and clinical leaders sometimes feel like they are speaking different languages—and, in fact, many physicians couldn’t pick their hospital’s CFO out of a police lineup—successful healthcare systems bridge that gap, enabling clinical and finance leaders to work together toward common goals.

It’s easy for us doctor types to be leery of our hospital’s financial team. If you’ve ever been in direct conversation with your CFO, you may have found the discussion was packed with terms like “EBIDA,” “capital allocation,” and “operating margin,” and seemed to imply that the organization is prioritizing its bond rating over its composite PSI [patient safety indicators] performance. But the truth is that our finance teams are frustrated, too. In fact, they are more than frustrated—they are scared.

They really haven’t been sleeping well lately. They’d feel better if doctors could try to see the world that they see. A CFO’s core responsibility is ensuring a responsible, long-range financial plan that meets the needs of their hospital stakeholders—to paraphrase Tom Wolfe paraphrasing astronaut Gus Grissom, “no bucks, no Buck Rogers”—and that responsibility got a lot harder in 2014. By understanding their perspective, we clinicians should be able to take actions that result in better care of our patients today—and ensure a sustainable hospital that can take care of patients tomorrow. So that we can better empathize with our green-visored colleagues, here are a few of the thoughts going through their heads as they toss and turn at 3 a.m.

Change Is All Around

There are many urgent pressures on hospital, physician, and healthcare revenues. Keep in mind that a hospital’s costs in terms of pharmaceuticals, equipment, and labor (the average hospital has nearly 60% of its cost in labor) are not really going down to offset that revenue loss. While we’ve become uncomfortably familiar with RAC audits, value-based purchasing, the sustainable growth rate, and sequestration, I’d suggest that these revenue challenges pale in comparison to the insomnia created by the rapid rise of healthcare consumerism. Lost, or at least buried, in the stories about ACA politics, coverage of the uninsured, website malfunctions, and dropped insurance plans is the fact that the nature of insurance is changing.

Although offerings like medical savings accounts and high-deductible plans have been around for years, they are increasingly mainstream, because the plans offered through the insurance exchanges, which have surpassed the seven million mark in enrollment as of the time of this writing, all carry substantial patient commitments. The great majority of these plans—81% through February—are either “bronze” or “silver” level—and keep in mind that the average “gold” plan, in covering 80% of anticipated expenses, leaves patients with higher commitments than most large-employer group plans probably do. From that standpoint, they require patients, doctors, and hospitals to manage healthcare differently than they have in the past: We have to be mindful that patients are paying more of the “first dollar.”

The problem, from a CFO’s perspective, is at least twofold: First, a lot of patients don’t pay the portion of their bill for which they are responsible. Many doctors, hospitals, and healthcare systems are moving toward more assertive and up-front collections for non-emergency care; unfortunately, at best, we don’t do a very good job and, at worst, we create an uncomfortable space where we either channel the practices of collection agencies or leave much-needed funds on the table. As the deductibles, co-pays, and co-insurance obligations rise, so do the uncollected accounts. Our advocacy for patients increasingly requires us to be better stewards of their resources.

The second insomnia-inducing aspect of consumerism is transparency of pricing. As the exchanges move to create a “Priceline.com”-like approach to selecting an insurance plan, a similar transformation is occurring in how payers—and, with the spread of plans with higher patient obligations, patients themselves—are looking at how we set prices for everything from MRIs and laboratory services to hospitalization and physician charges. While we as individuals are used to price transparency in purchasing consumer goods, the third-party payment system in healthcare has insulated us, and our hospitals, from the consequences of the market system. (Please note, dear reader: I’m not defending either the past practices or current policy. I’m simply diagnosing why your CFO has black circles under his or her eyes.)

So, prices are increasingly published and available for comparison shopping by both insurers and individuals with those high deductibles or co-insurance amounts. As charges hit their pocketbooks, there is good reason to believe that patients will be “brand loyal” only to the point where they stop appreciating value. Systems with a reliable advantage in pricing (think: academic medical centers) run a great risk of losing business quickly if they cannot demonstrate value for those prices. Hospital-based physicians have been in the position of being the “translators” of value-based care—by always advocating for measurably better care, we help both our patients and our organizations.

Variation in Care

Perhaps most befuddling to our CFO friends are the variations in costs, outcomes, and clinical processes that seemingly similar patients with seemingly similar problems incur. Wide variations might occur based on just about any parameter, from the name of the attending physician to the day of the week of admission. Of course, at times, this variation could be explainable by, say, clinically relevant features that are simply not adjusted for, or the absence of literature to guide decisions. But, all too often, no reasonable explanation exists, and underneath that is a simmering concern that wide variations reflect failure to adhere to known guidelines, uneven distribution of resources, and “waste” deeply embedded in the healthcare value stream.

Less widely understood to clinicians is that, from the CFO’s perspective, the movement toward “value over volume” and risk-bearing systems such as accountable care organizations (ACOs) requires healthcare organizations to think like insurance companies. They must be able to accurately predict clinical outcomes within a population so that they can assess their actuarial risk and manage appropriately. Wide variations in care make those predictions less valid and outcomes more unpredictable, greatly raising the stakes for an ACO or other risk-bearing model.

From the CFO’s perspective, a key advantage to the move toward systems directly employing physicians is that a management structure can be created to decrease this variation; however, I’d question whether many physician groups, much less employed-group practices, have the appropriate management culture or the sophistication with data to do this effectively.

The Cost of Recapitalization

Most of the hospitals I’ve worked in are a jumble of incrementally newer additions built on a decades-old core facility. Clinicians tend to see the consequences as patients see them: not enough private rooms, outdated technology and equipment, poorly integrated computer and health IT systems, and inadequate storage for equipment. Your CFO certainly sees these same things, but has the additional challenge of trying to keep up with the demands for new facilities and capital purchases while maintaining the older physical plant and preserving the long-term financial strength of the organization. Even though roofing, HVAC, and new flooring are rarely as sexy as a new surgical robot, it won’t do much good to invest in that new OR equipment if the roof is leaking. And healthcare construction is really expensive, even more so because of entirely appropriate requirements that renovations bring older structures up to modern codes.

In the healthcare world, these expenses are formidable. Hospitals, like other businesses, sometimes borrow money to fund projects—particularly new construction projects. Nonprofit hospitals can be attractive to lenders because of their tax-advantaged nature. But, like our personal credit ratings, a healthcare system that enters into the bond market has specific metrics at which lenders look carefully to determine the cost of such lending, such as payer mix, income margin, debt ratios, and earnings before interest, depreciation, and amortization (EBIDA). And that’s where we come full circle to that latest conversation with the CFO.

So in order to preserve the ability to meet the needs of stakeholders, our friends in finance need to make sure a long-range plan is in place that continues to fund operations, growth, and ongoing maintenance, including the ability to borrow money when appropriate. Going forward, thriving healthcare organizations will have to be consumer-minded and successful in managing the risks of population health. The uncertainty created by the exchanges and transparency, and the inability to accurately gauge and manage the risk of adverse outcomes, has our CFO colleagues pleading with us for a prescription that will ease their restless nights. Here’s how we can help:

• Focus on working with your group to measure and minimize variations in care processes and outcomes among patients and doctors;
• Be mindful that in a value-based world, CMS and insurers now look at both inpatient and outpatient utilization and costs, and we need to do the same in our transitional care planning; and
• Be conscious that our prescriptions for care are increasingly impacting patients’ wallets, so we need to articulate and demonstrate the clinical value that underlies each decision.

In Sum

The next time you or your nocturnist is admitting that nth patient at 3 a.m., consider that your CFO may also be wide awake, struggling with his or her own version of a management challenge. As physicians who practice in hospitals, which are perhaps the most costly environments in the healthcare world, you and your colleagues may be well positioned to help make your hospitals more efficient, to better manage and improve those outcomes, and to help identify and prioritize the most pressing capital needs.

In short, just what the doctor ordered for your CFO to finally get a good night’s sleep.

Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.

The changes launched by the Affordable Care Act are upon us and have created considerable trepidation among many in healthcare, particularly our chief financial officers (CFOs). The CFOs’ core responsibilities include financial planning, contracting, and setting budgets. Although finance teams and clinical leaders sometimes feel like they are speaking different languages—and, in fact, many physicians couldn’t pick their hospital’s CFO out of a police lineup—successful healthcare systems bridge that gap, enabling clinical and finance leaders to work together toward common goals.

It’s easy for us doctor types to be leery of our hospital’s financial team. If you’ve ever been in direct conversation with your CFO, you may have found the discussion was packed with terms like “EBIDA,” “capital allocation,” and “operating margin,” and seemed to imply that the organization is prioritizing its bond rating over its composite PSI [patient safety indicators] performance. But the truth is that our finance teams are frustrated, too. In fact, they are more than frustrated—they are scared.

They really haven’t been sleeping well lately. They’d feel better if doctors could try to see the world that they see. A CFO’s core responsibility is ensuring a responsible, long-range financial plan that meets the needs of their hospital stakeholders—to paraphrase Tom Wolfe paraphrasing astronaut Gus Grissom, “no bucks, no Buck Rogers”—and that responsibility got a lot harder in 2014. By understanding their perspective, we clinicians should be able to take actions that result in better care of our patients today—and ensure a sustainable hospital that can take care of patients tomorrow. So that we can better empathize with our green-visored colleagues, here are a few of the thoughts going through their heads as they toss and turn at 3 a.m.

Change Is All Around

There are many urgent pressures on hospital, physician, and healthcare revenues. Keep in mind that a hospital’s costs in terms of pharmaceuticals, equipment, and labor (the average hospital has nearly 60% of its cost in labor) are not really going down to offset that revenue loss. While we’ve become uncomfortably familiar with RAC audits, value-based purchasing, the sustainable growth rate, and sequestration, I’d suggest that these revenue challenges pale in comparison to the insomnia created by the rapid rise of healthcare consumerism. Lost, or at least buried, in the stories about ACA politics, coverage of the uninsured, website malfunctions, and dropped insurance plans is the fact that the nature of insurance is changing.

Although offerings like medical savings accounts and high-deductible plans have been around for years, they are increasingly mainstream, because the plans offered through the insurance exchanges, which have surpassed the seven million mark in enrollment as of the time of this writing, all carry substantial patient commitments. The great majority of these plans—81% through February—are either “bronze” or “silver” level—and keep in mind that the average “gold” plan, in covering 80% of anticipated expenses, leaves patients with higher commitments than most large-employer group plans probably do. From that standpoint, they require patients, doctors, and hospitals to manage healthcare differently than they have in the past: We have to be mindful that patients are paying more of the “first dollar.”

The problem, from a CFO’s perspective, is at least twofold: First, a lot of patients don’t pay the portion of their bill for which they are responsible. Many doctors, hospitals, and healthcare systems are moving toward more assertive and up-front collections for non-emergency care; unfortunately, at best, we don’t do a very good job and, at worst, we create an uncomfortable space where we either channel the practices of collection agencies or leave much-needed funds on the table. As the deductibles, co-pays, and co-insurance obligations rise, so do the uncollected accounts. Our advocacy for patients increasingly requires us to be better stewards of their resources.

The second insomnia-inducing aspect of consumerism is transparency of pricing. As the exchanges move to create a “Priceline.com”-like approach to selecting an insurance plan, a similar transformation is occurring in how payers—and, with the spread of plans with higher patient obligations, patients themselves—are looking at how we set prices for everything from MRIs and laboratory services to hospitalization and physician charges. While we as individuals are used to price transparency in purchasing consumer goods, the third-party payment system in healthcare has insulated us, and our hospitals, from the consequences of the market system. (Please note, dear reader: I’m not defending either the past practices or current policy. I’m simply diagnosing why your CFO has black circles under his or her eyes.)

So, prices are increasingly published and available for comparison shopping by both insurers and individuals with those high deductibles or co-insurance amounts. As charges hit their pocketbooks, there is good reason to believe that patients will be “brand loyal” only to the point where they stop appreciating value. Systems with a reliable advantage in pricing (think: academic medical centers) run a great risk of losing business quickly if they cannot demonstrate value for those prices. Hospital-based physicians have been in the position of being the “translators” of value-based care—by always advocating for measurably better care, we help both our patients and our organizations.

Variation in Care

Perhaps most befuddling to our CFO friends are the variations in costs, outcomes, and clinical processes that seemingly similar patients with seemingly similar problems incur. Wide variations might occur based on just about any parameter, from the name of the attending physician to the day of the week of admission. Of course, at times, this variation could be explainable by, say, clinically relevant features that are simply not adjusted for, or the absence of literature to guide decisions. But, all too often, no reasonable explanation exists, and underneath that is a simmering concern that wide variations reflect failure to adhere to known guidelines, uneven distribution of resources, and “waste” deeply embedded in the healthcare value stream.

Less widely understood to clinicians is that, from the CFO’s perspective, the movement toward “value over volume” and risk-bearing systems such as accountable care organizations (ACOs) requires healthcare organizations to think like insurance companies. They must be able to accurately predict clinical outcomes within a population so that they can assess their actuarial risk and manage appropriately. Wide variations in care make those predictions less valid and outcomes more unpredictable, greatly raising the stakes for an ACO or other risk-bearing model.

From the CFO’s perspective, a key advantage to the move toward systems directly employing physicians is that a management structure can be created to decrease this variation; however, I’d question whether many physician groups, much less employed-group practices, have the appropriate management culture or the sophistication with data to do this effectively.

The Cost of Recapitalization

Most of the hospitals I’ve worked in are a jumble of incrementally newer additions built on a decades-old core facility. Clinicians tend to see the consequences as patients see them: not enough private rooms, outdated technology and equipment, poorly integrated computer and health IT systems, and inadequate storage for equipment. Your CFO certainly sees these same things, but has the additional challenge of trying to keep up with the demands for new facilities and capital purchases while maintaining the older physical plant and preserving the long-term financial strength of the organization. Even though roofing, HVAC, and new flooring are rarely as sexy as a new surgical robot, it won’t do much good to invest in that new OR equipment if the roof is leaking. And healthcare construction is really expensive, even more so because of entirely appropriate requirements that renovations bring older structures up to modern codes.

In the healthcare world, these expenses are formidable. Hospitals, like other businesses, sometimes borrow money to fund projects—particularly new construction projects. Nonprofit hospitals can be attractive to lenders because of their tax-advantaged nature. But, like our personal credit ratings, a healthcare system that enters into the bond market has specific metrics at which lenders look carefully to determine the cost of such lending, such as payer mix, income margin, debt ratios, and earnings before interest, depreciation, and amortization (EBIDA). And that’s where we come full circle to that latest conversation with the CFO.

So in order to preserve the ability to meet the needs of stakeholders, our friends in finance need to make sure a long-range plan is in place that continues to fund operations, growth, and ongoing maintenance, including the ability to borrow money when appropriate. Going forward, thriving healthcare organizations will have to be consumer-minded and successful in managing the risks of population health. The uncertainty created by the exchanges and transparency, and the inability to accurately gauge and manage the risk of adverse outcomes, has our CFO colleagues pleading with us for a prescription that will ease their restless nights. Here’s how we can help:

• Focus on working with your group to measure and minimize variations in care processes and outcomes among patients and doctors;
• Be mindful that in a value-based world, CMS and insurers now look at both inpatient and outpatient utilization and costs, and we need to do the same in our transitional care planning; and
• Be conscious that our prescriptions for care are increasingly impacting patients’ wallets, so we need to articulate and demonstrate the clinical value that underlies each decision.

In Sum

The next time you or your nocturnist is admitting that nth patient at 3 a.m., consider that your CFO may also be wide awake, struggling with his or her own version of a management challenge. As physicians who practice in hospitals, which are perhaps the most costly environments in the healthcare world, you and your colleagues may be well positioned to help make your hospitals more efficient, to better manage and improve those outcomes, and to help identify and prioritize the most pressing capital needs.

In short, just what the doctor ordered for your CFO to finally get a good night’s sleep.

Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.

In 2010, my office received a call from a Norwich, Conn., family whose 89-year-old father had fallen and broken his hip. After he was treated in the local hospital for four days, his doctor prescribed follow-on skilled nursing facility (SNF) care. Upon his arrival at the nursing home, his family was informed that they would have to pay more than $10,000 up front to cover the cost of his care: Because he had never been admitted to the hospital as an inpatient, Medicare would not cover the prescribed rehabilitative care that he needed to return home safely.

I know that hospitalists are already far too familiar with stories like this. Together, we can work to make sure it doesn’t happen again.

Support Is Growing

For me, that family’s story was a call for action. Shortly after speaking with the family, I introduced the Improving Access to Medicare Coverage Act (H.R. 1179). The bill is simple: It would restore the three-day hospital stay standard for SNF coverage, whether the stay is coded as inpatient under Part A or outpatient observation under Part B. Two Congresses later, support for the proposal is growing. In the 113th Congress, the bill has 137 bipartisan cosponsors, an indication of how widespread this problem is for Medicare beneficiaries.

The outdated Medicare law on skilled nursing care coverage is creating financial and healthcare dilemmas for families across the country. Under current law, beneficiaries must have a hospital inpatient stay of at least three days in order to qualify for Medicare coverage SNF benefits; however, more and more patients are being coded under observation status, and access to post-acute SNF care is diminishing. Patients are suffering, and healthcare providers are caught in the middle.

In fact, the Office of the Inspector General at the Department of Health and Human Services released a report last fall that showed that Medicare beneficiaries in 2012 had more than 600,000 hospital stays that lasted three nights, yet none were admitted as inpatients. Even though these beneficiaries likely received the same care inpatients received, their observation status designation disqualified them from Medicare coverage of the SNF benefit. For their families, prescribed follow-on SNF care would have an out-of-pocket cost averaging more than $10,000. For seniors on fixed incomes, that is a devastating financial penalty for a service that should be covered by their health plans.

Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for skilled nursing coverage.

—Rep. Joe Courtney

Administrative Oversight

There are many reasons for the growth in observation status treatments, but a primary driver is increasing scrutiny of admitting practices by recovery audit contractors (RACs). The consequences of RAC review processes have created difficult situations for hospitals, because admitting decisions are reviewable for three years, and hospitals can be hit with claw-back penalties for payments on behalf of patients RACs determine were incorrectly admitted. To prevent costly penalties and protracted appeals of individual cases, many hospitals feel an understandable amount of pressure to err on the side of treating patients under outpatient observation status covered under Part B.

The original intent of the three-day inpatient stay requirement was to serve as a tangible measure of medical necessity of SNF care. And, when the three-day inpatient stay prerequisite was written into law, long-term hospital observation stays were nonexistent. This intent has been lost in a changing system of hospital oversight under RACs and admitting practices.

The impact on patients and families is tragic.

Ann Sheehy, MD, MS, FHM, a hospitalist speaking on behalf of the Society of Hospital Medicine on a recent conference call I hosted, detailed the scenes she sees every day with her own patients. She described how doctors, knowing that a patient lacks the means to pay for rehabilitative care out of pocket and the support system to recover safely at home, sometimes keep the patient in the hospital longer, at a higher cost to Medicare. In other cases, Dr. Sheehy noted that patients end up back in the hospital soon after being discharged, having foregone expensive SNF care and subsequently suffered preventable injuries and illnesses. Both of these outcomes are bad for patients—and bad for Medicare expenditures.

Three-Day Fix

While the problem of observation status treatment is complex, the solution is simple.

As observation status becomes more ingrained in the healthcare lexicon, a legislative fix to restore the three-day hospital stay standard is needed now more than ever. Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for SNF coverage.

My bill, H.R. 1179, is the most direct solution to rectify the flaw that leaves hundreds of thousands of beneficiaries wondering how their stay in the hospital does not “count” and scrambling to figure out how to pay for care—or foregoing it entirely. The strong support in the advocacy community for this legislation—especially from SHM—and the sway of outside groups cannot be overstated. In Washington’s current climate, the only thing that moves bipartisan issues forward is outside pressure.

Together, I hope hospitalists and members of Congress will reach the critical mass needed to pass this legislation and ensure that Medicare beneficiaries are covered for medically necessary care.

Joseph “Joe” Courtney is the U.S. Representative for Connecticut’s second congressional district, serving since 2007. The district includes most of the eastern third of the state, including Norwich and New London.

In 2010, my office received a call from a Norwich, Conn., family whose 89-year-old father had fallen and broken his hip. After he was treated in the local hospital for four days, his doctor prescribed follow-on skilled nursing facility (SNF) care. Upon his arrival at the nursing home, his family was informed that they would have to pay more than $10,000 up front to cover the cost of his care: Because he had never been admitted to the hospital as an inpatient, Medicare would not cover the prescribed rehabilitative care that he needed to return home safely.

I know that hospitalists are already far too familiar with stories like this. Together, we can work to make sure it doesn’t happen again.

Support Is Growing

For me, that family’s story was a call for action. Shortly after speaking with the family, I introduced the Improving Access to Medicare Coverage Act (H.R. 1179). The bill is simple: It would restore the three-day hospital stay standard for SNF coverage, whether the stay is coded as inpatient under Part A or outpatient observation under Part B. Two Congresses later, support for the proposal is growing. In the 113th Congress, the bill has 137 bipartisan cosponsors, an indication of how widespread this problem is for Medicare beneficiaries.

The outdated Medicare law on skilled nursing care coverage is creating financial and healthcare dilemmas for families across the country. Under current law, beneficiaries must have a hospital inpatient stay of at least three days in order to qualify for Medicare coverage SNF benefits; however, more and more patients are being coded under observation status, and access to post-acute SNF care is diminishing. Patients are suffering, and healthcare providers are caught in the middle.

In fact, the Office of the Inspector General at the Department of Health and Human Services released a report last fall that showed that Medicare beneficiaries in 2012 had more than 600,000 hospital stays that lasted three nights, yet none were admitted as inpatients. Even though these beneficiaries likely received the same care inpatients received, their observation status designation disqualified them from Medicare coverage of the SNF benefit. For their families, prescribed follow-on SNF care would have an out-of-pocket cost averaging more than $10,000. For seniors on fixed incomes, that is a devastating financial penalty for a service that should be covered by their health plans.

Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for skilled nursing coverage.

—Rep. Joe Courtney

Administrative Oversight

There are many reasons for the growth in observation status treatments, but a primary driver is increasing scrutiny of admitting practices by recovery audit contractors (RACs). The consequences of RAC review processes have created difficult situations for hospitals, because admitting decisions are reviewable for three years, and hospitals can be hit with claw-back penalties for payments on behalf of patients RACs determine were incorrectly admitted. To prevent costly penalties and protracted appeals of individual cases, many hospitals feel an understandable amount of pressure to err on the side of treating patients under outpatient observation status covered under Part B.

The original intent of the three-day inpatient stay requirement was to serve as a tangible measure of medical necessity of SNF care. And, when the three-day inpatient stay prerequisite was written into law, long-term hospital observation stays were nonexistent. This intent has been lost in a changing system of hospital oversight under RACs and admitting practices.

The impact on patients and families is tragic.

Ann Sheehy, MD, MS, FHM, a hospitalist speaking on behalf of the Society of Hospital Medicine on a recent conference call I hosted, detailed the scenes she sees every day with her own patients. She described how doctors, knowing that a patient lacks the means to pay for rehabilitative care out of pocket and the support system to recover safely at home, sometimes keep the patient in the hospital longer, at a higher cost to Medicare. In other cases, Dr. Sheehy noted that patients end up back in the hospital soon after being discharged, having foregone expensive SNF care and subsequently suffered preventable injuries and illnesses. Both of these outcomes are bad for patients—and bad for Medicare expenditures.

Three-Day Fix

While the problem of observation status treatment is complex, the solution is simple.

As observation status becomes more ingrained in the healthcare lexicon, a legislative fix to restore the three-day hospital stay standard is needed now more than ever. Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for SNF coverage.

My bill, H.R. 1179, is the most direct solution to rectify the flaw that leaves hundreds of thousands of beneficiaries wondering how their stay in the hospital does not “count” and scrambling to figure out how to pay for care—or foregoing it entirely. The strong support in the advocacy community for this legislation—especially from SHM—and the sway of outside groups cannot be overstated. In Washington’s current climate, the only thing that moves bipartisan issues forward is outside pressure.

Together, I hope hospitalists and members of Congress will reach the critical mass needed to pass this legislation and ensure that Medicare beneficiaries are covered for medically necessary care.

Joseph “Joe” Courtney is the U.S. Representative for Connecticut’s second congressional district, serving since 2007. The district includes most of the eastern third of the state, including Norwich and New London.

In 2010, my office received a call from a Norwich, Conn., family whose 89-year-old father had fallen and broken his hip. After he was treated in the local hospital for four days, his doctor prescribed follow-on skilled nursing facility (SNF) care. Upon his arrival at the nursing home, his family was informed that they would have to pay more than $10,000 up front to cover the cost of his care: Because he had never been admitted to the hospital as an inpatient, Medicare would not cover the prescribed rehabilitative care that he needed to return home safely.

I know that hospitalists are already far too familiar with stories like this. Together, we can work to make sure it doesn’t happen again.

Support Is Growing

For me, that family’s story was a call for action. Shortly after speaking with the family, I introduced the Improving Access to Medicare Coverage Act (H.R. 1179). The bill is simple: It would restore the three-day hospital stay standard for SNF coverage, whether the stay is coded as inpatient under Part A or outpatient observation under Part B. Two Congresses later, support for the proposal is growing. In the 113th Congress, the bill has 137 bipartisan cosponsors, an indication of how widespread this problem is for Medicare beneficiaries.

The outdated Medicare law on skilled nursing care coverage is creating financial and healthcare dilemmas for families across the country. Under current law, beneficiaries must have a hospital inpatient stay of at least three days in order to qualify for Medicare coverage SNF benefits; however, more and more patients are being coded under observation status, and access to post-acute SNF care is diminishing. Patients are suffering, and healthcare providers are caught in the middle.

In fact, the Office of the Inspector General at the Department of Health and Human Services released a report last fall that showed that Medicare beneficiaries in 2012 had more than 600,000 hospital stays that lasted three nights, yet none were admitted as inpatients. Even though these beneficiaries likely received the same care inpatients received, their observation status designation disqualified them from Medicare coverage of the SNF benefit. For their families, prescribed follow-on SNF care would have an out-of-pocket cost averaging more than $10,000. For seniors on fixed incomes, that is a devastating financial penalty for a service that should be covered by their health plans.

Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for skilled nursing coverage.

—Rep. Joe Courtney

Administrative Oversight

There are many reasons for the growth in observation status treatments, but a primary driver is increasing scrutiny of admitting practices by recovery audit contractors (RACs). The consequences of RAC review processes have created difficult situations for hospitals, because admitting decisions are reviewable for three years, and hospitals can be hit with claw-back penalties for payments on behalf of patients RACs determine were incorrectly admitted. To prevent costly penalties and protracted appeals of individual cases, many hospitals feel an understandable amount of pressure to err on the side of treating patients under outpatient observation status covered under Part B.

The original intent of the three-day inpatient stay requirement was to serve as a tangible measure of medical necessity of SNF care. And, when the three-day inpatient stay prerequisite was written into law, long-term hospital observation stays were nonexistent. This intent has been lost in a changing system of hospital oversight under RACs and admitting practices.

The impact on patients and families is tragic.

Ann Sheehy, MD, MS, FHM, a hospitalist speaking on behalf of the Society of Hospital Medicine on a recent conference call I hosted, detailed the scenes she sees every day with her own patients. She described how doctors, knowing that a patient lacks the means to pay for rehabilitative care out of pocket and the support system to recover safely at home, sometimes keep the patient in the hospital longer, at a higher cost to Medicare. In other cases, Dr. Sheehy noted that patients end up back in the hospital soon after being discharged, having foregone expensive SNF care and subsequently suffered preventable injuries and illnesses. Both of these outcomes are bad for patients—and bad for Medicare expenditures.

Three-Day Fix

While the problem of observation status treatment is complex, the solution is simple.

As observation status becomes more ingrained in the healthcare lexicon, a legislative fix to restore the three-day hospital stay standard is needed now more than ever. Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for SNF coverage.

My bill, H.R. 1179, is the most direct solution to rectify the flaw that leaves hundreds of thousands of beneficiaries wondering how their stay in the hospital does not “count” and scrambling to figure out how to pay for care—or foregoing it entirely. The strong support in the advocacy community for this legislation—especially from SHM—and the sway of outside groups cannot be overstated. In Washington’s current climate, the only thing that moves bipartisan issues forward is outside pressure.

Together, I hope hospitalists and members of Congress will reach the critical mass needed to pass this legislation and ensure that Medicare beneficiaries are covered for medically necessary care.

Joseph “Joe” Courtney is the U.S. Representative for Connecticut’s second congressional district, serving since 2007. The district includes most of the eastern third of the state, including Norwich and New London.

It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.

In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.

Here are some excerpts from my interview with Jason:

Question: What is an accountable care unit (ACU)?

Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.

Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?

A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.

Q: What makes an ACU successful?

A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.

SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.

“In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.”

—Jason Stein, MD, SFHM

Q: What is the biggest challenge in implementing and sustaining an ACU?

A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”

Naturally, not everyone immediately sees that they can gain rather than lose efficiency.

Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.

Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?

A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.

But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.

Q: How have ACUs performed so far?

A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.

The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.

Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?

A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”¹

Q: Any final thoughts?

A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

Reference

1. Bohmer RM. The four habits of high-value health care organizations. New Engl J Med. 2011;365(22):2045-2047.

It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.

In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.

Here are some excerpts from my interview with Jason:

Question: What is an accountable care unit (ACU)?

Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.

Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?

A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.

Q: What makes an ACU successful?

A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.

SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.

“In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.”

—Jason Stein, MD, SFHM

Q: What is the biggest challenge in implementing and sustaining an ACU?

A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”

Naturally, not everyone immediately sees that they can gain rather than lose efficiency.

Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.

Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?

A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.

But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.

Q: How have ACUs performed so far?

A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.

The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.

Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?

A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”¹

Q: Any final thoughts?

A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

Reference

1. Bohmer RM. The four habits of high-value health care organizations. New Engl J Med. 2011;365(22):2045-2047.

It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.

In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.

Here are some excerpts from my interview with Jason:

Question: What is an accountable care unit (ACU)?

Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.

Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?

A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.

Q: What makes an ACU successful?

A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.

SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.

“In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.”

—Jason Stein, MD, SFHM

Q: What is the biggest challenge in implementing and sustaining an ACU?

A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”

Naturally, not everyone immediately sees that they can gain rather than lose efficiency.

Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.

Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?

A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.

But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.

Q: How have ACUs performed so far?

A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.

The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.

Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?

A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”¹

Q: Any final thoughts?

A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

Reference

1. Bohmer RM. The four habits of high-value health care organizations. New Engl J Med. 2011;365(22):2045-2047.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Healthcare-associated infections financially impact the U.S. system
2. No mortality benefit with treatment of single peripheral pulmonary emboli
3. Modified (shorter) IV acetylcysteine infusion reduces adverse effects
4. Comorbidities contribute to potentially avoidable hospital readmissions
5. Resident handoff bundle reduces medical errors and adverse events, improves handoff quality
6. Uncomplicated skin infections in the ambulatory setting commonly involve avoidable antibiotic exposure
7. Warfarin initiation in atrial fibrillation associated with increased short-term risk of stroke
8. Multifaceted discharge interventions reduce rates of pediatric readmission and post-hospital ED utilization
9. Sepsis diagnoses are common, but many septic patients in ED do not receive antibiotics
10. New oral anticoagulants safe, effective for atrial fibrillation treatment

Healthcare-Associated Infections Continue to Impact the U.S. Healthcare System Financially

Clinical question: What is the estimated cost of healthcare-associated infections (HAI) to the U.S. healthcare system?

Background: In spite of education efforts, HAIs occur frequently and contribute to high healthcare costs in the U.S. This study sought to estimate the costs of HAIs to the U.S. system using statistical analyses of published data.

Study design: Simulations of published data.

Setting: Published studies on five major HAIs.

Synopsis: Monte Carlo simulations based upon published point estimates were used to estimate per-case cost and confidence intervals, with extrapolation to total costs to the U.S. healthcare system. Overall, five major HAIs occur approximately 440,000 times annually and cost the healthcare system an estimated $9.78 billion (range $8.28 to $11.5 billion) in 2009.

Surgical site infections (36.0%) were the most common of the studied HAIs, with increased per-case cost of $20,785, equating to an estimated $3.30 billion annually (33.7% of total HAI costs). Clostridium difficile infection accounted for 30.3% of HAI but only 15.4% of costs ($1.51 billion). Central line-associated bloodstream infections were most costly per case ($45,814), with total costs of $1.85 billion (18.9% of costs). Ventilator-associated pneumonia accounted for $3.09 billion, or 31.7% of total costs. Catheter-associated urinary tract infection only represented 0.3% of total costs, or $27.9 million annually.

The authors suggest that changes in payment reform likely will drive hospitals to further invest in HAI reduction efforts.

Bottom line: HAIs remain frequent and expensive complications of hospitalization, in spite of improvement efforts to date.

Citation: Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.

No Mortality Benefit with Treatment of Single Peripheral Pulmonary Emboli

Clinical question: Does treatment of single peripheral pulmonary emboli impact mortality and rates of post-discharge venous thromboembolism (VTE)?

Background: With the increase in CT pulmonary angiography (CTPA) use the past decade, there has been an increased rate of detection of peripheral filling defects. When confronted with a single peripheral filling defect (SPFD), clinicians face the dilemma of whether treatment is necessary, given the risks associated with anticoagulation.

Study design: Retrospective cohort.

Setting: Community teaching hospital in Norwalk, Conn.

Synopsis: A total of 4,906 CTPAs were screened, revealing 153 scans with an SPFD. Primary analysis included 134 patients 18 years or older. Of these patients, 61 (45.5%) received treatment with anticoagulation (n=51) or IVC filter alone (n=10).

This study revealed no difference in adjusted 90-day mortality between treated and untreated groups. No statistically significant difference was found in the rate of post-discharge VTE within 90 days.

Characteristics associated with treatment for SPFD were patient immobility, previous VTE, and radiology labeling the filling defect as a pulmonary embolus. It is important to note that none of the patients who had a normal second imaging study (e.g. V/Q scan or ultrasound) were treated; therefore, the use of secondary studies could mitigate some of the uncertainty around SPFD management, though this is not recommended in current diagnostic algorithms. Because this is a single-center study with a modest sample size, the comparability of findings to other centers might be limited. Larger studies are needed to help clarify these findings.

Bottom line: Treatment of SPFD was not associated with a difference in mortality or post-discharge VTE within 90 days.

Citation: Green O, Lempel J, Kolodziej A, et al. Treatment of single peripheral pulmonary emboli: patient outcomes and factors associated with decision to treat. J Hosp Med. 2014;9(1):42-47.

Modified IV Acetylcysteine Infusion Reduces Adverse Effects

Clinical question: Does a shorter regimen of IV acetylcysteine reduce adverse effects compared to the standard regimen?

Background: Acetaminophen poisoning is common, and recommended treatment is IV acetylcysteine; however, the standard regimen has many adverse effects, including vomiting and anaphylactoid reactions. Although studies have outlined these side effects, no published trials have compared their frequency to that of a shorter protocol.

Study design: Double-blinded, randomized controlled trial.

Setting: Three acute care hospitals in the United Kingdom.

Synopsis: Of 3,311 patients who presented with acetaminophen overdose, 222 underwent randomization to the standard (duration 20-25 hours) or modified (12 hours) acetylcysteine regimen, with or without pre-treatment with IV ondansetron 4 mg. The primary outcome of vomiting, retching, or need for rescue antiemetic treatment within two hours of acetylcysteine initiation was significantly less frequent in patients who received the shorter regimen, compared to those allocated to the standard regimen.

Specifically, the adjusted odds ratio was 0.26 with the modified regimen (97.5% CI, 0.13-0.52; P<0.0001). The primary outcome was significantly less in patients pre-treated with ondansetron compared to placebo (OR 0.41, 97.5% CI 0.2-0.8; P=0.003). Anaphylactic reactions were significantly reduced with the shorter protocol; no significant difference in hepatotoxicity was noted.

It is reasonable to infer that the shorter acetylcysteine regimen substantially reduces the frequency of vomiting and serious anaphylactoid reactions when compared with the standard schedule; however, hospitalists should note that this study was not powered to assess for non-inferiority of the shorter regimen with regard to prevention of acetaminophen’s hepatotoxic effects. Further studies are needed to confirm the efficacy and safety of the modified regimen before widespread adoption into clinical practice.

Bottom line: A shorter acetylcysteine regimen is associated with decreased occurrence of vomiting and anaphylactoid reactions compared to the standard protocol for treating acetaminophen toxicity. Additional research is needed to assess non-inferiority of this modified regimen for prevention of hepatotoxic effects.

Citation: Bateman DN, Dear JW, Thanacoody HK, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomized controlled trial. Lancet. 2014;383(9918):697-704.

Comorbidities Contribute to Potentially Avoidable Hospital Readmissions

Clinical question: What is the role of comorbidities in 30-day potentially avoidable readmissions?

Background: Higher comorbidity burden has been associated with 30-day readmissions. This study evaluated the role of comorbidities in the 30-day rate of potentially avoidable readmissions from a tertiary-care medical center.

Study design: Retrospective cohort.

Setting: Tertiary-care teaching hospital and affiliated network.

Synopsis: Investigators tested the hypothesis that comorbidities significantly contribute to 30-day, potentially avoidable readmissions in a cohort of consecutively discharged medical patients at an academic medical center over a 12-month period. Out of a total of 10,731 discharges, there were 2,398 readmissions to hospitals in the same health system. Of those 2,398 readmissions, 858 (35.8%) were judged potentially avoidable using a validated algorithm. Frequently, the reason for readmission was not related to the index discharge diagnosis but to a complication of known comorbidities.

The authors identified the top five diagnoses for readmission as infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder. Among those patients who had a readmission diagnosis different from the index-case discharge diagnosis, the comorbidities of neoplastic disease, heart failure, and chronic kidney disease significantly contributed to readmission as compared to those without similar comorbidities.

Bottom line: The reason for readmission often is not related to the index hospitalization diagnosis but, rather, to comorbidities present at the index episode of care; thus, attention to management of comorbidities in the post-discharge period is important in circumventing potentially avoidable readmissions.

Citation: Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347:F7171.

Resident Handoff Bundle Reduces Medical Errors and Adverse Events, Improves Handoff Quality

Clinical question: In a pediatric inpatient setting, is the use of a handoff program associated with improved patient safety measures and handoff quality?

Background: Sentinel events related to errors in communication are a significant patient safety dilemma and an impetus for ongoing efforts to improve handoffs in postgraduate medical education. Various strategies to be incorporated into the handoff process have been suggested in the literature, but research is limited with regard to the relationship between handoffs and patient safety.

Study design: Prospective, pre-post study.

Setting: Academic, pediatric hospital in an urban setting.

Synopsis: Overall, 1,255 patient admissions (642 pre-/613 post-handoff intervention) were evaluated on two inpatient units during the periods of July 2009-September 2009 (pre-intervention) and November 2009-January 2010 (post-intervention). The intervention was a handoff “bundle” consisting of a standardized communication and handoff training session, a verbal mnemonic to standardize handoffs, and a new unified resident-intern handoff structure in a private, quiet setting. A computerized handoff tool was also added in one unit. Primary outcomes were a comparison of the rate of medical errors per 100 admissions and rates of preventable adverse events before and after the intervention.

Implementation of the bundle resulted in a significant decrease in medical errors (18.3 from 33.8 per 100 admissions, P<0.001) and preventable adverse events (1.5 from 3.3 per 100 admissions, P=0.04). Secondary outcomes included reductions in omissions of key data in the written handoff (even greater in the group using the computerized tool) and increased percentage of time spent in direct patient care, with no change in handoff duration. Additionally, handoffs were more likely to occur in a quiet, private location.

Limitations included the potential for confounding in a pre-post intervention design, the difficulty in ascertaining the value of the individual components of the bundle, and the potential lack of generalizability.

Bottom line: In a pediatric hospital setting, a multifaceted handoff bundle is associated with improved handoff quality and reductions in medical errors and preventable adverse events.

Citation: Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262-2270.

Uncomplicated Skin Infections in Ambulatory Setting Commonly Involve Avoidable Antibiotic Exposure

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Warfarin Initiation in Atrial Fibrillation Associated with Increased Short-Term Risk of Stroke

Clinical question: Is the initiation of warfarin associated with an increased risk of ischemic stroke in patients with atrial fibrillation (Afib)?

Background: Two Afib trials of oral factor Xa inhibitors showed an increased risk of stroke when patients were transitioned to open label warfarin at the end of the study. Warfarin can, theoretically, lead to a transient hypercoagulable state upon treatment initiation, so further study is indicated to determine if the initiation of warfarin is associated with increased stroke risk among Afib patients.

Study design: Population-based, nested case-control.

Setting: UK Clinical Practice Research Datalink.

Synopsis: A cohort of 70,766 patients with newly diagnosed Afib was identified from a large primary care database. Conditional logistic regression was used to estimate adjusted rate ratios (RR) of stroke associated with warfarin monotherapy, classified according to time since initiation of treatment when compared to patients not on antithrombotic therapy.

Warfarin was associated with a 71% increased risk of stroke in the first 30 days of use (RR 1.71, 95% CI 1.39-2.12). Risk was highest in the first week of warfarin treatment, which is consistent with the known transient pro-coagulant effect of warfarin. Decreased risks were observed with warfarin initiation >30 days before the ischemic event (31-90 days: RR 0.50, 95% CI 0.34-0.75; >90 days: RR 0.55, 95% CI 0.50-0.61).

Limitations included the extraction of data from a database, which could lead to misclassification of diagnosis or therapy, and the observational nature of the study.

Bottom line: There may be an increased risk of ischemic stroke during the first 30 days of treatment with warfarin in patients with Afib.

Citation: Azoulay L, Dell-Aniello S, Simon T, Renoux C, Suissa S. Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes [published online ahead of print December 18, 2013]. Eur Heart J.

Multifaceted Discharge Interventions Reduce Rates of Pediatric Readmission and Post-Hospital ED Utilization

Clinical question: Do interventions at discharge reduce the rate of readmissions and post-hospitalization ED visits among pediatric patients?

Background: Readmissions are a high-priority quality measure in both the adult and pediatric settings. Although a broadening body of literature is evaluating the impact of interventions on readmissions in adult populations, the literature does not contain a similar breadth of assessments of interventions in the pediatric setting.

Study design: Systematic review.

Setting: English-language articles studying pediatric inpatient discharge interventions.

Synopsis: A total of 1,296 unique articles were identified from PubMed and the Cumulative Index to Nursing and Allied Health Literature. Additional articles were identified on review of references, yielding 14 articles that met inclusion criteria. Included studies evaluated the effect of pediatric discharge interventions on the primary outcomes of hospital readmission or post-hospitalization ED visits. Interventions focused on three main patient populations: asthma, cancer, and prematurity.

Six studies demonstrated statistically significant reductions in readmissions and/or ED visits, while two studies actually demonstrated an increase in post-discharge utilization. All successful interventions began in the inpatient setting and were multifaceted, with four of six studies including an educational component and a post-discharge follow-up component.

While all of the studies evaluated sought to enhance the transitional care from the inpatient to outpatient setting, only the interventions that included one responsible party (individual or team) with expertise in the medical condition providing oversight and support were successful in reducing the specified outcomes. A significant limitation was that many of the studies identified were not sufficiently powered to detect either outcome of interest.

Bottom line: A multifaceted intervention involving educational and post-discharge follow-up components with an experienced individual or team supporting the transition is associated with a reduction in hospital readmissions and post-discharge ED utilization.

Citation: Auger KA, Kenyon CC, Feudtner C, Davis MM. Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med.

Sepsis Diagnoses Are Common in ED, but Many Septic Patients in the ED Do Not Receive Antibiotics

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

New Oral Anticoagulants Safe and Effective for Atrial Fibrillation Treatment

Clinical question: Is there a difference in efficacy and safety among new oral anticoagulants compared to warfarin in subgroups of patients with atrial fibrillation (Afib)?

Background: Studies of new oral anticoagulants have demonstrated that these agents are at least as safe and effective as warfarin for prevention of stroke and systemic embolism in Afib. This study was designed to look at available phase 3 randomized trials, with the goal of subgroup analysis for both efficacy and bleeding risks.

Study design: Meta-analysis.

Setting: Phase 3 randomized controlled trials of patients with Afib.

Synopsis: The analysis included four trials of Afib patients randomized to receive warfarin or a novel oral anticoagulant (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban. In total, 42,411 patients received an NOAC and 29,272 patients received warfarin. Separate analyses were performed for high-dose and low-dose NOACs.

The high-dose NOAC demonstrated a 19% reduction in stroke and systemic embolic events as compared to warfarin, largely due to the reduction of hemorrhagic strokes by the NOAC. The low-dose NOAC showed similar efficacy to warfarin for reduction of stroke and systemic embolic events, with an increase noted in the subset of ischemic stroke in low-dose NOAC. Both doses of NOAC demonstrated a significant reduction in all-cause mortality. NOAC showed a non-significant reduction in bleeding compared to warfarin; however, subset analysis demonstrated an increase in gastrointestinal bleeding with high-dose NOAC and a significant reduction in intracranial hemorrhage with low-dose NOAC.

A notable limitation of the study is that it only included clinical trials in the analysis.

Bottom line: In relation to stroke, systemic embolic events, and all-cause mortality, new oral anticoagulants showed a favorable efficacy and safety profile as compared to warfarin in Afib patients.

Citation: Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Healthcare-associated infections financially impact the U.S. system
2. No mortality benefit with treatment of single peripheral pulmonary emboli
3. Modified (shorter) IV acetylcysteine infusion reduces adverse effects
4. Comorbidities contribute to potentially avoidable hospital readmissions
5. Resident handoff bundle reduces medical errors and adverse events, improves handoff quality
6. Uncomplicated skin infections in the ambulatory setting commonly involve avoidable antibiotic exposure
7. Warfarin initiation in atrial fibrillation associated with increased short-term risk of stroke
8. Multifaceted discharge interventions reduce rates of pediatric readmission and post-hospital ED utilization
9. Sepsis diagnoses are common, but many septic patients in ED do not receive antibiotics
10. New oral anticoagulants safe, effective for atrial fibrillation treatment

Healthcare-Associated Infections Continue to Impact the U.S. Healthcare System Financially

Clinical question: What is the estimated cost of healthcare-associated infections (HAI) to the U.S. healthcare system?

Background: In spite of education efforts, HAIs occur frequently and contribute to high healthcare costs in the U.S. This study sought to estimate the costs of HAIs to the U.S. system using statistical analyses of published data.

Study design: Simulations of published data.

Setting: Published studies on five major HAIs.

Synopsis: Monte Carlo simulations based upon published point estimates were used to estimate per-case cost and confidence intervals, with extrapolation to total costs to the U.S. healthcare system. Overall, five major HAIs occur approximately 440,000 times annually and cost the healthcare system an estimated $9.78 billion (range $8.28 to $11.5 billion) in 2009.

Surgical site infections (36.0%) were the most common of the studied HAIs, with increased per-case cost of $20,785, equating to an estimated $3.30 billion annually (33.7% of total HAI costs). Clostridium difficile infection accounted for 30.3% of HAI but only 15.4% of costs ($1.51 billion). Central line-associated bloodstream infections were most costly per case ($45,814), with total costs of $1.85 billion (18.9% of costs). Ventilator-associated pneumonia accounted for $3.09 billion, or 31.7% of total costs. Catheter-associated urinary tract infection only represented 0.3% of total costs, or $27.9 million annually.

The authors suggest that changes in payment reform likely will drive hospitals to further invest in HAI reduction efforts.

Bottom line: HAIs remain frequent and expensive complications of hospitalization, in spite of improvement efforts to date.

Citation: Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.

No Mortality Benefit with Treatment of Single Peripheral Pulmonary Emboli

Clinical question: Does treatment of single peripheral pulmonary emboli impact mortality and rates of post-discharge venous thromboembolism (VTE)?

Background: With the increase in CT pulmonary angiography (CTPA) use the past decade, there has been an increased rate of detection of peripheral filling defects. When confronted with a single peripheral filling defect (SPFD), clinicians face the dilemma of whether treatment is necessary, given the risks associated with anticoagulation.

Study design: Retrospective cohort.

Setting: Community teaching hospital in Norwalk, Conn.

Synopsis: A total of 4,906 CTPAs were screened, revealing 153 scans with an SPFD. Primary analysis included 134 patients 18 years or older. Of these patients, 61 (45.5%) received treatment with anticoagulation (n=51) or IVC filter alone (n=10).

This study revealed no difference in adjusted 90-day mortality between treated and untreated groups. No statistically significant difference was found in the rate of post-discharge VTE within 90 days.

Characteristics associated with treatment for SPFD were patient immobility, previous VTE, and radiology labeling the filling defect as a pulmonary embolus. It is important to note that none of the patients who had a normal second imaging study (e.g. V/Q scan or ultrasound) were treated; therefore, the use of secondary studies could mitigate some of the uncertainty around SPFD management, though this is not recommended in current diagnostic algorithms. Because this is a single-center study with a modest sample size, the comparability of findings to other centers might be limited. Larger studies are needed to help clarify these findings.

Bottom line: Treatment of SPFD was not associated with a difference in mortality or post-discharge VTE within 90 days.

Citation: Green O, Lempel J, Kolodziej A, et al. Treatment of single peripheral pulmonary emboli: patient outcomes and factors associated with decision to treat. J Hosp Med. 2014;9(1):42-47.

Modified IV Acetylcysteine Infusion Reduces Adverse Effects

Clinical question: Does a shorter regimen of IV acetylcysteine reduce adverse effects compared to the standard regimen?

Background: Acetaminophen poisoning is common, and recommended treatment is IV acetylcysteine; however, the standard regimen has many adverse effects, including vomiting and anaphylactoid reactions. Although studies have outlined these side effects, no published trials have compared their frequency to that of a shorter protocol.

Study design: Double-blinded, randomized controlled trial.

Setting: Three acute care hospitals in the United Kingdom.

Synopsis: Of 3,311 patients who presented with acetaminophen overdose, 222 underwent randomization to the standard (duration 20-25 hours) or modified (12 hours) acetylcysteine regimen, with or without pre-treatment with IV ondansetron 4 mg. The primary outcome of vomiting, retching, or need for rescue antiemetic treatment within two hours of acetylcysteine initiation was significantly less frequent in patients who received the shorter regimen, compared to those allocated to the standard regimen.

Specifically, the adjusted odds ratio was 0.26 with the modified regimen (97.5% CI, 0.13-0.52; P<0.0001). The primary outcome was significantly less in patients pre-treated with ondansetron compared to placebo (OR 0.41, 97.5% CI 0.2-0.8; P=0.003). Anaphylactic reactions were significantly reduced with the shorter protocol; no significant difference in hepatotoxicity was noted.

It is reasonable to infer that the shorter acetylcysteine regimen substantially reduces the frequency of vomiting and serious anaphylactoid reactions when compared with the standard schedule; however, hospitalists should note that this study was not powered to assess for non-inferiority of the shorter regimen with regard to prevention of acetaminophen’s hepatotoxic effects. Further studies are needed to confirm the efficacy and safety of the modified regimen before widespread adoption into clinical practice.

Bottom line: A shorter acetylcysteine regimen is associated with decreased occurrence of vomiting and anaphylactoid reactions compared to the standard protocol for treating acetaminophen toxicity. Additional research is needed to assess non-inferiority of this modified regimen for prevention of hepatotoxic effects.

Citation: Bateman DN, Dear JW, Thanacoody HK, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomized controlled trial. Lancet. 2014;383(9918):697-704.

Comorbidities Contribute to Potentially Avoidable Hospital Readmissions

Clinical question: What is the role of comorbidities in 30-day potentially avoidable readmissions?

Background: Higher comorbidity burden has been associated with 30-day readmissions. This study evaluated the role of comorbidities in the 30-day rate of potentially avoidable readmissions from a tertiary-care medical center.

Study design: Retrospective cohort.

Setting: Tertiary-care teaching hospital and affiliated network.

Synopsis: Investigators tested the hypothesis that comorbidities significantly contribute to 30-day, potentially avoidable readmissions in a cohort of consecutively discharged medical patients at an academic medical center over a 12-month period. Out of a total of 10,731 discharges, there were 2,398 readmissions to hospitals in the same health system. Of those 2,398 readmissions, 858 (35.8%) were judged potentially avoidable using a validated algorithm. Frequently, the reason for readmission was not related to the index discharge diagnosis but to a complication of known comorbidities.

The authors identified the top five diagnoses for readmission as infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder. Among those patients who had a readmission diagnosis different from the index-case discharge diagnosis, the comorbidities of neoplastic disease, heart failure, and chronic kidney disease significantly contributed to readmission as compared to those without similar comorbidities.

Bottom line: The reason for readmission often is not related to the index hospitalization diagnosis but, rather, to comorbidities present at the index episode of care; thus, attention to management of comorbidities in the post-discharge period is important in circumventing potentially avoidable readmissions.

Citation: Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347:F7171.

Resident Handoff Bundle Reduces Medical Errors and Adverse Events, Improves Handoff Quality

Clinical question: In a pediatric inpatient setting, is the use of a handoff program associated with improved patient safety measures and handoff quality?

Background: Sentinel events related to errors in communication are a significant patient safety dilemma and an impetus for ongoing efforts to improve handoffs in postgraduate medical education. Various strategies to be incorporated into the handoff process have been suggested in the literature, but research is limited with regard to the relationship between handoffs and patient safety.

Study design: Prospective, pre-post study.

Setting: Academic, pediatric hospital in an urban setting.

Synopsis: Overall, 1,255 patient admissions (642 pre-/613 post-handoff intervention) were evaluated on two inpatient units during the periods of July 2009-September 2009 (pre-intervention) and November 2009-January 2010 (post-intervention). The intervention was a handoff “bundle” consisting of a standardized communication and handoff training session, a verbal mnemonic to standardize handoffs, and a new unified resident-intern handoff structure in a private, quiet setting. A computerized handoff tool was also added in one unit. Primary outcomes were a comparison of the rate of medical errors per 100 admissions and rates of preventable adverse events before and after the intervention.

Implementation of the bundle resulted in a significant decrease in medical errors (18.3 from 33.8 per 100 admissions, P<0.001) and preventable adverse events (1.5 from 3.3 per 100 admissions, P=0.04). Secondary outcomes included reductions in omissions of key data in the written handoff (even greater in the group using the computerized tool) and increased percentage of time spent in direct patient care, with no change in handoff duration. Additionally, handoffs were more likely to occur in a quiet, private location.

Limitations included the potential for confounding in a pre-post intervention design, the difficulty in ascertaining the value of the individual components of the bundle, and the potential lack of generalizability.

Bottom line: In a pediatric hospital setting, a multifaceted handoff bundle is associated with improved handoff quality and reductions in medical errors and preventable adverse events.

Citation: Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262-2270.

Uncomplicated Skin Infections in Ambulatory Setting Commonly Involve Avoidable Antibiotic Exposure

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Warfarin Initiation in Atrial Fibrillation Associated with Increased Short-Term Risk of Stroke

Clinical question: Is the initiation of warfarin associated with an increased risk of ischemic stroke in patients with atrial fibrillation (Afib)?

Background: Two Afib trials of oral factor Xa inhibitors showed an increased risk of stroke when patients were transitioned to open label warfarin at the end of the study. Warfarin can, theoretically, lead to a transient hypercoagulable state upon treatment initiation, so further study is indicated to determine if the initiation of warfarin is associated with increased stroke risk among Afib patients.

Study design: Population-based, nested case-control.

Setting: UK Clinical Practice Research Datalink.

Synopsis: A cohort of 70,766 patients with newly diagnosed Afib was identified from a large primary care database. Conditional logistic regression was used to estimate adjusted rate ratios (RR) of stroke associated with warfarin monotherapy, classified according to time since initiation of treatment when compared to patients not on antithrombotic therapy.

Warfarin was associated with a 71% increased risk of stroke in the first 30 days of use (RR 1.71, 95% CI 1.39-2.12). Risk was highest in the first week of warfarin treatment, which is consistent with the known transient pro-coagulant effect of warfarin. Decreased risks were observed with warfarin initiation >30 days before the ischemic event (31-90 days: RR 0.50, 95% CI 0.34-0.75; >90 days: RR 0.55, 95% CI 0.50-0.61).

Limitations included the extraction of data from a database, which could lead to misclassification of diagnosis or therapy, and the observational nature of the study.

Bottom line: There may be an increased risk of ischemic stroke during the first 30 days of treatment with warfarin in patients with Afib.

Citation: Azoulay L, Dell-Aniello S, Simon T, Renoux C, Suissa S. Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes [published online ahead of print December 18, 2013]. Eur Heart J.

Multifaceted Discharge Interventions Reduce Rates of Pediatric Readmission and Post-Hospital ED Utilization

Clinical question: Do interventions at discharge reduce the rate of readmissions and post-hospitalization ED visits among pediatric patients?

Background: Readmissions are a high-priority quality measure in both the adult and pediatric settings. Although a broadening body of literature is evaluating the impact of interventions on readmissions in adult populations, the literature does not contain a similar breadth of assessments of interventions in the pediatric setting.

Study design: Systematic review.

Setting: English-language articles studying pediatric inpatient discharge interventions.

Synopsis: A total of 1,296 unique articles were identified from PubMed and the Cumulative Index to Nursing and Allied Health Literature. Additional articles were identified on review of references, yielding 14 articles that met inclusion criteria. Included studies evaluated the effect of pediatric discharge interventions on the primary outcomes of hospital readmission or post-hospitalization ED visits. Interventions focused on three main patient populations: asthma, cancer, and prematurity.

Six studies demonstrated statistically significant reductions in readmissions and/or ED visits, while two studies actually demonstrated an increase in post-discharge utilization. All successful interventions began in the inpatient setting and were multifaceted, with four of six studies including an educational component and a post-discharge follow-up component.

While all of the studies evaluated sought to enhance the transitional care from the inpatient to outpatient setting, only the interventions that included one responsible party (individual or team) with expertise in the medical condition providing oversight and support were successful in reducing the specified outcomes. A significant limitation was that many of the studies identified were not sufficiently powered to detect either outcome of interest.

Bottom line: A multifaceted intervention involving educational and post-discharge follow-up components with an experienced individual or team supporting the transition is associated with a reduction in hospital readmissions and post-discharge ED utilization.

Citation: Auger KA, Kenyon CC, Feudtner C, Davis MM. Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med.

Sepsis Diagnoses Are Common in ED, but Many Septic Patients in the ED Do Not Receive Antibiotics

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

New Oral Anticoagulants Safe and Effective for Atrial Fibrillation Treatment

Clinical question: Is there a difference in efficacy and safety among new oral anticoagulants compared to warfarin in subgroups of patients with atrial fibrillation (Afib)?

Background: Studies of new oral anticoagulants have demonstrated that these agents are at least as safe and effective as warfarin for prevention of stroke and systemic embolism in Afib. This study was designed to look at available phase 3 randomized trials, with the goal of subgroup analysis for both efficacy and bleeding risks.

Study design: Meta-analysis.

Setting: Phase 3 randomized controlled trials of patients with Afib.

Synopsis: The analysis included four trials of Afib patients randomized to receive warfarin or a novel oral anticoagulant (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban. In total, 42,411 patients received an NOAC and 29,272 patients received warfarin. Separate analyses were performed for high-dose and low-dose NOACs.

The high-dose NOAC demonstrated a 19% reduction in stroke and systemic embolic events as compared to warfarin, largely due to the reduction of hemorrhagic strokes by the NOAC. The low-dose NOAC showed similar efficacy to warfarin for reduction of stroke and systemic embolic events, with an increase noted in the subset of ischemic stroke in low-dose NOAC. Both doses of NOAC demonstrated a significant reduction in all-cause mortality. NOAC showed a non-significant reduction in bleeding compared to warfarin; however, subset analysis demonstrated an increase in gastrointestinal bleeding with high-dose NOAC and a significant reduction in intracranial hemorrhage with low-dose NOAC.

A notable limitation of the study is that it only included clinical trials in the analysis.

Bottom line: In relation to stroke, systemic embolic events, and all-cause mortality, new oral anticoagulants showed a favorable efficacy and safety profile as compared to warfarin in Afib patients.

Citation: Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Healthcare-associated infections financially impact the U.S. system
2. No mortality benefit with treatment of single peripheral pulmonary emboli
3. Modified (shorter) IV acetylcysteine infusion reduces adverse effects
4. Comorbidities contribute to potentially avoidable hospital readmissions
5. Resident handoff bundle reduces medical errors and adverse events, improves handoff quality
6. Uncomplicated skin infections in the ambulatory setting commonly involve avoidable antibiotic exposure
7. Warfarin initiation in atrial fibrillation associated with increased short-term risk of stroke
8. Multifaceted discharge interventions reduce rates of pediatric readmission and post-hospital ED utilization
9. Sepsis diagnoses are common, but many septic patients in ED do not receive antibiotics
10. New oral anticoagulants safe, effective for atrial fibrillation treatment

Healthcare-Associated Infections Continue to Impact the U.S. Healthcare System Financially

Clinical question: What is the estimated cost of healthcare-associated infections (HAI) to the U.S. healthcare system?

Background: In spite of education efforts, HAIs occur frequently and contribute to high healthcare costs in the U.S. This study sought to estimate the costs of HAIs to the U.S. system using statistical analyses of published data.

Study design: Simulations of published data.

Setting: Published studies on five major HAIs.

Synopsis: Monte Carlo simulations based upon published point estimates were used to estimate per-case cost and confidence intervals, with extrapolation to total costs to the U.S. healthcare system. Overall, five major HAIs occur approximately 440,000 times annually and cost the healthcare system an estimated $9.78 billion (range $8.28 to $11.5 billion) in 2009.

Surgical site infections (36.0%) were the most common of the studied HAIs, with increased per-case cost of $20,785, equating to an estimated $3.30 billion annually (33.7% of total HAI costs). Clostridium difficile infection accounted for 30.3% of HAI but only 15.4% of costs ($1.51 billion). Central line-associated bloodstream infections were most costly per case ($45,814), with total costs of $1.85 billion (18.9% of costs). Ventilator-associated pneumonia accounted for $3.09 billion, or 31.7% of total costs. Catheter-associated urinary tract infection only represented 0.3% of total costs, or $27.9 million annually.

The authors suggest that changes in payment reform likely will drive hospitals to further invest in HAI reduction efforts.

Bottom line: HAIs remain frequent and expensive complications of hospitalization, in spite of improvement efforts to date.

Citation: Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.

No Mortality Benefit with Treatment of Single Peripheral Pulmonary Emboli

Clinical question: Does treatment of single peripheral pulmonary emboli impact mortality and rates of post-discharge venous thromboembolism (VTE)?

Background: With the increase in CT pulmonary angiography (CTPA) use the past decade, there has been an increased rate of detection of peripheral filling defects. When confronted with a single peripheral filling defect (SPFD), clinicians face the dilemma of whether treatment is necessary, given the risks associated with anticoagulation.

Study design: Retrospective cohort.

Setting: Community teaching hospital in Norwalk, Conn.

Synopsis: A total of 4,906 CTPAs were screened, revealing 153 scans with an SPFD. Primary analysis included 134 patients 18 years or older. Of these patients, 61 (45.5%) received treatment with anticoagulation (n=51) or IVC filter alone (n=10).

This study revealed no difference in adjusted 90-day mortality between treated and untreated groups. No statistically significant difference was found in the rate of post-discharge VTE within 90 days.

Characteristics associated with treatment for SPFD were patient immobility, previous VTE, and radiology labeling the filling defect as a pulmonary embolus. It is important to note that none of the patients who had a normal second imaging study (e.g. V/Q scan or ultrasound) were treated; therefore, the use of secondary studies could mitigate some of the uncertainty around SPFD management, though this is not recommended in current diagnostic algorithms. Because this is a single-center study with a modest sample size, the comparability of findings to other centers might be limited. Larger studies are needed to help clarify these findings.

Bottom line: Treatment of SPFD was not associated with a difference in mortality or post-discharge VTE within 90 days.

Citation: Green O, Lempel J, Kolodziej A, et al. Treatment of single peripheral pulmonary emboli: patient outcomes and factors associated with decision to treat. J Hosp Med. 2014;9(1):42-47.

Modified IV Acetylcysteine Infusion Reduces Adverse Effects

Clinical question: Does a shorter regimen of IV acetylcysteine reduce adverse effects compared to the standard regimen?

Background: Acetaminophen poisoning is common, and recommended treatment is IV acetylcysteine; however, the standard regimen has many adverse effects, including vomiting and anaphylactoid reactions. Although studies have outlined these side effects, no published trials have compared their frequency to that of a shorter protocol.

Study design: Double-blinded, randomized controlled trial.

Setting: Three acute care hospitals in the United Kingdom.

Synopsis: Of 3,311 patients who presented with acetaminophen overdose, 222 underwent randomization to the standard (duration 20-25 hours) or modified (12 hours) acetylcysteine regimen, with or without pre-treatment with IV ondansetron 4 mg. The primary outcome of vomiting, retching, or need for rescue antiemetic treatment within two hours of acetylcysteine initiation was significantly less frequent in patients who received the shorter regimen, compared to those allocated to the standard regimen.

Specifically, the adjusted odds ratio was 0.26 with the modified regimen (97.5% CI, 0.13-0.52; P<0.0001). The primary outcome was significantly less in patients pre-treated with ondansetron compared to placebo (OR 0.41, 97.5% CI 0.2-0.8; P=0.003). Anaphylactic reactions were significantly reduced with the shorter protocol; no significant difference in hepatotoxicity was noted.

It is reasonable to infer that the shorter acetylcysteine regimen substantially reduces the frequency of vomiting and serious anaphylactoid reactions when compared with the standard schedule; however, hospitalists should note that this study was not powered to assess for non-inferiority of the shorter regimen with regard to prevention of acetaminophen’s hepatotoxic effects. Further studies are needed to confirm the efficacy and safety of the modified regimen before widespread adoption into clinical practice.

Bottom line: A shorter acetylcysteine regimen is associated with decreased occurrence of vomiting and anaphylactoid reactions compared to the standard protocol for treating acetaminophen toxicity. Additional research is needed to assess non-inferiority of this modified regimen for prevention of hepatotoxic effects.

Citation: Bateman DN, Dear JW, Thanacoody HK, et al. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomized controlled trial. Lancet. 2014;383(9918):697-704.

Comorbidities Contribute to Potentially Avoidable Hospital Readmissions

Clinical question: What is the role of comorbidities in 30-day potentially avoidable readmissions?

Background: Higher comorbidity burden has been associated with 30-day readmissions. This study evaluated the role of comorbidities in the 30-day rate of potentially avoidable readmissions from a tertiary-care medical center.

Study design: Retrospective cohort.

Setting: Tertiary-care teaching hospital and affiliated network.

Synopsis: Investigators tested the hypothesis that comorbidities significantly contribute to 30-day, potentially avoidable readmissions in a cohort of consecutively discharged medical patients at an academic medical center over a 12-month period. Out of a total of 10,731 discharges, there were 2,398 readmissions to hospitals in the same health system. Of those 2,398 readmissions, 858 (35.8%) were judged potentially avoidable using a validated algorithm. Frequently, the reason for readmission was not related to the index discharge diagnosis but to a complication of known comorbidities.

The authors identified the top five diagnoses for readmission as infection, neoplasm, heart failure, gastrointestinal disorder, and liver disorder. Among those patients who had a readmission diagnosis different from the index-case discharge diagnosis, the comorbidities of neoplastic disease, heart failure, and chronic kidney disease significantly contributed to readmission as compared to those without similar comorbidities.

Bottom line: The reason for readmission often is not related to the index hospitalization diagnosis but, rather, to comorbidities present at the index episode of care; thus, attention to management of comorbidities in the post-discharge period is important in circumventing potentially avoidable readmissions.

Citation: Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347:F7171.

Resident Handoff Bundle Reduces Medical Errors and Adverse Events, Improves Handoff Quality

Clinical question: In a pediatric inpatient setting, is the use of a handoff program associated with improved patient safety measures and handoff quality?

Background: Sentinel events related to errors in communication are a significant patient safety dilemma and an impetus for ongoing efforts to improve handoffs in postgraduate medical education. Various strategies to be incorporated into the handoff process have been suggested in the literature, but research is limited with regard to the relationship between handoffs and patient safety.

Study design: Prospective, pre-post study.

Setting: Academic, pediatric hospital in an urban setting.

Synopsis: Overall, 1,255 patient admissions (642 pre-/613 post-handoff intervention) were evaluated on two inpatient units during the periods of July 2009-September 2009 (pre-intervention) and November 2009-January 2010 (post-intervention). The intervention was a handoff “bundle” consisting of a standardized communication and handoff training session, a verbal mnemonic to standardize handoffs, and a new unified resident-intern handoff structure in a private, quiet setting. A computerized handoff tool was also added in one unit. Primary outcomes were a comparison of the rate of medical errors per 100 admissions and rates of preventable adverse events before and after the intervention.

Implementation of the bundle resulted in a significant decrease in medical errors (18.3 from 33.8 per 100 admissions, P<0.001) and preventable adverse events (1.5 from 3.3 per 100 admissions, P=0.04). Secondary outcomes included reductions in omissions of key data in the written handoff (even greater in the group using the computerized tool) and increased percentage of time spent in direct patient care, with no change in handoff duration. Additionally, handoffs were more likely to occur in a quiet, private location.

Limitations included the potential for confounding in a pre-post intervention design, the difficulty in ascertaining the value of the individual components of the bundle, and the potential lack of generalizability.

Bottom line: In a pediatric hospital setting, a multifaceted handoff bundle is associated with improved handoff quality and reductions in medical errors and preventable adverse events.

Citation: Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262-2270.

Uncomplicated Skin Infections in Ambulatory Setting Commonly Involve Avoidable Antibiotic Exposure

Clinical question: What are the current prescribing practices for antibiotics used to treat skin and soft tissue infections in the outpatient setting?

Background: Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotic use. Because antibiotic use is associated with bacterial resistance and adverse events, understanding antibiotic prescribing practices is necessary to minimize these types of complications.

Study design: Retrospective cohort.

Setting: Ambulatory care setting in the Denver Health System.

Synopsis: Data from 364 adults and children who presented to an ambulatory setting with a primary diagnosis of skin and soft tissue infection were analyzed using a stepwise multivariate logistic regression in order to determine factors associated with avoidable antibiotic exposure. Among cellulitis cases, 61% of patients were prescribed antibiotics to treat methicillin-resistant Staphylococcus aureus. Avoidable antibiotic exposure occurred in 46% of cases, including use of antibiotics with broad Gram-negative activity (4%), combination therapy (12%), and treatment for ≥10 days (42%). Use of short-course, single-antibiotic treatment approaches consistent with national guidelines would have reduced prescribed antibiotic days by 19%, to 55%.

Bottom line: Avoidable antibiotic exposure frequently occurs in the treatment of uncomplicated skin infections; using short-course, single-antibiotic treatment strategies could significantly reduce total antibiotic use.

Citation: Hurley HJ, Knepper BC, Price CS, Mehler PS, Burman WJ, Jenkins TC. Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting. Am J Med. 2013;126(12):1099-1106.

Warfarin Initiation in Atrial Fibrillation Associated with Increased Short-Term Risk of Stroke

Clinical question: Is the initiation of warfarin associated with an increased risk of ischemic stroke in patients with atrial fibrillation (Afib)?

Background: Two Afib trials of oral factor Xa inhibitors showed an increased risk of stroke when patients were transitioned to open label warfarin at the end of the study. Warfarin can, theoretically, lead to a transient hypercoagulable state upon treatment initiation, so further study is indicated to determine if the initiation of warfarin is associated with increased stroke risk among Afib patients.

Study design: Population-based, nested case-control.

Setting: UK Clinical Practice Research Datalink.

Synopsis: A cohort of 70,766 patients with newly diagnosed Afib was identified from a large primary care database. Conditional logistic regression was used to estimate adjusted rate ratios (RR) of stroke associated with warfarin monotherapy, classified according to time since initiation of treatment when compared to patients not on antithrombotic therapy.

Warfarin was associated with a 71% increased risk of stroke in the first 30 days of use (RR 1.71, 95% CI 1.39-2.12). Risk was highest in the first week of warfarin treatment, which is consistent with the known transient pro-coagulant effect of warfarin. Decreased risks were observed with warfarin initiation >30 days before the ischemic event (31-90 days: RR 0.50, 95% CI 0.34-0.75; >90 days: RR 0.55, 95% CI 0.50-0.61).

Limitations included the extraction of data from a database, which could lead to misclassification of diagnosis or therapy, and the observational nature of the study.

Bottom line: There may be an increased risk of ischemic stroke during the first 30 days of treatment with warfarin in patients with Afib.

Citation: Azoulay L, Dell-Aniello S, Simon T, Renoux C, Suissa S. Initiation of warfarin in patients with atrial fibrillation: early effects on ischaemic strokes [published online ahead of print December 18, 2013]. Eur Heart J.

Multifaceted Discharge Interventions Reduce Rates of Pediatric Readmission and Post-Hospital ED Utilization

Clinical question: Do interventions at discharge reduce the rate of readmissions and post-hospitalization ED visits among pediatric patients?

Background: Readmissions are a high-priority quality measure in both the adult and pediatric settings. Although a broadening body of literature is evaluating the impact of interventions on readmissions in adult populations, the literature does not contain a similar breadth of assessments of interventions in the pediatric setting.

Study design: Systematic review.

Setting: English-language articles studying pediatric inpatient discharge interventions.

Synopsis: A total of 1,296 unique articles were identified from PubMed and the Cumulative Index to Nursing and Allied Health Literature. Additional articles were identified on review of references, yielding 14 articles that met inclusion criteria. Included studies evaluated the effect of pediatric discharge interventions on the primary outcomes of hospital readmission or post-hospitalization ED visits. Interventions focused on three main patient populations: asthma, cancer, and prematurity.

Six studies demonstrated statistically significant reductions in readmissions and/or ED visits, while two studies actually demonstrated an increase in post-discharge utilization. All successful interventions began in the inpatient setting and were multifaceted, with four of six studies including an educational component and a post-discharge follow-up component.

While all of the studies evaluated sought to enhance the transitional care from the inpatient to outpatient setting, only the interventions that included one responsible party (individual or team) with expertise in the medical condition providing oversight and support were successful in reducing the specified outcomes. A significant limitation was that many of the studies identified were not sufficiently powered to detect either outcome of interest.

Bottom line: A multifaceted intervention involving educational and post-discharge follow-up components with an experienced individual or team supporting the transition is associated with a reduction in hospital readmissions and post-discharge ED utilization.

Citation: Auger KA, Kenyon CC, Feudtner C, Davis MM. Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review [published online ahead of print December 20, 2013]. J Hosp Med.

Sepsis Diagnoses Are Common in ED, but Many Septic Patients in the ED Do Not Receive Antibiotics

Clinical question: Has the frequency of sepsis rates, along with administration of antibiotics in U.S. emergency departments (EDs), changed over time?

Background: Prior studies reviewing discharge data from hospitals suggest an increase of sepsis over time; however, little epidemiological research has evaluated the diagnosis of sepsis and antibiotic use in ED settings.

Study design: Retrospective, four-stage probability sample.

Setting: National Hospital Ambulatory Medical Care Survey (NHAMCS).

Synopsis: The NHAMCS includes a sample of all U.S. ED visits, except federal, military, and VA hospitals. According to NHAMCS data, an estimated 1.3 billion visits by adults to U.S. EDs occurred from 1994-2009, or approximately 81 million visits per year. Explicit sepsis was defined by the presence of the following, with ICD-9 codes: septicemia (038), sepsis (995.91), severe sepsis (995.92), or septic shock (785.52). Implicit sepsis was defined as a code indicating infection plus a code indicting organ dysfunction.

In U.S. EDs, explicit sepsis did not become more prevalent from 1994-2009; however, implicitly diagnosed sepsis increased by 7% every two years. There were 260,000 explicit sepsis-related ED visits per year, or 1.23 visits per 1,000 U.S. population. In-hospital mortality was 17% and 9% for the explicit and implicit diagnosis groups, respectively. On review of the explicit sepsis group, only 61% of the patients were found to have received antibiotics in the ED. The rate did increase over the time studied, from 52% in 1994-1997 to 69% in 2006-2009.

The study was limited by the retrospective analysis of data not designed to track sepsis or antibiotic use.

Bottom Line: Explicitly recognized sepsis remained stable in the ED setting from 1994-2009, and early antibiotic use has improved during this time, but there is still much opportunity for improvement.

Citation: Filbin MR, Arias SA, Camargo CA Jr, Barche A, Pallin DJ. Sepsis visits and antibiotic utilization in the U.S. emergency departments. Crit Care Med. 2014;42(3):528-535.

New Oral Anticoagulants Safe and Effective for Atrial Fibrillation Treatment

Clinical question: Is there a difference in efficacy and safety among new oral anticoagulants compared to warfarin in subgroups of patients with atrial fibrillation (Afib)?

Background: Studies of new oral anticoagulants have demonstrated that these agents are at least as safe and effective as warfarin for prevention of stroke and systemic embolism in Afib. This study was designed to look at available phase 3 randomized trials, with the goal of subgroup analysis for both efficacy and bleeding risks.

Study design: Meta-analysis.

Setting: Phase 3 randomized controlled trials of patients with Afib.

Synopsis: The analysis included four trials of Afib patients randomized to receive warfarin or a novel oral anticoagulant (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban. In total, 42,411 patients received an NOAC and 29,272 patients received warfarin. Separate analyses were performed for high-dose and low-dose NOACs.

The high-dose NOAC demonstrated a 19% reduction in stroke and systemic embolic events as compared to warfarin, largely due to the reduction of hemorrhagic strokes by the NOAC. The low-dose NOAC showed similar efficacy to warfarin for reduction of stroke and systemic embolic events, with an increase noted in the subset of ischemic stroke in low-dose NOAC. Both doses of NOAC demonstrated a significant reduction in all-cause mortality. NOAC showed a non-significant reduction in bleeding compared to warfarin; however, subset analysis demonstrated an increase in gastrointestinal bleeding with high-dose NOAC and a significant reduction in intracranial hemorrhage with low-dose NOAC.

A notable limitation of the study is that it only included clinical trials in the analysis.

Bottom line: In relation to stroke, systemic embolic events, and all-cause mortality, new oral anticoagulants showed a favorable efficacy and safety profile as compared to warfarin in Afib patients.

Citation: Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-962.