Like all healthcare payors, Medicare has for some time tried to change from being a passive payor of services to a purchaser of value. There might be a lot of ways to do that, but one easy to conceptualize method is for Medicare to pay different amounts for a given service (i.e. a hospital stay for congestive heart failure) based on the quality of that service. Of course, the details of how to measure quality and implement such a program become terribly complex in a hurry.

Hospital value-based purchasing (HVBP), one of the provisions health reform, is one of the Centers for Medicare & Medicaid Services’ (CMS) first large-scale attempts to do just that.

CMS’ goals for this program include improving clinical quality, encouraging more patient-centered care, encouraging hospitals and clinicians to work together to improve quality of care, and empowering consumers to make value-based decisions about their healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

You already were aware that baseline measurements of quality performance for your hospital were collected from July 2009 through March 2010, right? And data collected from July 2010 through March 2011 serves as the first “Performance Period” to determine payment that will begin in October 2012. (If you are not aware, visit www.hospitalcompare.hhs.gov to see the performance your hospital is currently reporting. All the providers in your hospitalist group should be familiar with the data; another good site is www.whynotthebest.org. But keep in mind there is a significant delay in getting the data to display on these sites. In many cases, the data they display today is from nearly a year prior.)

Some Generalizations

HVBP has a number of features that are typical of new reimbursement programs:

• It is budget-neutral for Medicare. In other words, some hospitals will perform well and realize reimbursement increases; some hospitals will not perform well and will see reduced reimbursement.
• It builds on previous programs. HVBP essentially moves performance on core measures and HCAHPS surveys, all of which have been in place several years, from being publically reported to serving as metrics that influence reimbursement.
• The dollar amounts involved grow each year.
• Expect the program to evolve continuously. For example, the number and type of quality metrics on which the program is based will increase each year.

How It Works

Medicare will start withholding a portion of diagnosis-related group (DRG) payments to hospitals, starting with 1% initially and increasing by 0.25% annually, so that 2% is withheld in 2017. Keep in mind that amount is withheld from all DRG payments to a hospital, not just those related to the diagnoses that are part of the HVBP program.

Based on performance on core measures and patient satisfaction, hospitals have a chance to earn additional compensation that could be more or less than the initial 2% withholding. Additional performance measures will be added every year or so.

There are two ways a hospital can earn some of this performance-based compensation based on its “Total Performance Score.” Expressed in the language of Little League baseball, a hospital needs to be either a most valuable player—an MVP—or a most improved player.

The MVP pathway, known as “achievement,” is to grade hospitals on a curve established from the data collected for all hospitals the prior year. Those at the high end of the curve are paid more than the amount that was withheld from them (so they are “net winners”); those at the bottom of the curve are paid nothing (“net losers,” as they lost the chance to earn back any of the amount withheld).

The most improved pathway, cleverly called “improvement,” is for a hospital to improve its performance over its previous baseline, even if it fails to attain a high score relative to others. Measurement of the first baseline year ran from July 2010 through March 2011, and will be used as the reference point for performance from July 2011 through March 2012.

The precise amount of the payment for either of the two methods above is based on a sliding scale rather than an all-or-none threshold. SHM’s website (www.hospitalmedicine.org/hvbp) has an example of this calculation. A simple way to think of it is that a hospital won’t have to do a lot to earn back some portion of the amount withheld, but it has to hit a home run to earn back more than that.

The Dollars at Risk

It is worth thinking about the most a hospital could lose or gain under HVBP. Let’s take an example of a hospital that is paid $50 million annually by Medicare across all DRGs (this would be a pretty small hospital). In 2013, Medicare will pay that hospital only $49.5 million; that is, it will withhold 1% ($500,000) as part of the HVBP program. After the hospital’s Total Performance Score is computed, Medicare might pay more to the hospital in the form of an “add on” to the hospital’s typical DRG payments. If performance stinks or is worse than most hospitals and does not improve significantly over its own baseline, Medicare might not pay a nickel more. But for respectable performance, it might be paid 80% of the amount withheld—$400,000, in this example. So this hypothetical hospital would end up being a “net loser” of $100,000. By 2017, when 2% is withheld, the dollars at risk would be double.

From a practical perspective, the amount by which reimbursement will go up or down for most hospitals will be significantly less than the total withhold amount for most hospitals, so it probably won’t be enough to result in financial disaster or great profits. (Your hospital CFO may dispute this conclusion and you should listen to them.) But because a new “grading curve” is established each year, a score that puts a hospital in a financially attractive category one year might not look so good the next year. Therefore, a hospital whose performance stands still will likely become a net loser within a year or two.

Even if you were to conclude that the potential financial upside isn’t compelling enough to devote a lot of energy to perform well, the fact that most of the measures really do matter to our patients, and that this information is publicly reported, means every hospital should do whatever it takes to perform well. I suspect that patients and employers, as well as all types of payors, will pay more and more attention to your hospital’s performance and overall hospital volume affected in locales where patients have a choice of more than one hospital.

Learn More

I’ve provided only a very general HVBP overview here. Most hospitalist groups should identify at least one person who develops meaningful expertise in this program and other components of healthcare reform (i.e. bundled payments, penalties for excess readmissions, and penalties for hospital-acquired conditions). SHM is a terrific educational resource for these things and has a very informative HVBP toolkit available via its website.

Thanks to Drs. Win Whitcomb and Pat Torcson for helping to explain all this stuff to me. They and others at SHM do a great job of staying on top of things like healthcare reform.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Like all healthcare payors, Medicare has for some time tried to change from being a passive payor of services to a purchaser of value. There might be a lot of ways to do that, but one easy to conceptualize method is for Medicare to pay different amounts for a given service (i.e. a hospital stay for congestive heart failure) based on the quality of that service. Of course, the details of how to measure quality and implement such a program become terribly complex in a hurry.

Hospital value-based purchasing (HVBP), one of the provisions health reform, is one of the Centers for Medicare & Medicaid Services’ (CMS) first large-scale attempts to do just that.

CMS’ goals for this program include improving clinical quality, encouraging more patient-centered care, encouraging hospitals and clinicians to work together to improve quality of care, and empowering consumers to make value-based decisions about their healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

You already were aware that baseline measurements of quality performance for your hospital were collected from July 2009 through March 2010, right? And data collected from July 2010 through March 2011 serves as the first “Performance Period” to determine payment that will begin in October 2012. (If you are not aware, visit www.hospitalcompare.hhs.gov to see the performance your hospital is currently reporting. All the providers in your hospitalist group should be familiar with the data; another good site is www.whynotthebest.org. But keep in mind there is a significant delay in getting the data to display on these sites. In many cases, the data they display today is from nearly a year prior.)

Some Generalizations

HVBP has a number of features that are typical of new reimbursement programs:

• It is budget-neutral for Medicare. In other words, some hospitals will perform well and realize reimbursement increases; some hospitals will not perform well and will see reduced reimbursement.
• It builds on previous programs. HVBP essentially moves performance on core measures and HCAHPS surveys, all of which have been in place several years, from being publically reported to serving as metrics that influence reimbursement.
• The dollar amounts involved grow each year.
• Expect the program to evolve continuously. For example, the number and type of quality metrics on which the program is based will increase each year.

How It Works

Medicare will start withholding a portion of diagnosis-related group (DRG) payments to hospitals, starting with 1% initially and increasing by 0.25% annually, so that 2% is withheld in 2017. Keep in mind that amount is withheld from all DRG payments to a hospital, not just those related to the diagnoses that are part of the HVBP program.

Based on performance on core measures and patient satisfaction, hospitals have a chance to earn additional compensation that could be more or less than the initial 2% withholding. Additional performance measures will be added every year or so.

There are two ways a hospital can earn some of this performance-based compensation based on its “Total Performance Score.” Expressed in the language of Little League baseball, a hospital needs to be either a most valuable player—an MVP—or a most improved player.

The MVP pathway, known as “achievement,” is to grade hospitals on a curve established from the data collected for all hospitals the prior year. Those at the high end of the curve are paid more than the amount that was withheld from them (so they are “net winners”); those at the bottom of the curve are paid nothing (“net losers,” as they lost the chance to earn back any of the amount withheld).

The most improved pathway, cleverly called “improvement,” is for a hospital to improve its performance over its previous baseline, even if it fails to attain a high score relative to others. Measurement of the first baseline year ran from July 2010 through March 2011, and will be used as the reference point for performance from July 2011 through March 2012.

The precise amount of the payment for either of the two methods above is based on a sliding scale rather than an all-or-none threshold. SHM’s website (www.hospitalmedicine.org/hvbp) has an example of this calculation. A simple way to think of it is that a hospital won’t have to do a lot to earn back some portion of the amount withheld, but it has to hit a home run to earn back more than that.

The Dollars at Risk

It is worth thinking about the most a hospital could lose or gain under HVBP. Let’s take an example of a hospital that is paid $50 million annually by Medicare across all DRGs (this would be a pretty small hospital). In 2013, Medicare will pay that hospital only $49.5 million; that is, it will withhold 1% ($500,000) as part of the HVBP program. After the hospital’s Total Performance Score is computed, Medicare might pay more to the hospital in the form of an “add on” to the hospital’s typical DRG payments. If performance stinks or is worse than most hospitals and does not improve significantly over its own baseline, Medicare might not pay a nickel more. But for respectable performance, it might be paid 80% of the amount withheld—$400,000, in this example. So this hypothetical hospital would end up being a “net loser” of $100,000. By 2017, when 2% is withheld, the dollars at risk would be double.

From a practical perspective, the amount by which reimbursement will go up or down for most hospitals will be significantly less than the total withhold amount for most hospitals, so it probably won’t be enough to result in financial disaster or great profits. (Your hospital CFO may dispute this conclusion and you should listen to them.) But because a new “grading curve” is established each year, a score that puts a hospital in a financially attractive category one year might not look so good the next year. Therefore, a hospital whose performance stands still will likely become a net loser within a year or two.

Even if you were to conclude that the potential financial upside isn’t compelling enough to devote a lot of energy to perform well, the fact that most of the measures really do matter to our patients, and that this information is publicly reported, means every hospital should do whatever it takes to perform well. I suspect that patients and employers, as well as all types of payors, will pay more and more attention to your hospital’s performance and overall hospital volume affected in locales where patients have a choice of more than one hospital.

Learn More

I’ve provided only a very general HVBP overview here. Most hospitalist groups should identify at least one person who develops meaningful expertise in this program and other components of healthcare reform (i.e. bundled payments, penalties for excess readmissions, and penalties for hospital-acquired conditions). SHM is a terrific educational resource for these things and has a very informative HVBP toolkit available via its website.

Thanks to Drs. Win Whitcomb and Pat Torcson for helping to explain all this stuff to me. They and others at SHM do a great job of staying on top of things like healthcare reform.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Like all healthcare payors, Medicare has for some time tried to change from being a passive payor of services to a purchaser of value. There might be a lot of ways to do that, but one easy to conceptualize method is for Medicare to pay different amounts for a given service (i.e. a hospital stay for congestive heart failure) based on the quality of that service. Of course, the details of how to measure quality and implement such a program become terribly complex in a hurry.

Hospital value-based purchasing (HVBP), one of the provisions health reform, is one of the Centers for Medicare & Medicaid Services’ (CMS) first large-scale attempts to do just that.

CMS’ goals for this program include improving clinical quality, encouraging more patient-centered care, encouraging hospitals and clinicians to work together to improve quality of care, and empowering consumers to make value-based decisions about their healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

You already were aware that baseline measurements of quality performance for your hospital were collected from July 2009 through March 2010, right? And data collected from July 2010 through March 2011 serves as the first “Performance Period” to determine payment that will begin in October 2012. (If you are not aware, visit www.hospitalcompare.hhs.gov to see the performance your hospital is currently reporting. All the providers in your hospitalist group should be familiar with the data; another good site is www.whynotthebest.org. But keep in mind there is a significant delay in getting the data to display on these sites. In many cases, the data they display today is from nearly a year prior.)

Some Generalizations

HVBP has a number of features that are typical of new reimbursement programs:

• It is budget-neutral for Medicare. In other words, some hospitals will perform well and realize reimbursement increases; some hospitals will not perform well and will see reduced reimbursement.
• It builds on previous programs. HVBP essentially moves performance on core measures and HCAHPS surveys, all of which have been in place several years, from being publically reported to serving as metrics that influence reimbursement.
• The dollar amounts involved grow each year.
• Expect the program to evolve continuously. For example, the number and type of quality metrics on which the program is based will increase each year.

How It Works

Medicare will start withholding a portion of diagnosis-related group (DRG) payments to hospitals, starting with 1% initially and increasing by 0.25% annually, so that 2% is withheld in 2017. Keep in mind that amount is withheld from all DRG payments to a hospital, not just those related to the diagnoses that are part of the HVBP program.

Based on performance on core measures and patient satisfaction, hospitals have a chance to earn additional compensation that could be more or less than the initial 2% withholding. Additional performance measures will be added every year or so.

There are two ways a hospital can earn some of this performance-based compensation based on its “Total Performance Score.” Expressed in the language of Little League baseball, a hospital needs to be either a most valuable player—an MVP—or a most improved player.

The MVP pathway, known as “achievement,” is to grade hospitals on a curve established from the data collected for all hospitals the prior year. Those at the high end of the curve are paid more than the amount that was withheld from them (so they are “net winners”); those at the bottom of the curve are paid nothing (“net losers,” as they lost the chance to earn back any of the amount withheld).

The most improved pathway, cleverly called “improvement,” is for a hospital to improve its performance over its previous baseline, even if it fails to attain a high score relative to others. Measurement of the first baseline year ran from July 2010 through March 2011, and will be used as the reference point for performance from July 2011 through March 2012.

The precise amount of the payment for either of the two methods above is based on a sliding scale rather than an all-or-none threshold. SHM’s website (www.hospitalmedicine.org/hvbp) has an example of this calculation. A simple way to think of it is that a hospital won’t have to do a lot to earn back some portion of the amount withheld, but it has to hit a home run to earn back more than that.

The Dollars at Risk

It is worth thinking about the most a hospital could lose or gain under HVBP. Let’s take an example of a hospital that is paid $50 million annually by Medicare across all DRGs (this would be a pretty small hospital). In 2013, Medicare will pay that hospital only $49.5 million; that is, it will withhold 1% ($500,000) as part of the HVBP program. After the hospital’s Total Performance Score is computed, Medicare might pay more to the hospital in the form of an “add on” to the hospital’s typical DRG payments. If performance stinks or is worse than most hospitals and does not improve significantly over its own baseline, Medicare might not pay a nickel more. But for respectable performance, it might be paid 80% of the amount withheld—$400,000, in this example. So this hypothetical hospital would end up being a “net loser” of $100,000. By 2017, when 2% is withheld, the dollars at risk would be double.

From a practical perspective, the amount by which reimbursement will go up or down for most hospitals will be significantly less than the total withhold amount for most hospitals, so it probably won’t be enough to result in financial disaster or great profits. (Your hospital CFO may dispute this conclusion and you should listen to them.) But because a new “grading curve” is established each year, a score that puts a hospital in a financially attractive category one year might not look so good the next year. Therefore, a hospital whose performance stands still will likely become a net loser within a year or two.

Even if you were to conclude that the potential financial upside isn’t compelling enough to devote a lot of energy to perform well, the fact that most of the measures really do matter to our patients, and that this information is publicly reported, means every hospital should do whatever it takes to perform well. I suspect that patients and employers, as well as all types of payors, will pay more and more attention to your hospital’s performance and overall hospital volume affected in locales where patients have a choice of more than one hospital.

Learn More

I’ve provided only a very general HVBP overview here. Most hospitalist groups should identify at least one person who develops meaningful expertise in this program and other components of healthcare reform (i.e. bundled payments, penalties for excess readmissions, and penalties for hospital-acquired conditions). SHM is a terrific educational resource for these things and has a very informative HVBP toolkit available via its website.

Thanks to Drs. Win Whitcomb and Pat Torcson for helping to explain all this stuff to me. They and others at SHM do a great job of staying on top of things like healthcare reform.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Let emails from various sources reminding me about legislative advocacy. I know this is something that SHM is involved with, but do I really make a difference?

R.L., Portland, Ore.

Dr. Hospitalist responds:

It’s been a rather dizzying 15 years for hospitalists, as we all know. We’ve gone from a novelty act to a specialty with its own certification. Now, more than ever, people are looking to us to provide leadership in healthcare, and not just by practicing good medicine. There is a real role for advocacy from all of us who are on the front lines of care. The same questions that your local hospital asks are the ones being asked on the national stage: How do you define quality care? How can we control costs? What does the future of medicine look like?

These are not insignificant questions, but neither should you consider them to be “above your pay grade.” Legislators face incredibly difficult decisions that will fundamentally change the nature of healthcare in your career. These are not abstract arguments. There are millions of dollars at stake, with many disparate voices and interests shouting to be heard.

I would argue that the voice of the physician is important. You are the one providing care at the bedside, serving your community. If the saying goes “all politics is local,” then it is doubly true for healthcare.

It is imperative for all of us to continue to educate, advocate, and lead. You don’t have to be an “expert” in healthcare policy any more than you have to be an “expert” in congestive heart failure—patients benefit in both instances. Nobody is going to hold your hand and get Mrs. Jones back on the illustrious “curve”; she needs treatment, she needs it now, and your skills are more than up to the task. The same can be said for advocacy. You don’t need to be an expert, and you don’t need to wait until you have it all figured out; opportunities to advocate are available—right now. How?

• Check out the SHM website (www.hospitalmedicine.org); “Advocacy” is a link on left side of the home page.
• Contact your state medical society.
• Email your congressman or senator about an issue that’s important to you.
• Consider joining SHM’s Public PolicyCommittee. These folks are doing good work, outside of their daily hospitalist commitments.

Don’t try to solve all the issues; just pick one that’s important to you. Is it the SGR and payment reform? Quality measures? Liability reform?

It does not matter if your political shadings run blue, red, or purple. The bottom line is, start somewhere. You will make a difference, and it will take you less time to send your legislator an email through the tools on SHM’s advocacy portal than it did to read this article. One might argue rather convincingly that it will be more rewarding as well.

Let emails from various sources reminding me about legislative advocacy. I know this is something that SHM is involved with, but do I really make a difference?

R.L., Portland, Ore.

Dr. Hospitalist responds:

It’s been a rather dizzying 15 years for hospitalists, as we all know. We’ve gone from a novelty act to a specialty with its own certification. Now, more than ever, people are looking to us to provide leadership in healthcare, and not just by practicing good medicine. There is a real role for advocacy from all of us who are on the front lines of care. The same questions that your local hospital asks are the ones being asked on the national stage: How do you define quality care? How can we control costs? What does the future of medicine look like?

These are not insignificant questions, but neither should you consider them to be “above your pay grade.” Legislators face incredibly difficult decisions that will fundamentally change the nature of healthcare in your career. These are not abstract arguments. There are millions of dollars at stake, with many disparate voices and interests shouting to be heard.

I would argue that the voice of the physician is important. You are the one providing care at the bedside, serving your community. If the saying goes “all politics is local,” then it is doubly true for healthcare.

It is imperative for all of us to continue to educate, advocate, and lead. You don’t have to be an “expert” in healthcare policy any more than you have to be an “expert” in congestive heart failure—patients benefit in both instances. Nobody is going to hold your hand and get Mrs. Jones back on the illustrious “curve”; she needs treatment, she needs it now, and your skills are more than up to the task. The same can be said for advocacy. You don’t need to be an expert, and you don’t need to wait until you have it all figured out; opportunities to advocate are available—right now. How?

• Check out the SHM website (www.hospitalmedicine.org); “Advocacy” is a link on left side of the home page.
• Contact your state medical society.
• Email your congressman or senator about an issue that’s important to you.
• Consider joining SHM’s Public PolicyCommittee. These folks are doing good work, outside of their daily hospitalist commitments.

Don’t try to solve all the issues; just pick one that’s important to you. Is it the SGR and payment reform? Quality measures? Liability reform?

It does not matter if your political shadings run blue, red, or purple. The bottom line is, start somewhere. You will make a difference, and it will take you less time to send your legislator an email through the tools on SHM’s advocacy portal than it did to read this article. One might argue rather convincingly that it will be more rewarding as well.

Let emails from various sources reminding me about legislative advocacy. I know this is something that SHM is involved with, but do I really make a difference?

R.L., Portland, Ore.

Dr. Hospitalist responds:

It’s been a rather dizzying 15 years for hospitalists, as we all know. We’ve gone from a novelty act to a specialty with its own certification. Now, more than ever, people are looking to us to provide leadership in healthcare, and not just by practicing good medicine. There is a real role for advocacy from all of us who are on the front lines of care. The same questions that your local hospital asks are the ones being asked on the national stage: How do you define quality care? How can we control costs? What does the future of medicine look like?

These are not insignificant questions, but neither should you consider them to be “above your pay grade.” Legislators face incredibly difficult decisions that will fundamentally change the nature of healthcare in your career. These are not abstract arguments. There are millions of dollars at stake, with many disparate voices and interests shouting to be heard.

I would argue that the voice of the physician is important. You are the one providing care at the bedside, serving your community. If the saying goes “all politics is local,” then it is doubly true for healthcare.

It is imperative for all of us to continue to educate, advocate, and lead. You don’t have to be an “expert” in healthcare policy any more than you have to be an “expert” in congestive heart failure—patients benefit in both instances. Nobody is going to hold your hand and get Mrs. Jones back on the illustrious “curve”; she needs treatment, she needs it now, and your skills are more than up to the task. The same can be said for advocacy. You don’t need to be an expert, and you don’t need to wait until you have it all figured out; opportunities to advocate are available—right now. How?

• Check out the SHM website (www.hospitalmedicine.org); “Advocacy” is a link on left side of the home page.
• Contact your state medical society.
• Email your congressman or senator about an issue that’s important to you.
• Consider joining SHM’s Public PolicyCommittee. These folks are doing good work, outside of their daily hospitalist commitments.

Don’t try to solve all the issues; just pick one that’s important to you. Is it the SGR and payment reform? Quality measures? Liability reform?

It does not matter if your political shadings run blue, red, or purple. The bottom line is, start somewhere. You will make a difference, and it will take you less time to send your legislator an email through the tools on SHM’s advocacy portal than it did to read this article. One might argue rather convincingly that it will be more rewarding as well.

Pre-existing diabetes, hypertension, and other ongoing conditions are tough enough to manage in children as they blossom into adolescents and then young adults. To make matters more complex, hospitalists on occasion encounter pregnant teenagers with chronic illnesses.

The physicians and nurses on a pediatric floor might not be comfortable with obstetrics, or they might lack the equipment for monitoring fetal heart tones. In such instances, a pregnant teen would be best served in an adult hospital with obstetric services, says Heather Toth, MD, director of the med-peds residency program at the Medical College of Wisconsin in Milwaukee.

At times, however, a non-pediatric hospital might be hard-pressed to find a blood pressure cuff snug enough for a smaller patient. Collaboration between adult and pediatric providers is essential to iron out these types of kinks, Dr. Toth says.

It’s understandable if “internal-medicine hospitalists get nervous about pregnant patients,” says Rob Olson, MD, an OBGYN hospitalist at PeaceHealth St. Joseph Medical Center in Bellingham, Wash., and editor of ObGynHospitalist.com. Because adolescents’ emotions can be more magnified, “you’ve got all the drama of their teen life as well as the complications of the pregnancy.”

Like adult expectant mothers, teens present with pregnancy-related complications, most commonly preeclampsia, as well as premature labor. Gestational diabetes and urinary tract or kidney infections also occur, says Laura Elizabeth Riley, MD, director of labor and delivery at Massachusetts General Hospital in Boston.

“We take care of pregnant teens with medical conditions just as we would adults,” Dr. Riley says, adding that pediatric hospitalists typically don’t get involved in care on a maternity ward.

OBGYNs are in charge of pregnant teens. If complications arise, a maternal fetal medicine specialist would intervene, says Patrice M. Weiss, MD, chair of the Patient Safety and Quality Committee at the American Congress of Obstetricians and Gynecologists.

The degree of a pregnancy complication is related to the severity of a patient’s underlying medical condition. Teen pregnancies already are considered high-risk due to young age, says Dr. Weiss, who is the OBGYN chair and professor at the Carilion Clinic/Virginia Tech Carilion School of Medicine in Roanoke.

Preventing teen pregnancies is the biggest challenge, followed by some expectant mothers’ reluctance to seek prenatal care and keep appointments, says Tod Aeby, MD, generalist division director of obstetrics, gynecology, and women’s health at the University of Hawaii at Manoa’s John A. Burns School of Medicine in Honolulu.

“Parents in denial, angry, or embarrassed about their pregnant teen can also be another barrier to early and consistent care,” Dr. Aeby says.

In his experience, many of the chronic conditions affecting these adolescents fall in the categories of mental health (eating disorders, depression, schizophrenia, bipolar affective disorder) or autoimmune diseases (lupus or Type 1 diabetes). Asthma and obesity also are prevalent in Hawaii, so hospitalists should consider regional factors.

“Many pregnant teens do well with pregnancy—they are young and healthy,” says Dr. Riley of Mass General. “Some have a host of social issues, which can complicate pregnancy, so it is important that their social supports be evaluated prior to discharge with a newborn.”

Pre-existing diabetes, hypertension, and other ongoing conditions are tough enough to manage in children as they blossom into adolescents and then young adults. To make matters more complex, hospitalists on occasion encounter pregnant teenagers with chronic illnesses.

The physicians and nurses on a pediatric floor might not be comfortable with obstetrics, or they might lack the equipment for monitoring fetal heart tones. In such instances, a pregnant teen would be best served in an adult hospital with obstetric services, says Heather Toth, MD, director of the med-peds residency program at the Medical College of Wisconsin in Milwaukee.

At times, however, a non-pediatric hospital might be hard-pressed to find a blood pressure cuff snug enough for a smaller patient. Collaboration between adult and pediatric providers is essential to iron out these types of kinks, Dr. Toth says.

It’s understandable if “internal-medicine hospitalists get nervous about pregnant patients,” says Rob Olson, MD, an OBGYN hospitalist at PeaceHealth St. Joseph Medical Center in Bellingham, Wash., and editor of ObGynHospitalist.com. Because adolescents’ emotions can be more magnified, “you’ve got all the drama of their teen life as well as the complications of the pregnancy.”

Like adult expectant mothers, teens present with pregnancy-related complications, most commonly preeclampsia, as well as premature labor. Gestational diabetes and urinary tract or kidney infections also occur, says Laura Elizabeth Riley, MD, director of labor and delivery at Massachusetts General Hospital in Boston.

“We take care of pregnant teens with medical conditions just as we would adults,” Dr. Riley says, adding that pediatric hospitalists typically don’t get involved in care on a maternity ward.

OBGYNs are in charge of pregnant teens. If complications arise, a maternal fetal medicine specialist would intervene, says Patrice M. Weiss, MD, chair of the Patient Safety and Quality Committee at the American Congress of Obstetricians and Gynecologists.

The degree of a pregnancy complication is related to the severity of a patient’s underlying medical condition. Teen pregnancies already are considered high-risk due to young age, says Dr. Weiss, who is the OBGYN chair and professor at the Carilion Clinic/Virginia Tech Carilion School of Medicine in Roanoke.

Preventing teen pregnancies is the biggest challenge, followed by some expectant mothers’ reluctance to seek prenatal care and keep appointments, says Tod Aeby, MD, generalist division director of obstetrics, gynecology, and women’s health at the University of Hawaii at Manoa’s John A. Burns School of Medicine in Honolulu.

“Parents in denial, angry, or embarrassed about their pregnant teen can also be another barrier to early and consistent care,” Dr. Aeby says.

In his experience, many of the chronic conditions affecting these adolescents fall in the categories of mental health (eating disorders, depression, schizophrenia, bipolar affective disorder) or autoimmune diseases (lupus or Type 1 diabetes). Asthma and obesity also are prevalent in Hawaii, so hospitalists should consider regional factors.

“Many pregnant teens do well with pregnancy—they are young and healthy,” says Dr. Riley of Mass General. “Some have a host of social issues, which can complicate pregnancy, so it is important that their social supports be evaluated prior to discharge with a newborn.”

Pre-existing diabetes, hypertension, and other ongoing conditions are tough enough to manage in children as they blossom into adolescents and then young adults. To make matters more complex, hospitalists on occasion encounter pregnant teenagers with chronic illnesses.

The physicians and nurses on a pediatric floor might not be comfortable with obstetrics, or they might lack the equipment for monitoring fetal heart tones. In such instances, a pregnant teen would be best served in an adult hospital with obstetric services, says Heather Toth, MD, director of the med-peds residency program at the Medical College of Wisconsin in Milwaukee.

At times, however, a non-pediatric hospital might be hard-pressed to find a blood pressure cuff snug enough for a smaller patient. Collaboration between adult and pediatric providers is essential to iron out these types of kinks, Dr. Toth says.

It’s understandable if “internal-medicine hospitalists get nervous about pregnant patients,” says Rob Olson, MD, an OBGYN hospitalist at PeaceHealth St. Joseph Medical Center in Bellingham, Wash., and editor of ObGynHospitalist.com. Because adolescents’ emotions can be more magnified, “you’ve got all the drama of their teen life as well as the complications of the pregnancy.”

Like adult expectant mothers, teens present with pregnancy-related complications, most commonly preeclampsia, as well as premature labor. Gestational diabetes and urinary tract or kidney infections also occur, says Laura Elizabeth Riley, MD, director of labor and delivery at Massachusetts General Hospital in Boston.

“We take care of pregnant teens with medical conditions just as we would adults,” Dr. Riley says, adding that pediatric hospitalists typically don’t get involved in care on a maternity ward.

OBGYNs are in charge of pregnant teens. If complications arise, a maternal fetal medicine specialist would intervene, says Patrice M. Weiss, MD, chair of the Patient Safety and Quality Committee at the American Congress of Obstetricians and Gynecologists.

The degree of a pregnancy complication is related to the severity of a patient’s underlying medical condition. Teen pregnancies already are considered high-risk due to young age, says Dr. Weiss, who is the OBGYN chair and professor at the Carilion Clinic/Virginia Tech Carilion School of Medicine in Roanoke.

Preventing teen pregnancies is the biggest challenge, followed by some expectant mothers’ reluctance to seek prenatal care and keep appointments, says Tod Aeby, MD, generalist division director of obstetrics, gynecology, and women’s health at the University of Hawaii at Manoa’s John A. Burns School of Medicine in Honolulu.

“Parents in denial, angry, or embarrassed about their pregnant teen can also be another barrier to early and consistent care,” Dr. Aeby says.

In his experience, many of the chronic conditions affecting these adolescents fall in the categories of mental health (eating disorders, depression, schizophrenia, bipolar affective disorder) or autoimmune diseases (lupus or Type 1 diabetes). Asthma and obesity also are prevalent in Hawaii, so hospitalists should consider regional factors.

“Many pregnant teens do well with pregnancy—they are young and healthy,” says Dr. Riley of Mass General. “Some have a host of social issues, which can complicate pregnancy, so it is important that their social supports be evaluated prior to discharge with a newborn.”

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Pediatricians can play an essential role in diagnosis, counseling, and management of atopic eczema. Your decision to treat these children and adolescents in your practice largely depends on your comfort level and the progression of their condition over time. In general, referral to a dermatology colleague is not warranted unless you are unsure about some aspect of the condition, or the eczema fails to improve.

To diagnose atopic eczema, look for the telltale signs, especially the cracking and fissuring of the skin on the flexural folds of the arms and legs. Besides the flexural areas of arms and legs, atopic eczema often presents on the cheeks, but can manifest anywhere on the body.

Counseling is paramount because eczema is not an individual patient disease; it affects the entire family. Parents must spend an inordinate amount of time taking care of the affected child, thereby reducing time with siblings. In addition, the condition is very, very itchy. The extreme pruritus that characterizes atopic eczema often keeps the child and parent awake at night, which can, in turn, negatively affect the next day for children at school and parents at work.

Provide information on eczema to educate everyone in the family, extended family, and anyone who participates in the child’s care. From the outset, they need to understand that optimal outcome will require a long-term commitment. Atopic eczema needs to be managed and controlled for years because there is no magic bullet or cure.

Realistic expectations, therefore, are important. I tell families that I do not want "perfection to be the enemy of very good." An acceptable goal, for example, is a child who still has minor areas of involvement that do not interfere with the child’s or the family’s normal activities.

The good news is that the majority of eczema patients will improve over time. For young children, this can take many years, usually into adolescence. Even so, I explain that the child’s skin will always be more sensitive than the skin of an unaffected person.

When I speak with a parent who is learning for the first time that their child has atopic eczema, I say that it’s as if your child were having "asthma of the skin." Most parents can relate because either they or someone in the family has asthma. The analogy also works because symptoms will wax and wane, certain triggers can worsen the eczema, and there is a shared genetic etiology. When the genes are expressed in the lungs, asthma is the result; when the genes are expressed in the nasal passages, we call it hay fever or allergic rhinitis; and when the genes manifest in the skin, we call it atopic eczema. Some children have a combination of these disorders.

Stress the importance of keeping the skin hydrated to minimize flare-ups. I recommend liberal application of a moisturizing emollient twice daily, including immediately following once-daily bathing. Instruct patients to dry themselves gently with a cotton towel. Parents often ask how much moisturizer to apply. Sometimes I jokingly tell parents that if they give their child a hug and the child has is covered with so much moisturizing cream that she squirts up out of the parent’s arms, then enough moisturizer has been applied.

This regimen also can help repair the skin barrier to optimize control of the atopic eczema. I recommend use of a newer emollient cream rich in lipids and ceramides, such as Coria Laboratories’ CeraVe. I also suggest nondetergent cleansers like Pharmaceutical Specialties’ Vanicream cleansing bar, Galderma’s Cetaphil, Unilever’s Dove cleanser, and the like. These products cleanse without harsh detergents that take away the skin’s natural moisturizing oils.

Winter can be a particularly challenging time for eczema patients because of illness and dry skin. Although a meticulous skin care program is always important, it is especially so when the child is fighting an upper respiratory infection or other illness because it can help prevent a tremendous flare in the atopic eczema.

Maintenance of skin hydration also decreases the ability of protease enzymes (produced by bacteria in the skin) to enter the microcracks and fissures and exacerbate the eczema. In more severe presentations, consider an anti-Staphylococcus antibiotic such as Keflex for 7-10 days to decrease the bacterial skin load.

A dilute bleach bath once a week also can help decrease this bacterial load and prevent flare-ups. Emphasize that only a small amount of bleach (add 1/8 cup to a full bath) is necessary; it should not smell as strong as a swimming pool. On the same day, bed linens and pajamas should be washed with bleach as well.

You as a pediatrician can help to dispel an overemphasis on food and other allergens as eczema triggers. Instruct parents that if they notice a consistent flare-up after certain exposures, these may be triggers for their child’s eczema My philosophy is to "test and adjust," but not to eliminate things across the board just because families read on the Internet that a food or substance causes atopic eczema. In my experience, fewer than 20% of patients with atopic eczema actually have true allergies and/or triggers for their condition. I also provide a prescription for a mild (group VI) steroid and moderate (group IV) steroid to use twice daily for 7 days with mild and moderate flare-ups.

Additional resources on atopic eczema are available online from the American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis). I also have a video on my website called "Power Over Eczema." I encourage the patient’s parents to watch this video and to show it to anyone involved in the care of the child, including older siblings, nannies, babysitters, and grandparents.

Pediatricians can play an essential role in diagnosis, counseling, and management of atopic eczema. Your decision to treat these children and adolescents in your practice largely depends on your comfort level and the progression of their condition over time. In general, referral to a dermatology colleague is not warranted unless you are unsure about some aspect of the condition, or the eczema fails to improve.

To diagnose atopic eczema, look for the telltale signs, especially the cracking and fissuring of the skin on the flexural folds of the arms and legs. Besides the flexural areas of arms and legs, atopic eczema often presents on the cheeks, but can manifest anywhere on the body.

Counseling is paramount because eczema is not an individual patient disease; it affects the entire family. Parents must spend an inordinate amount of time taking care of the affected child, thereby reducing time with siblings. In addition, the condition is very, very itchy. The extreme pruritus that characterizes atopic eczema often keeps the child and parent awake at night, which can, in turn, negatively affect the next day for children at school and parents at work.

Provide information on eczema to educate everyone in the family, extended family, and anyone who participates in the child’s care. From the outset, they need to understand that optimal outcome will require a long-term commitment. Atopic eczema needs to be managed and controlled for years because there is no magic bullet or cure.

Realistic expectations, therefore, are important. I tell families that I do not want "perfection to be the enemy of very good." An acceptable goal, for example, is a child who still has minor areas of involvement that do not interfere with the child’s or the family’s normal activities.

The good news is that the majority of eczema patients will improve over time. For young children, this can take many years, usually into adolescence. Even so, I explain that the child’s skin will always be more sensitive than the skin of an unaffected person.

When I speak with a parent who is learning for the first time that their child has atopic eczema, I say that it’s as if your child were having "asthma of the skin." Most parents can relate because either they or someone in the family has asthma. The analogy also works because symptoms will wax and wane, certain triggers can worsen the eczema, and there is a shared genetic etiology. When the genes are expressed in the lungs, asthma is the result; when the genes are expressed in the nasal passages, we call it hay fever or allergic rhinitis; and when the genes manifest in the skin, we call it atopic eczema. Some children have a combination of these disorders.

Stress the importance of keeping the skin hydrated to minimize flare-ups. I recommend liberal application of a moisturizing emollient twice daily, including immediately following once-daily bathing. Instruct patients to dry themselves gently with a cotton towel. Parents often ask how much moisturizer to apply. Sometimes I jokingly tell parents that if they give their child a hug and the child has is covered with so much moisturizing cream that she squirts up out of the parent’s arms, then enough moisturizer has been applied.

This regimen also can help repair the skin barrier to optimize control of the atopic eczema. I recommend use of a newer emollient cream rich in lipids and ceramides, such as Coria Laboratories’ CeraVe. I also suggest nondetergent cleansers like Pharmaceutical Specialties’ Vanicream cleansing bar, Galderma’s Cetaphil, Unilever’s Dove cleanser, and the like. These products cleanse without harsh detergents that take away the skin’s natural moisturizing oils.

Winter can be a particularly challenging time for eczema patients because of illness and dry skin. Although a meticulous skin care program is always important, it is especially so when the child is fighting an upper respiratory infection or other illness because it can help prevent a tremendous flare in the atopic eczema.

Maintenance of skin hydration also decreases the ability of protease enzymes (produced by bacteria in the skin) to enter the microcracks and fissures and exacerbate the eczema. In more severe presentations, consider an anti-Staphylococcus antibiotic such as Keflex for 7-10 days to decrease the bacterial skin load.

A dilute bleach bath once a week also can help decrease this bacterial load and prevent flare-ups. Emphasize that only a small amount of bleach (add 1/8 cup to a full bath) is necessary; it should not smell as strong as a swimming pool. On the same day, bed linens and pajamas should be washed with bleach as well.

You as a pediatrician can help to dispel an overemphasis on food and other allergens as eczema triggers. Instruct parents that if they notice a consistent flare-up after certain exposures, these may be triggers for their child’s eczema My philosophy is to "test and adjust," but not to eliminate things across the board just because families read on the Internet that a food or substance causes atopic eczema. In my experience, fewer than 20% of patients with atopic eczema actually have true allergies and/or triggers for their condition. I also provide a prescription for a mild (group VI) steroid and moderate (group IV) steroid to use twice daily for 7 days with mild and moderate flare-ups.

Additional resources on atopic eczema are available online from the American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis). I also have a video on my website called "Power Over Eczema." I encourage the patient’s parents to watch this video and to show it to anyone involved in the care of the child, including older siblings, nannies, babysitters, and grandparents.

Pediatricians can play an essential role in diagnosis, counseling, and management of atopic eczema. Your decision to treat these children and adolescents in your practice largely depends on your comfort level and the progression of their condition over time. In general, referral to a dermatology colleague is not warranted unless you are unsure about some aspect of the condition, or the eczema fails to improve.

To diagnose atopic eczema, look for the telltale signs, especially the cracking and fissuring of the skin on the flexural folds of the arms and legs. Besides the flexural areas of arms and legs, atopic eczema often presents on the cheeks, but can manifest anywhere on the body.

Counseling is paramount because eczema is not an individual patient disease; it affects the entire family. Parents must spend an inordinate amount of time taking care of the affected child, thereby reducing time with siblings. In addition, the condition is very, very itchy. The extreme pruritus that characterizes atopic eczema often keeps the child and parent awake at night, which can, in turn, negatively affect the next day for children at school and parents at work.

Provide information on eczema to educate everyone in the family, extended family, and anyone who participates in the child’s care. From the outset, they need to understand that optimal outcome will require a long-term commitment. Atopic eczema needs to be managed and controlled for years because there is no magic bullet or cure.

Realistic expectations, therefore, are important. I tell families that I do not want "perfection to be the enemy of very good." An acceptable goal, for example, is a child who still has minor areas of involvement that do not interfere with the child’s or the family’s normal activities.

The good news is that the majority of eczema patients will improve over time. For young children, this can take many years, usually into adolescence. Even so, I explain that the child’s skin will always be more sensitive than the skin of an unaffected person.

When I speak with a parent who is learning for the first time that their child has atopic eczema, I say that it’s as if your child were having "asthma of the skin." Most parents can relate because either they or someone in the family has asthma. The analogy also works because symptoms will wax and wane, certain triggers can worsen the eczema, and there is a shared genetic etiology. When the genes are expressed in the lungs, asthma is the result; when the genes are expressed in the nasal passages, we call it hay fever or allergic rhinitis; and when the genes manifest in the skin, we call it atopic eczema. Some children have a combination of these disorders.

Stress the importance of keeping the skin hydrated to minimize flare-ups. I recommend liberal application of a moisturizing emollient twice daily, including immediately following once-daily bathing. Instruct patients to dry themselves gently with a cotton towel. Parents often ask how much moisturizer to apply. Sometimes I jokingly tell parents that if they give their child a hug and the child has is covered with so much moisturizing cream that she squirts up out of the parent’s arms, then enough moisturizer has been applied.

This regimen also can help repair the skin barrier to optimize control of the atopic eczema. I recommend use of a newer emollient cream rich in lipids and ceramides, such as Coria Laboratories’ CeraVe. I also suggest nondetergent cleansers like Pharmaceutical Specialties’ Vanicream cleansing bar, Galderma’s Cetaphil, Unilever’s Dove cleanser, and the like. These products cleanse without harsh detergents that take away the skin’s natural moisturizing oils.

Winter can be a particularly challenging time for eczema patients because of illness and dry skin. Although a meticulous skin care program is always important, it is especially so when the child is fighting an upper respiratory infection or other illness because it can help prevent a tremendous flare in the atopic eczema.

Maintenance of skin hydration also decreases the ability of protease enzymes (produced by bacteria in the skin) to enter the microcracks and fissures and exacerbate the eczema. In more severe presentations, consider an anti-Staphylococcus antibiotic such as Keflex for 7-10 days to decrease the bacterial skin load.

A dilute bleach bath once a week also can help decrease this bacterial load and prevent flare-ups. Emphasize that only a small amount of bleach (add 1/8 cup to a full bath) is necessary; it should not smell as strong as a swimming pool. On the same day, bed linens and pajamas should be washed with bleach as well.

You as a pediatrician can help to dispel an overemphasis on food and other allergens as eczema triggers. Instruct parents that if they notice a consistent flare-up after certain exposures, these may be triggers for their child’s eczema My philosophy is to "test and adjust," but not to eliminate things across the board just because families read on the Internet that a food or substance causes atopic eczema. In my experience, fewer than 20% of patients with atopic eczema actually have true allergies and/or triggers for their condition. I also provide a prescription for a mild (group VI) steroid and moderate (group IV) steroid to use twice daily for 7 days with mild and moderate flare-ups.

Additional resources on atopic eczema are available online from the American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis). I also have a video on my website called "Power Over Eczema." I encourage the patient’s parents to watch this video and to show it to anyone involved in the care of the child, including older siblings, nannies, babysitters, and grandparents.

The American College of Physicians Foundation (ACPF) has unveiled a quartet of new interventions aimed at improving care of atrial fibrillation (Afib) and stroke prevention.

Hospitalists are a core constituency for the tools, says Doron Schneider, MD, FACP, co-chair of the foundation's Initiative on Atrial Fibrillation and Stroke Prevention and medical director of the Center for Patient Safety and Healthcare Quality at Abington (Pa.) Health System.

"Atrial fibrillation is so common that the hospitalist is going to see it as primary diagnosis ... or as a background condition presenting with cellulitis and other conditions," Dr. Schneider says. "We want them to look at every patient, and if they have Afib, you don't want to treat the cellulitis and not treat the Afib because the Afib is not presenting. We want them to take a holistic approach."

The interventions are:

• A 20-page booklet for patients and caregivers titled “Afib: What You and Your Family Should Know.” The idea is to empower patients and their supporters with basic knowledge on how to live with their condition.
• Three patient education videos that cover basic facts, medication issues, and post-discharge tips for living a healthier lifestyle.
• A one-page physician support worksheet to help hospitalists and other physicians assess stroke risk and calculate outpatient bleeding risk.
• A guidebook on how to incorporate ACPF and other interventions into a hospital system’s practices.

Dr. Schneider adds that for "real and sustained change in quality initiatives," physicians need to improve all parts of a problem. “If you don't have systems redesigned to allow for education to be delivered or to get content to doctors, it's never going to happen," he says. "A lot of material is produced in the world that never gets to the bedside."

The American College of Physicians Foundation (ACPF) has unveiled a quartet of new interventions aimed at improving care of atrial fibrillation (Afib) and stroke prevention.

Hospitalists are a core constituency for the tools, says Doron Schneider, MD, FACP, co-chair of the foundation's Initiative on Atrial Fibrillation and Stroke Prevention and medical director of the Center for Patient Safety and Healthcare Quality at Abington (Pa.) Health System.

"Atrial fibrillation is so common that the hospitalist is going to see it as primary diagnosis ... or as a background condition presenting with cellulitis and other conditions," Dr. Schneider says. "We want them to look at every patient, and if they have Afib, you don't want to treat the cellulitis and not treat the Afib because the Afib is not presenting. We want them to take a holistic approach."

The interventions are:

• A 20-page booklet for patients and caregivers titled “Afib: What You and Your Family Should Know.” The idea is to empower patients and their supporters with basic knowledge on how to live with their condition.
• Three patient education videos that cover basic facts, medication issues, and post-discharge tips for living a healthier lifestyle.
• A one-page physician support worksheet to help hospitalists and other physicians assess stroke risk and calculate outpatient bleeding risk.
• A guidebook on how to incorporate ACPF and other interventions into a hospital system’s practices.

Dr. Schneider adds that for "real and sustained change in quality initiatives," physicians need to improve all parts of a problem. “If you don't have systems redesigned to allow for education to be delivered or to get content to doctors, it's never going to happen," he says. "A lot of material is produced in the world that never gets to the bedside."

The American College of Physicians Foundation (ACPF) has unveiled a quartet of new interventions aimed at improving care of atrial fibrillation (Afib) and stroke prevention.

Hospitalists are a core constituency for the tools, says Doron Schneider, MD, FACP, co-chair of the foundation's Initiative on Atrial Fibrillation and Stroke Prevention and medical director of the Center for Patient Safety and Healthcare Quality at Abington (Pa.) Health System.

"Atrial fibrillation is so common that the hospitalist is going to see it as primary diagnosis ... or as a background condition presenting with cellulitis and other conditions," Dr. Schneider says. "We want them to look at every patient, and if they have Afib, you don't want to treat the cellulitis and not treat the Afib because the Afib is not presenting. We want them to take a holistic approach."

The interventions are:

• A 20-page booklet for patients and caregivers titled “Afib: What You and Your Family Should Know.” The idea is to empower patients and their supporters with basic knowledge on how to live with their condition.
• Three patient education videos that cover basic facts, medication issues, and post-discharge tips for living a healthier lifestyle.
• A one-page physician support worksheet to help hospitalists and other physicians assess stroke risk and calculate outpatient bleeding risk.
• A guidebook on how to incorporate ACPF and other interventions into a hospital system’s practices.

Dr. Schneider adds that for "real and sustained change in quality initiatives," physicians need to improve all parts of a problem. “If you don't have systems redesigned to allow for education to be delivered or to get content to doctors, it's never going to happen," he says. "A lot of material is produced in the world that never gets to the bedside."

Clinical question: To what extent does diagnostic phlebotomy contribute to hospital-acquired anemia (HAA) during acute myocardial infarction (AMI)?

Background: During AMI, hospital-acquired HAA is associated with higher mortality and poorer health status. Moderate to severe HAA (nadir hemoglobin level <11 g/dL) has been shown to be prognostically important. The contribution of diagnostic phlebotomy blood loss on HAA is unknown and is a potentially modifiable factor.

Study design: Retrospective observational cohort study.

Setting: Fifty-seven U.S. hospitals.

Synopsis: Using Cerner Corp.'s Health Facts database, information was collected on 17,676 patients with AMI. Moderate to severe HAA developed in 3,551 (20%) patients who were not anemic upon admission. The diagnostic blood loss was estimated by assuming minimal blood volume per adult tube required to perform the lab work obtained. The mean phlebotomy volume was higher in patients with HAA compared with patients without HAA (173.8 mL vs. 83.5 mL; P<0.001). There was significant variation of diagnostic blood loss between hospitals. The risk of HAA increased by 18% (RR 1.18; 95% CI, 1.13-1.22) for every 50 mL of diagnostic blood loss.

Patients with HAA were noted to have greater disease severity and comorbidities. No causal inference can be made given the observational nature of the study. Randomized trials are needed to evaluate if strategies to reduce diagnostic blood loss can reduce HAA and improve clinical outcomes for patients with AMI.

Bottom line: Diagnostic blood loss is associated with development of hospital-acquired anemia in patients with acute myocardial infarction.

Citation: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med. 2011;171:1646-1653.

For more physician reviews of HM-relevant research, visit our website.

Clinical question: To what extent does diagnostic phlebotomy contribute to hospital-acquired anemia (HAA) during acute myocardial infarction (AMI)?

Background: During AMI, hospital-acquired HAA is associated with higher mortality and poorer health status. Moderate to severe HAA (nadir hemoglobin level <11 g/dL) has been shown to be prognostically important. The contribution of diagnostic phlebotomy blood loss on HAA is unknown and is a potentially modifiable factor.

Study design: Retrospective observational cohort study.

Setting: Fifty-seven U.S. hospitals.

Synopsis: Using Cerner Corp.'s Health Facts database, information was collected on 17,676 patients with AMI. Moderate to severe HAA developed in 3,551 (20%) patients who were not anemic upon admission. The diagnostic blood loss was estimated by assuming minimal blood volume per adult tube required to perform the lab work obtained. The mean phlebotomy volume was higher in patients with HAA compared with patients without HAA (173.8 mL vs. 83.5 mL; P<0.001). There was significant variation of diagnostic blood loss between hospitals. The risk of HAA increased by 18% (RR 1.18; 95% CI, 1.13-1.22) for every 50 mL of diagnostic blood loss.

Patients with HAA were noted to have greater disease severity and comorbidities. No causal inference can be made given the observational nature of the study. Randomized trials are needed to evaluate if strategies to reduce diagnostic blood loss can reduce HAA and improve clinical outcomes for patients with AMI.

Bottom line: Diagnostic blood loss is associated with development of hospital-acquired anemia in patients with acute myocardial infarction.

Citation: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med. 2011;171:1646-1653.

For more physician reviews of HM-relevant research, visit our website.

Clinical question: To what extent does diagnostic phlebotomy contribute to hospital-acquired anemia (HAA) during acute myocardial infarction (AMI)?

Background: During AMI, hospital-acquired HAA is associated with higher mortality and poorer health status. Moderate to severe HAA (nadir hemoglobin level <11 g/dL) has been shown to be prognostically important. The contribution of diagnostic phlebotomy blood loss on HAA is unknown and is a potentially modifiable factor.

Study design: Retrospective observational cohort study.

Setting: Fifty-seven U.S. hospitals.

Synopsis: Using Cerner Corp.'s Health Facts database, information was collected on 17,676 patients with AMI. Moderate to severe HAA developed in 3,551 (20%) patients who were not anemic upon admission. The diagnostic blood loss was estimated by assuming minimal blood volume per adult tube required to perform the lab work obtained. The mean phlebotomy volume was higher in patients with HAA compared with patients without HAA (173.8 mL vs. 83.5 mL; P<0.001). There was significant variation of diagnostic blood loss between hospitals. The risk of HAA increased by 18% (RR 1.18; 95% CI, 1.13-1.22) for every 50 mL of diagnostic blood loss.

Patients with HAA were noted to have greater disease severity and comorbidities. No causal inference can be made given the observational nature of the study. Randomized trials are needed to evaluate if strategies to reduce diagnostic blood loss can reduce HAA and improve clinical outcomes for patients with AMI.

Bottom line: Diagnostic blood loss is associated with development of hospital-acquired anemia in patients with acute myocardial infarction.

Citation: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med. 2011;171:1646-1653.

For more physician reviews of HM-relevant research, visit our website.

These are hard times for the United States. Our economy is floundering. Unemployment is high. Bankers and financiers seem to be getting away with immoral and even illegal actions. People are disgruntled and dissatisfied. Our government seems to be unable or unwilling to right the obvious wrongs or to get us out of the morass. There is general malaise.

I believe there is a common thread that underlies our present situation. It is the overarching attitude that behavior in our society is primarily determined by the WIIFM principle or ‘What’s in it for me’.

Let us look at some specific examples. Elected politicians in the executive and legislative branches of our federal government should make decisions on the basis of what is best for society and our country. Unfortunately this consideration is a minor motivation.

Uniformly our President and Congress do what is most likely to get themselves re-elected, i.e., what is best for them personally, not what is best for our country. They are constantly campaigning rather than governing. As a result, actions to support entrepreneurship and private job creation are not taken, and class warfare is encouraged because more votes will be gained than lost.

Attorneys who block tort reform are another example of the WIIFM principle. They must know that the present system is imperfect and costing our society billions of dollars, at least some of which are unjustified. Yet they spend millions supporting the re-election campaigns of legislators to block even a wisp of reform. Both the attorneys and the legislators who are influenced by this legal form of bribery are clearly guided by WIIFM. Society pays and suffers.

Similarly, bankers and others in the financial community, known collectively as Wall Street, guided by the WIIFM principle expend great efforts to preserve a system riddled with opaque derivative securities and other practices which benefit a few clever manipulators and harm our financial system and our society. Financial donations to politicians, again legalized bribery, and unfair executive compensation help to sustain a system in which rewards are far in excess of the value contributed to society.

Labor unions and their leaders are also substantially motivated by WIIFM. Otherwise they might compromise on demands to preserve unsustainable pension and benefit systems that are bankrupting our state and federal governments. The promise of votes and again contribution-associated influence over elected leaders are part of the toxic mix. Once again WIIFM triumphs over what is good for our overall economy and our country. The effort to close the job-creating Boeing plant in South Carolina and the pension preserving battles in Wisconsin and Ohio are glaring examples of the evils of WIIFM.

So also are the efforts of some to block any tax increase. If government waste, spending excesses, and unfair tax loopholes can be sharply diminished, reasonable tax increases can be considered part of a shared sacrifice for the common good of deficit reduction. All must acknowledge that our economic problems can only be solved by the compromise of such shared sacrifice. We will be better off in the long run and so will our progeny.

Physicians can also be motivated by the WIIFM principle. There is the temptation to maintain diminishing incomes at all costs – even by performing procedures that may not be fully indicated or justified, or by spending less than adequate time with individual patients. Our health care system is imperfect in many ways, but physicians too must resist the urge to be guided predominantly by WIIFM.

Finally there is the public at large. Are we guided in our voting by short-term WIIFM? Should we vote for the candidate who will lower our personal taxes the most in the next few years? Or should we vote for the individual who we believe will act in the best interests of our country at-large and its future long-term well-being?

We must all recognize the intrinsic dangers of being motivated excessively by WIIFM. Our country cannot survive and prosper if everyone pursues that motivation. We do not have the resources to do so. We must all display some of the courage, restraint, and spirit of compromise of our forefathers who took huge political and physical risks to found our country. They were motivated by a desire to do what was best for the country at large, to work for the greater good, to do what was right for the whole society. It often required self-denial, shared sacrifice, compromise, altruism, and the responsibility to act for the common good. The WIIFM principle had to be suppressed. The result was a United States of unparalleled greatness.

Today we are drifting away from that greatness. Aside from our military and a few other rare exceptions, the WIIFM principle seems to underlie that drift. Although some self-interest is acceptable and part of the human nature, we must all resist the temptation to make that our predominant motivation. Otherwise our country will decline, and we are doomed to failure.

Clearly, this recognition and movement away from WIIFM, this ‘me-first attitude’, this idea of ‘let someone else sacrifice’ should begin with our key political leaders. They must find the courage to do what is right for our country, and give up their WIIFM motivation of acting solely to get re-elected. If they can start the ball rolling in the right direction, surely other segments of society and indeed all of us should be able to follow.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is also an associate medical editor for Vascular Specialist.

The ideas and opinions expresssed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher.

These are hard times for the United States. Our economy is floundering. Unemployment is high. Bankers and financiers seem to be getting away with immoral and even illegal actions. People are disgruntled and dissatisfied. Our government seems to be unable or unwilling to right the obvious wrongs or to get us out of the morass. There is general malaise.

I believe there is a common thread that underlies our present situation. It is the overarching attitude that behavior in our society is primarily determined by the WIIFM principle or ‘What’s in it for me’.

Let us look at some specific examples. Elected politicians in the executive and legislative branches of our federal government should make decisions on the basis of what is best for society and our country. Unfortunately this consideration is a minor motivation.

Uniformly our President and Congress do what is most likely to get themselves re-elected, i.e., what is best for them personally, not what is best for our country. They are constantly campaigning rather than governing. As a result, actions to support entrepreneurship and private job creation are not taken, and class warfare is encouraged because more votes will be gained than lost.

Attorneys who block tort reform are another example of the WIIFM principle. They must know that the present system is imperfect and costing our society billions of dollars, at least some of which are unjustified. Yet they spend millions supporting the re-election campaigns of legislators to block even a wisp of reform. Both the attorneys and the legislators who are influenced by this legal form of bribery are clearly guided by WIIFM. Society pays and suffers.

Similarly, bankers and others in the financial community, known collectively as Wall Street, guided by the WIIFM principle expend great efforts to preserve a system riddled with opaque derivative securities and other practices which benefit a few clever manipulators and harm our financial system and our society. Financial donations to politicians, again legalized bribery, and unfair executive compensation help to sustain a system in which rewards are far in excess of the value contributed to society.

Labor unions and their leaders are also substantially motivated by WIIFM. Otherwise they might compromise on demands to preserve unsustainable pension and benefit systems that are bankrupting our state and federal governments. The promise of votes and again contribution-associated influence over elected leaders are part of the toxic mix. Once again WIIFM triumphs over what is good for our overall economy and our country. The effort to close the job-creating Boeing plant in South Carolina and the pension preserving battles in Wisconsin and Ohio are glaring examples of the evils of WIIFM.

So also are the efforts of some to block any tax increase. If government waste, spending excesses, and unfair tax loopholes can be sharply diminished, reasonable tax increases can be considered part of a shared sacrifice for the common good of deficit reduction. All must acknowledge that our economic problems can only be solved by the compromise of such shared sacrifice. We will be better off in the long run and so will our progeny.

Physicians can also be motivated by the WIIFM principle. There is the temptation to maintain diminishing incomes at all costs – even by performing procedures that may not be fully indicated or justified, or by spending less than adequate time with individual patients. Our health care system is imperfect in many ways, but physicians too must resist the urge to be guided predominantly by WIIFM.

Finally there is the public at large. Are we guided in our voting by short-term WIIFM? Should we vote for the candidate who will lower our personal taxes the most in the next few years? Or should we vote for the individual who we believe will act in the best interests of our country at-large and its future long-term well-being?

We must all recognize the intrinsic dangers of being motivated excessively by WIIFM. Our country cannot survive and prosper if everyone pursues that motivation. We do not have the resources to do so. We must all display some of the courage, restraint, and spirit of compromise of our forefathers who took huge political and physical risks to found our country. They were motivated by a desire to do what was best for the country at large, to work for the greater good, to do what was right for the whole society. It often required self-denial, shared sacrifice, compromise, altruism, and the responsibility to act for the common good. The WIIFM principle had to be suppressed. The result was a United States of unparalleled greatness.

Today we are drifting away from that greatness. Aside from our military and a few other rare exceptions, the WIIFM principle seems to underlie that drift. Although some self-interest is acceptable and part of the human nature, we must all resist the temptation to make that our predominant motivation. Otherwise our country will decline, and we are doomed to failure.

Clearly, this recognition and movement away from WIIFM, this ‘me-first attitude’, this idea of ‘let someone else sacrifice’ should begin with our key political leaders. They must find the courage to do what is right for our country, and give up their WIIFM motivation of acting solely to get re-elected. If they can start the ball rolling in the right direction, surely other segments of society and indeed all of us should be able to follow.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is also an associate medical editor for Vascular Specialist.

The ideas and opinions expresssed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher.

These are hard times for the United States. Our economy is floundering. Unemployment is high. Bankers and financiers seem to be getting away with immoral and even illegal actions. People are disgruntled and dissatisfied. Our government seems to be unable or unwilling to right the obvious wrongs or to get us out of the morass. There is general malaise.

I believe there is a common thread that underlies our present situation. It is the overarching attitude that behavior in our society is primarily determined by the WIIFM principle or ‘What’s in it for me’.

Let us look at some specific examples. Elected politicians in the executive and legislative branches of our federal government should make decisions on the basis of what is best for society and our country. Unfortunately this consideration is a minor motivation.

Uniformly our President and Congress do what is most likely to get themselves re-elected, i.e., what is best for them personally, not what is best for our country. They are constantly campaigning rather than governing. As a result, actions to support entrepreneurship and private job creation are not taken, and class warfare is encouraged because more votes will be gained than lost.

Attorneys who block tort reform are another example of the WIIFM principle. They must know that the present system is imperfect and costing our society billions of dollars, at least some of which are unjustified. Yet they spend millions supporting the re-election campaigns of legislators to block even a wisp of reform. Both the attorneys and the legislators who are influenced by this legal form of bribery are clearly guided by WIIFM. Society pays and suffers.

Similarly, bankers and others in the financial community, known collectively as Wall Street, guided by the WIIFM principle expend great efforts to preserve a system riddled with opaque derivative securities and other practices which benefit a few clever manipulators and harm our financial system and our society. Financial donations to politicians, again legalized bribery, and unfair executive compensation help to sustain a system in which rewards are far in excess of the value contributed to society.

Labor unions and their leaders are also substantially motivated by WIIFM. Otherwise they might compromise on demands to preserve unsustainable pension and benefit systems that are bankrupting our state and federal governments. The promise of votes and again contribution-associated influence over elected leaders are part of the toxic mix. Once again WIIFM triumphs over what is good for our overall economy and our country. The effort to close the job-creating Boeing plant in South Carolina and the pension preserving battles in Wisconsin and Ohio are glaring examples of the evils of WIIFM.

So also are the efforts of some to block any tax increase. If government waste, spending excesses, and unfair tax loopholes can be sharply diminished, reasonable tax increases can be considered part of a shared sacrifice for the common good of deficit reduction. All must acknowledge that our economic problems can only be solved by the compromise of such shared sacrifice. We will be better off in the long run and so will our progeny.

Physicians can also be motivated by the WIIFM principle. There is the temptation to maintain diminishing incomes at all costs – even by performing procedures that may not be fully indicated or justified, or by spending less than adequate time with individual patients. Our health care system is imperfect in many ways, but physicians too must resist the urge to be guided predominantly by WIIFM.

Finally there is the public at large. Are we guided in our voting by short-term WIIFM? Should we vote for the candidate who will lower our personal taxes the most in the next few years? Or should we vote for the individual who we believe will act in the best interests of our country at-large and its future long-term well-being?

We must all recognize the intrinsic dangers of being motivated excessively by WIIFM. Our country cannot survive and prosper if everyone pursues that motivation. We do not have the resources to do so. We must all display some of the courage, restraint, and spirit of compromise of our forefathers who took huge political and physical risks to found our country. They were motivated by a desire to do what was best for the country at large, to work for the greater good, to do what was right for the whole society. It often required self-denial, shared sacrifice, compromise, altruism, and the responsibility to act for the common good. The WIIFM principle had to be suppressed. The result was a United States of unparalleled greatness.

Today we are drifting away from that greatness. Aside from our military and a few other rare exceptions, the WIIFM principle seems to underlie that drift. Although some self-interest is acceptable and part of the human nature, we must all resist the temptation to make that our predominant motivation. Otherwise our country will decline, and we are doomed to failure.

Clearly, this recognition and movement away from WIIFM, this ‘me-first attitude’, this idea of ‘let someone else sacrifice’ should begin with our key political leaders. They must find the courage to do what is right for our country, and give up their WIIFM motivation of acting solely to get re-elected. If they can start the ball rolling in the right direction, surely other segments of society and indeed all of us should be able to follow.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is also an associate medical editor for Vascular Specialist.

The ideas and opinions expresssed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher.

ORLANDO – The ACE inhibitor ramipril boosted both walking ability and quality of life in patients with peripheral arterial disease in a double-blind, randomized trial.

"The magnitude of these effects is greater than that reported for conventional medical therapies," Dr. Anna A. Ahimastos observed when presenting the study findings at the annual meeting of the American Heart Association.

She reported on 343 patients with peripheral arterial disease (PAD) who were randomized to 24 weeks of ramipril at 10 mg once daily or placebo. They averaged 65 years of age, 80% were men, the baseline ankle-brachial index was 0.56, and 36% had diabetes.

At 24 weeks, the average pain-free walking time (PFWT) in the ramipril group had increased by 87%, compared with a baseline of 131 seconds. The maximum walk time (MWT) improved by 139% from a baseline of 229 seconds. This corresponded to a clinically meaningful 172-meter increase in walking distance on a standardized treadmill test conducted at a speed of 3.2 km/hr and a 12% gradient, according to Dr. Ahimastos of the Baker IDI Heart and Diabetes Institute at Alfred Hospital in Melbourne. In contrast, both PFWT and MWT decreased modestly over the course of 24 weeks in the control group.

A finding of particular importance in this impaired population was the documented improvement in quality of life that accompanied 24 weeks of ramipril, she continued. Daily functional capacity as measured by the WIQ (Walking Impairment Questionnaire) score domains of walking distance, speed, and stair climbing improved by 184%-213%. Scores on the SF-36 (36-Item Short Form) physical function component showed a significant 7% improvement from a baseline average of 38.5.

Results of this study are consistent with those of an earlier randomized, double-blind pilot study that Dr. Ahimastos and coworkers conducted in 40 patients (Ann. Intern. Med. 2006;144:660-4).

The pilot study showed average gains of 164% in PFWT and 243% in MWT with 24 weeks of ramipril, a magnitude of benefit roughly twice that seen in the new, much larger trial. This is probably because the pilot study employed quite restrictive inclusion criteria, whereas the new study included a broader spectrum of PAD patients, including those with diabetes and with aortoiliac or infrainguinal disease.

Outcomes in the two randomized trials of ramipril for PAD – gains of 87%-164% in PFWT and 139%-243% in MWT – compare favorably with the results of placebo-controlled studies of conventional therapies. The phosphodiesterase-3 inhibitor cilostazol has shown 32%-82% improvements in PFWT and MWT. Pentoxifylline, another phosphodiesterase inhibitor, produced a 12% gain in MWT. And exercise training has shown a 150% improvement in both MWT and PFWT. However, the compliance rate with exercise is quite low in the PAD population, she noted.

Audience members who have grown accustomed to negative clinical trials being reported for PAD were enthusiastic at the prospect of finally gaining an additional effective medical therapy for this difficult condition. And they were curious as to Dr. Ahimastos’s thoughts on the mechanism of benefit.

She replied that at this point she can only speculate, since clinical trials don’t provide answers regarding mechanisms and the data from the new study were unblinded only the week prior to her presentation. She noted that ACE inhibitors have antiangiogenic and vasodilatory effects. The enhanced nitric oxide release and the drugs’ effects on bradykinin might also be relevant.

The improvement in walking doesn’t appear to stem from ramipril’s blood pressure–lowering effect, however, as the blood pressure reductions were minimal – less than 3 mm Hg in both systolic and diastolic blood pressure – and the degree of blood pressure reduction in individual patients didn’t correlate with their magnitude of walking improvement.

She and her colleagues don’t know whether angiotensin-receptor blockers would have similar clinical benefits on walking in PAD patients. That will prove difficult to study. For ethical reasons, future clinical trials are unlikely, as there is now evidence-based agreement among experts that patients with PAD should be on an ACE inhibitor or ARB anyway for cardiovascular protection.

The study was funded by Australia’s National Heart Foundation. Dr. Ahimastos declared having no financial conflicts.

ORLANDO – The ACE inhibitor ramipril boosted both walking ability and quality of life in patients with peripheral arterial disease in a double-blind, randomized trial.

"The magnitude of these effects is greater than that reported for conventional medical therapies," Dr. Anna A. Ahimastos observed when presenting the study findings at the annual meeting of the American Heart Association.

She reported on 343 patients with peripheral arterial disease (PAD) who were randomized to 24 weeks of ramipril at 10 mg once daily or placebo. They averaged 65 years of age, 80% were men, the baseline ankle-brachial index was 0.56, and 36% had diabetes.

At 24 weeks, the average pain-free walking time (PFWT) in the ramipril group had increased by 87%, compared with a baseline of 131 seconds. The maximum walk time (MWT) improved by 139% from a baseline of 229 seconds. This corresponded to a clinically meaningful 172-meter increase in walking distance on a standardized treadmill test conducted at a speed of 3.2 km/hr and a 12% gradient, according to Dr. Ahimastos of the Baker IDI Heart and Diabetes Institute at Alfred Hospital in Melbourne. In contrast, both PFWT and MWT decreased modestly over the course of 24 weeks in the control group.

A finding of particular importance in this impaired population was the documented improvement in quality of life that accompanied 24 weeks of ramipril, she continued. Daily functional capacity as measured by the WIQ (Walking Impairment Questionnaire) score domains of walking distance, speed, and stair climbing improved by 184%-213%. Scores on the SF-36 (36-Item Short Form) physical function component showed a significant 7% improvement from a baseline average of 38.5.

Results of this study are consistent with those of an earlier randomized, double-blind pilot study that Dr. Ahimastos and coworkers conducted in 40 patients (Ann. Intern. Med. 2006;144:660-4).

The pilot study showed average gains of 164% in PFWT and 243% in MWT with 24 weeks of ramipril, a magnitude of benefit roughly twice that seen in the new, much larger trial. This is probably because the pilot study employed quite restrictive inclusion criteria, whereas the new study included a broader spectrum of PAD patients, including those with diabetes and with aortoiliac or infrainguinal disease.

Outcomes in the two randomized trials of ramipril for PAD – gains of 87%-164% in PFWT and 139%-243% in MWT – compare favorably with the results of placebo-controlled studies of conventional therapies. The phosphodiesterase-3 inhibitor cilostazol has shown 32%-82% improvements in PFWT and MWT. Pentoxifylline, another phosphodiesterase inhibitor, produced a 12% gain in MWT. And exercise training has shown a 150% improvement in both MWT and PFWT. However, the compliance rate with exercise is quite low in the PAD population, she noted.

Audience members who have grown accustomed to negative clinical trials being reported for PAD were enthusiastic at the prospect of finally gaining an additional effective medical therapy for this difficult condition. And they were curious as to Dr. Ahimastos’s thoughts on the mechanism of benefit.

She replied that at this point she can only speculate, since clinical trials don’t provide answers regarding mechanisms and the data from the new study were unblinded only the week prior to her presentation. She noted that ACE inhibitors have antiangiogenic and vasodilatory effects. The enhanced nitric oxide release and the drugs’ effects on bradykinin might also be relevant.

The improvement in walking doesn’t appear to stem from ramipril’s blood pressure–lowering effect, however, as the blood pressure reductions were minimal – less than 3 mm Hg in both systolic and diastolic blood pressure – and the degree of blood pressure reduction in individual patients didn’t correlate with their magnitude of walking improvement.

She and her colleagues don’t know whether angiotensin-receptor blockers would have similar clinical benefits on walking in PAD patients. That will prove difficult to study. For ethical reasons, future clinical trials are unlikely, as there is now evidence-based agreement among experts that patients with PAD should be on an ACE inhibitor or ARB anyway for cardiovascular protection.

The study was funded by Australia’s National Heart Foundation. Dr. Ahimastos declared having no financial conflicts.

ORLANDO – The ACE inhibitor ramipril boosted both walking ability and quality of life in patients with peripheral arterial disease in a double-blind, randomized trial.

"The magnitude of these effects is greater than that reported for conventional medical therapies," Dr. Anna A. Ahimastos observed when presenting the study findings at the annual meeting of the American Heart Association.

She reported on 343 patients with peripheral arterial disease (PAD) who were randomized to 24 weeks of ramipril at 10 mg once daily or placebo. They averaged 65 years of age, 80% were men, the baseline ankle-brachial index was 0.56, and 36% had diabetes.

At 24 weeks, the average pain-free walking time (PFWT) in the ramipril group had increased by 87%, compared with a baseline of 131 seconds. The maximum walk time (MWT) improved by 139% from a baseline of 229 seconds. This corresponded to a clinically meaningful 172-meter increase in walking distance on a standardized treadmill test conducted at a speed of 3.2 km/hr and a 12% gradient, according to Dr. Ahimastos of the Baker IDI Heart and Diabetes Institute at Alfred Hospital in Melbourne. In contrast, both PFWT and MWT decreased modestly over the course of 24 weeks in the control group.

A finding of particular importance in this impaired population was the documented improvement in quality of life that accompanied 24 weeks of ramipril, she continued. Daily functional capacity as measured by the WIQ (Walking Impairment Questionnaire) score domains of walking distance, speed, and stair climbing improved by 184%-213%. Scores on the SF-36 (36-Item Short Form) physical function component showed a significant 7% improvement from a baseline average of 38.5.

Results of this study are consistent with those of an earlier randomized, double-blind pilot study that Dr. Ahimastos and coworkers conducted in 40 patients (Ann. Intern. Med. 2006;144:660-4).

The pilot study showed average gains of 164% in PFWT and 243% in MWT with 24 weeks of ramipril, a magnitude of benefit roughly twice that seen in the new, much larger trial. This is probably because the pilot study employed quite restrictive inclusion criteria, whereas the new study included a broader spectrum of PAD patients, including those with diabetes and with aortoiliac or infrainguinal disease.

Outcomes in the two randomized trials of ramipril for PAD – gains of 87%-164% in PFWT and 139%-243% in MWT – compare favorably with the results of placebo-controlled studies of conventional therapies. The phosphodiesterase-3 inhibitor cilostazol has shown 32%-82% improvements in PFWT and MWT. Pentoxifylline, another phosphodiesterase inhibitor, produced a 12% gain in MWT. And exercise training has shown a 150% improvement in both MWT and PFWT. However, the compliance rate with exercise is quite low in the PAD population, she noted.

Audience members who have grown accustomed to negative clinical trials being reported for PAD were enthusiastic at the prospect of finally gaining an additional effective medical therapy for this difficult condition. And they were curious as to Dr. Ahimastos’s thoughts on the mechanism of benefit.

She replied that at this point she can only speculate, since clinical trials don’t provide answers regarding mechanisms and the data from the new study were unblinded only the week prior to her presentation. She noted that ACE inhibitors have antiangiogenic and vasodilatory effects. The enhanced nitric oxide release and the drugs’ effects on bradykinin might also be relevant.

The improvement in walking doesn’t appear to stem from ramipril’s blood pressure–lowering effect, however, as the blood pressure reductions were minimal – less than 3 mm Hg in both systolic and diastolic blood pressure – and the degree of blood pressure reduction in individual patients didn’t correlate with their magnitude of walking improvement.

She and her colleagues don’t know whether angiotensin-receptor blockers would have similar clinical benefits on walking in PAD patients. That will prove difficult to study. For ethical reasons, future clinical trials are unlikely, as there is now evidence-based agreement among experts that patients with PAD should be on an ACE inhibitor or ARB anyway for cardiovascular protection.

The study was funded by Australia’s National Heart Foundation. Dr. Ahimastos declared having no financial conflicts.