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Uncomplicated appendicitis can be treated successfully with antibiotics
Clinical question: What is the late recurrence rate for patients with uncomplicated appendicitis treated with antibiotics only?
Background: Short-term results support antibiotic treatment as alternative to surgery for uncomplicated appendicitis. Long-term outcomes have not been assessed.
Study design: Observational follow-up.
Setting: Six hospitals in Finland.
Synopsis: The APPAC trial looked at 530 patients, aged 18-60 years, with CT confirmed acute uncomplicated appendicitis, who were randomized to receive either appendectomy or antibiotics. In this follow-up report, outcomes were assessed by telephone interviews conducted 3-5 years after the initial interventions. Overall, 100 of 256 (39.1%) of the antibiotic group ultimately underwent appendectomy within 5 years. Of those, 70/100 (70%) had their recurrence within 1 year of their initial presentation.
Bottom line: Patients with uncomplicated appendicitis treated with antibiotics have a 39% cumulative 5-year recurrence rate, with most recurrences occurring within the first year.
Citation: Salminem P et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018;320(12):1259-65.
Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Clinical question: What is the late recurrence rate for patients with uncomplicated appendicitis treated with antibiotics only?
Background: Short-term results support antibiotic treatment as alternative to surgery for uncomplicated appendicitis. Long-term outcomes have not been assessed.
Study design: Observational follow-up.
Setting: Six hospitals in Finland.
Synopsis: The APPAC trial looked at 530 patients, aged 18-60 years, with CT confirmed acute uncomplicated appendicitis, who were randomized to receive either appendectomy or antibiotics. In this follow-up report, outcomes were assessed by telephone interviews conducted 3-5 years after the initial interventions. Overall, 100 of 256 (39.1%) of the antibiotic group ultimately underwent appendectomy within 5 years. Of those, 70/100 (70%) had their recurrence within 1 year of their initial presentation.
Bottom line: Patients with uncomplicated appendicitis treated with antibiotics have a 39% cumulative 5-year recurrence rate, with most recurrences occurring within the first year.
Citation: Salminem P et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018;320(12):1259-65.
Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Clinical question: What is the late recurrence rate for patients with uncomplicated appendicitis treated with antibiotics only?
Background: Short-term results support antibiotic treatment as alternative to surgery for uncomplicated appendicitis. Long-term outcomes have not been assessed.
Study design: Observational follow-up.
Setting: Six hospitals in Finland.
Synopsis: The APPAC trial looked at 530 patients, aged 18-60 years, with CT confirmed acute uncomplicated appendicitis, who were randomized to receive either appendectomy or antibiotics. In this follow-up report, outcomes were assessed by telephone interviews conducted 3-5 years after the initial interventions. Overall, 100 of 256 (39.1%) of the antibiotic group ultimately underwent appendectomy within 5 years. Of those, 70/100 (70%) had their recurrence within 1 year of their initial presentation.
Bottom line: Patients with uncomplicated appendicitis treated with antibiotics have a 39% cumulative 5-year recurrence rate, with most recurrences occurring within the first year.
Citation: Salminem P et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018;320(12):1259-65.
Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Adjustment for characteristics not used by Medicare reduces hospital variations in readmission rates
Clinical question: Can differences in hospital readmission rates be explained by patient characteristics not accounted for by Medicare?
Background: In its Pay for Performance program, Medicare ties payments to readmission rates but adjusts these rates only for limited patient characteristics. Hospitals serving higher-risk patients have received greater penalties. These programs may have the unintended consequence of penalizing hospitals that provide care to higher-risk patients.
Study design: Observational study.
Setting: Medicare admissions claims from 2013 through 2014 in 2,215 hospitals.
Synopsis: Using Medicare claims for admission and linked U.S. census data, the study assessed several clinical and social characteristics not currently used for risk adjustment. A sample of 1,169,014 index admissions among 1,003,664 unique beneficiaries was analyzed. The study compared rates with and without these additional adjustments.
Additional adjustments reduced overall variation in hospital readmission by 9.6%, changed rates upward or downward by 0.4%-0.7% for the 10% of hospitals most affected by the readjustments, and they would be expected to reduce penalties by 52%, 46%, and 41% for hospitals with the largest 1%, 5%, and 10% of penalty reductions, respectively.
Bottom line: Hospitals serving higher-risk patients may be penalized because of the patients they serve rather that the quality of care they provide.
Citation: Roberts ET et al. Assessment of the effect of adjustment for patient characteristics on hospital readmission rates: Implications for Pay for Performance. JAMA Intern Med. 2018;178(11)1498-1507.
Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Clinical question: Can differences in hospital readmission rates be explained by patient characteristics not accounted for by Medicare?
Background: In its Pay for Performance program, Medicare ties payments to readmission rates but adjusts these rates only for limited patient characteristics. Hospitals serving higher-risk patients have received greater penalties. These programs may have the unintended consequence of penalizing hospitals that provide care to higher-risk patients.
Study design: Observational study.
Setting: Medicare admissions claims from 2013 through 2014 in 2,215 hospitals.
Synopsis: Using Medicare claims for admission and linked U.S. census data, the study assessed several clinical and social characteristics not currently used for risk adjustment. A sample of 1,169,014 index admissions among 1,003,664 unique beneficiaries was analyzed. The study compared rates with and without these additional adjustments.
Additional adjustments reduced overall variation in hospital readmission by 9.6%, changed rates upward or downward by 0.4%-0.7% for the 10% of hospitals most affected by the readjustments, and they would be expected to reduce penalties by 52%, 46%, and 41% for hospitals with the largest 1%, 5%, and 10% of penalty reductions, respectively.
Bottom line: Hospitals serving higher-risk patients may be penalized because of the patients they serve rather that the quality of care they provide.
Citation: Roberts ET et al. Assessment of the effect of adjustment for patient characteristics on hospital readmission rates: Implications for Pay for Performance. JAMA Intern Med. 2018;178(11)1498-1507.
Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Clinical question: Can differences in hospital readmission rates be explained by patient characteristics not accounted for by Medicare?
Background: In its Pay for Performance program, Medicare ties payments to readmission rates but adjusts these rates only for limited patient characteristics. Hospitals serving higher-risk patients have received greater penalties. These programs may have the unintended consequence of penalizing hospitals that provide care to higher-risk patients.
Study design: Observational study.
Setting: Medicare admissions claims from 2013 through 2014 in 2,215 hospitals.
Synopsis: Using Medicare claims for admission and linked U.S. census data, the study assessed several clinical and social characteristics not currently used for risk adjustment. A sample of 1,169,014 index admissions among 1,003,664 unique beneficiaries was analyzed. The study compared rates with and without these additional adjustments.
Additional adjustments reduced overall variation in hospital readmission by 9.6%, changed rates upward or downward by 0.4%-0.7% for the 10% of hospitals most affected by the readjustments, and they would be expected to reduce penalties by 52%, 46%, and 41% for hospitals with the largest 1%, 5%, and 10% of penalty reductions, respectively.
Bottom line: Hospitals serving higher-risk patients may be penalized because of the patients they serve rather that the quality of care they provide.
Citation: Roberts ET et al. Assessment of the effect of adjustment for patient characteristics on hospital readmission rates: Implications for Pay for Performance. JAMA Intern Med. 2018;178(11)1498-1507.
Dr. Asuen is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Almost one-third of ED patients with gout are prescribed opioids
Patients with gout who visit the emergency department are regularly prescribed opioids, based on a review of electronic medical records.
“In addition to regulatory changes, the burden of opioid prescription could be potentially reduced by creating prompts for providers in electronic record systems to avoid prescribing opioids in opioid-naive patients or using lower intensity and shorter duration of prescription,” wrote Deepan S. Dalal, MD, of Brown University, Providence, R.I., and coauthors. The study was published in Arthritis Care & Research.
To determine frequency, dose, and duration of opioid prescription at ED discharge, the researchers reviewed the records of 456 patients with acute gout who were discharged in Rhode Island between March 30, 2015, and Sept. 30, 2017. All data were gathered via electronic medical system records.
Of the 456 discharged patients, 129 (28.3%) were prescribed opioids; 102 (79%) were not on opioids at the time. A full prescription description was available for 119 of the 129 patients; 96 (81%) were prescribed oxycodone or oxycodone combinations. Hydrocodone was prescribed for 9 patients (8%) and tramadol was prescribed for 11 patients (9%).
The median duration of each prescription was 8 days (interquartile range, 5-14 days) and the average daily dose was 37.9 mg of morphine equivalent. Patients who were prescribed opioids tended to be younger and male. After multivariable analysis, diabetes, polyarticular gout attack, and prior opioid use were all associated with a more than 100% higher odds of receiving an opioid prescription.
The authors acknowledged their study’s limitations, including their inability to determine the physicians’ reasoning behind each prescription or the prescribing habits of each provider. In addition, they were only able to assess the prescriptions as being written and not the number of pills actually taken or not taken.
No conflicts of interest were reported.
SOURCE: Dalal DS et al. Arthritis Care Res. 2019 Jul 3. doi: 10.1002/acr.23928.
Patients with gout who visit the emergency department are regularly prescribed opioids, based on a review of electronic medical records.
“In addition to regulatory changes, the burden of opioid prescription could be potentially reduced by creating prompts for providers in electronic record systems to avoid prescribing opioids in opioid-naive patients or using lower intensity and shorter duration of prescription,” wrote Deepan S. Dalal, MD, of Brown University, Providence, R.I., and coauthors. The study was published in Arthritis Care & Research.
To determine frequency, dose, and duration of opioid prescription at ED discharge, the researchers reviewed the records of 456 patients with acute gout who were discharged in Rhode Island between March 30, 2015, and Sept. 30, 2017. All data were gathered via electronic medical system records.
Of the 456 discharged patients, 129 (28.3%) were prescribed opioids; 102 (79%) were not on opioids at the time. A full prescription description was available for 119 of the 129 patients; 96 (81%) were prescribed oxycodone or oxycodone combinations. Hydrocodone was prescribed for 9 patients (8%) and tramadol was prescribed for 11 patients (9%).
The median duration of each prescription was 8 days (interquartile range, 5-14 days) and the average daily dose was 37.9 mg of morphine equivalent. Patients who were prescribed opioids tended to be younger and male. After multivariable analysis, diabetes, polyarticular gout attack, and prior opioid use were all associated with a more than 100% higher odds of receiving an opioid prescription.
The authors acknowledged their study’s limitations, including their inability to determine the physicians’ reasoning behind each prescription or the prescribing habits of each provider. In addition, they were only able to assess the prescriptions as being written and not the number of pills actually taken or not taken.
No conflicts of interest were reported.
SOURCE: Dalal DS et al. Arthritis Care Res. 2019 Jul 3. doi: 10.1002/acr.23928.
Patients with gout who visit the emergency department are regularly prescribed opioids, based on a review of electronic medical records.
“In addition to regulatory changes, the burden of opioid prescription could be potentially reduced by creating prompts for providers in electronic record systems to avoid prescribing opioids in opioid-naive patients or using lower intensity and shorter duration of prescription,” wrote Deepan S. Dalal, MD, of Brown University, Providence, R.I., and coauthors. The study was published in Arthritis Care & Research.
To determine frequency, dose, and duration of opioid prescription at ED discharge, the researchers reviewed the records of 456 patients with acute gout who were discharged in Rhode Island between March 30, 2015, and Sept. 30, 2017. All data were gathered via electronic medical system records.
Of the 456 discharged patients, 129 (28.3%) were prescribed opioids; 102 (79%) were not on opioids at the time. A full prescription description was available for 119 of the 129 patients; 96 (81%) were prescribed oxycodone or oxycodone combinations. Hydrocodone was prescribed for 9 patients (8%) and tramadol was prescribed for 11 patients (9%).
The median duration of each prescription was 8 days (interquartile range, 5-14 days) and the average daily dose was 37.9 mg of morphine equivalent. Patients who were prescribed opioids tended to be younger and male. After multivariable analysis, diabetes, polyarticular gout attack, and prior opioid use were all associated with a more than 100% higher odds of receiving an opioid prescription.
The authors acknowledged their study’s limitations, including their inability to determine the physicians’ reasoning behind each prescription or the prescribing habits of each provider. In addition, they were only able to assess the prescriptions as being written and not the number of pills actually taken or not taken.
No conflicts of interest were reported.
SOURCE: Dalal DS et al. Arthritis Care Res. 2019 Jul 3. doi: 10.1002/acr.23928.
FROM ARTHRITIS CARE & RESEARCH
Key clinical point: Though there are other effective conventional treatments, opioids are often prescribed for patients who present to the ED with gout.
Major finding: After multivariable analysis, diabetes, polyarticular gout attack, and prior opioid use were all associated with a more than 100% higher odds of opioid prescription.
Study details: A retrospective cohort study of 456 patients with acute gout discharged from EDs in Rhode Island.
Disclosures: The authors reported no conflicts of interest.
Source: Dalal DS et al. Arthritis Care Res. 2019 Jul 3. doi: 10.1002/acr.23928.
Some burnout factors are within a physician’s control
SAN DIEGO – Eat a healthy lunch. Get more sleep. Move your body. How many times in the course of a week do you give patients gentle reminders to practice these most basic steps of self-care? And how many times in the course of a week do you allow these basics to go by the wayside for yourself?
Self-care is one of the elements that can defend against physician burnout, Carol Burke, MD, said at a session on physician burnout held during the annual Digestive Disease Week®. Personal self-care can make a real difference, and shouldn’t be ignored as the profession works to reel back some of the institutional changes that challenge physicians today.
In the workplace, unhealthy stress levels can contribute to burnout, disruptive behavior, decreased productivity, and disengagement. Burnout – a response to chronic stress characterized by a diminished sense of personal accomplishment and emotional exhaustion – can result in cynicism, a lack of compassion, and feelings of depersonalization, said Dr. Burke.
Contributors to physician stress have been well documented, said Dr. Burke, a professor of gastroenterology at the Cleveland Clinic. These range from personal debt and the struggle for work-life balance to an increased focus on metrics and documentation at the expense of authentic patient engagement. All of these factors are measurable by means of the validated Maslach Burnout Inventory, said Dr. Burke. A recent survey that used this measure indicated that nearly half of physician respondents report experiencing burnout.
In 2017, Dr. Burke led a survey of American College of Gastroenterology members that showed 49.3% of respondents reported feeling emotional exhaustion and/or depersonalization. Some key themes emerged from the survey, she said. Women and younger physicians were more likely to experience burnout. Having children in the middle years (11-15 years old) and spending more time on domestic duties and child care increased the risk of burnout.
And doing patient-related work at home or having a spouse or partner bring work home also upped burnout risk. Skipping breakfast and lunch during the workweek was another risk factor, which highlights the importance of basic self-care as armor against the administrative onslaught, said Dr. Burke.
Measured by volume alone, physician work can be overwhelming: 45% of physicians in the United States work more than 60 hours weekly, compared with fewer than 10% of the general workforce, said Dr. Burke.
What factors within the control of an individual practitioner can reduce the risk of debilitating burnout and improve quality of life? Physicians who do report a high quality of life, said Dr. Burke, are more likely to have a positive outlook. They also practice basic self-care like taking vacations, exercising regularly, and engaging in hobbies outside of work.
For exhausted, overworked clinicians, getting a good night’s sleep is a critical form of self-care. But erratic schedules, stress, and family demands can all sabotage plans for better sleep hygiene. Still, attending to sleep is important, said Dr. Burke. Individuals with disturbed sleep are less mindful and have less self-compassion. Sleep disturbance is also strongly correlated with perceived stress.
She also reported that the odds ratio for burnout was 14.7 for physicians who reported insomnia when compared with those without sleep disturbance, and it was 9.9 for those who reported nonrestorative sleep.
Physical activity can help sleep and also help other markers of burnout. Dr. Burke pointed to a recent study of 4,402 medical students. Participants were able to reduce burnout risk when they met the Centers for Disease Control and Prevention recommendations of achieving at least 150 minutes/week of moderate exercise or 75 minutes/week of vigorous exercise, plus at least 2 days/week of strength training (P less than .001; Acad Med. 2017;92:1006).
These physician-targeted programs can work, she said: “Faciliated interventions improve well-being, attitudes associated with patient-centered care, meaning and engagement in work, and reduce burnout.”
Practice-focused interventions to reclaim a semblance of control over one’s time are varied, and some are easier to implement than others. Virtual visits and group visits are surprisingly well received by patients, and each can be huge time-savers for physicians, said Dr. Burke. There are billing and workflow pitfalls to avoid, but group visits, in particular, can be practice changing for those who have heavy backlogs and see many patients with the same condition.
Medical scribes can improve productivity and reduce physician time spent on documentation. Also, said Dr. Burke, visits can appropriately be billed at a higher level of complexity when contemporaneous documentation is thorough. Clinicians overall feel that they can engage more fully with patients, and also feel more effective, when well-trained scribes are integrated into a practice, she said.
Female physicians have repeatedly been shown to have patient panels that are more demanding, and male and female patients alike expect more empathy and social support from their physicians, said Dr. Burke. When psychosocial complexities are interwoven with patient care, as they are more frequently for female providers, a 15-minute visit can easily run twice that – or more. Dr. Burke is among the physicians advocating for recognition of this invisible burden on female clinicians, either through adaptive scheduling or differential productivity expectations. This approach is not without controversy, she acknowledged; still, practices should acknowledge that clinic flow can be very different for male and female gastroenterologists, she said.
Dr. Burke reported no relevant conflicts of interest.
SAN DIEGO – Eat a healthy lunch. Get more sleep. Move your body. How many times in the course of a week do you give patients gentle reminders to practice these most basic steps of self-care? And how many times in the course of a week do you allow these basics to go by the wayside for yourself?
Self-care is one of the elements that can defend against physician burnout, Carol Burke, MD, said at a session on physician burnout held during the annual Digestive Disease Week®. Personal self-care can make a real difference, and shouldn’t be ignored as the profession works to reel back some of the institutional changes that challenge physicians today.
In the workplace, unhealthy stress levels can contribute to burnout, disruptive behavior, decreased productivity, and disengagement. Burnout – a response to chronic stress characterized by a diminished sense of personal accomplishment and emotional exhaustion – can result in cynicism, a lack of compassion, and feelings of depersonalization, said Dr. Burke.
Contributors to physician stress have been well documented, said Dr. Burke, a professor of gastroenterology at the Cleveland Clinic. These range from personal debt and the struggle for work-life balance to an increased focus on metrics and documentation at the expense of authentic patient engagement. All of these factors are measurable by means of the validated Maslach Burnout Inventory, said Dr. Burke. A recent survey that used this measure indicated that nearly half of physician respondents report experiencing burnout.
In 2017, Dr. Burke led a survey of American College of Gastroenterology members that showed 49.3% of respondents reported feeling emotional exhaustion and/or depersonalization. Some key themes emerged from the survey, she said. Women and younger physicians were more likely to experience burnout. Having children in the middle years (11-15 years old) and spending more time on domestic duties and child care increased the risk of burnout.
And doing patient-related work at home or having a spouse or partner bring work home also upped burnout risk. Skipping breakfast and lunch during the workweek was another risk factor, which highlights the importance of basic self-care as armor against the administrative onslaught, said Dr. Burke.
Measured by volume alone, physician work can be overwhelming: 45% of physicians in the United States work more than 60 hours weekly, compared with fewer than 10% of the general workforce, said Dr. Burke.
What factors within the control of an individual practitioner can reduce the risk of debilitating burnout and improve quality of life? Physicians who do report a high quality of life, said Dr. Burke, are more likely to have a positive outlook. They also practice basic self-care like taking vacations, exercising regularly, and engaging in hobbies outside of work.
For exhausted, overworked clinicians, getting a good night’s sleep is a critical form of self-care. But erratic schedules, stress, and family demands can all sabotage plans for better sleep hygiene. Still, attending to sleep is important, said Dr. Burke. Individuals with disturbed sleep are less mindful and have less self-compassion. Sleep disturbance is also strongly correlated with perceived stress.
She also reported that the odds ratio for burnout was 14.7 for physicians who reported insomnia when compared with those without sleep disturbance, and it was 9.9 for those who reported nonrestorative sleep.
Physical activity can help sleep and also help other markers of burnout. Dr. Burke pointed to a recent study of 4,402 medical students. Participants were able to reduce burnout risk when they met the Centers for Disease Control and Prevention recommendations of achieving at least 150 minutes/week of moderate exercise or 75 minutes/week of vigorous exercise, plus at least 2 days/week of strength training (P less than .001; Acad Med. 2017;92:1006).
These physician-targeted programs can work, she said: “Faciliated interventions improve well-being, attitudes associated with patient-centered care, meaning and engagement in work, and reduce burnout.”
Practice-focused interventions to reclaim a semblance of control over one’s time are varied, and some are easier to implement than others. Virtual visits and group visits are surprisingly well received by patients, and each can be huge time-savers for physicians, said Dr. Burke. There are billing and workflow pitfalls to avoid, but group visits, in particular, can be practice changing for those who have heavy backlogs and see many patients with the same condition.
Medical scribes can improve productivity and reduce physician time spent on documentation. Also, said Dr. Burke, visits can appropriately be billed at a higher level of complexity when contemporaneous documentation is thorough. Clinicians overall feel that they can engage more fully with patients, and also feel more effective, when well-trained scribes are integrated into a practice, she said.
Female physicians have repeatedly been shown to have patient panels that are more demanding, and male and female patients alike expect more empathy and social support from their physicians, said Dr. Burke. When psychosocial complexities are interwoven with patient care, as they are more frequently for female providers, a 15-minute visit can easily run twice that – or more. Dr. Burke is among the physicians advocating for recognition of this invisible burden on female clinicians, either through adaptive scheduling or differential productivity expectations. This approach is not without controversy, she acknowledged; still, practices should acknowledge that clinic flow can be very different for male and female gastroenterologists, she said.
Dr. Burke reported no relevant conflicts of interest.
SAN DIEGO – Eat a healthy lunch. Get more sleep. Move your body. How many times in the course of a week do you give patients gentle reminders to practice these most basic steps of self-care? And how many times in the course of a week do you allow these basics to go by the wayside for yourself?
Self-care is one of the elements that can defend against physician burnout, Carol Burke, MD, said at a session on physician burnout held during the annual Digestive Disease Week®. Personal self-care can make a real difference, and shouldn’t be ignored as the profession works to reel back some of the institutional changes that challenge physicians today.
In the workplace, unhealthy stress levels can contribute to burnout, disruptive behavior, decreased productivity, and disengagement. Burnout – a response to chronic stress characterized by a diminished sense of personal accomplishment and emotional exhaustion – can result in cynicism, a lack of compassion, and feelings of depersonalization, said Dr. Burke.
Contributors to physician stress have been well documented, said Dr. Burke, a professor of gastroenterology at the Cleveland Clinic. These range from personal debt and the struggle for work-life balance to an increased focus on metrics and documentation at the expense of authentic patient engagement. All of these factors are measurable by means of the validated Maslach Burnout Inventory, said Dr. Burke. A recent survey that used this measure indicated that nearly half of physician respondents report experiencing burnout.
In 2017, Dr. Burke led a survey of American College of Gastroenterology members that showed 49.3% of respondents reported feeling emotional exhaustion and/or depersonalization. Some key themes emerged from the survey, she said. Women and younger physicians were more likely to experience burnout. Having children in the middle years (11-15 years old) and spending more time on domestic duties and child care increased the risk of burnout.
And doing patient-related work at home or having a spouse or partner bring work home also upped burnout risk. Skipping breakfast and lunch during the workweek was another risk factor, which highlights the importance of basic self-care as armor against the administrative onslaught, said Dr. Burke.
Measured by volume alone, physician work can be overwhelming: 45% of physicians in the United States work more than 60 hours weekly, compared with fewer than 10% of the general workforce, said Dr. Burke.
What factors within the control of an individual practitioner can reduce the risk of debilitating burnout and improve quality of life? Physicians who do report a high quality of life, said Dr. Burke, are more likely to have a positive outlook. They also practice basic self-care like taking vacations, exercising regularly, and engaging in hobbies outside of work.
For exhausted, overworked clinicians, getting a good night’s sleep is a critical form of self-care. But erratic schedules, stress, and family demands can all sabotage plans for better sleep hygiene. Still, attending to sleep is important, said Dr. Burke. Individuals with disturbed sleep are less mindful and have less self-compassion. Sleep disturbance is also strongly correlated with perceived stress.
She also reported that the odds ratio for burnout was 14.7 for physicians who reported insomnia when compared with those without sleep disturbance, and it was 9.9 for those who reported nonrestorative sleep.
Physical activity can help sleep and also help other markers of burnout. Dr. Burke pointed to a recent study of 4,402 medical students. Participants were able to reduce burnout risk when they met the Centers for Disease Control and Prevention recommendations of achieving at least 150 minutes/week of moderate exercise or 75 minutes/week of vigorous exercise, plus at least 2 days/week of strength training (P less than .001; Acad Med. 2017;92:1006).
These physician-targeted programs can work, she said: “Faciliated interventions improve well-being, attitudes associated with patient-centered care, meaning and engagement in work, and reduce burnout.”
Practice-focused interventions to reclaim a semblance of control over one’s time are varied, and some are easier to implement than others. Virtual visits and group visits are surprisingly well received by patients, and each can be huge time-savers for physicians, said Dr. Burke. There are billing and workflow pitfalls to avoid, but group visits, in particular, can be practice changing for those who have heavy backlogs and see many patients with the same condition.
Medical scribes can improve productivity and reduce physician time spent on documentation. Also, said Dr. Burke, visits can appropriately be billed at a higher level of complexity when contemporaneous documentation is thorough. Clinicians overall feel that they can engage more fully with patients, and also feel more effective, when well-trained scribes are integrated into a practice, she said.
Female physicians have repeatedly been shown to have patient panels that are more demanding, and male and female patients alike expect more empathy and social support from their physicians, said Dr. Burke. When psychosocial complexities are interwoven with patient care, as they are more frequently for female providers, a 15-minute visit can easily run twice that – or more. Dr. Burke is among the physicians advocating for recognition of this invisible burden on female clinicians, either through adaptive scheduling or differential productivity expectations. This approach is not without controversy, she acknowledged; still, practices should acknowledge that clinic flow can be very different for male and female gastroenterologists, she said.
Dr. Burke reported no relevant conflicts of interest.
EXPERT ANALYSIS FROM DDW 2019
The hospitalist role in treating opioid use disorder
Screen patients at the time of admission
Let’s begin with a brief case. A 25-year-old patient with a history of injection heroin use is in your care. He is admitted for treatment of endocarditis and will remain in the hospital for intravenous antibiotics for several weeks. Over the first few days of hospitalization, he frequently asks for pain medicine, stating that he is in severe pain, withdrawal, and having opioid cravings. On day 3, he leaves the hospital against medical advice. After 2 weeks, he presents to the ED in septic shock and spends several weeks in the ICU. Or, alternatively, he is found down in the community and pronounced dead from a heroin overdose.
These cases occur all too often, and hospitalists across the nation are actively building knowledge and programs to improve care for patients with opioid use disorder (OUD). It is evident that opioid misuse is the public health crisis of our time. In 2017, over 70,000 patients died from an overdose, and over 2 million patients in the United States have a diagnosis of OUD.1,2 Many of these patients interact with the hospital at some point during the course of their illness for management of overdose, withdrawal, and other complications of OUD, including endocarditis, osteomyelitis, and skin and soft tissue infections. Moreover, just 20% of the 580,000 patients hospitalized with OUD in 2015 presented as a direct sequelae of the disease.3 Patients with OUD are often admitted for unrelated reasons, but their addiction goes unaddressed.
Opioid use disorder, like many of the other conditions we see, is a chronic relapsing remitting medical disease and a risk factor for premature mortality. When a patient with diabetes is admitted with cellulitis, we might check an A1C, provide diabetic counseling, and offer evidence-based diabetes treatment, including medications like insulin. We rarely build similar systems of care within the walls of our hospitals to treat OUD like we do for diabetes or other commonly encountered diseases like heart failure and chronic obstructive pulmonary disease.
We should be intentional about separating prevention from treatment. Significant work has gone into reducing the availability of prescription opioids and increasing utilization of prescription drug monitoring programs. As a result, the average morphine milligram equivalent per opioid prescription has decreased since 2010.4 An unintended consequence of restricting legal opioids is potentially pushing patients with opioid addiction towards heroin and fentanyl. Limiting opioid prescriptions alone will only decrease opioid overdose mortality by 5% through 2025.5 Thus, treatment of OUD is critical and something that hospitalists should be trained and engaged in.
Food and Drug Administration–approved OUD treatment includes buprenorphine, methadone, and extended-release naltrexone. Buprenorphine is a partial opioid agonist that treats withdrawal and cravings. Buprenorphine started in the hospital reduces mortality, increases time spent in outpatient treatment after discharge, and reduces opioid-related 30-day readmissions by over 50%.6-8 The number needed to treat with buprenorphine to prevent return to illicit opioid use is two.9 While physicians require an 8-hour “x-waiver” training (physician assistants and nurse practitioners require a 24-hour training) to prescribe buprenorphine for the outpatient treatment of OUD, such certification is not required to order the medication as part of an acute hospitalization.
Hospitalization represents a reachable moment and unique opportunity to start treatment for OUD. Patients are away from triggering environments and surrounded by supportive staff. Unfortunately, up to 30% of these patients leave the hospital against medical advice because of inadequately treated withdrawal, unaddressed cravings, and fear of mistreatment.10 Buprenorphine therapy may help tackle the physiological piece of hospital-based treatment, but we also must work on shifting the culture of our institutions. Importantly, OUD is a medical diagnosis. These patients must receive the same dignity, autonomy, and meaningful care afforded to patients with other medical diagnoses. Patients with OUD are not “addicts,” “abusers,” or “frequent fliers.”
Hospitalists have a clear and compelling role in treating OUD. The National Academy of Medicine recently held a workshop where they compared similarities of the HIV crisis with today’s opioid epidemic. The Academy advocated for the development of hospital-based protocols that empower physicians, physician assistants, and nurse practitioners to integrate the treatment of OUD into their practice.11 Some in our field may feel that treating underlying addiction is a role for behavioral health practitioners. This is akin to having said that HIV specialists should be the only providers to treat patients with HIV during its peak. There are simply not enough psychiatrists or addiction medicine specialists to treat all of the patients who need us during this time of national urgency.
There are several examples of institutions that are laying the groundwork for this important work. The University of California, San Francisco; Oregon Health and Science University, Portland; the University of Colorado at Denver, Aurora; Rush Medical College, Boston; Boston Medical Center; the Icahn School of Medicine at Mount Sinai, New York; and the University of Texas at Austin – to name a few. Offering OUD treatment in the hospital setting must be our new and only acceptable standard of care.
What is next? We can start by screening patients for OUD at the time of admission. This can be accomplished by asking two questions: Does the patient misuse prescription or nonprescription opioids? And if so, does the patient become sick if they abruptly stop? If the patient says yes to both, steps should be taken to provide direct and purposeful care related to OUD. Hospitalists should become familiar with buprenorphine therapy and work to reduce stigma by using people-first language with patients, staff, and in medical documentation.
As a society, we should balance our past focus on optimizing opioid prescribing with current efforts to bolster treatment. To that end, a group of SHM members applied to establish a Substance Use Disorder Special Interest Group, which was recently approved by the SHM board of directors. Details on its rollout will be announced shortly. The intention is that this group will serve as a resource to SHM membership and leadership
As practitioners of hospital medicine, we may not have anticipated playing a direct role in treating patients’ underlying addiction. By empowering hospitalists and wisely using medical hospitalization as a time to treat OUD, we can all have an incredible impact on our patients. Let’s get to work.
Mr. Bottner is a hospitalist at Dell Seton Medical Center, Austin, Texas, and clinical assistant professor at the University of Texas at Austin.
References
1. Katz J. You draw it: Just how bad is the drug overdose epidemic? New York Times. https://www.nytimes.com/interactive/2017/04/14/upshot/drug-overdose-epidemic-you-draw-it.html. Published Oct 26, 2017.
2. National Institute on Drug Abuse. Ohio – Opioid summaries by state. 2018. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/ohio_2018.pdf.
3. Peterson C et al. U.S. hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011-2015. J Subst Abuse Treat. 2018;92:35-39. doi: 10.1016/j.jsat.2018.06.008.
4. Guy GP. Vital Signs: Changes in opioid prescribing in the United States, 2006-2015. Morb Mortal Wkly Rep. 2017;66. doi: 10.15585/mmwr.mm6626a4.
5. Chen Q et al. Prevention of prescription opioid misuse and projected overdose deaths in the United States. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2018.7621.
6. Liebschutz J et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: A randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-76.
7. Moreno JL et al. Predictors for 30-day and 90-day hospital readmission among patients with opioid use disorder. J Addict Med. 2019. doi: 10.1097/ADM.0000000000000499.
8. Larochelle MR et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. June 2018. doi: 10.7326/M17-3107.
9. Raleigh MF. Buprenorphine maintenance vs. placebo for opioid dependence. Am Fam Physician. 2017;95(5). https://www.aafp.org/afp/2017/0301/od1.html. Accessed May 12, 2019.
10. Ti L et al. Leaving the hospital against medical advice among people who use illicit drugs: A systematic review. Am J Public Health. 2015;105(12):2587. doi: 10.2105/AJPH.2015.302885a.
11. Springer SAM et al. Integrating treatment at the intersection of opioid use disorder and infectious disease epidemics in medical settings: A call for action after a National Academies of Sciences, Engineering, and Medicine workshop. Ann Intern Med. 2018;169(5):335-6. doi: 10.7326/M18-1203.
Screen patients at the time of admission
Screen patients at the time of admission
Let’s begin with a brief case. A 25-year-old patient with a history of injection heroin use is in your care. He is admitted for treatment of endocarditis and will remain in the hospital for intravenous antibiotics for several weeks. Over the first few days of hospitalization, he frequently asks for pain medicine, stating that he is in severe pain, withdrawal, and having opioid cravings. On day 3, he leaves the hospital against medical advice. After 2 weeks, he presents to the ED in septic shock and spends several weeks in the ICU. Or, alternatively, he is found down in the community and pronounced dead from a heroin overdose.
These cases occur all too often, and hospitalists across the nation are actively building knowledge and programs to improve care for patients with opioid use disorder (OUD). It is evident that opioid misuse is the public health crisis of our time. In 2017, over 70,000 patients died from an overdose, and over 2 million patients in the United States have a diagnosis of OUD.1,2 Many of these patients interact with the hospital at some point during the course of their illness for management of overdose, withdrawal, and other complications of OUD, including endocarditis, osteomyelitis, and skin and soft tissue infections. Moreover, just 20% of the 580,000 patients hospitalized with OUD in 2015 presented as a direct sequelae of the disease.3 Patients with OUD are often admitted for unrelated reasons, but their addiction goes unaddressed.
Opioid use disorder, like many of the other conditions we see, is a chronic relapsing remitting medical disease and a risk factor for premature mortality. When a patient with diabetes is admitted with cellulitis, we might check an A1C, provide diabetic counseling, and offer evidence-based diabetes treatment, including medications like insulin. We rarely build similar systems of care within the walls of our hospitals to treat OUD like we do for diabetes or other commonly encountered diseases like heart failure and chronic obstructive pulmonary disease.
We should be intentional about separating prevention from treatment. Significant work has gone into reducing the availability of prescription opioids and increasing utilization of prescription drug monitoring programs. As a result, the average morphine milligram equivalent per opioid prescription has decreased since 2010.4 An unintended consequence of restricting legal opioids is potentially pushing patients with opioid addiction towards heroin and fentanyl. Limiting opioid prescriptions alone will only decrease opioid overdose mortality by 5% through 2025.5 Thus, treatment of OUD is critical and something that hospitalists should be trained and engaged in.
Food and Drug Administration–approved OUD treatment includes buprenorphine, methadone, and extended-release naltrexone. Buprenorphine is a partial opioid agonist that treats withdrawal and cravings. Buprenorphine started in the hospital reduces mortality, increases time spent in outpatient treatment after discharge, and reduces opioid-related 30-day readmissions by over 50%.6-8 The number needed to treat with buprenorphine to prevent return to illicit opioid use is two.9 While physicians require an 8-hour “x-waiver” training (physician assistants and nurse practitioners require a 24-hour training) to prescribe buprenorphine for the outpatient treatment of OUD, such certification is not required to order the medication as part of an acute hospitalization.
Hospitalization represents a reachable moment and unique opportunity to start treatment for OUD. Patients are away from triggering environments and surrounded by supportive staff. Unfortunately, up to 30% of these patients leave the hospital against medical advice because of inadequately treated withdrawal, unaddressed cravings, and fear of mistreatment.10 Buprenorphine therapy may help tackle the physiological piece of hospital-based treatment, but we also must work on shifting the culture of our institutions. Importantly, OUD is a medical diagnosis. These patients must receive the same dignity, autonomy, and meaningful care afforded to patients with other medical diagnoses. Patients with OUD are not “addicts,” “abusers,” or “frequent fliers.”
Hospitalists have a clear and compelling role in treating OUD. The National Academy of Medicine recently held a workshop where they compared similarities of the HIV crisis with today’s opioid epidemic. The Academy advocated for the development of hospital-based protocols that empower physicians, physician assistants, and nurse practitioners to integrate the treatment of OUD into their practice.11 Some in our field may feel that treating underlying addiction is a role for behavioral health practitioners. This is akin to having said that HIV specialists should be the only providers to treat patients with HIV during its peak. There are simply not enough psychiatrists or addiction medicine specialists to treat all of the patients who need us during this time of national urgency.
There are several examples of institutions that are laying the groundwork for this important work. The University of California, San Francisco; Oregon Health and Science University, Portland; the University of Colorado at Denver, Aurora; Rush Medical College, Boston; Boston Medical Center; the Icahn School of Medicine at Mount Sinai, New York; and the University of Texas at Austin – to name a few. Offering OUD treatment in the hospital setting must be our new and only acceptable standard of care.
What is next? We can start by screening patients for OUD at the time of admission. This can be accomplished by asking two questions: Does the patient misuse prescription or nonprescription opioids? And if so, does the patient become sick if they abruptly stop? If the patient says yes to both, steps should be taken to provide direct and purposeful care related to OUD. Hospitalists should become familiar with buprenorphine therapy and work to reduce stigma by using people-first language with patients, staff, and in medical documentation.
As a society, we should balance our past focus on optimizing opioid prescribing with current efforts to bolster treatment. To that end, a group of SHM members applied to establish a Substance Use Disorder Special Interest Group, which was recently approved by the SHM board of directors. Details on its rollout will be announced shortly. The intention is that this group will serve as a resource to SHM membership and leadership
As practitioners of hospital medicine, we may not have anticipated playing a direct role in treating patients’ underlying addiction. By empowering hospitalists and wisely using medical hospitalization as a time to treat OUD, we can all have an incredible impact on our patients. Let’s get to work.
Mr. Bottner is a hospitalist at Dell Seton Medical Center, Austin, Texas, and clinical assistant professor at the University of Texas at Austin.
References
1. Katz J. You draw it: Just how bad is the drug overdose epidemic? New York Times. https://www.nytimes.com/interactive/2017/04/14/upshot/drug-overdose-epidemic-you-draw-it.html. Published Oct 26, 2017.
2. National Institute on Drug Abuse. Ohio – Opioid summaries by state. 2018. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/ohio_2018.pdf.
3. Peterson C et al. U.S. hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011-2015. J Subst Abuse Treat. 2018;92:35-39. doi: 10.1016/j.jsat.2018.06.008.
4. Guy GP. Vital Signs: Changes in opioid prescribing in the United States, 2006-2015. Morb Mortal Wkly Rep. 2017;66. doi: 10.15585/mmwr.mm6626a4.
5. Chen Q et al. Prevention of prescription opioid misuse and projected overdose deaths in the United States. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2018.7621.
6. Liebschutz J et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: A randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-76.
7. Moreno JL et al. Predictors for 30-day and 90-day hospital readmission among patients with opioid use disorder. J Addict Med. 2019. doi: 10.1097/ADM.0000000000000499.
8. Larochelle MR et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. June 2018. doi: 10.7326/M17-3107.
9. Raleigh MF. Buprenorphine maintenance vs. placebo for opioid dependence. Am Fam Physician. 2017;95(5). https://www.aafp.org/afp/2017/0301/od1.html. Accessed May 12, 2019.
10. Ti L et al. Leaving the hospital against medical advice among people who use illicit drugs: A systematic review. Am J Public Health. 2015;105(12):2587. doi: 10.2105/AJPH.2015.302885a.
11. Springer SAM et al. Integrating treatment at the intersection of opioid use disorder and infectious disease epidemics in medical settings: A call for action after a National Academies of Sciences, Engineering, and Medicine workshop. Ann Intern Med. 2018;169(5):335-6. doi: 10.7326/M18-1203.
Let’s begin with a brief case. A 25-year-old patient with a history of injection heroin use is in your care. He is admitted for treatment of endocarditis and will remain in the hospital for intravenous antibiotics for several weeks. Over the first few days of hospitalization, he frequently asks for pain medicine, stating that he is in severe pain, withdrawal, and having opioid cravings. On day 3, he leaves the hospital against medical advice. After 2 weeks, he presents to the ED in septic shock and spends several weeks in the ICU. Or, alternatively, he is found down in the community and pronounced dead from a heroin overdose.
These cases occur all too often, and hospitalists across the nation are actively building knowledge and programs to improve care for patients with opioid use disorder (OUD). It is evident that opioid misuse is the public health crisis of our time. In 2017, over 70,000 patients died from an overdose, and over 2 million patients in the United States have a diagnosis of OUD.1,2 Many of these patients interact with the hospital at some point during the course of their illness for management of overdose, withdrawal, and other complications of OUD, including endocarditis, osteomyelitis, and skin and soft tissue infections. Moreover, just 20% of the 580,000 patients hospitalized with OUD in 2015 presented as a direct sequelae of the disease.3 Patients with OUD are often admitted for unrelated reasons, but their addiction goes unaddressed.
Opioid use disorder, like many of the other conditions we see, is a chronic relapsing remitting medical disease and a risk factor for premature mortality. When a patient with diabetes is admitted with cellulitis, we might check an A1C, provide diabetic counseling, and offer evidence-based diabetes treatment, including medications like insulin. We rarely build similar systems of care within the walls of our hospitals to treat OUD like we do for diabetes or other commonly encountered diseases like heart failure and chronic obstructive pulmonary disease.
We should be intentional about separating prevention from treatment. Significant work has gone into reducing the availability of prescription opioids and increasing utilization of prescription drug monitoring programs. As a result, the average morphine milligram equivalent per opioid prescription has decreased since 2010.4 An unintended consequence of restricting legal opioids is potentially pushing patients with opioid addiction towards heroin and fentanyl. Limiting opioid prescriptions alone will only decrease opioid overdose mortality by 5% through 2025.5 Thus, treatment of OUD is critical and something that hospitalists should be trained and engaged in.
Food and Drug Administration–approved OUD treatment includes buprenorphine, methadone, and extended-release naltrexone. Buprenorphine is a partial opioid agonist that treats withdrawal and cravings. Buprenorphine started in the hospital reduces mortality, increases time spent in outpatient treatment after discharge, and reduces opioid-related 30-day readmissions by over 50%.6-8 The number needed to treat with buprenorphine to prevent return to illicit opioid use is two.9 While physicians require an 8-hour “x-waiver” training (physician assistants and nurse practitioners require a 24-hour training) to prescribe buprenorphine for the outpatient treatment of OUD, such certification is not required to order the medication as part of an acute hospitalization.
Hospitalization represents a reachable moment and unique opportunity to start treatment for OUD. Patients are away from triggering environments and surrounded by supportive staff. Unfortunately, up to 30% of these patients leave the hospital against medical advice because of inadequately treated withdrawal, unaddressed cravings, and fear of mistreatment.10 Buprenorphine therapy may help tackle the physiological piece of hospital-based treatment, but we also must work on shifting the culture of our institutions. Importantly, OUD is a medical diagnosis. These patients must receive the same dignity, autonomy, and meaningful care afforded to patients with other medical diagnoses. Patients with OUD are not “addicts,” “abusers,” or “frequent fliers.”
Hospitalists have a clear and compelling role in treating OUD. The National Academy of Medicine recently held a workshop where they compared similarities of the HIV crisis with today’s opioid epidemic. The Academy advocated for the development of hospital-based protocols that empower physicians, physician assistants, and nurse practitioners to integrate the treatment of OUD into their practice.11 Some in our field may feel that treating underlying addiction is a role for behavioral health practitioners. This is akin to having said that HIV specialists should be the only providers to treat patients with HIV during its peak. There are simply not enough psychiatrists or addiction medicine specialists to treat all of the patients who need us during this time of national urgency.
There are several examples of institutions that are laying the groundwork for this important work. The University of California, San Francisco; Oregon Health and Science University, Portland; the University of Colorado at Denver, Aurora; Rush Medical College, Boston; Boston Medical Center; the Icahn School of Medicine at Mount Sinai, New York; and the University of Texas at Austin – to name a few. Offering OUD treatment in the hospital setting must be our new and only acceptable standard of care.
What is next? We can start by screening patients for OUD at the time of admission. This can be accomplished by asking two questions: Does the patient misuse prescription or nonprescription opioids? And if so, does the patient become sick if they abruptly stop? If the patient says yes to both, steps should be taken to provide direct and purposeful care related to OUD. Hospitalists should become familiar with buprenorphine therapy and work to reduce stigma by using people-first language with patients, staff, and in medical documentation.
As a society, we should balance our past focus on optimizing opioid prescribing with current efforts to bolster treatment. To that end, a group of SHM members applied to establish a Substance Use Disorder Special Interest Group, which was recently approved by the SHM board of directors. Details on its rollout will be announced shortly. The intention is that this group will serve as a resource to SHM membership and leadership
As practitioners of hospital medicine, we may not have anticipated playing a direct role in treating patients’ underlying addiction. By empowering hospitalists and wisely using medical hospitalization as a time to treat OUD, we can all have an incredible impact on our patients. Let’s get to work.
Mr. Bottner is a hospitalist at Dell Seton Medical Center, Austin, Texas, and clinical assistant professor at the University of Texas at Austin.
References
1. Katz J. You draw it: Just how bad is the drug overdose epidemic? New York Times. https://www.nytimes.com/interactive/2017/04/14/upshot/drug-overdose-epidemic-you-draw-it.html. Published Oct 26, 2017.
2. National Institute on Drug Abuse. Ohio – Opioid summaries by state. 2018. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/ohio_2018.pdf.
3. Peterson C et al. U.S. hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011-2015. J Subst Abuse Treat. 2018;92:35-39. doi: 10.1016/j.jsat.2018.06.008.
4. Guy GP. Vital Signs: Changes in opioid prescribing in the United States, 2006-2015. Morb Mortal Wkly Rep. 2017;66. doi: 10.15585/mmwr.mm6626a4.
5. Chen Q et al. Prevention of prescription opioid misuse and projected overdose deaths in the United States. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2018.7621.
6. Liebschutz J et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: A randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-76.
7. Moreno JL et al. Predictors for 30-day and 90-day hospital readmission among patients with opioid use disorder. J Addict Med. 2019. doi: 10.1097/ADM.0000000000000499.
8. Larochelle MR et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. June 2018. doi: 10.7326/M17-3107.
9. Raleigh MF. Buprenorphine maintenance vs. placebo for opioid dependence. Am Fam Physician. 2017;95(5). https://www.aafp.org/afp/2017/0301/od1.html. Accessed May 12, 2019.
10. Ti L et al. Leaving the hospital against medical advice among people who use illicit drugs: A systematic review. Am J Public Health. 2015;105(12):2587. doi: 10.2105/AJPH.2015.302885a.
11. Springer SAM et al. Integrating treatment at the intersection of opioid use disorder and infectious disease epidemics in medical settings: A call for action after a National Academies of Sciences, Engineering, and Medicine workshop. Ann Intern Med. 2018;169(5):335-6. doi: 10.7326/M18-1203.
Same-day discharge after elective PCI has increased value and patient satisfaction
Background: SDDs are as safe as non-SDDs (NSDDs) in patients after elective PCI, yet there has been only a modest increase in SDD.
Study design: Observational cross-sectional cohort study.
Setting: 493 hospitals in the United States.
Synopsis: With use of the national Premier Healthcare Database, 672,470 elective PCIs from January 2006 to December 2015 with 1-year follow-up showed a wide variation in SDD from 0% to 83% among hospitals with the overall corrected rate of 3.5%. Low-volume PCI hospitals did not increase the rate. Additionally, the cost of SDD patients was $5,128 less than NSDD patients. There was cost saving even with higher-risk transfemoral approaches and patients needing periprocedural hemodynamic or ventilatory support. Complications (death, bleeding, acute kidney injury, or acute MI at 30, 90, and 365 days) were not higher for SDD than for NSDD patients.
Limitations include that 2015 data may not reflect current practices. ICD 9 codes used for obtaining complications data can be misclassified. Cost savings are variable. Patients with periprocedural complications were not candidates for SDD but were included in the data. The study does not account for variation in technique, PCI characteristics, or SDD criteria of hospitals.
Bottom line: Prevalence of SDDs for elective PCI patients varies by institution and is an underutilized opportunity to significantly reduce hospital costs and increase patient satisfaction while maintaining the safety of patients.
Citation: Amin AP et al. Association of same-day discharge after elective percutaneous coronary intervention in the United States with costs and outcomes. JAMA Cardiol. Published online 2018 Sep 26. doi: 10.1001/jamacardio.2018.3029.
Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Background: SDDs are as safe as non-SDDs (NSDDs) in patients after elective PCI, yet there has been only a modest increase in SDD.
Study design: Observational cross-sectional cohort study.
Setting: 493 hospitals in the United States.
Synopsis: With use of the national Premier Healthcare Database, 672,470 elective PCIs from January 2006 to December 2015 with 1-year follow-up showed a wide variation in SDD from 0% to 83% among hospitals with the overall corrected rate of 3.5%. Low-volume PCI hospitals did not increase the rate. Additionally, the cost of SDD patients was $5,128 less than NSDD patients. There was cost saving even with higher-risk transfemoral approaches and patients needing periprocedural hemodynamic or ventilatory support. Complications (death, bleeding, acute kidney injury, or acute MI at 30, 90, and 365 days) were not higher for SDD than for NSDD patients.
Limitations include that 2015 data may not reflect current practices. ICD 9 codes used for obtaining complications data can be misclassified. Cost savings are variable. Patients with periprocedural complications were not candidates for SDD but were included in the data. The study does not account for variation in technique, PCI characteristics, or SDD criteria of hospitals.
Bottom line: Prevalence of SDDs for elective PCI patients varies by institution and is an underutilized opportunity to significantly reduce hospital costs and increase patient satisfaction while maintaining the safety of patients.
Citation: Amin AP et al. Association of same-day discharge after elective percutaneous coronary intervention in the United States with costs and outcomes. JAMA Cardiol. Published online 2018 Sep 26. doi: 10.1001/jamacardio.2018.3029.
Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Background: SDDs are as safe as non-SDDs (NSDDs) in patients after elective PCI, yet there has been only a modest increase in SDD.
Study design: Observational cross-sectional cohort study.
Setting: 493 hospitals in the United States.
Synopsis: With use of the national Premier Healthcare Database, 672,470 elective PCIs from January 2006 to December 2015 with 1-year follow-up showed a wide variation in SDD from 0% to 83% among hospitals with the overall corrected rate of 3.5%. Low-volume PCI hospitals did not increase the rate. Additionally, the cost of SDD patients was $5,128 less than NSDD patients. There was cost saving even with higher-risk transfemoral approaches and patients needing periprocedural hemodynamic or ventilatory support. Complications (death, bleeding, acute kidney injury, or acute MI at 30, 90, and 365 days) were not higher for SDD than for NSDD patients.
Limitations include that 2015 data may not reflect current practices. ICD 9 codes used for obtaining complications data can be misclassified. Cost savings are variable. Patients with periprocedural complications were not candidates for SDD but were included in the data. The study does not account for variation in technique, PCI characteristics, or SDD criteria of hospitals.
Bottom line: Prevalence of SDDs for elective PCI patients varies by institution and is an underutilized opportunity to significantly reduce hospital costs and increase patient satisfaction while maintaining the safety of patients.
Citation: Amin AP et al. Association of same-day discharge after elective percutaneous coronary intervention in the United States with costs and outcomes. JAMA Cardiol. Published online 2018 Sep 26. doi: 10.1001/jamacardio.2018.3029.
Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Risk of cardiac events jumps after COPD exacerbation
particularly in older individuals, new research has found.
In Respirology, researchers report the outcomes of a nationwide, register-based study involving 118,807 patients with chronic obstructive pulmonary disease (COPD) who experienced a major adverse cardiac event after an exacerbation.
They found that the risk of any major cardiac adverse event increased 270% in the 4 weeks after the onset of an exacerbation (95% confidence interval, 3.60-3.80). The strongest association was seen for cardiovascular death, for which there was a 333% increase in risk, but there was also a 257% increase in the risk of acute MI and 178% increase in the risk of stroke.
The risk of major adverse cardiac events was even higher among individuals who were hospitalized because of their COPD exacerbation (odds ratio, 5.92), compared with a 150% increase in risk among those who weren’t hospitalized but were treated with oral corticosteroids and 108% increase among those treated with amoxicillin with enzyme inhibitors.
The risk of a major cardiac event after a COPD exacerbation also increased with age. Among individuals younger than 55 years, there was a 131% increase in risk, but among those aged 55-69 years there was a 234% increase, among those aged 70-79 years the risk increased 282%, and among those aged 80 years and older it increased 318%.
Mette Reilev, from the department of public health at the University of Southern Denmark, Odense, and coauthors suggested that acute exacerbations were associated with elevated levels of systemic inflammatory markers such as fibrinogen and interleukin-6, which were potently prothrombotic and could potentially trigger cardiovascular events.
“Additionally, exacerbations may trigger type II myocardial infarctions secondary to an imbalance in oxygen supply and demand,” they wrote.
The authors raised the question of whether cardiovascular prevention strategies should be part of treatment recommendations for people with COPD, and suggested that prevention of COPD exacerbations could be justified even on cardiovascular grounds alone.
“Studies investigating the effect of cardiovascular treatment on the course of disease among COPD exacerbators are extremely scarce,” they wrote. “Thus, it is currently unknown how to optimize treatment and mitigate the increased risk of [major adverse cardiovascular events] following the onset of exacerbations.”
However, they noted that prednisolone treatment for more severe exacerbations may have a confounding effect, as oral corticosteroids could induce dyslipidemia, hypertension, and hyperglycemia, and increase long-term cardiovascular risk.
Six authors declared funding from the pharmaceutical industry – three of which were institutional support – unrelated to the study.
SOURCE: Reilev M et al. Respirology. 2019 Jun 21. doi: 10.1111/resp.13620.
particularly in older individuals, new research has found.
In Respirology, researchers report the outcomes of a nationwide, register-based study involving 118,807 patients with chronic obstructive pulmonary disease (COPD) who experienced a major adverse cardiac event after an exacerbation.
They found that the risk of any major cardiac adverse event increased 270% in the 4 weeks after the onset of an exacerbation (95% confidence interval, 3.60-3.80). The strongest association was seen for cardiovascular death, for which there was a 333% increase in risk, but there was also a 257% increase in the risk of acute MI and 178% increase in the risk of stroke.
The risk of major adverse cardiac events was even higher among individuals who were hospitalized because of their COPD exacerbation (odds ratio, 5.92), compared with a 150% increase in risk among those who weren’t hospitalized but were treated with oral corticosteroids and 108% increase among those treated with amoxicillin with enzyme inhibitors.
The risk of a major cardiac event after a COPD exacerbation also increased with age. Among individuals younger than 55 years, there was a 131% increase in risk, but among those aged 55-69 years there was a 234% increase, among those aged 70-79 years the risk increased 282%, and among those aged 80 years and older it increased 318%.
Mette Reilev, from the department of public health at the University of Southern Denmark, Odense, and coauthors suggested that acute exacerbations were associated with elevated levels of systemic inflammatory markers such as fibrinogen and interleukin-6, which were potently prothrombotic and could potentially trigger cardiovascular events.
“Additionally, exacerbations may trigger type II myocardial infarctions secondary to an imbalance in oxygen supply and demand,” they wrote.
The authors raised the question of whether cardiovascular prevention strategies should be part of treatment recommendations for people with COPD, and suggested that prevention of COPD exacerbations could be justified even on cardiovascular grounds alone.
“Studies investigating the effect of cardiovascular treatment on the course of disease among COPD exacerbators are extremely scarce,” they wrote. “Thus, it is currently unknown how to optimize treatment and mitigate the increased risk of [major adverse cardiovascular events] following the onset of exacerbations.”
However, they noted that prednisolone treatment for more severe exacerbations may have a confounding effect, as oral corticosteroids could induce dyslipidemia, hypertension, and hyperglycemia, and increase long-term cardiovascular risk.
Six authors declared funding from the pharmaceutical industry – three of which were institutional support – unrelated to the study.
SOURCE: Reilev M et al. Respirology. 2019 Jun 21. doi: 10.1111/resp.13620.
particularly in older individuals, new research has found.
In Respirology, researchers report the outcomes of a nationwide, register-based study involving 118,807 patients with chronic obstructive pulmonary disease (COPD) who experienced a major adverse cardiac event after an exacerbation.
They found that the risk of any major cardiac adverse event increased 270% in the 4 weeks after the onset of an exacerbation (95% confidence interval, 3.60-3.80). The strongest association was seen for cardiovascular death, for which there was a 333% increase in risk, but there was also a 257% increase in the risk of acute MI and 178% increase in the risk of stroke.
The risk of major adverse cardiac events was even higher among individuals who were hospitalized because of their COPD exacerbation (odds ratio, 5.92), compared with a 150% increase in risk among those who weren’t hospitalized but were treated with oral corticosteroids and 108% increase among those treated with amoxicillin with enzyme inhibitors.
The risk of a major cardiac event after a COPD exacerbation also increased with age. Among individuals younger than 55 years, there was a 131% increase in risk, but among those aged 55-69 years there was a 234% increase, among those aged 70-79 years the risk increased 282%, and among those aged 80 years and older it increased 318%.
Mette Reilev, from the department of public health at the University of Southern Denmark, Odense, and coauthors suggested that acute exacerbations were associated with elevated levels of systemic inflammatory markers such as fibrinogen and interleukin-6, which were potently prothrombotic and could potentially trigger cardiovascular events.
“Additionally, exacerbations may trigger type II myocardial infarctions secondary to an imbalance in oxygen supply and demand,” they wrote.
The authors raised the question of whether cardiovascular prevention strategies should be part of treatment recommendations for people with COPD, and suggested that prevention of COPD exacerbations could be justified even on cardiovascular grounds alone.
“Studies investigating the effect of cardiovascular treatment on the course of disease among COPD exacerbators are extremely scarce,” they wrote. “Thus, it is currently unknown how to optimize treatment and mitigate the increased risk of [major adverse cardiovascular events] following the onset of exacerbations.”
However, they noted that prednisolone treatment for more severe exacerbations may have a confounding effect, as oral corticosteroids could induce dyslipidemia, hypertension, and hyperglycemia, and increase long-term cardiovascular risk.
Six authors declared funding from the pharmaceutical industry – three of which were institutional support – unrelated to the study.
SOURCE: Reilev M et al. Respirology. 2019 Jun 21. doi: 10.1111/resp.13620.
FROM RESPIROLOGY
Evidence supports accuracy of COPD diagnosis tool
The ratio of the forced expiratory volume in 1 second to the forced vital capacity (FEV1:FVC) at the recommended threshold of 0.70 effectively diagnosed individuals at risk for clinically significant COPD, a longitudinal study of more than 24,000 individuals has found.
Guidelines from respiratory societies have long recommended a diagnosis of airflow obstruction when the FEV1:FVC is less than 0.70, but no rigorous, population-based studies have been conducted to support this recommendation, wrote Surya P. Bhatt, MD, of the University of Alabama at Birmingham, and colleagues.
“The selection of a threshold for defining airflow obstruction has major implications for patient care and public health as the prevalence of airflow obstruction can vary by as much as 33% depending on which threshold is selected,” they said.
In a study published in JAMA, the researchers reviewed data from 24,207 participants in the National Heart, Lung, and Blood Institute Pooled Cohorts Study to assess the accuracy of different thresholds in predicting COPD events in a large, multiethnic, U.S. population. All participants underwent spirometry; the average age at spirometry was 63 years, and 54% of the patients were women. Patients were enrolled during 1987-2000 and received follow-up longitudinally through 2016.
Overall, 3,925 participants experienced COPD-related events during an average of 15 years of follow-up (more than 340,757 person-years). These events included 3,563 hospitalizations and 447 deaths related to COPD.
The researchers compared three thresholds for FEV1:FVC ratios: a fixed optimal threshold of 0.71, a lower limit of normal (LLN) defined as 0.034, and the currently recommended 0.70.
The optimal 0.71 was not significantly different from the recommended 0.70 but was significantly more accurate than the LLN of 0.034. In addition, the 0.70 value was the optimal predictor in a subgroup analysis of ever-smokers and in multivariate analysis.
The findings were limited by several factors including the use of prebronchodilator spirometry, lack of adjustment for medication use, and limitation of outcomes to COPD mortality or clinical events mainly caused by COPD, which might exclude patients with mild to moderate disease, the researchers noted.
However, ” to help clinicians identify patients at increased risk for significant COPD, they said.
Lead author Dr. Bhatt disclosed a National Institutes of Health grant, consulting fees from Sunovion and research funds from Proterix Bio. The study was supported by grants from multiple agencies of the National Institutes of Health, including the National Heart, Lung, and Blood Institute, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.
The ratio of the forced expiratory volume in 1 second to the forced vital capacity (FEV1:FVC) at the recommended threshold of 0.70 effectively diagnosed individuals at risk for clinically significant COPD, a longitudinal study of more than 24,000 individuals has found.
Guidelines from respiratory societies have long recommended a diagnosis of airflow obstruction when the FEV1:FVC is less than 0.70, but no rigorous, population-based studies have been conducted to support this recommendation, wrote Surya P. Bhatt, MD, of the University of Alabama at Birmingham, and colleagues.
“The selection of a threshold for defining airflow obstruction has major implications for patient care and public health as the prevalence of airflow obstruction can vary by as much as 33% depending on which threshold is selected,” they said.
In a study published in JAMA, the researchers reviewed data from 24,207 participants in the National Heart, Lung, and Blood Institute Pooled Cohorts Study to assess the accuracy of different thresholds in predicting COPD events in a large, multiethnic, U.S. population. All participants underwent spirometry; the average age at spirometry was 63 years, and 54% of the patients were women. Patients were enrolled during 1987-2000 and received follow-up longitudinally through 2016.
Overall, 3,925 participants experienced COPD-related events during an average of 15 years of follow-up (more than 340,757 person-years). These events included 3,563 hospitalizations and 447 deaths related to COPD.
The researchers compared three thresholds for FEV1:FVC ratios: a fixed optimal threshold of 0.71, a lower limit of normal (LLN) defined as 0.034, and the currently recommended 0.70.
The optimal 0.71 was not significantly different from the recommended 0.70 but was significantly more accurate than the LLN of 0.034. In addition, the 0.70 value was the optimal predictor in a subgroup analysis of ever-smokers and in multivariate analysis.
The findings were limited by several factors including the use of prebronchodilator spirometry, lack of adjustment for medication use, and limitation of outcomes to COPD mortality or clinical events mainly caused by COPD, which might exclude patients with mild to moderate disease, the researchers noted.
However, ” to help clinicians identify patients at increased risk for significant COPD, they said.
Lead author Dr. Bhatt disclosed a National Institutes of Health grant, consulting fees from Sunovion and research funds from Proterix Bio. The study was supported by grants from multiple agencies of the National Institutes of Health, including the National Heart, Lung, and Blood Institute, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.
The ratio of the forced expiratory volume in 1 second to the forced vital capacity (FEV1:FVC) at the recommended threshold of 0.70 effectively diagnosed individuals at risk for clinically significant COPD, a longitudinal study of more than 24,000 individuals has found.
Guidelines from respiratory societies have long recommended a diagnosis of airflow obstruction when the FEV1:FVC is less than 0.70, but no rigorous, population-based studies have been conducted to support this recommendation, wrote Surya P. Bhatt, MD, of the University of Alabama at Birmingham, and colleagues.
“The selection of a threshold for defining airflow obstruction has major implications for patient care and public health as the prevalence of airflow obstruction can vary by as much as 33% depending on which threshold is selected,” they said.
In a study published in JAMA, the researchers reviewed data from 24,207 participants in the National Heart, Lung, and Blood Institute Pooled Cohorts Study to assess the accuracy of different thresholds in predicting COPD events in a large, multiethnic, U.S. population. All participants underwent spirometry; the average age at spirometry was 63 years, and 54% of the patients were women. Patients were enrolled during 1987-2000 and received follow-up longitudinally through 2016.
Overall, 3,925 participants experienced COPD-related events during an average of 15 years of follow-up (more than 340,757 person-years). These events included 3,563 hospitalizations and 447 deaths related to COPD.
The researchers compared three thresholds for FEV1:FVC ratios: a fixed optimal threshold of 0.71, a lower limit of normal (LLN) defined as 0.034, and the currently recommended 0.70.
The optimal 0.71 was not significantly different from the recommended 0.70 but was significantly more accurate than the LLN of 0.034. In addition, the 0.70 value was the optimal predictor in a subgroup analysis of ever-smokers and in multivariate analysis.
The findings were limited by several factors including the use of prebronchodilator spirometry, lack of adjustment for medication use, and limitation of outcomes to COPD mortality or clinical events mainly caused by COPD, which might exclude patients with mild to moderate disease, the researchers noted.
However, ” to help clinicians identify patients at increased risk for significant COPD, they said.
Lead author Dr. Bhatt disclosed a National Institutes of Health grant, consulting fees from Sunovion and research funds from Proterix Bio. The study was supported by grants from multiple agencies of the National Institutes of Health, including the National Heart, Lung, and Blood Institute, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.
FROM JAMA
Lipoprotein(a) levels tied to higher ischemic stroke risk
High levels of lipoprotein(a) [Lp(a)] and LPA genotypes were linked to increased ischemic stroke risk in a recent large, contemporary general population study, investigators are reporting in the Journal of the American College of Cardiology.
Anne Langsted, MD, with Copenhagen University Hospital and the University of Copenhagen in Denmark, and her co-researchers evaluated the impact of high Lp(a) levels in a large contemporary cohort of 49,699 individuals in the Copenhagen General Population Study, and another 10,813 individuals in the Copenhagen City Heart Study.
Measurements assessed included plasma lipoprotein(a) levels and carrier or noncarrier status for LPA rs10455872. The endpoint of ischemic stroke was ascertained from Danish national health registries and confirmed by physicians.
Although risk estimates were less pronounced than what was reported before regarding the link between Lp(a) for ischemic heart disease and aortic valve stenosis, the risk of stroke was increased by a factor of 1.6 among individuals with high Lp(a) levels as compared to those with lower levels, the investigators said.
Compared with noncarriers of LPA rs1045572, the hazard ratio for ischemic stroke was 1.23 for carriers of LPA rs1045572, which was associated with high levels plasma lipoprotein(a) levels, according to the researchers.
“Our results indicate a causal association of Lp(a) with risk of ischemic stroke, and emphasize the need for randomized, controlled clinical trials on the effect of Lp(a)-lowering to prevent cardiovascular disease including ischemic stroke,” About 20% of the general population have high Lp(a) levels, and some individuals have extremely high levels, Dr. Langsted and co-authors said in their report.
Interest in Lp(a) as a risk factor for cardiovascular disease has been reignited following large studies showing that high Lp(a) levels were linked to increased risk of myocardial infarction and aortic valve stenosis, according to the investigators.
However, results of various studies are conflicting as to whether high Lp(a) levels increase risk of hemorrhagic or ischemic stroke, they said.
Both cohort studies used in the analysis were supported by sources in Denmark including the Danish Medical Research Council and Copenhagen University Hospital. Dr. Langsted had no disclosures. One co-author reported disclosures related to Akcea, Amgen, Sanofi, Regeneron, and AstraZeneca.
SOURCE: Langsted A, et al. JACC 2019;74[1]: 54-66. doi: 10.1016/j.jacc.2019.03.524
This study linking high lipoprotein(a) [Lp(a)] levels to stroke risk, taken together with previous research, provide a sound basis to routinely perform one-time screening so that individuals with inherited high levels can try to avoid adverse cardiovascular outcomes, according to Christie M. Ballantyne, MD.
“As someone in the dual role of preventive cardiologist and patient with a strong family history of cardiovascular disease, I think that we have sufficient evidence that high Lp(a) is strongly associated with an increased risk of myocardial infarction, stroke, and aortic valve stenosis,” Dr. Ballantyne wrote in an editorial comment on the study.
Evidence is now “overwhelming” that high Lp(a) is linked to myocardial infarction and stroke, and it’s known that statins and aspirin reduce risk of these outcomes, he said in the commentary.
Despite that, scientific statements do not recommend routine Lp(a) testing due to a lack of clinical trials evidence; as a result, clinical trials are not including Lp(a) as a routine measurement: “We thus have a loop of futility—lack of routine measurement leads to lack of data,” he said.
This most recent study from Langsted and colleagues demonstrates that high Lp(a) levels, and genetic variants associated with Lp(a), are associated with increased ischemic stroke risk. “The genetics strongly supported that high Lp(a) levels were in the causal pathway for ischemic stroke and coronary heart disease,” Dr. Ballantyne said.
One major strength and weakness of the study is its large and relatively homogeneous European population—that bolstered the genetic analyses, but also means the data can’t be extrapolated to other populations, such as Africans and East Asians, who have higher stroke rates compared with Europeans, Dr. Ballantyne said.
Dr. Ballantyne is with the Department of Medicine and Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Tex. His editorial comment appears in the Journal of the American College of Cardiology (2019;74[1]:67-9. doi:10.1016/j.jacc.2019.05.029 . Dr. Ballantyne reported disclosures related to Akcea, Amgen, and Novartis.
This study linking high lipoprotein(a) [Lp(a)] levels to stroke risk, taken together with previous research, provide a sound basis to routinely perform one-time screening so that individuals with inherited high levels can try to avoid adverse cardiovascular outcomes, according to Christie M. Ballantyne, MD.
“As someone in the dual role of preventive cardiologist and patient with a strong family history of cardiovascular disease, I think that we have sufficient evidence that high Lp(a) is strongly associated with an increased risk of myocardial infarction, stroke, and aortic valve stenosis,” Dr. Ballantyne wrote in an editorial comment on the study.
Evidence is now “overwhelming” that high Lp(a) is linked to myocardial infarction and stroke, and it’s known that statins and aspirin reduce risk of these outcomes, he said in the commentary.
Despite that, scientific statements do not recommend routine Lp(a) testing due to a lack of clinical trials evidence; as a result, clinical trials are not including Lp(a) as a routine measurement: “We thus have a loop of futility—lack of routine measurement leads to lack of data,” he said.
This most recent study from Langsted and colleagues demonstrates that high Lp(a) levels, and genetic variants associated with Lp(a), are associated with increased ischemic stroke risk. “The genetics strongly supported that high Lp(a) levels were in the causal pathway for ischemic stroke and coronary heart disease,” Dr. Ballantyne said.
One major strength and weakness of the study is its large and relatively homogeneous European population—that bolstered the genetic analyses, but also means the data can’t be extrapolated to other populations, such as Africans and East Asians, who have higher stroke rates compared with Europeans, Dr. Ballantyne said.
Dr. Ballantyne is with the Department of Medicine and Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Tex. His editorial comment appears in the Journal of the American College of Cardiology (2019;74[1]:67-9. doi:10.1016/j.jacc.2019.05.029 . Dr. Ballantyne reported disclosures related to Akcea, Amgen, and Novartis.
This study linking high lipoprotein(a) [Lp(a)] levels to stroke risk, taken together with previous research, provide a sound basis to routinely perform one-time screening so that individuals with inherited high levels can try to avoid adverse cardiovascular outcomes, according to Christie M. Ballantyne, MD.
“As someone in the dual role of preventive cardiologist and patient with a strong family history of cardiovascular disease, I think that we have sufficient evidence that high Lp(a) is strongly associated with an increased risk of myocardial infarction, stroke, and aortic valve stenosis,” Dr. Ballantyne wrote in an editorial comment on the study.
Evidence is now “overwhelming” that high Lp(a) is linked to myocardial infarction and stroke, and it’s known that statins and aspirin reduce risk of these outcomes, he said in the commentary.
Despite that, scientific statements do not recommend routine Lp(a) testing due to a lack of clinical trials evidence; as a result, clinical trials are not including Lp(a) as a routine measurement: “We thus have a loop of futility—lack of routine measurement leads to lack of data,” he said.
This most recent study from Langsted and colleagues demonstrates that high Lp(a) levels, and genetic variants associated with Lp(a), are associated with increased ischemic stroke risk. “The genetics strongly supported that high Lp(a) levels were in the causal pathway for ischemic stroke and coronary heart disease,” Dr. Ballantyne said.
One major strength and weakness of the study is its large and relatively homogeneous European population—that bolstered the genetic analyses, but also means the data can’t be extrapolated to other populations, such as Africans and East Asians, who have higher stroke rates compared with Europeans, Dr. Ballantyne said.
Dr. Ballantyne is with the Department of Medicine and Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Tex. His editorial comment appears in the Journal of the American College of Cardiology (2019;74[1]:67-9. doi:10.1016/j.jacc.2019.05.029 . Dr. Ballantyne reported disclosures related to Akcea, Amgen, and Novartis.
High levels of lipoprotein(a) [Lp(a)] and LPA genotypes were linked to increased ischemic stroke risk in a recent large, contemporary general population study, investigators are reporting in the Journal of the American College of Cardiology.
Anne Langsted, MD, with Copenhagen University Hospital and the University of Copenhagen in Denmark, and her co-researchers evaluated the impact of high Lp(a) levels in a large contemporary cohort of 49,699 individuals in the Copenhagen General Population Study, and another 10,813 individuals in the Copenhagen City Heart Study.
Measurements assessed included plasma lipoprotein(a) levels and carrier or noncarrier status for LPA rs10455872. The endpoint of ischemic stroke was ascertained from Danish national health registries and confirmed by physicians.
Although risk estimates were less pronounced than what was reported before regarding the link between Lp(a) for ischemic heart disease and aortic valve stenosis, the risk of stroke was increased by a factor of 1.6 among individuals with high Lp(a) levels as compared to those with lower levels, the investigators said.
Compared with noncarriers of LPA rs1045572, the hazard ratio for ischemic stroke was 1.23 for carriers of LPA rs1045572, which was associated with high levels plasma lipoprotein(a) levels, according to the researchers.
“Our results indicate a causal association of Lp(a) with risk of ischemic stroke, and emphasize the need for randomized, controlled clinical trials on the effect of Lp(a)-lowering to prevent cardiovascular disease including ischemic stroke,” About 20% of the general population have high Lp(a) levels, and some individuals have extremely high levels, Dr. Langsted and co-authors said in their report.
Interest in Lp(a) as a risk factor for cardiovascular disease has been reignited following large studies showing that high Lp(a) levels were linked to increased risk of myocardial infarction and aortic valve stenosis, according to the investigators.
However, results of various studies are conflicting as to whether high Lp(a) levels increase risk of hemorrhagic or ischemic stroke, they said.
Both cohort studies used in the analysis were supported by sources in Denmark including the Danish Medical Research Council and Copenhagen University Hospital. Dr. Langsted had no disclosures. One co-author reported disclosures related to Akcea, Amgen, Sanofi, Regeneron, and AstraZeneca.
SOURCE: Langsted A, et al. JACC 2019;74[1]: 54-66. doi: 10.1016/j.jacc.2019.03.524
High levels of lipoprotein(a) [Lp(a)] and LPA genotypes were linked to increased ischemic stroke risk in a recent large, contemporary general population study, investigators are reporting in the Journal of the American College of Cardiology.
Anne Langsted, MD, with Copenhagen University Hospital and the University of Copenhagen in Denmark, and her co-researchers evaluated the impact of high Lp(a) levels in a large contemporary cohort of 49,699 individuals in the Copenhagen General Population Study, and another 10,813 individuals in the Copenhagen City Heart Study.
Measurements assessed included plasma lipoprotein(a) levels and carrier or noncarrier status for LPA rs10455872. The endpoint of ischemic stroke was ascertained from Danish national health registries and confirmed by physicians.
Although risk estimates were less pronounced than what was reported before regarding the link between Lp(a) for ischemic heart disease and aortic valve stenosis, the risk of stroke was increased by a factor of 1.6 among individuals with high Lp(a) levels as compared to those with lower levels, the investigators said.
Compared with noncarriers of LPA rs1045572, the hazard ratio for ischemic stroke was 1.23 for carriers of LPA rs1045572, which was associated with high levels plasma lipoprotein(a) levels, according to the researchers.
“Our results indicate a causal association of Lp(a) with risk of ischemic stroke, and emphasize the need for randomized, controlled clinical trials on the effect of Lp(a)-lowering to prevent cardiovascular disease including ischemic stroke,” About 20% of the general population have high Lp(a) levels, and some individuals have extremely high levels, Dr. Langsted and co-authors said in their report.
Interest in Lp(a) as a risk factor for cardiovascular disease has been reignited following large studies showing that high Lp(a) levels were linked to increased risk of myocardial infarction and aortic valve stenosis, according to the investigators.
However, results of various studies are conflicting as to whether high Lp(a) levels increase risk of hemorrhagic or ischemic stroke, they said.
Both cohort studies used in the analysis were supported by sources in Denmark including the Danish Medical Research Council and Copenhagen University Hospital. Dr. Langsted had no disclosures. One co-author reported disclosures related to Akcea, Amgen, Sanofi, Regeneron, and AstraZeneca.
SOURCE: Langsted A, et al. JACC 2019;74[1]: 54-66. doi: 10.1016/j.jacc.2019.03.524
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
Key clinical point:
Major finding: Stroke risk was 1.6X higher with high Lp(a) levels.
Study details: Analysis of 49,699 individuals in the Copenhagen General Population Study, and 10,813 individuals in the Copenhagen City Heart Study.
Disclosures: Both studies were supported by the sources in Denmark including the Danish Medical Research Council and Copenhagen University Hospital. Dr. Langsted had no disclosures.
Source: Langsted A, et al. JACC 2019;74[1]: 54-66. doi: 10.1016/j.jacc.2019.03.524
Mitral valve repair improves prognosis in heart failure patients with secondary MR
Background: In patients with primary degenerative MR, MVR is curative, with the transcatheter approach being safer than surgical repair. However, it is unknown whether patients with secondary MR from left ventricular dilatation would confer the same benefit of MVR.
Study design: Multicenter, randomized, controlled, parallel-group, open-label trial.
Setting: 78 sites in the United States and Canada.
Synopsis: From December 2012 to June 2017, 614 patients from 78 centers in the United States and Canada with symptomatic MR were enrolled with 302 patients assigned to the device group (transcatheter MVR and medical treatment) and 312 to the control group (medical therapy). Over 2 years, the device group’s annual rate for heart failure hospitalizations was significantly lower (35.8%/patient-year versus 67.9%/patient-year in the control group), as was all-cause mortality (29.1% for the device group versus 46.1%). The rate of freedom from device-related complications was 96.6%, better than the goal of 88%. There was improvement in quality of life, functional capacity, severity of MR, and left ventricular remodeling.
Limitations include that investigators were not blinded because the device was visible on imaging. Longer follow-up in the device group may have contributed to the observed decreased mortality. It is unknown whether less-symptomatic patients would attain the same benefit.
Bottom line: In patients with symptomatic, moderate to severe, and severe secondary MR, MVR lowers rates of hospitalization, decreases mortality, and improves quality of life.
Citation: Stone GW et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Sep 23. doi: 10.1056/NEJMoa1806640.
Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Background: In patients with primary degenerative MR, MVR is curative, with the transcatheter approach being safer than surgical repair. However, it is unknown whether patients with secondary MR from left ventricular dilatation would confer the same benefit of MVR.
Study design: Multicenter, randomized, controlled, parallel-group, open-label trial.
Setting: 78 sites in the United States and Canada.
Synopsis: From December 2012 to June 2017, 614 patients from 78 centers in the United States and Canada with symptomatic MR were enrolled with 302 patients assigned to the device group (transcatheter MVR and medical treatment) and 312 to the control group (medical therapy). Over 2 years, the device group’s annual rate for heart failure hospitalizations was significantly lower (35.8%/patient-year versus 67.9%/patient-year in the control group), as was all-cause mortality (29.1% for the device group versus 46.1%). The rate of freedom from device-related complications was 96.6%, better than the goal of 88%. There was improvement in quality of life, functional capacity, severity of MR, and left ventricular remodeling.
Limitations include that investigators were not blinded because the device was visible on imaging. Longer follow-up in the device group may have contributed to the observed decreased mortality. It is unknown whether less-symptomatic patients would attain the same benefit.
Bottom line: In patients with symptomatic, moderate to severe, and severe secondary MR, MVR lowers rates of hospitalization, decreases mortality, and improves quality of life.
Citation: Stone GW et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Sep 23. doi: 10.1056/NEJMoa1806640.
Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.
Background: In patients with primary degenerative MR, MVR is curative, with the transcatheter approach being safer than surgical repair. However, it is unknown whether patients with secondary MR from left ventricular dilatation would confer the same benefit of MVR.
Study design: Multicenter, randomized, controlled, parallel-group, open-label trial.
Setting: 78 sites in the United States and Canada.
Synopsis: From December 2012 to June 2017, 614 patients from 78 centers in the United States and Canada with symptomatic MR were enrolled with 302 patients assigned to the device group (transcatheter MVR and medical treatment) and 312 to the control group (medical therapy). Over 2 years, the device group’s annual rate for heart failure hospitalizations was significantly lower (35.8%/patient-year versus 67.9%/patient-year in the control group), as was all-cause mortality (29.1% for the device group versus 46.1%). The rate of freedom from device-related complications was 96.6%, better than the goal of 88%. There was improvement in quality of life, functional capacity, severity of MR, and left ventricular remodeling.
Limitations include that investigators were not blinded because the device was visible on imaging. Longer follow-up in the device group may have contributed to the observed decreased mortality. It is unknown whether less-symptomatic patients would attain the same benefit.
Bottom line: In patients with symptomatic, moderate to severe, and severe secondary MR, MVR lowers rates of hospitalization, decreases mortality, and improves quality of life.
Citation: Stone GW et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Sep 23. doi: 10.1056/NEJMoa1806640.
Dr. Kochar is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.