After the welcomes and plenary sessions by leaders in healthcare, will you go to a breakout session called “More Non-Evidence-Based Medicine: Things We Do for No Reason” or the workshop on point-of-care evidence?

Now is the time to start deciding with the new HM13 “Day at a Glance” schedules, available at www.hospitalmedicine2013.org. With more than 100 events, sessions, and work groups, the schedule is a roadmap for hospitalists planning their annual meeting experience in advance.

This year, hospitalists will have extra help in planning their HM13 strategy digitally. For the first time, hospitalists will be able to use their smartphones and tablet devices to review the HM13 agenda and plan their own personal schedules before they arrive at the conference.

To download a printable PDF of the HM13 “Day at a Glance,” visit www.hospitalmedicine2013.org/pdf/At-A-Glance.pdf.

After the welcomes and plenary sessions by leaders in healthcare, will you go to a breakout session called “More Non-Evidence-Based Medicine: Things We Do for No Reason” or the workshop on point-of-care evidence?

Now is the time to start deciding with the new HM13 “Day at a Glance” schedules, available at www.hospitalmedicine2013.org. With more than 100 events, sessions, and work groups, the schedule is a roadmap for hospitalists planning their annual meeting experience in advance.

This year, hospitalists will have extra help in planning their HM13 strategy digitally. For the first time, hospitalists will be able to use their smartphones and tablet devices to review the HM13 agenda and plan their own personal schedules before they arrive at the conference.

To download a printable PDF of the HM13 “Day at a Glance,” visit www.hospitalmedicine2013.org/pdf/At-A-Glance.pdf.

After the welcomes and plenary sessions by leaders in healthcare, will you go to a breakout session called “More Non-Evidence-Based Medicine: Things We Do for No Reason” or the workshop on point-of-care evidence?

Now is the time to start deciding with the new HM13 “Day at a Glance” schedules, available at www.hospitalmedicine2013.org. With more than 100 events, sessions, and work groups, the schedule is a roadmap for hospitalists planning their annual meeting experience in advance.

This year, hospitalists will have extra help in planning their HM13 strategy digitally. For the first time, hospitalists will be able to use their smartphones and tablet devices to review the HM13 agenda and plan their own personal schedules before they arrive at the conference.

To download a printable PDF of the HM13 “Day at a Glance,” visit www.hospitalmedicine2013.org/pdf/At-A-Glance.pdf.

This month, hospitalists will be a vital part of Choosing Wisely, an important public initiative from the American Board of Internal Medicine (ABIM) Foundation that identifies treatments and procedures that might be overused by caregivers.

On Feb. 21 in Washington, D.C., the ABIM Foundation, SHM, and more than a dozen other medical specialties will announce recommendations that, in the ABIM Foundation’s words, “represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.” Hospitalists who helped SHM develop its recommendations will be in attendance to help field questions about SHM’s work with Choosing Wisely and its lists.

SHM has developed two lists of recommendations: one for adult HM and another for pediatric HM. SHM will make a special announcement Feb. 21 in The Hospitalist eWire with both lists and commentary for how hospitalists can have informed conversations with their patients about the lists. The Hospitalist will follow up with a feature story and other information about Choosing Wisely in its March issue.

As part of the campaign, the ABIM Foundation, SHM, and consumer magazine Consumer Reports have teamed up to develop material specifically designed to educate patients about the Choosing Wisely recommendations. Materials will be available on the ABIM Foundation and SHM websites.

SHM will continue the conversation about high-value care and working with patients to make wise decisions well beyond February and March. At HM13, SHM’s annual meeting in Washington, D.C., SHM will offer a pre-course on Choosing Wisely and its philosophy. The pre-course is May 16, the day before the official start of HM13.

For more information about Choosing Wisely, visit www.choosingwisely.org. To register for the Choosing Wisely pre-course at HM13, visit www.hospitalmedicine2013.org.

This month, hospitalists will be a vital part of Choosing Wisely, an important public initiative from the American Board of Internal Medicine (ABIM) Foundation that identifies treatments and procedures that might be overused by caregivers.

On Feb. 21 in Washington, D.C., the ABIM Foundation, SHM, and more than a dozen other medical specialties will announce recommendations that, in the ABIM Foundation’s words, “represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.” Hospitalists who helped SHM develop its recommendations will be in attendance to help field questions about SHM’s work with Choosing Wisely and its lists.

SHM has developed two lists of recommendations: one for adult HM and another for pediatric HM. SHM will make a special announcement Feb. 21 in The Hospitalist eWire with both lists and commentary for how hospitalists can have informed conversations with their patients about the lists. The Hospitalist will follow up with a feature story and other information about Choosing Wisely in its March issue.

As part of the campaign, the ABIM Foundation, SHM, and consumer magazine Consumer Reports have teamed up to develop material specifically designed to educate patients about the Choosing Wisely recommendations. Materials will be available on the ABIM Foundation and SHM websites.

SHM will continue the conversation about high-value care and working with patients to make wise decisions well beyond February and March. At HM13, SHM’s annual meeting in Washington, D.C., SHM will offer a pre-course on Choosing Wisely and its philosophy. The pre-course is May 16, the day before the official start of HM13.

For more information about Choosing Wisely, visit www.choosingwisely.org. To register for the Choosing Wisely pre-course at HM13, visit www.hospitalmedicine2013.org.

This month, hospitalists will be a vital part of Choosing Wisely, an important public initiative from the American Board of Internal Medicine (ABIM) Foundation that identifies treatments and procedures that might be overused by caregivers.

On Feb. 21 in Washington, D.C., the ABIM Foundation, SHM, and more than a dozen other medical specialties will announce recommendations that, in the ABIM Foundation’s words, “represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.” Hospitalists who helped SHM develop its recommendations will be in attendance to help field questions about SHM’s work with Choosing Wisely and its lists.

SHM has developed two lists of recommendations: one for adult HM and another for pediatric HM. SHM will make a special announcement Feb. 21 in The Hospitalist eWire with both lists and commentary for how hospitalists can have informed conversations with their patients about the lists. The Hospitalist will follow up with a feature story and other information about Choosing Wisely in its March issue.

As part of the campaign, the ABIM Foundation, SHM, and consumer magazine Consumer Reports have teamed up to develop material specifically designed to educate patients about the Choosing Wisely recommendations. Materials will be available on the ABIM Foundation and SHM websites.

SHM will continue the conversation about high-value care and working with patients to make wise decisions well beyond February and March. At HM13, SHM’s annual meeting in Washington, D.C., SHM will offer a pre-course on Choosing Wisely and its philosophy. The pre-course is May 16, the day before the official start of HM13.

For more information about Choosing Wisely, visit www.choosingwisely.org. To register for the Choosing Wisely pre-course at HM13, visit www.hospitalmedicine2013.org.

Background Hypersensitivity reactions to chemotherapy agents occur with relatively high frequency with some of the most widely used chemotherapeutic drug classes. Desensitization using a standard 12-step protocol has been successful, but takes about 6.5 hours. Limited studies have shown that a faster protocol may also be safe.

Objective To determine when desensitization could be safely speeded up.

Methods Patients with documented HSRs (24 patients) were desensitized initially with the standard 12-step protocol for 1 or 2 treatments, for a total of 180 desensitizations. Those patients who had negative skin testing and who tolerated the desensitizations were switched to the more rapid desensitization protocol (16 patients).

Results All 16 patients were successfully desensitized, having received the full dose of their chemotherapy. Eight patients were not advanced to the rapid protocol because they had reactions during initial desensitizations or they had a positive skin test; all of them were successfully desensitized using the 12-step protocol at the slower rate of infusion. These data present criteria for defining which patients may be safely transitioned to a rapid desensitization protocol.

Limitation Most of the patients in the study (21 of 24) were women.

Conclusions Patients with HSRs to chemotherapy agents, who tolerate an initial 12-step desensitization and have a negative skin test, can be advanced to a more rapid protocol. It is likely that patients with HSRs to the taxanes can be started on the more rapid protocol without starting on the 12-step protocol.

*Click on the PDF icon at the top of this introduction to read the full article.

Background Hypersensitivity reactions to chemotherapy agents occur with relatively high frequency with some of the most widely used chemotherapeutic drug classes. Desensitization using a standard 12-step protocol has been successful, but takes about 6.5 hours. Limited studies have shown that a faster protocol may also be safe.

Objective To determine when desensitization could be safely speeded up.

Methods Patients with documented HSRs (24 patients) were desensitized initially with the standard 12-step protocol for 1 or 2 treatments, for a total of 180 desensitizations. Those patients who had negative skin testing and who tolerated the desensitizations were switched to the more rapid desensitization protocol (16 patients).

Results All 16 patients were successfully desensitized, having received the full dose of their chemotherapy. Eight patients were not advanced to the rapid protocol because they had reactions during initial desensitizations or they had a positive skin test; all of them were successfully desensitized using the 12-step protocol at the slower rate of infusion. These data present criteria for defining which patients may be safely transitioned to a rapid desensitization protocol.

Limitation Most of the patients in the study (21 of 24) were women.

Conclusions Patients with HSRs to chemotherapy agents, who tolerate an initial 12-step desensitization and have a negative skin test, can be advanced to a more rapid protocol. It is likely that patients with HSRs to the taxanes can be started on the more rapid protocol without starting on the 12-step protocol.

*Click on the PDF icon at the top of this introduction to read the full article.

Background Hypersensitivity reactions to chemotherapy agents occur with relatively high frequency with some of the most widely used chemotherapeutic drug classes. Desensitization using a standard 12-step protocol has been successful, but takes about 6.5 hours. Limited studies have shown that a faster protocol may also be safe.

Objective To determine when desensitization could be safely speeded up.

Methods Patients with documented HSRs (24 patients) were desensitized initially with the standard 12-step protocol for 1 or 2 treatments, for a total of 180 desensitizations. Those patients who had negative skin testing and who tolerated the desensitizations were switched to the more rapid desensitization protocol (16 patients).

Results All 16 patients were successfully desensitized, having received the full dose of their chemotherapy. Eight patients were not advanced to the rapid protocol because they had reactions during initial desensitizations or they had a positive skin test; all of them were successfully desensitized using the 12-step protocol at the slower rate of infusion. These data present criteria for defining which patients may be safely transitioned to a rapid desensitization protocol.

Limitation Most of the patients in the study (21 of 24) were women.

Conclusions Patients with HSRs to chemotherapy agents, who tolerate an initial 12-step desensitization and have a negative skin test, can be advanced to a more rapid protocol. It is likely that patients with HSRs to the taxanes can be started on the more rapid protocol without starting on the 12-step protocol.

*Click on the PDF icon at the top of this introduction to read the full article.

Background Decision support interventions help patients who are facing difficult treatment decisions and improve shared decision making. There is little evidence of the economic impact of these interventions.

Objective To determine the costs of providing a decision support intervention in the form of consultation planning (CP) and consultation planning with recording and summary (CPRS) to women with breast cancer and to compare the cost benefit of CP and CPRS by telephone versus in person.

Methods Sixty-eight women with breast cancer who were being treated at a rural cancer resource center were randomized to CP in person or by telephone. All participants were then provided with an audio-recording of the physician consultation along with a typed summary for the full intervention (CPRS). Surveys completed by the participants and center staff provided data for measuring costs and willingness-to-pay (WTP) benefits. Societal perspective costs and incremental net benefit (INB) across delivery methods was determined.

Results Total CP costs were $208.72 for telephone and $264.00 for in-person delivery. Significantly lower telephone-group costs (P ˂ .001) were a result of lower participant travel expenses. Participants were willing to pay $154.12 for telephone and $144.03 for in-person CP (P = .85). WTP did not exceed costs of either delivery method compared with no intervention. INB of providing CP for telephone versus in person was $65.37, favoring telephone delivery. Sensitivity analysis revealed that with more efficient CP training, WTP became greater than the costs of delivering CP by telephone versus no intervention.

Limitations There may be some income distribution effects in the measurement of WTP.

Conclusions Providing CP by telephone was significantly less costly with no significant difference in benefit. Participants’ WTP only exceeded the full cost of CP with more efficient training or higher participant volume. A positive INB showed telephone delivery is efficient and may increase accessibility to decision support services, particularly in rural communities.


Click on the PDF icon at the top of this introduction to read the full article.



 

Background Decision support interventions help patients who are facing difficult treatment decisions and improve shared decision making. There is little evidence of the economic impact of these interventions.

Objective To determine the costs of providing a decision support intervention in the form of consultation planning (CP) and consultation planning with recording and summary (CPRS) to women with breast cancer and to compare the cost benefit of CP and CPRS by telephone versus in person.

Methods Sixty-eight women with breast cancer who were being treated at a rural cancer resource center were randomized to CP in person or by telephone. All participants were then provided with an audio-recording of the physician consultation along with a typed summary for the full intervention (CPRS). Surveys completed by the participants and center staff provided data for measuring costs and willingness-to-pay (WTP) benefits. Societal perspective costs and incremental net benefit (INB) across delivery methods was determined.

Results Total CP costs were $208.72 for telephone and $264.00 for in-person delivery. Significantly lower telephone-group costs (P ˂ .001) were a result of lower participant travel expenses. Participants were willing to pay $154.12 for telephone and $144.03 for in-person CP (P = .85). WTP did not exceed costs of either delivery method compared with no intervention. INB of providing CP for telephone versus in person was $65.37, favoring telephone delivery. Sensitivity analysis revealed that with more efficient CP training, WTP became greater than the costs of delivering CP by telephone versus no intervention.

Limitations There may be some income distribution effects in the measurement of WTP.

Conclusions Providing CP by telephone was significantly less costly with no significant difference in benefit. Participants’ WTP only exceeded the full cost of CP with more efficient training or higher participant volume. A positive INB showed telephone delivery is efficient and may increase accessibility to decision support services, particularly in rural communities.


Click on the PDF icon at the top of this introduction to read the full article.



 

Background Decision support interventions help patients who are facing difficult treatment decisions and improve shared decision making. There is little evidence of the economic impact of these interventions.

Objective To determine the costs of providing a decision support intervention in the form of consultation planning (CP) and consultation planning with recording and summary (CPRS) to women with breast cancer and to compare the cost benefit of CP and CPRS by telephone versus in person.

Methods Sixty-eight women with breast cancer who were being treated at a rural cancer resource center were randomized to CP in person or by telephone. All participants were then provided with an audio-recording of the physician consultation along with a typed summary for the full intervention (CPRS). Surveys completed by the participants and center staff provided data for measuring costs and willingness-to-pay (WTP) benefits. Societal perspective costs and incremental net benefit (INB) across delivery methods was determined.

Results Total CP costs were $208.72 for telephone and $264.00 for in-person delivery. Significantly lower telephone-group costs (P ˂ .001) were a result of lower participant travel expenses. Participants were willing to pay $154.12 for telephone and $144.03 for in-person CP (P = .85). WTP did not exceed costs of either delivery method compared with no intervention. INB of providing CP for telephone versus in person was $65.37, favoring telephone delivery. Sensitivity analysis revealed that with more efficient CP training, WTP became greater than the costs of delivering CP by telephone versus no intervention.

Limitations There may be some income distribution effects in the measurement of WTP.

Conclusions Providing CP by telephone was significantly less costly with no significant difference in benefit. Participants’ WTP only exceeded the full cost of CP with more efficient training or higher participant volume. A positive INB showed telephone delivery is efficient and may increase accessibility to decision support services, particularly in rural communities.


Click on the PDF icon at the top of this introduction to read the full article.



 

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

Larry Beresford is a freelance writer in Oakland, Calif.

Articles first published in the Jan. 16, 2013, edition of The Hospitalist eWire.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

Larry Beresford is a freelance writer in Oakland, Calif.

Articles first published in the Jan. 16, 2013, edition of The Hospitalist eWire.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

Larry Beresford is a freelance writer in Oakland, Calif.

Articles first published in the Jan. 16, 2013, edition of The Hospitalist eWire.

Physicians who rank poorly in their communication skills with patients were associated with reduced rates of medication adherence in a new report.

A cross-sectional study of nearly 9,4000 patients in the Diabetes Study of Northern California (DISTANCE) found roughly 30% of patients who gave their physicians poor ratings when it came to involving them in decisions, understanding their problems with medications, and eliciting their trust were less likely to refill their cardiometabolic medications than those whose doctors were deemed to be good communicators, researchers found. For each 10-point decrease in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the prevalence of poor medication adherence increased by 0.9% (P +0.1), the researchers added.

“One of the tricks is that medication adherence is an inherently physician-centric concept,” says lead author Neda Ratanawongsa, MD, MPH, assistant professor in the department of medicine at the University of California at San Francisco (UCSF). “We’re asking you to take medicine that we think will be best for you. That’s been the way that physicians operate for years, often appropriately so. But part of this is figuring out how to encourage the patients to disclose their decision that ‘Yes, I do want to take that medicine’ or ‘No, here’s why I don’t want to take that medicine.’”

Dr. Ratanawongsa adds that hospitalists and other physicians have to develop a sense of trust with patients to build relationships. Future studies could then track patient satisfaction and adherence over time to see if a corollary exists. Also, she says, hospitalists shouldn’t be discouraged that most of their relationships aren’t long-term ones like those found in other specialties.

“I wouldn’t underestimate the impact a hospitalist could have, whether one-time interaction or not, to change an existing therapy program,” Dr. Ratanawongsa says. “It’s important for hospitalists to understand the power of their words.”

Richard Quinn is a freelance writer in New Jersey.

Physicians who rank poorly in their communication skills with patients were associated with reduced rates of medication adherence in a new report.

A cross-sectional study of nearly 9,4000 patients in the Diabetes Study of Northern California (DISTANCE) found roughly 30% of patients who gave their physicians poor ratings when it came to involving them in decisions, understanding their problems with medications, and eliciting their trust were less likely to refill their cardiometabolic medications than those whose doctors were deemed to be good communicators, researchers found. For each 10-point decrease in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the prevalence of poor medication adherence increased by 0.9% (P +0.1), the researchers added.

“One of the tricks is that medication adherence is an inherently physician-centric concept,” says lead author Neda Ratanawongsa, MD, MPH, assistant professor in the department of medicine at the University of California at San Francisco (UCSF). “We’re asking you to take medicine that we think will be best for you. That’s been the way that physicians operate for years, often appropriately so. But part of this is figuring out how to encourage the patients to disclose their decision that ‘Yes, I do want to take that medicine’ or ‘No, here’s why I don’t want to take that medicine.’”

Dr. Ratanawongsa adds that hospitalists and other physicians have to develop a sense of trust with patients to build relationships. Future studies could then track patient satisfaction and adherence over time to see if a corollary exists. Also, she says, hospitalists shouldn’t be discouraged that most of their relationships aren’t long-term ones like those found in other specialties.

“I wouldn’t underestimate the impact a hospitalist could have, whether one-time interaction or not, to change an existing therapy program,” Dr. Ratanawongsa says. “It’s important for hospitalists to understand the power of their words.”

Richard Quinn is a freelance writer in New Jersey.

Physicians who rank poorly in their communication skills with patients were associated with reduced rates of medication adherence in a new report.

A cross-sectional study of nearly 9,4000 patients in the Diabetes Study of Northern California (DISTANCE) found roughly 30% of patients who gave their physicians poor ratings when it came to involving them in decisions, understanding their problems with medications, and eliciting their trust were less likely to refill their cardiometabolic medications than those whose doctors were deemed to be good communicators, researchers found. For each 10-point decrease in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the prevalence of poor medication adherence increased by 0.9% (P +0.1), the researchers added.

“One of the tricks is that medication adherence is an inherently physician-centric concept,” says lead author Neda Ratanawongsa, MD, MPH, assistant professor in the department of medicine at the University of California at San Francisco (UCSF). “We’re asking you to take medicine that we think will be best for you. That’s been the way that physicians operate for years, often appropriately so. But part of this is figuring out how to encourage the patients to disclose their decision that ‘Yes, I do want to take that medicine’ or ‘No, here’s why I don’t want to take that medicine.’”

Dr. Ratanawongsa adds that hospitalists and other physicians have to develop a sense of trust with patients to build relationships. Future studies could then track patient satisfaction and adherence over time to see if a corollary exists. Also, she says, hospitalists shouldn’t be discouraged that most of their relationships aren’t long-term ones like those found in other specialties.

“I wouldn’t underestimate the impact a hospitalist could have, whether one-time interaction or not, to change an existing therapy program,” Dr. Ratanawongsa says. “It’s important for hospitalists to understand the power of their words.”

Richard Quinn is a freelance writer in New Jersey.

Rajan Gurunathan, MD, was an undergraduate student at Johns Hopkins University in Baltimore in the early 1990s weighing his career options.

“I went through a lot of permutations, actually,” he says. “Scientist, clinical researcher, doctor, physician/scientist—all of those things entered my mind at some point.”

He applied to dual-track MD and PhD programs, but ultimately decided that interacting with people—patients in particular—was the goal for him. He earned his medical degree from UMDNJ-Robert Wood Johnson Medical School in Camden, N.J., and completed his internship in the department of medicine at St. Luke’s-Roosevelt Hospital Center in New York City, not far from where he grew up as a child in northern New Jersey.

And he never left.

I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

Dr. Gurunathan has risen through the ranks at St. Luke’s-Roosevelt, from resident to chief resident to chief of the section of hospital medicine. He is a faculty member for the Clinical Quality Fellowship Program at the Great New York Hospital Association and an assistant clinical professor of medicine at Columbia University College of Physicians and Surgeons in New York.

His long tenure at St. Luke’s-Roosevelt has been “an incredible experience because I really get a sense and feeling of commitment from the community,” he adds. “I’ve seen it grow over time and see how the needs have changed and how the service the hospital has been able to provide has only grown over time.”

After several years of presenting posters at SHM’s annual meetings, Dr. Gurunathan joined Team Hospitalist in April 2012 to become an even more active member of his specialty.

QUESTION: When you started as an intern 15 years ago, did you expect that you’d still be at the same institution?

Answer: No, I wouldn’t have expected that at all. In fact, there was a time where I was briefly considering a general medicine fellowship at Johns Hopkins, and I was prepared to go there. And family circumstances, etc., made me decide not to move on and to make a commitment and join the department as faculty, first as a chief and then as faculty. And I was really lucky to have those opportunities, because while my course didn’t go exactly the way that I’d planned, I wouldn’t have changed a thing.

Q: When you now deal with the residents and younger staff members, what’s that experience like for you?

A: It’s a really neat experience, and often brings a chuckle to my face when I see that they’re frustrated about the same things, because I can certainly commiserate. But I can really also see the value of what they provide every day, and having been in their shoes, I know a little bit about what they’ve been through and the work that they do. So I have a real appreciation for that.

Q: What brought you to hospital medicine?

A: I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

Q: Is there something specific about the setting that’s kept you in the academic world?

A: A lot of things, actually. As I mentioned, hospitals in general should have a collegial nature. Again, it’s a really nice place where people share a unique common goal of banding together and fighting a goal, and academic departments are the same. So it’s being with people with like-minded intellectual interests. And we’re fortunate enough to have a number of strong mentors within the department who have had a lot of clinical training and bring a lot of experience and a wealth of knowledge, and being able to utilize their experience and draw from their experiences only makes people better clinicians. And we’re fortunate enough to have a pretty supportive department in general where there is a lot of collegiality and camaraderie.

Q: As an administrator, what is the value of being an SHM member, to you?

A: I think what I’ve seen administratively is the changing face of healthcare and how hospitals are going to need to continue to transform with time due to things that are both regulatory- and quality-of-care-based, in terms of improving outcomes and keeping people healthy. SHM has really embraced [those changes] and taken them head-on for really important reasons, not only in terms of helping people adapt to the changing landscape, but also training them in the ways that we need to be thinking about problems now and in the future.

Q: You’ve attended multiple annual meetings and presented posters. What value have you taken out of them, and would you recommend the experience to others?

A: Absolutely. I think as people develop, it’s good to always learn new skills, and my clinical research is an area that I would actually like to build up. So I’ve had a little bit of exposure, and it’s been nice to be able to draw from the resources of SHM and be able to partake. We presented something last year, which was a really neat experience, and we’re looking to bring some new faculty this year and encourage them to get involved in the scholarship process. These are the kinds of things that can really help hone skills, and that’s a good thing.

Q: Once you’re inside the doors of a New York City hospital, is daily practice much different than anywhere else?

A: I would say yes and no. I would say no in that I think all hospitals are really neat places and really incredible places. I heard somebody say once at a talk that hospitals were places of refuge, and I really do believe that. That being said, I think there is something slightly unique about New York City in a lot of ways. Certainly the challenges that New York City hospitals face are somewhat unique in terms of patient population, difficulty in socioeconomic factors, insurance issues. I think they are really fun places to work, but they’re not for the faint of heart.

Richard Quinn is a freelance writer in New Jersey.

Rajan Gurunathan, MD, was an undergraduate student at Johns Hopkins University in Baltimore in the early 1990s weighing his career options.

“I went through a lot of permutations, actually,” he says. “Scientist, clinical researcher, doctor, physician/scientist—all of those things entered my mind at some point.”

He applied to dual-track MD and PhD programs, but ultimately decided that interacting with people—patients in particular—was the goal for him. He earned his medical degree from UMDNJ-Robert Wood Johnson Medical School in Camden, N.J., and completed his internship in the department of medicine at St. Luke’s-Roosevelt Hospital Center in New York City, not far from where he grew up as a child in northern New Jersey.

And he never left.

I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

Dr. Gurunathan has risen through the ranks at St. Luke’s-Roosevelt, from resident to chief resident to chief of the section of hospital medicine. He is a faculty member for the Clinical Quality Fellowship Program at the Great New York Hospital Association and an assistant clinical professor of medicine at Columbia University College of Physicians and Surgeons in New York.

His long tenure at St. Luke’s-Roosevelt has been “an incredible experience because I really get a sense and feeling of commitment from the community,” he adds. “I’ve seen it grow over time and see how the needs have changed and how the service the hospital has been able to provide has only grown over time.”

After several years of presenting posters at SHM’s annual meetings, Dr. Gurunathan joined Team Hospitalist in April 2012 to become an even more active member of his specialty.

QUESTION: When you started as an intern 15 years ago, did you expect that you’d still be at the same institution?

Answer: No, I wouldn’t have expected that at all. In fact, there was a time where I was briefly considering a general medicine fellowship at Johns Hopkins, and I was prepared to go there. And family circumstances, etc., made me decide not to move on and to make a commitment and join the department as faculty, first as a chief and then as faculty. And I was really lucky to have those opportunities, because while my course didn’t go exactly the way that I’d planned, I wouldn’t have changed a thing.

Q: When you now deal with the residents and younger staff members, what’s that experience like for you?

A: It’s a really neat experience, and often brings a chuckle to my face when I see that they’re frustrated about the same things, because I can certainly commiserate. But I can really also see the value of what they provide every day, and having been in their shoes, I know a little bit about what they’ve been through and the work that they do. So I have a real appreciation for that.

Q: What brought you to hospital medicine?

A: I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

Q: Is there something specific about the setting that’s kept you in the academic world?

A: A lot of things, actually. As I mentioned, hospitals in general should have a collegial nature. Again, it’s a really nice place where people share a unique common goal of banding together and fighting a goal, and academic departments are the same. So it’s being with people with like-minded intellectual interests. And we’re fortunate enough to have a number of strong mentors within the department who have had a lot of clinical training and bring a lot of experience and a wealth of knowledge, and being able to utilize their experience and draw from their experiences only makes people better clinicians. And we’re fortunate enough to have a pretty supportive department in general where there is a lot of collegiality and camaraderie.

Q: As an administrator, what is the value of being an SHM member, to you?

A: I think what I’ve seen administratively is the changing face of healthcare and how hospitals are going to need to continue to transform with time due to things that are both regulatory- and quality-of-care-based, in terms of improving outcomes and keeping people healthy. SHM has really embraced [those changes] and taken them head-on for really important reasons, not only in terms of helping people adapt to the changing landscape, but also training them in the ways that we need to be thinking about problems now and in the future.

Q: You’ve attended multiple annual meetings and presented posters. What value have you taken out of them, and would you recommend the experience to others?

A: Absolutely. I think as people develop, it’s good to always learn new skills, and my clinical research is an area that I would actually like to build up. So I’ve had a little bit of exposure, and it’s been nice to be able to draw from the resources of SHM and be able to partake. We presented something last year, which was a really neat experience, and we’re looking to bring some new faculty this year and encourage them to get involved in the scholarship process. These are the kinds of things that can really help hone skills, and that’s a good thing.

Q: Once you’re inside the doors of a New York City hospital, is daily practice much different than anywhere else?

A: I would say yes and no. I would say no in that I think all hospitals are really neat places and really incredible places. I heard somebody say once at a talk that hospitals were places of refuge, and I really do believe that. That being said, I think there is something slightly unique about New York City in a lot of ways. Certainly the challenges that New York City hospitals face are somewhat unique in terms of patient population, difficulty in socioeconomic factors, insurance issues. I think they are really fun places to work, but they’re not for the faint of heart.

Richard Quinn is a freelance writer in New Jersey.

Rajan Gurunathan, MD, was an undergraduate student at Johns Hopkins University in Baltimore in the early 1990s weighing his career options.

“I went through a lot of permutations, actually,” he says. “Scientist, clinical researcher, doctor, physician/scientist—all of those things entered my mind at some point.”

He applied to dual-track MD and PhD programs, but ultimately decided that interacting with people—patients in particular—was the goal for him. He earned his medical degree from UMDNJ-Robert Wood Johnson Medical School in Camden, N.J., and completed his internship in the department of medicine at St. Luke’s-Roosevelt Hospital Center in New York City, not far from where he grew up as a child in northern New Jersey.

And he never left.

I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

Dr. Gurunathan has risen through the ranks at St. Luke’s-Roosevelt, from resident to chief resident to chief of the section of hospital medicine. He is a faculty member for the Clinical Quality Fellowship Program at the Great New York Hospital Association and an assistant clinical professor of medicine at Columbia University College of Physicians and Surgeons in New York.

His long tenure at St. Luke’s-Roosevelt has been “an incredible experience because I really get a sense and feeling of commitment from the community,” he adds. “I’ve seen it grow over time and see how the needs have changed and how the service the hospital has been able to provide has only grown over time.”

After several years of presenting posters at SHM’s annual meetings, Dr. Gurunathan joined Team Hospitalist in April 2012 to become an even more active member of his specialty.

QUESTION: When you started as an intern 15 years ago, did you expect that you’d still be at the same institution?

Answer: No, I wouldn’t have expected that at all. In fact, there was a time where I was briefly considering a general medicine fellowship at Johns Hopkins, and I was prepared to go there. And family circumstances, etc., made me decide not to move on and to make a commitment and join the department as faculty, first as a chief and then as faculty. And I was really lucky to have those opportunities, because while my course didn’t go exactly the way that I’d planned, I wouldn’t have changed a thing.

Q: When you now deal with the residents and younger staff members, what’s that experience like for you?

A: It’s a really neat experience, and often brings a chuckle to my face when I see that they’re frustrated about the same things, because I can certainly commiserate. But I can really also see the value of what they provide every day, and having been in their shoes, I know a little bit about what they’ve been through and the work that they do. So I have a real appreciation for that.

Q: What brought you to hospital medicine?

A: I’ve always enjoyed the collegiality of a hospital environment in terms of multiple disciplines working together in ways to help care for patients. It’s a paradox in the sense that it’s fascinating to see disease and be able to be impactful in that way, but it’s also unfortunate sometimes to see what people have to go through.

Q: Is there something specific about the setting that’s kept you in the academic world?

A: A lot of things, actually. As I mentioned, hospitals in general should have a collegial nature. Again, it’s a really nice place where people share a unique common goal of banding together and fighting a goal, and academic departments are the same. So it’s being with people with like-minded intellectual interests. And we’re fortunate enough to have a number of strong mentors within the department who have had a lot of clinical training and bring a lot of experience and a wealth of knowledge, and being able to utilize their experience and draw from their experiences only makes people better clinicians. And we’re fortunate enough to have a pretty supportive department in general where there is a lot of collegiality and camaraderie.

Q: As an administrator, what is the value of being an SHM member, to you?

A: I think what I’ve seen administratively is the changing face of healthcare and how hospitals are going to need to continue to transform with time due to things that are both regulatory- and quality-of-care-based, in terms of improving outcomes and keeping people healthy. SHM has really embraced [those changes] and taken them head-on for really important reasons, not only in terms of helping people adapt to the changing landscape, but also training them in the ways that we need to be thinking about problems now and in the future.

Q: You’ve attended multiple annual meetings and presented posters. What value have you taken out of them, and would you recommend the experience to others?

A: Absolutely. I think as people develop, it’s good to always learn new skills, and my clinical research is an area that I would actually like to build up. So I’ve had a little bit of exposure, and it’s been nice to be able to draw from the resources of SHM and be able to partake. We presented something last year, which was a really neat experience, and we’re looking to bring some new faculty this year and encourage them to get involved in the scholarship process. These are the kinds of things that can really help hone skills, and that’s a good thing.

Q: Once you’re inside the doors of a New York City hospital, is daily practice much different than anywhere else?

A: I would say yes and no. I would say no in that I think all hospitals are really neat places and really incredible places. I heard somebody say once at a talk that hospitals were places of refuge, and I really do believe that. That being said, I think there is something slightly unique about New York City in a lot of ways. Certainly the challenges that New York City hospitals face are somewhat unique in terms of patient population, difficulty in socioeconomic factors, insurance issues. I think they are really fun places to work, but they’re not for the faint of heart.

Richard Quinn is a freelance writer in New Jersey.

New oral anticoagulants promise to impact hospitalists and their patients—but the question is how much

When the FDA gave the nod to factor Xa-inhibitor rivaroxaban in November for use in treating acute DVT and pulmonary embolism (PE), it was just the latest development in the swiftly evolving world of oral anticoagulants—a world that hospitalists had better get used to living in, and quick.

As many as 80% of the patients that hospitalists encounter are on some kind of anticoagulant, experts say. But the extent to which the emergence of the new drugs— particularly rivaroxaban, which also is approved for stroke prevention in nonvalvular atrial fibrillation (afib) and for DVT and PE prevention in knee and hip replacement patients—will affect the daily routines of hospitalists remains to be seen.

Hospitalists specializing in VTE prevention and vascular experts say that the new drugs will make life simpler for hospitalists in some ways, mainly because for some patients, a pill will replace the injectable enoxaparin that has been used to bridge patients to warfarin. But with more options available, things will become more complicated as well, they say.

Approvals for the new agents, which aim to replace warfarin and its need for constant monitoring and concern over drug and food interactions, have been coming rapid-fire. Along with rivaroxaban in the new oral anticoagulant group are dabigatran, approved in late 2010 for stroke prevention in nonvalvular afib, and apixaban, which is expected to be approved for the same indication this year.

“Of all three drugs, [rivaroxaban] has the broadest indications for use,” said Hiren Shah, MD, assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director of hospital medicine at Northwestern Memorial Hospital in Chicago. “Because of that, it’s likely that it’s going to be the agent that will be adopted much more broadly and more easily than dabigatran.”

But apixaban might come on strong in the U.S. when it’s approved because it shows better promise for patients with renal impairment and has a lower risk of intracranial hemorrhage, says Geno Merli, MD, director of the Jefferson Center for Vascular Disease and chief medical officer at Thomas Jefferson University Hospital in Philadelphia.

“I think the two other [manufacturers] are afraid of apixaban because apixaban’s safety profile was much better,” he says.

Steven Deitelzweig, MD, FACP, SFHM, secretary of the Gulf State chapter of SHM and a DVT prevention specialist at Ochsner Health System New Orleans, says hurdles to adoption of the new agents will include whether a system is integrated and can assure appropriate follow-up and concerns over proper patient selection and cost, as the cost-benefit analyses haven’t been done yet.

“The learning curve, or the adoption curve, is really going to be very variable around the country,” he says.

Experts agree changes are on the way as the new anticoagulants gain more traction. Here are some things they say hospitalists should watch out for.

Care and Discharge

Dr. Shah says the availability of the oral agents will streamline care and discharge of patients.

“The care and coordination process that needs to occur with the use of parenteral agents and warfarin is significantly more complex than the patient education and care coordination that will be required with the new oral anticoagulants,” he says. “That’s where there’s a significant time savings.”

Ian Jenkins, MD, assistant professor in the division of hospital medicine at the University of California at San Diego, says the windfall of time saved might not hit hospitalists directly, at least at some centers.

“The education is being done by pharmacy here for warfarin, and nurses handle enoxaparin injection teaching,” he says. “So the workload that benefits may be that of our colleagues.”

Dr. Shah notes that the responsibility in patient counseling ultimately falls within hospitalists’ purview, so he predicts that any greater simplicity in that regard would help hospitalists.

Who Ends up Hospitalized?

The option of oral agents might help diminish the number of patients who have to stay in the hospital for enoxaparin injections that bridge them to warfarin, a topic at a recent roundtable discussion Dr. Shah attended.

“It was shocking to me that I have many colleagues throughout the country who have patients who are in the hospital simply to get parenteral injections because they can’t take them themselves at home and have no loved ones or friends to help them,” he says.

Dr. Merli agrees that the new agents might affect hospitalists’ patient census. Many patients, he says, will be discharged straight from the ED.

“The DVT patients probably won’t get [admitted]. You’re going to put them on rivaroxaban and send them home,” he says. “You’re not going to get [admitted] with a DVT anymore, unless it’s extensive. And if it’s an extensive DVT, you’re not going to get rivaroxaban. You’re going to get enoxaparin or you’re going to get thrombolytics therapy followed by IV heparin followed by enoxaparin. So I don’t see rivaroxaban jumping into the marketplace and being a boon to hospitalists immediately.”

If patients skip hospitalization and are discharged straight from the ED, Dr. Deitelzweig says, “there will be patients who will backfill those spots.”

“I think most of the people will come in as observation status, if not inpatient,” he says, although simpler DVT patients will be likelier candidates for discharge from the ER. He predicts that stays might be shorter, though.

But Dr. Merli says hospitalists shouldn’t expect a big effect on length of stay.

“I don’t think you’re going to reduce dramatically length of stay because you have an oral pill,” he says.

QI Initiatives

What might be a boon, though, are opportunities for quality-improvement (QI) initiatives related to the new therapies, Dr. Jenkins says. “Many of these projects that are being done with anticoagulants … do focus on warfarin safety; it’s a frequent part of readmission and patient harm,” he says. “Having it much simpler to treat and educate these patients is actually going to be a boon, I think, for hospitalists working on quality-improvement projects, and for people who do that education, whether that is a hospitalist or a pharmacist or some other member of the staff.”

There are downsides, though, he notes. One is cost. Another is reversibility. Warfarin can be easily reversed in the event of a bleed, but that’s not the case with rivaroxaban and dabigatran. And none of the new therapies are suitable for patients with renal failure.

“Right now, we’re stuck with IV heparin and Coumadin in the hospital, and rivaroxaban won’t change this,” he says. “Rivaroxaban patients one might help with PCC; but with dabigatran, I don’t think much will help besides time and dialysis, which is dangerous in unstable anticoagulated patients.”

Dr. Shah, though, says he’s aware of only two times that bleeding reversal protocols—based on anecdotal evidence, because no method has been scientifically proven—had to be invoked at Northwestern in the past year.

It might be “more of a theoretical problem than one in reality,” he explains, “simply because we have not found the need to reverse oral anticoagulants very often given their short half-lives.”

The new agents, all the experts agree, will require hospitalists to stay on their toes.

“There are so many different facets in each case, whether it’s the age or the renal function or whether there’s a fall risk and what their compliance is, what their funding is, what the exact indication is,” Dr. Jenkins says. “Keeping up with those things is actually quite challenging.”

His main resources are the American College of Chest Physicians’ guidelines on anticoagulants, his center’s own protocols, and the primary literature for the main trials (see “Additional Reading,” right). He also looks to the inpatient pharmacist for guidance.

Dr. Shah says it is important to be aware of the patient-inclusion criteria, study design, and outcomes measured for each agent through their trials.

“There is a lot of information out there, and there are very subtle aspects of some of these trials and you’ve got to really understand: Does it apply to the patient that is front of me?” he said. “There’s a lot to know, there’s no doubt about it.”

Thomas R. Collins is a freelance writer in South Florida.

New oral anticoagulants promise to impact hospitalists and their patients—but the question is how much

When the FDA gave the nod to factor Xa-inhibitor rivaroxaban in November for use in treating acute DVT and pulmonary embolism (PE), it was just the latest development in the swiftly evolving world of oral anticoagulants—a world that hospitalists had better get used to living in, and quick.

As many as 80% of the patients that hospitalists encounter are on some kind of anticoagulant, experts say. But the extent to which the emergence of the new drugs— particularly rivaroxaban, which also is approved for stroke prevention in nonvalvular atrial fibrillation (afib) and for DVT and PE prevention in knee and hip replacement patients—will affect the daily routines of hospitalists remains to be seen.

Hospitalists specializing in VTE prevention and vascular experts say that the new drugs will make life simpler for hospitalists in some ways, mainly because for some patients, a pill will replace the injectable enoxaparin that has been used to bridge patients to warfarin. But with more options available, things will become more complicated as well, they say.

Approvals for the new agents, which aim to replace warfarin and its need for constant monitoring and concern over drug and food interactions, have been coming rapid-fire. Along with rivaroxaban in the new oral anticoagulant group are dabigatran, approved in late 2010 for stroke prevention in nonvalvular afib, and apixaban, which is expected to be approved for the same indication this year.

“Of all three drugs, [rivaroxaban] has the broadest indications for use,” said Hiren Shah, MD, assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director of hospital medicine at Northwestern Memorial Hospital in Chicago. “Because of that, it’s likely that it’s going to be the agent that will be adopted much more broadly and more easily than dabigatran.”

But apixaban might come on strong in the U.S. when it’s approved because it shows better promise for patients with renal impairment and has a lower risk of intracranial hemorrhage, says Geno Merli, MD, director of the Jefferson Center for Vascular Disease and chief medical officer at Thomas Jefferson University Hospital in Philadelphia.

“I think the two other [manufacturers] are afraid of apixaban because apixaban’s safety profile was much better,” he says.

Steven Deitelzweig, MD, FACP, SFHM, secretary of the Gulf State chapter of SHM and a DVT prevention specialist at Ochsner Health System New Orleans, says hurdles to adoption of the new agents will include whether a system is integrated and can assure appropriate follow-up and concerns over proper patient selection and cost, as the cost-benefit analyses haven’t been done yet.

“The learning curve, or the adoption curve, is really going to be very variable around the country,” he says.

Experts agree changes are on the way as the new anticoagulants gain more traction. Here are some things they say hospitalists should watch out for.

Care and Discharge

Dr. Shah says the availability of the oral agents will streamline care and discharge of patients.

“The care and coordination process that needs to occur with the use of parenteral agents and warfarin is significantly more complex than the patient education and care coordination that will be required with the new oral anticoagulants,” he says. “That’s where there’s a significant time savings.”

Ian Jenkins, MD, assistant professor in the division of hospital medicine at the University of California at San Diego, says the windfall of time saved might not hit hospitalists directly, at least at some centers.

“The education is being done by pharmacy here for warfarin, and nurses handle enoxaparin injection teaching,” he says. “So the workload that benefits may be that of our colleagues.”

Dr. Shah notes that the responsibility in patient counseling ultimately falls within hospitalists’ purview, so he predicts that any greater simplicity in that regard would help hospitalists.

Who Ends up Hospitalized?

The option of oral agents might help diminish the number of patients who have to stay in the hospital for enoxaparin injections that bridge them to warfarin, a topic at a recent roundtable discussion Dr. Shah attended.

“It was shocking to me that I have many colleagues throughout the country who have patients who are in the hospital simply to get parenteral injections because they can’t take them themselves at home and have no loved ones or friends to help them,” he says.

Dr. Merli agrees that the new agents might affect hospitalists’ patient census. Many patients, he says, will be discharged straight from the ED.

“The DVT patients probably won’t get [admitted]. You’re going to put them on rivaroxaban and send them home,” he says. “You’re not going to get [admitted] with a DVT anymore, unless it’s extensive. And if it’s an extensive DVT, you’re not going to get rivaroxaban. You’re going to get enoxaparin or you’re going to get thrombolytics therapy followed by IV heparin followed by enoxaparin. So I don’t see rivaroxaban jumping into the marketplace and being a boon to hospitalists immediately.”

If patients skip hospitalization and are discharged straight from the ED, Dr. Deitelzweig says, “there will be patients who will backfill those spots.”

“I think most of the people will come in as observation status, if not inpatient,” he says, although simpler DVT patients will be likelier candidates for discharge from the ER. He predicts that stays might be shorter, though.

But Dr. Merli says hospitalists shouldn’t expect a big effect on length of stay.

“I don’t think you’re going to reduce dramatically length of stay because you have an oral pill,” he says.

QI Initiatives

What might be a boon, though, are opportunities for quality-improvement (QI) initiatives related to the new therapies, Dr. Jenkins says. “Many of these projects that are being done with anticoagulants … do focus on warfarin safety; it’s a frequent part of readmission and patient harm,” he says. “Having it much simpler to treat and educate these patients is actually going to be a boon, I think, for hospitalists working on quality-improvement projects, and for people who do that education, whether that is a hospitalist or a pharmacist or some other member of the staff.”

There are downsides, though, he notes. One is cost. Another is reversibility. Warfarin can be easily reversed in the event of a bleed, but that’s not the case with rivaroxaban and dabigatran. And none of the new therapies are suitable for patients with renal failure.

“Right now, we’re stuck with IV heparin and Coumadin in the hospital, and rivaroxaban won’t change this,” he says. “Rivaroxaban patients one might help with PCC; but with dabigatran, I don’t think much will help besides time and dialysis, which is dangerous in unstable anticoagulated patients.”

Dr. Shah, though, says he’s aware of only two times that bleeding reversal protocols—based on anecdotal evidence, because no method has been scientifically proven—had to be invoked at Northwestern in the past year.

It might be “more of a theoretical problem than one in reality,” he explains, “simply because we have not found the need to reverse oral anticoagulants very often given their short half-lives.”

The new agents, all the experts agree, will require hospitalists to stay on their toes.

“There are so many different facets in each case, whether it’s the age or the renal function or whether there’s a fall risk and what their compliance is, what their funding is, what the exact indication is,” Dr. Jenkins says. “Keeping up with those things is actually quite challenging.”

His main resources are the American College of Chest Physicians’ guidelines on anticoagulants, his center’s own protocols, and the primary literature for the main trials (see “Additional Reading,” right). He also looks to the inpatient pharmacist for guidance.

Dr. Shah says it is important to be aware of the patient-inclusion criteria, study design, and outcomes measured for each agent through their trials.

“There is a lot of information out there, and there are very subtle aspects of some of these trials and you’ve got to really understand: Does it apply to the patient that is front of me?” he said. “There’s a lot to know, there’s no doubt about it.”

Thomas R. Collins is a freelance writer in South Florida.

New oral anticoagulants promise to impact hospitalists and their patients—but the question is how much

When the FDA gave the nod to factor Xa-inhibitor rivaroxaban in November for use in treating acute DVT and pulmonary embolism (PE), it was just the latest development in the swiftly evolving world of oral anticoagulants—a world that hospitalists had better get used to living in, and quick.

As many as 80% of the patients that hospitalists encounter are on some kind of anticoagulant, experts say. But the extent to which the emergence of the new drugs— particularly rivaroxaban, which also is approved for stroke prevention in nonvalvular atrial fibrillation (afib) and for DVT and PE prevention in knee and hip replacement patients—will affect the daily routines of hospitalists remains to be seen.

Hospitalists specializing in VTE prevention and vascular experts say that the new drugs will make life simpler for hospitalists in some ways, mainly because for some patients, a pill will replace the injectable enoxaparin that has been used to bridge patients to warfarin. But with more options available, things will become more complicated as well, they say.

Approvals for the new agents, which aim to replace warfarin and its need for constant monitoring and concern over drug and food interactions, have been coming rapid-fire. Along with rivaroxaban in the new oral anticoagulant group are dabigatran, approved in late 2010 for stroke prevention in nonvalvular afib, and apixaban, which is expected to be approved for the same indication this year.

“Of all three drugs, [rivaroxaban] has the broadest indications for use,” said Hiren Shah, MD, assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director of hospital medicine at Northwestern Memorial Hospital in Chicago. “Because of that, it’s likely that it’s going to be the agent that will be adopted much more broadly and more easily than dabigatran.”

But apixaban might come on strong in the U.S. when it’s approved because it shows better promise for patients with renal impairment and has a lower risk of intracranial hemorrhage, says Geno Merli, MD, director of the Jefferson Center for Vascular Disease and chief medical officer at Thomas Jefferson University Hospital in Philadelphia.

“I think the two other [manufacturers] are afraid of apixaban because apixaban’s safety profile was much better,” he says.

Steven Deitelzweig, MD, FACP, SFHM, secretary of the Gulf State chapter of SHM and a DVT prevention specialist at Ochsner Health System New Orleans, says hurdles to adoption of the new agents will include whether a system is integrated and can assure appropriate follow-up and concerns over proper patient selection and cost, as the cost-benefit analyses haven’t been done yet.

“The learning curve, or the adoption curve, is really going to be very variable around the country,” he says.

Experts agree changes are on the way as the new anticoagulants gain more traction. Here are some things they say hospitalists should watch out for.

Care and Discharge

Dr. Shah says the availability of the oral agents will streamline care and discharge of patients.

“The care and coordination process that needs to occur with the use of parenteral agents and warfarin is significantly more complex than the patient education and care coordination that will be required with the new oral anticoagulants,” he says. “That’s where there’s a significant time savings.”

Ian Jenkins, MD, assistant professor in the division of hospital medicine at the University of California at San Diego, says the windfall of time saved might not hit hospitalists directly, at least at some centers.

“The education is being done by pharmacy here for warfarin, and nurses handle enoxaparin injection teaching,” he says. “So the workload that benefits may be that of our colleagues.”

Dr. Shah notes that the responsibility in patient counseling ultimately falls within hospitalists’ purview, so he predicts that any greater simplicity in that regard would help hospitalists.

Who Ends up Hospitalized?

The option of oral agents might help diminish the number of patients who have to stay in the hospital for enoxaparin injections that bridge them to warfarin, a topic at a recent roundtable discussion Dr. Shah attended.

“It was shocking to me that I have many colleagues throughout the country who have patients who are in the hospital simply to get parenteral injections because they can’t take them themselves at home and have no loved ones or friends to help them,” he says.

Dr. Merli agrees that the new agents might affect hospitalists’ patient census. Many patients, he says, will be discharged straight from the ED.

“The DVT patients probably won’t get [admitted]. You’re going to put them on rivaroxaban and send them home,” he says. “You’re not going to get [admitted] with a DVT anymore, unless it’s extensive. And if it’s an extensive DVT, you’re not going to get rivaroxaban. You’re going to get enoxaparin or you’re going to get thrombolytics therapy followed by IV heparin followed by enoxaparin. So I don’t see rivaroxaban jumping into the marketplace and being a boon to hospitalists immediately.”

If patients skip hospitalization and are discharged straight from the ED, Dr. Deitelzweig says, “there will be patients who will backfill those spots.”

“I think most of the people will come in as observation status, if not inpatient,” he says, although simpler DVT patients will be likelier candidates for discharge from the ER. He predicts that stays might be shorter, though.

But Dr. Merli says hospitalists shouldn’t expect a big effect on length of stay.

“I don’t think you’re going to reduce dramatically length of stay because you have an oral pill,” he says.

QI Initiatives

What might be a boon, though, are opportunities for quality-improvement (QI) initiatives related to the new therapies, Dr. Jenkins says. “Many of these projects that are being done with anticoagulants … do focus on warfarin safety; it’s a frequent part of readmission and patient harm,” he says. “Having it much simpler to treat and educate these patients is actually going to be a boon, I think, for hospitalists working on quality-improvement projects, and for people who do that education, whether that is a hospitalist or a pharmacist or some other member of the staff.”

There are downsides, though, he notes. One is cost. Another is reversibility. Warfarin can be easily reversed in the event of a bleed, but that’s not the case with rivaroxaban and dabigatran. And none of the new therapies are suitable for patients with renal failure.

“Right now, we’re stuck with IV heparin and Coumadin in the hospital, and rivaroxaban won’t change this,” he says. “Rivaroxaban patients one might help with PCC; but with dabigatran, I don’t think much will help besides time and dialysis, which is dangerous in unstable anticoagulated patients.”

Dr. Shah, though, says he’s aware of only two times that bleeding reversal protocols—based on anecdotal evidence, because no method has been scientifically proven—had to be invoked at Northwestern in the past year.

It might be “more of a theoretical problem than one in reality,” he explains, “simply because we have not found the need to reverse oral anticoagulants very often given their short half-lives.”

The new agents, all the experts agree, will require hospitalists to stay on their toes.

“There are so many different facets in each case, whether it’s the age or the renal function or whether there’s a fall risk and what their compliance is, what their funding is, what the exact indication is,” Dr. Jenkins says. “Keeping up with those things is actually quite challenging.”

His main resources are the American College of Chest Physicians’ guidelines on anticoagulants, his center’s own protocols, and the primary literature for the main trials (see “Additional Reading,” right). He also looks to the inpatient pharmacist for guidance.

Dr. Shah says it is important to be aware of the patient-inclusion criteria, study design, and outcomes measured for each agent through their trials.

“There is a lot of information out there, and there are very subtle aspects of some of these trials and you’ve got to really understand: Does it apply to the patient that is front of me?” he said. “There’s a lot to know, there’s no doubt about it.”

Thomas R. Collins is a freelance writer in South Florida.