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CHICAGO – A European clinical trial that targeted a mean arterial blood pressure after cardiac arrest higher than what the existing guidelines recommend found that the approach was safe, improved blood flow and oxygen to the brain, helped patients recover quicker, and reduced the number of adverse cardiac events, although it did not reduce the extent of anoxic brain damage or improve functional outcomes, the lead investigator reported at the American Heart Association scientific sessions.

The Neuroprotect trial randomly assigned 112 adult survivors of an out-of-hospital cardiac arrest who were unconscious upon admission to two study groups: early goal-directed hemodynamic optimization (EGDHO), in which researchers used a targeted mean arterial pressure (MAP) of 85-100 mm Hg and mixed venous oxygen saturation between 65% and 75% during the first 36 hours after ICU admission; and the standard care group, in which they used the guideline-recommended MAP target of 65 mm Hg, said Koen Ameloot, MD, of East Limburg Hospital in Genk, Belgium.

“EGDHO clearly improved cerebral perfusion and oxygenation, thereby for the first time providing the proof of concept for this new hemodynamic target,” Dr. Ameloot said. “However, this did not result in the reduction of the extent of anoxic brain hemorrhage or effusion rate on MRI or an improvement in functional outcome at 180 days.”

He noted the trial was predicated on improving upon the so-called “two-hit” model of cardiac arrest sequelae: the first hit being the no-flow and low-flow period before achieving restoration of spontaneous circulation; the second hit being hypoperfusion and reperfusion injury during ICU stay.

Dr. Ameloot referenced a study in which he and other coauthors reported that patients with a MAP target of 65 mm Hg “experience a profound drop of cerebral oxygen saturation during the first 12 hours of ICU stay that may cause additional brain damage” (Resuscitation. 2018;123:92-7).

The researchers explored the question of what is the optimal MAP if a target of 65 mm Hg is too low, Dr. Ameloot said. “We showed that maximal brain oxygenation is achieved with a MAP of 100 mm Hg, while lower MAPs were associated with submaximal brain perfusion and higher MAPs with excessive after-load, a reduction in stroke volume, and suboptimal cerebral oxygenation.”

During the 36-hour intervention period, the EGDHO patients received higher doses of norepinephrine, Dr. Ameloot said. “This resulted in significant improvement of cerebral oxygenation during the first 12 hours and was paralleled by significantly higher cerebral perfusion in the subset of patients in whom Doppler measurements were performed,” he said. “While patients allocated to the MAP 65 mm Hg target experienced a profound drop of cerebral oxygenation during the critical first 6-12 hours of ICU stay, cerebral oxygenation was maintained at 67% in patients assigned to EGDHO.”

However, the rate of anoxic brain damage, measured as the percentage of irreversibly damaged anoxic voxels on diffusion-weighted MRI – the primary endpoint of the study – was actually higher in the EGDHO group, 16% vs. 12%, Dr. Ameloot said. “The percentage of anoxic voxels was only a poor predictor of favorable neurological outcome at 180 days, questioning the validity of the primary endpoint,” he said. He also noted that 23% of the trial participants did not have an MRI scan because of higher than expected 5-day rates of death.

“The percentage of patients with favorable neurological outcome tended to be somewhat higher in the intervention arm, although this did not reach statistical significance at ICU discharge and at 180 days,” Dr. Ameloot said. He noted that 42% of the intervention group and 33% of controls in the full-analysis set (P = .30) and 43% and 27%, respectively, in the per-protocol set (P = .15) had a favorable neurological outcome, as calculated using the Glasgow-Pittsburgh Cerebral Performance Category scores of 1 or 2, at 180 days.

The study did not reveal any noteworthy differences in ICU stay (7 vs. 8 days, P = .13) or days on mechanical ventilation (5 vs. 7, P = .31), although fewer patients in the EGDHO group required a tracheostomy (4% vs. 18%, P = .02). The intervention group also had lower rates of cardiac events, including recurrent cardiac arrest, limb ischemia, new atrial fibrillation, and pulmonary edema (13% vs. 33%; P = .02), Dr. Ameloot said.

Future post-hoc analyses of the data will explore the hypothesis that higher blood pressure leads to improved coronary perfusion and reduced infarct size, thus improving prognosis, he added.

“Should this trial therefore be the definite end to the promising hypothesis that improving brain oxygenation might reduce the second hit in post–cardiac arrest patients? I don’t think so,” Dr. Ameloot said. He noted a few limits to the study: that the perfusion rate on MRI was a poor predictor of 180-day outcome; that more patients than expected entered the trial without receiving basic life support and with nonshockable rhythms; and that there was possibly less extensive brain damage among controls at baseline. “Only an adequately powered clinical trial can provide an answer about the effects of EGDHO in post–cardiac arrest patients,” Dr. Ameloot said.

Dr. Ameloot had no financial relationships to disclose.

SOURCE: Ameloot K et al. AHA 2018, Abstract 18620
 

CHICAGO – A European clinical trial that targeted a mean arterial blood pressure after cardiac arrest higher than what the existing guidelines recommend found that the approach was safe, improved blood flow and oxygen to the brain, helped patients recover quicker, and reduced the number of adverse cardiac events, although it did not reduce the extent of anoxic brain damage or improve functional outcomes, the lead investigator reported at the American Heart Association scientific sessions.

The Neuroprotect trial randomly assigned 112 adult survivors of an out-of-hospital cardiac arrest who were unconscious upon admission to two study groups: early goal-directed hemodynamic optimization (EGDHO), in which researchers used a targeted mean arterial pressure (MAP) of 85-100 mm Hg and mixed venous oxygen saturation between 65% and 75% during the first 36 hours after ICU admission; and the standard care group, in which they used the guideline-recommended MAP target of 65 mm Hg, said Koen Ameloot, MD, of East Limburg Hospital in Genk, Belgium.

“EGDHO clearly improved cerebral perfusion and oxygenation, thereby for the first time providing the proof of concept for this new hemodynamic target,” Dr. Ameloot said. “However, this did not result in the reduction of the extent of anoxic brain hemorrhage or effusion rate on MRI or an improvement in functional outcome at 180 days.”

He noted the trial was predicated on improving upon the so-called “two-hit” model of cardiac arrest sequelae: the first hit being the no-flow and low-flow period before achieving restoration of spontaneous circulation; the second hit being hypoperfusion and reperfusion injury during ICU stay.

Dr. Ameloot referenced a study in which he and other coauthors reported that patients with a MAP target of 65 mm Hg “experience a profound drop of cerebral oxygen saturation during the first 12 hours of ICU stay that may cause additional brain damage” (Resuscitation. 2018;123:92-7).

The researchers explored the question of what is the optimal MAP if a target of 65 mm Hg is too low, Dr. Ameloot said. “We showed that maximal brain oxygenation is achieved with a MAP of 100 mm Hg, while lower MAPs were associated with submaximal brain perfusion and higher MAPs with excessive after-load, a reduction in stroke volume, and suboptimal cerebral oxygenation.”

During the 36-hour intervention period, the EGDHO patients received higher doses of norepinephrine, Dr. Ameloot said. “This resulted in significant improvement of cerebral oxygenation during the first 12 hours and was paralleled by significantly higher cerebral perfusion in the subset of patients in whom Doppler measurements were performed,” he said. “While patients allocated to the MAP 65 mm Hg target experienced a profound drop of cerebral oxygenation during the critical first 6-12 hours of ICU stay, cerebral oxygenation was maintained at 67% in patients assigned to EGDHO.”

However, the rate of anoxic brain damage, measured as the percentage of irreversibly damaged anoxic voxels on diffusion-weighted MRI – the primary endpoint of the study – was actually higher in the EGDHO group, 16% vs. 12%, Dr. Ameloot said. “The percentage of anoxic voxels was only a poor predictor of favorable neurological outcome at 180 days, questioning the validity of the primary endpoint,” he said. He also noted that 23% of the trial participants did not have an MRI scan because of higher than expected 5-day rates of death.

“The percentage of patients with favorable neurological outcome tended to be somewhat higher in the intervention arm, although this did not reach statistical significance at ICU discharge and at 180 days,” Dr. Ameloot said. He noted that 42% of the intervention group and 33% of controls in the full-analysis set (P = .30) and 43% and 27%, respectively, in the per-protocol set (P = .15) had a favorable neurological outcome, as calculated using the Glasgow-Pittsburgh Cerebral Performance Category scores of 1 or 2, at 180 days.

The study did not reveal any noteworthy differences in ICU stay (7 vs. 8 days, P = .13) or days on mechanical ventilation (5 vs. 7, P = .31), although fewer patients in the EGDHO group required a tracheostomy (4% vs. 18%, P = .02). The intervention group also had lower rates of cardiac events, including recurrent cardiac arrest, limb ischemia, new atrial fibrillation, and pulmonary edema (13% vs. 33%; P = .02), Dr. Ameloot said.

Future post-hoc analyses of the data will explore the hypothesis that higher blood pressure leads to improved coronary perfusion and reduced infarct size, thus improving prognosis, he added.

“Should this trial therefore be the definite end to the promising hypothesis that improving brain oxygenation might reduce the second hit in post–cardiac arrest patients? I don’t think so,” Dr. Ameloot said. He noted a few limits to the study: that the perfusion rate on MRI was a poor predictor of 180-day outcome; that more patients than expected entered the trial without receiving basic life support and with nonshockable rhythms; and that there was possibly less extensive brain damage among controls at baseline. “Only an adequately powered clinical trial can provide an answer about the effects of EGDHO in post–cardiac arrest patients,” Dr. Ameloot said.

Dr. Ameloot had no financial relationships to disclose.

SOURCE: Ameloot K et al. AHA 2018, Abstract 18620
 

CHICAGO – A European clinical trial that targeted a mean arterial blood pressure after cardiac arrest higher than what the existing guidelines recommend found that the approach was safe, improved blood flow and oxygen to the brain, helped patients recover quicker, and reduced the number of adverse cardiac events, although it did not reduce the extent of anoxic brain damage or improve functional outcomes, the lead investigator reported at the American Heart Association scientific sessions.

The Neuroprotect trial randomly assigned 112 adult survivors of an out-of-hospital cardiac arrest who were unconscious upon admission to two study groups: early goal-directed hemodynamic optimization (EGDHO), in which researchers used a targeted mean arterial pressure (MAP) of 85-100 mm Hg and mixed venous oxygen saturation between 65% and 75% during the first 36 hours after ICU admission; and the standard care group, in which they used the guideline-recommended MAP target of 65 mm Hg, said Koen Ameloot, MD, of East Limburg Hospital in Genk, Belgium.

“EGDHO clearly improved cerebral perfusion and oxygenation, thereby for the first time providing the proof of concept for this new hemodynamic target,” Dr. Ameloot said. “However, this did not result in the reduction of the extent of anoxic brain hemorrhage or effusion rate on MRI or an improvement in functional outcome at 180 days.”

He noted the trial was predicated on improving upon the so-called “two-hit” model of cardiac arrest sequelae: the first hit being the no-flow and low-flow period before achieving restoration of spontaneous circulation; the second hit being hypoperfusion and reperfusion injury during ICU stay.

Dr. Ameloot referenced a study in which he and other coauthors reported that patients with a MAP target of 65 mm Hg “experience a profound drop of cerebral oxygen saturation during the first 12 hours of ICU stay that may cause additional brain damage” (Resuscitation. 2018;123:92-7).

The researchers explored the question of what is the optimal MAP if a target of 65 mm Hg is too low, Dr. Ameloot said. “We showed that maximal brain oxygenation is achieved with a MAP of 100 mm Hg, while lower MAPs were associated with submaximal brain perfusion and higher MAPs with excessive after-load, a reduction in stroke volume, and suboptimal cerebral oxygenation.”

During the 36-hour intervention period, the EGDHO patients received higher doses of norepinephrine, Dr. Ameloot said. “This resulted in significant improvement of cerebral oxygenation during the first 12 hours and was paralleled by significantly higher cerebral perfusion in the subset of patients in whom Doppler measurements were performed,” he said. “While patients allocated to the MAP 65 mm Hg target experienced a profound drop of cerebral oxygenation during the critical first 6-12 hours of ICU stay, cerebral oxygenation was maintained at 67% in patients assigned to EGDHO.”

However, the rate of anoxic brain damage, measured as the percentage of irreversibly damaged anoxic voxels on diffusion-weighted MRI – the primary endpoint of the study – was actually higher in the EGDHO group, 16% vs. 12%, Dr. Ameloot said. “The percentage of anoxic voxels was only a poor predictor of favorable neurological outcome at 180 days, questioning the validity of the primary endpoint,” he said. He also noted that 23% of the trial participants did not have an MRI scan because of higher than expected 5-day rates of death.

“The percentage of patients with favorable neurological outcome tended to be somewhat higher in the intervention arm, although this did not reach statistical significance at ICU discharge and at 180 days,” Dr. Ameloot said. He noted that 42% of the intervention group and 33% of controls in the full-analysis set (P = .30) and 43% and 27%, respectively, in the per-protocol set (P = .15) had a favorable neurological outcome, as calculated using the Glasgow-Pittsburgh Cerebral Performance Category scores of 1 or 2, at 180 days.

The study did not reveal any noteworthy differences in ICU stay (7 vs. 8 days, P = .13) or days on mechanical ventilation (5 vs. 7, P = .31), although fewer patients in the EGDHO group required a tracheostomy (4% vs. 18%, P = .02). The intervention group also had lower rates of cardiac events, including recurrent cardiac arrest, limb ischemia, new atrial fibrillation, and pulmonary edema (13% vs. 33%; P = .02), Dr. Ameloot said.

Future post-hoc analyses of the data will explore the hypothesis that higher blood pressure leads to improved coronary perfusion and reduced infarct size, thus improving prognosis, he added.

“Should this trial therefore be the definite end to the promising hypothesis that improving brain oxygenation might reduce the second hit in post–cardiac arrest patients? I don’t think so,” Dr. Ameloot said. He noted a few limits to the study: that the perfusion rate on MRI was a poor predictor of 180-day outcome; that more patients than expected entered the trial without receiving basic life support and with nonshockable rhythms; and that there was possibly less extensive brain damage among controls at baseline. “Only an adequately powered clinical trial can provide an answer about the effects of EGDHO in post–cardiac arrest patients,” Dr. Ameloot said.

Dr. Ameloot had no financial relationships to disclose.

SOURCE: Ameloot K et al. AHA 2018, Abstract 18620
 

As Dr. Melanie Schaffer neared the end of her family medicine residency in the spring of 2015, she found herself considering a hospital medicine fellowship. Unsure if she could get a hospitalist job in an urban market given the outpatient focus of her training, Dr. Schaffer began searching for fellowships on the Society of Hospital Medicine website.¹

Likewise, in 2014 Dr. Micah Prochaska was seriously contemplating a hospital medicine fellowship. He was about to graduate from internal medicine residency at the University of Chicago and was eager to gain skills and experience in clinical research.

In 2006, there were a total of 16 HM fellowship programs in the United States, catering to graduates of internal medicine, family medicine, and pediatric residencies.² Since that time, the number of hospital medicine fellowships has grown considerably, paralleling the explosive growth of hospital medicine as a specialty. For example, at one point in the summer of 2018, the SHM website listed 13 clinical family practice fellowships, 29 internal medicine fellowships, and 26 pediatric fellowships. Each fellowship emphasized different aspects of hospital medicine including clinical practice, research, quality improvement, and leadership.

Now more than ever, residents interested in hospital medicine may get overwhelmed by the multitude of options for fellowship training. And the question remains: why pursue fellowship training in the first place?

“I learned that as a family physician it is harder to get a job as a hospitalist outside of smaller communities, and I wanted to have extra training and credentials,” Dr. Schaffer said. “I pursued a fellowship in hospital medicine to hone my inpatient skills, obtain more ICU exposure, and work on procedures.”

Dr. Schaffer’s online search eventually led her to the Advanced Hospital Medicine Fellowship at Swedish Medical Center in Seattle. This 1-year hospital medicine fellowship started in 2008 with an intentional clinical focus, aiming to provide additional training opportunities in hospital medicine primarily to family medicine residency graduates.

“The goal of our program is to bridge the gap between the training of family medicine and internal medicine so our trainees can refine and develop their inpatient skills,” said Dr. David Wilson, program director of the Swedish Hospitalist Fellowship.

During her fellowship year, Dr. Schaffer was caring for hospitalized adult patients on a general medical ward, with supervision from a dedicated group of teaching hospitalists. She also completed rotations in the ICU, on subspecialty services, and received advanced training in point-of-care ultrasound.

Now in her second year of practice as a full time adult hospitalist at Swedish Medical Center, Dr. Schaffer believes her year of hospital medicine fellowship prepared her well for her current position.

“I am constantly using the tools and knowledge I acquired during my fellowship year,” she said. “I would encourage anyone who has an interest in working on procedural skills and gaining more ICU exposure to pursue a similar fellowship.”

In contrast to Dr. Schaffer, Dr. Prochaska was satisfied with his clinical training but chose to pursue a hospital medicine fellowship to develop research skills. Prior to starting the 2-year Hospitalist Scholars Training Program at the University of Chicago in 2014, Dr. Prochaska had a clear vision of becoming a hospital medicine health outcomes investigator, and believed this career would not be possible without the additional training offered by a research-focused fellowship program.

The Hospitalist Scholars Program at the University of Chicago, one of the first programs of its kind, offers a built-in master’s degree to all participants. At the conclusion of his fellowship training in 2016, Dr. Prochaska completed his Master’s in Health Sciences, which gives considerable attention to biostatistics and epidemiology. According to Dr. Prochaska, the key to becoming a successful academic researcher lies in one’s ability to write grants and receive funding, a skill he honed during this fellowship.

Now on faculty at the University of Chicago in the Section of Hospital Medicine, Dr. Prochaska devotes approximately 75% of his time to research and 25% to patient care.

Beyond the research training and experience he gained during his hospital medicine fellowship, Dr. Prochaska said he values the mentorship afforded to him. He noted that one of the most meaningful experiences during his 2 years of fellowship was having the opportunity to sit down with his program directors, Dr. Vineet Arora and Dr. David Meltzer, to discuss the trajectory of his career in academic medicine.

“It is hard to find senior mentors in hospital medicine,” Dr. Prochaska said. “You could get a master’s degree on your own, but with the fellowship program, your mentors can help you think about the next steps in your career.”

For Dr. Schaffer and Dr. Prochaska, fellowship provided training and experience well-matched to their individual goals and helped foster their careers in hospital medicine. For some, however, a fellowship may not be a necessary step on the path to becoming a hospitalist. Many leaders in the field of hospital medicine have advanced in their careers without further training. In addition, receiving little more than a resident’s salary for an additional year or more during fellowship may not be financially tenable for some. Given the ongoing demand for hospitalists across the country, the lack of a fellowship on your resume may not significantly diminish your chances of securing a position, especially in the community setting.

In the end, the decision of whether to pursue a hospital medicine fellowship is a personal one, and the programs available are as varied as the individuals completing them. “Any hospitalist interested in more than simply patient care – potentially QI, medical education, policy, or administration – should consider a fellowship,” Dr. Prochaska said. “Hospitalists have a unique opportunity to be involved in all these areas, but there are absolutely critical skills you need to develop beyond your clinical skills to succeed.” Fellowships are one way to enhance these nonclinical skills.

The best advice to those considering a hospital medicine fellowship? Dedicate some time to engage in self-assessment and goal setting, before jumping to SHM’s online list of programs.

Ask yourself: “Where do I see myself in 10 years? What do I wish to accomplish in my career as a hospitalist? What additional training (clinical, research, quality improvement, leadership) might I need to achieve these goals? Will completion of a hospital medicine fellowship help me make this vision a reality?”

For Dr. Schaffer, a clinical practice–focused hospital medicine fellowship served as a necessary bridge between her family medicine residency and her current position as an adult hospitalist. While for Dr. Prochaska, a research-intensive hospital medicine fellowship was a key step in launching his academic career.

Of course, for many trainees at the end of residency, your self-assessment may lead you in the opposite direction. In that case it is time to find your first “real job” as an attending physician. But if you feel you need more training to meet your personal goals you should rest assured – whether now or in the future, there is almost certainly a hospital medicine fellowship that is right for you.

Dr. Schouten is a hospitalist at Mayo Clinic in Rochester, Minn., and serves on the Society of Hospital Medicine Physicians in Training Committee. Dr. Sundar is a hospitalist at Emory Saint Joseph’s Hospital in Sandy Springs, Ga., and serves as the Site Assistant Director for Education.

References


1. www.hospitalmedicine.org/membership/hospitalist-fellowships/

2. Ranji et al. “Hospital medicine fellowships: Works in progress.” American J Med. 2006 Jan;119(1):72.e1-7. doi: 10.1016/j.amjmed.2005.07.061.
 

As Dr. Melanie Schaffer neared the end of her family medicine residency in the spring of 2015, she found herself considering a hospital medicine fellowship. Unsure if she could get a hospitalist job in an urban market given the outpatient focus of her training, Dr. Schaffer began searching for fellowships on the Society of Hospital Medicine website.¹

Likewise, in 2014 Dr. Micah Prochaska was seriously contemplating a hospital medicine fellowship. He was about to graduate from internal medicine residency at the University of Chicago and was eager to gain skills and experience in clinical research.

In 2006, there were a total of 16 HM fellowship programs in the United States, catering to graduates of internal medicine, family medicine, and pediatric residencies.² Since that time, the number of hospital medicine fellowships has grown considerably, paralleling the explosive growth of hospital medicine as a specialty. For example, at one point in the summer of 2018, the SHM website listed 13 clinical family practice fellowships, 29 internal medicine fellowships, and 26 pediatric fellowships. Each fellowship emphasized different aspects of hospital medicine including clinical practice, research, quality improvement, and leadership.

Now more than ever, residents interested in hospital medicine may get overwhelmed by the multitude of options for fellowship training. And the question remains: why pursue fellowship training in the first place?

“I learned that as a family physician it is harder to get a job as a hospitalist outside of smaller communities, and I wanted to have extra training and credentials,” Dr. Schaffer said. “I pursued a fellowship in hospital medicine to hone my inpatient skills, obtain more ICU exposure, and work on procedures.”

Dr. Schaffer’s online search eventually led her to the Advanced Hospital Medicine Fellowship at Swedish Medical Center in Seattle. This 1-year hospital medicine fellowship started in 2008 with an intentional clinical focus, aiming to provide additional training opportunities in hospital medicine primarily to family medicine residency graduates.

“The goal of our program is to bridge the gap between the training of family medicine and internal medicine so our trainees can refine and develop their inpatient skills,” said Dr. David Wilson, program director of the Swedish Hospitalist Fellowship.

During her fellowship year, Dr. Schaffer was caring for hospitalized adult patients on a general medical ward, with supervision from a dedicated group of teaching hospitalists. She also completed rotations in the ICU, on subspecialty services, and received advanced training in point-of-care ultrasound.

Now in her second year of practice as a full time adult hospitalist at Swedish Medical Center, Dr. Schaffer believes her year of hospital medicine fellowship prepared her well for her current position.

“I am constantly using the tools and knowledge I acquired during my fellowship year,” she said. “I would encourage anyone who has an interest in working on procedural skills and gaining more ICU exposure to pursue a similar fellowship.”

In contrast to Dr. Schaffer, Dr. Prochaska was satisfied with his clinical training but chose to pursue a hospital medicine fellowship to develop research skills. Prior to starting the 2-year Hospitalist Scholars Training Program at the University of Chicago in 2014, Dr. Prochaska had a clear vision of becoming a hospital medicine health outcomes investigator, and believed this career would not be possible without the additional training offered by a research-focused fellowship program.

The Hospitalist Scholars Program at the University of Chicago, one of the first programs of its kind, offers a built-in master’s degree to all participants. At the conclusion of his fellowship training in 2016, Dr. Prochaska completed his Master’s in Health Sciences, which gives considerable attention to biostatistics and epidemiology. According to Dr. Prochaska, the key to becoming a successful academic researcher lies in one’s ability to write grants and receive funding, a skill he honed during this fellowship.

Now on faculty at the University of Chicago in the Section of Hospital Medicine, Dr. Prochaska devotes approximately 75% of his time to research and 25% to patient care.

Beyond the research training and experience he gained during his hospital medicine fellowship, Dr. Prochaska said he values the mentorship afforded to him. He noted that one of the most meaningful experiences during his 2 years of fellowship was having the opportunity to sit down with his program directors, Dr. Vineet Arora and Dr. David Meltzer, to discuss the trajectory of his career in academic medicine.

“It is hard to find senior mentors in hospital medicine,” Dr. Prochaska said. “You could get a master’s degree on your own, but with the fellowship program, your mentors can help you think about the next steps in your career.”

For Dr. Schaffer and Dr. Prochaska, fellowship provided training and experience well-matched to their individual goals and helped foster their careers in hospital medicine. For some, however, a fellowship may not be a necessary step on the path to becoming a hospitalist. Many leaders in the field of hospital medicine have advanced in their careers without further training. In addition, receiving little more than a resident’s salary for an additional year or more during fellowship may not be financially tenable for some. Given the ongoing demand for hospitalists across the country, the lack of a fellowship on your resume may not significantly diminish your chances of securing a position, especially in the community setting.

In the end, the decision of whether to pursue a hospital medicine fellowship is a personal one, and the programs available are as varied as the individuals completing them. “Any hospitalist interested in more than simply patient care – potentially QI, medical education, policy, or administration – should consider a fellowship,” Dr. Prochaska said. “Hospitalists have a unique opportunity to be involved in all these areas, but there are absolutely critical skills you need to develop beyond your clinical skills to succeed.” Fellowships are one way to enhance these nonclinical skills.

The best advice to those considering a hospital medicine fellowship? Dedicate some time to engage in self-assessment and goal setting, before jumping to SHM’s online list of programs.

Ask yourself: “Where do I see myself in 10 years? What do I wish to accomplish in my career as a hospitalist? What additional training (clinical, research, quality improvement, leadership) might I need to achieve these goals? Will completion of a hospital medicine fellowship help me make this vision a reality?”

For Dr. Schaffer, a clinical practice–focused hospital medicine fellowship served as a necessary bridge between her family medicine residency and her current position as an adult hospitalist. While for Dr. Prochaska, a research-intensive hospital medicine fellowship was a key step in launching his academic career.

Of course, for many trainees at the end of residency, your self-assessment may lead you in the opposite direction. In that case it is time to find your first “real job” as an attending physician. But if you feel you need more training to meet your personal goals you should rest assured – whether now or in the future, there is almost certainly a hospital medicine fellowship that is right for you.

Dr. Schouten is a hospitalist at Mayo Clinic in Rochester, Minn., and serves on the Society of Hospital Medicine Physicians in Training Committee. Dr. Sundar is a hospitalist at Emory Saint Joseph’s Hospital in Sandy Springs, Ga., and serves as the Site Assistant Director for Education.

References


1. www.hospitalmedicine.org/membership/hospitalist-fellowships/

2. Ranji et al. “Hospital medicine fellowships: Works in progress.” American J Med. 2006 Jan;119(1):72.e1-7. doi: 10.1016/j.amjmed.2005.07.061.
 

As Dr. Melanie Schaffer neared the end of her family medicine residency in the spring of 2015, she found herself considering a hospital medicine fellowship. Unsure if she could get a hospitalist job in an urban market given the outpatient focus of her training, Dr. Schaffer began searching for fellowships on the Society of Hospital Medicine website.¹

Likewise, in 2014 Dr. Micah Prochaska was seriously contemplating a hospital medicine fellowship. He was about to graduate from internal medicine residency at the University of Chicago and was eager to gain skills and experience in clinical research.

In 2006, there were a total of 16 HM fellowship programs in the United States, catering to graduates of internal medicine, family medicine, and pediatric residencies.² Since that time, the number of hospital medicine fellowships has grown considerably, paralleling the explosive growth of hospital medicine as a specialty. For example, at one point in the summer of 2018, the SHM website listed 13 clinical family practice fellowships, 29 internal medicine fellowships, and 26 pediatric fellowships. Each fellowship emphasized different aspects of hospital medicine including clinical practice, research, quality improvement, and leadership.

Now more than ever, residents interested in hospital medicine may get overwhelmed by the multitude of options for fellowship training. And the question remains: why pursue fellowship training in the first place?

“I learned that as a family physician it is harder to get a job as a hospitalist outside of smaller communities, and I wanted to have extra training and credentials,” Dr. Schaffer said. “I pursued a fellowship in hospital medicine to hone my inpatient skills, obtain more ICU exposure, and work on procedures.”

Dr. Schaffer’s online search eventually led her to the Advanced Hospital Medicine Fellowship at Swedish Medical Center in Seattle. This 1-year hospital medicine fellowship started in 2008 with an intentional clinical focus, aiming to provide additional training opportunities in hospital medicine primarily to family medicine residency graduates.

“The goal of our program is to bridge the gap between the training of family medicine and internal medicine so our trainees can refine and develop their inpatient skills,” said Dr. David Wilson, program director of the Swedish Hospitalist Fellowship.

During her fellowship year, Dr. Schaffer was caring for hospitalized adult patients on a general medical ward, with supervision from a dedicated group of teaching hospitalists. She also completed rotations in the ICU, on subspecialty services, and received advanced training in point-of-care ultrasound.

Now in her second year of practice as a full time adult hospitalist at Swedish Medical Center, Dr. Schaffer believes her year of hospital medicine fellowship prepared her well for her current position.

“I am constantly using the tools and knowledge I acquired during my fellowship year,” she said. “I would encourage anyone who has an interest in working on procedural skills and gaining more ICU exposure to pursue a similar fellowship.”

In contrast to Dr. Schaffer, Dr. Prochaska was satisfied with his clinical training but chose to pursue a hospital medicine fellowship to develop research skills. Prior to starting the 2-year Hospitalist Scholars Training Program at the University of Chicago in 2014, Dr. Prochaska had a clear vision of becoming a hospital medicine health outcomes investigator, and believed this career would not be possible without the additional training offered by a research-focused fellowship program.

The Hospitalist Scholars Program at the University of Chicago, one of the first programs of its kind, offers a built-in master’s degree to all participants. At the conclusion of his fellowship training in 2016, Dr. Prochaska completed his Master’s in Health Sciences, which gives considerable attention to biostatistics and epidemiology. According to Dr. Prochaska, the key to becoming a successful academic researcher lies in one’s ability to write grants and receive funding, a skill he honed during this fellowship.

Now on faculty at the University of Chicago in the Section of Hospital Medicine, Dr. Prochaska devotes approximately 75% of his time to research and 25% to patient care.

Beyond the research training and experience he gained during his hospital medicine fellowship, Dr. Prochaska said he values the mentorship afforded to him. He noted that one of the most meaningful experiences during his 2 years of fellowship was having the opportunity to sit down with his program directors, Dr. Vineet Arora and Dr. David Meltzer, to discuss the trajectory of his career in academic medicine.

“It is hard to find senior mentors in hospital medicine,” Dr. Prochaska said. “You could get a master’s degree on your own, but with the fellowship program, your mentors can help you think about the next steps in your career.”

For Dr. Schaffer and Dr. Prochaska, fellowship provided training and experience well-matched to their individual goals and helped foster their careers in hospital medicine. For some, however, a fellowship may not be a necessary step on the path to becoming a hospitalist. Many leaders in the field of hospital medicine have advanced in their careers without further training. In addition, receiving little more than a resident’s salary for an additional year or more during fellowship may not be financially tenable for some. Given the ongoing demand for hospitalists across the country, the lack of a fellowship on your resume may not significantly diminish your chances of securing a position, especially in the community setting.

In the end, the decision of whether to pursue a hospital medicine fellowship is a personal one, and the programs available are as varied as the individuals completing them. “Any hospitalist interested in more than simply patient care – potentially QI, medical education, policy, or administration – should consider a fellowship,” Dr. Prochaska said. “Hospitalists have a unique opportunity to be involved in all these areas, but there are absolutely critical skills you need to develop beyond your clinical skills to succeed.” Fellowships are one way to enhance these nonclinical skills.

The best advice to those considering a hospital medicine fellowship? Dedicate some time to engage in self-assessment and goal setting, before jumping to SHM’s online list of programs.

Ask yourself: “Where do I see myself in 10 years? What do I wish to accomplish in my career as a hospitalist? What additional training (clinical, research, quality improvement, leadership) might I need to achieve these goals? Will completion of a hospital medicine fellowship help me make this vision a reality?”

For Dr. Schaffer, a clinical practice–focused hospital medicine fellowship served as a necessary bridge between her family medicine residency and her current position as an adult hospitalist. While for Dr. Prochaska, a research-intensive hospital medicine fellowship was a key step in launching his academic career.

Of course, for many trainees at the end of residency, your self-assessment may lead you in the opposite direction. In that case it is time to find your first “real job” as an attending physician. But if you feel you need more training to meet your personal goals you should rest assured – whether now or in the future, there is almost certainly a hospital medicine fellowship that is right for you.

Dr. Schouten is a hospitalist at Mayo Clinic in Rochester, Minn., and serves on the Society of Hospital Medicine Physicians in Training Committee. Dr. Sundar is a hospitalist at Emory Saint Joseph’s Hospital in Sandy Springs, Ga., and serves as the Site Assistant Director for Education.

References


1. www.hospitalmedicine.org/membership/hospitalist-fellowships/

2. Ranji et al. “Hospital medicine fellowships: Works in progress.” American J Med. 2006 Jan;119(1):72.e1-7. doi: 10.1016/j.amjmed.2005.07.061.
 

The Food and Drug Administration is asking for comments on its newly released draft guidance on how industry can reduce the risk of bacterial contamination in platelets destined for transfusion, especially those stored at room temperature.

The draft document, “Bacterial Risk Control Strategies for Blood Collection Establishments and Transfusion Services to Enhance the Safety and Availability of Platelets for Transfusion,” will be open for public comment through Feb. 4, 2019.

It is the first update to the policy document since 2016.

In the draft guidance, the FDA recommended three strategies for platelets stored for 5 days from collection. For apheresis platelets and prestorage pools, the FDA suggested an initial primary culture followed by a secondary culture on day 3 or day 4 or an initial primary culture followed by secondary testing with a rapid test. The third strategy – for apheresis platelets – is pathogen reduction alone.

The FDA also outlined three strategies for testing platelets stored for 7 days, all of which apply to apheresis platelets. The methods include an initial primary culture followed by a secondary culture no earlier than day 4, using a device labeled as a safety measure; an initial primary culture followed by a secondary rapid test, labeled as a safety measure; or large volume delayed sampling.

The supply of blood and blood components in the United States is among the safest in the world, FDA Commissioner Scott Gottlieb, MD, said in a statement. The FDA’s continuously updated protocols are intended to keep it that way.

“Blood and blood components are some of the most critical medical products American patients depend upon,” Dr. Gottlieb wrote. “But there remains risk, albeit uncommon, of contamination with infectious diseases, particularly with blood products that are stored at room temperature. While we’ve made great strides in reducing the risk of blood contamination through donor screening and laboratory testing, we continue to support innovations and blood product alternatives that can better keep pace with emerging pathogens and reduce some of the logistical challenges and costs associated with ensuring the safety of blood products.”

Since the 2016 guidance document was issued, new strategies for bacterial detection have become available that could potentially reduce the risk of contamination of platelets and permit extension of platelet dating up to 7 days, including bacterial testing strategies using culture-based devices, rapid bacterial detection devices, and the implementation of pathogen reduction technology.

The recommendations in the draft guidance incorporate ideas put forth during a July 2018 meeting of the agency’s Blood Products Advisory Committee. Committee members were asked to discuss the advantages and disadvantages of various strategies to control the risk of bacterial contamination in platelets, including the scientific evidence and the operational considerations involved. Their comments have been incorporated into the new draft guidance document.

In late November 2018, the FDA held a public workshop to encourage a scientific discussion on a range of pathogen reduction topics, including the development of novel technologies. “The ideal pathogen reduction technology would: be relatively inexpensive, be simple to implement on whole blood, allow treated blood to subsequently be separated into components or alternatively could be performed on apheresis products, inactivate a broad range of pathogens, and would have no adverse effect on product safety or product yield,” the FDA noted in a statement.

[email protected]

The Food and Drug Administration is asking for comments on its newly released draft guidance on how industry can reduce the risk of bacterial contamination in platelets destined for transfusion, especially those stored at room temperature.

The draft document, “Bacterial Risk Control Strategies for Blood Collection Establishments and Transfusion Services to Enhance the Safety and Availability of Platelets for Transfusion,” will be open for public comment through Feb. 4, 2019.

It is the first update to the policy document since 2016.

In the draft guidance, the FDA recommended three strategies for platelets stored for 5 days from collection. For apheresis platelets and prestorage pools, the FDA suggested an initial primary culture followed by a secondary culture on day 3 or day 4 or an initial primary culture followed by secondary testing with a rapid test. The third strategy – for apheresis platelets – is pathogen reduction alone.

The FDA also outlined three strategies for testing platelets stored for 7 days, all of which apply to apheresis platelets. The methods include an initial primary culture followed by a secondary culture no earlier than day 4, using a device labeled as a safety measure; an initial primary culture followed by a secondary rapid test, labeled as a safety measure; or large volume delayed sampling.

The supply of blood and blood components in the United States is among the safest in the world, FDA Commissioner Scott Gottlieb, MD, said in a statement. The FDA’s continuously updated protocols are intended to keep it that way.

“Blood and blood components are some of the most critical medical products American patients depend upon,” Dr. Gottlieb wrote. “But there remains risk, albeit uncommon, of contamination with infectious diseases, particularly with blood products that are stored at room temperature. While we’ve made great strides in reducing the risk of blood contamination through donor screening and laboratory testing, we continue to support innovations and blood product alternatives that can better keep pace with emerging pathogens and reduce some of the logistical challenges and costs associated with ensuring the safety of blood products.”

Since the 2016 guidance document was issued, new strategies for bacterial detection have become available that could potentially reduce the risk of contamination of platelets and permit extension of platelet dating up to 7 days, including bacterial testing strategies using culture-based devices, rapid bacterial detection devices, and the implementation of pathogen reduction technology.

The recommendations in the draft guidance incorporate ideas put forth during a July 2018 meeting of the agency’s Blood Products Advisory Committee. Committee members were asked to discuss the advantages and disadvantages of various strategies to control the risk of bacterial contamination in platelets, including the scientific evidence and the operational considerations involved. Their comments have been incorporated into the new draft guidance document.

In late November 2018, the FDA held a public workshop to encourage a scientific discussion on a range of pathogen reduction topics, including the development of novel technologies. “The ideal pathogen reduction technology would: be relatively inexpensive, be simple to implement on whole blood, allow treated blood to subsequently be separated into components or alternatively could be performed on apheresis products, inactivate a broad range of pathogens, and would have no adverse effect on product safety or product yield,” the FDA noted in a statement.

[email protected]

The Food and Drug Administration is asking for comments on its newly released draft guidance on how industry can reduce the risk of bacterial contamination in platelets destined for transfusion, especially those stored at room temperature.

The draft document, “Bacterial Risk Control Strategies for Blood Collection Establishments and Transfusion Services to Enhance the Safety and Availability of Platelets for Transfusion,” will be open for public comment through Feb. 4, 2019.

It is the first update to the policy document since 2016.

In the draft guidance, the FDA recommended three strategies for platelets stored for 5 days from collection. For apheresis platelets and prestorage pools, the FDA suggested an initial primary culture followed by a secondary culture on day 3 or day 4 or an initial primary culture followed by secondary testing with a rapid test. The third strategy – for apheresis platelets – is pathogen reduction alone.

The FDA also outlined three strategies for testing platelets stored for 7 days, all of which apply to apheresis platelets. The methods include an initial primary culture followed by a secondary culture no earlier than day 4, using a device labeled as a safety measure; an initial primary culture followed by a secondary rapid test, labeled as a safety measure; or large volume delayed sampling.

The supply of blood and blood components in the United States is among the safest in the world, FDA Commissioner Scott Gottlieb, MD, said in a statement. The FDA’s continuously updated protocols are intended to keep it that way.

“Blood and blood components are some of the most critical medical products American patients depend upon,” Dr. Gottlieb wrote. “But there remains risk, albeit uncommon, of contamination with infectious diseases, particularly with blood products that are stored at room temperature. While we’ve made great strides in reducing the risk of blood contamination through donor screening and laboratory testing, we continue to support innovations and blood product alternatives that can better keep pace with emerging pathogens and reduce some of the logistical challenges and costs associated with ensuring the safety of blood products.”

Since the 2016 guidance document was issued, new strategies for bacterial detection have become available that could potentially reduce the risk of contamination of platelets and permit extension of platelet dating up to 7 days, including bacterial testing strategies using culture-based devices, rapid bacterial detection devices, and the implementation of pathogen reduction technology.

The recommendations in the draft guidance incorporate ideas put forth during a July 2018 meeting of the agency’s Blood Products Advisory Committee. Committee members were asked to discuss the advantages and disadvantages of various strategies to control the risk of bacterial contamination in platelets, including the scientific evidence and the operational considerations involved. Their comments have been incorporated into the new draft guidance document.

In late November 2018, the FDA held a public workshop to encourage a scientific discussion on a range of pathogen reduction topics, including the development of novel technologies. “The ideal pathogen reduction technology would: be relatively inexpensive, be simple to implement on whole blood, allow treated blood to subsequently be separated into components or alternatively could be performed on apheresis products, inactivate a broad range of pathogens, and would have no adverse effect on product safety or product yield,” the FDA noted in a statement.

[email protected]

The current health care environment is undergoing a rapid transformation. In evolutionary biology, a theory exists called punctuated equilibrium. This theory suggests there are long periods of little or no morphological change amongst species and then, geologically speaking, short periods of rapid change in response to pressures within the environment. This rapid period of change adds significant diversity to the landscape of existing species. In health care, we are undergoing a period of “punctuation.”

A testament to the degree of change is a scan of the various consolidation activities occurring across the health care space. Some are more traditional, such as mergers of health systems with different or competing geographical footprints or hospitalist management companies that provide similar services and desire to increase their market share. Others that are more interesting are those that include mergers of seemingly different business lines or offerings, like CVS Health and Aetna; Humana and Kindred; or even organizations such as Amazon, Berkshire Hathaway, and JP Morgan hiring Atul Gawande as the CEO of their newly formed health care venture. The latter examples serve as an illustration of the reorganization that is occurring within health care delivery. This represents, at the very least, a blurring of the lines – if not a deconstruction and complete rebuild – of traditional lines of separation between payers, providers, employers, and retailers.

In other words, the silos are coming down, significant diversity in the landscape of existing species. A common theme across these changes is that most – if not all – participants will share some portion of the financial risk associated with these evolving models. High-deductible health plans, alternative payment models (APMs), and advanced APMs are examples of tactics and models that distribute the financial risk. The consolidations referenced above will likely continue to encourage distribution of the financial risk across patients, providers, employers, and payers.

A key theme coming into focus is that the evolving care delivery system will not be defined by bricks and mortar. Rather, it will follow the patient and go wherever he or she goes to meet his or her specific needs. This is why we’re seeing mergers comprised of a variety of assets, including personnel, technology, critical supplies (such as pharmaceuticals), and funding resources. This very purposeful and deliberate melting pot phenomenon will restructure and reformat the care delivery model.

To be successful within this new landscape, there will need to be a renewed focus on working within a collaborative model. The days of a single entity or provider being able to serve as the “be all” or “do all” is over, and the days of practicing medicine as the Lone Ranger are anachronistic. Instead, there is a need for health care providers to embrace and lead a team-based care model. Team-based care should have the patient at the center of the care delivery model and leverage the expertise of the various team members to practice at the “top of their expertise.”

In hospital medicine, this includes a variety of team members – from physicians, nurse practitioners, physician assistants, and clinical pharmacists to case managers, physical therapists, subject matter experts in quality improvement, and analysts – who identify operational priorities from the data rather than reporting predefined goals on dashboards. Although possibly a good start, this is by no means an exhaustive list of team members. The team will be defined by the goals the health care team aspires to achieve. These goals may include closer alignment with payers, employers, and post-acute partners; the goals will influence the composition of the team. Once the team is defined, the challenge will be to effectively integrate team members, so they are contributing their expertise to the patient care being delivered.

Some ingredients for effective team-based care include the following:

• Developing an effective process for engagement and providing a voice for all team members. Interdisciplinary team rounds where there is an established time for team members to plan and operationalize their plans around patient care can serve as an example of this type of structured process.
• Creating well-defined roles and responsibilities with key performance indicators to promote accountability. The team will have outcomes they are measuring and striving to impact, and each team member will have a role in achieving those goals. Being able to parse out and measure how each team member contributes to the overall outcome can be beneficial. This provides an opportunity for each team member to play a meaningful role in accomplishing the overall goal and allows for a measurement process to track success. For example, an overall team goal may be to have a specific percentage of eligible discharges completed by 11:00 a.m. To accomplish this goal, there may be specific objectives for the clinicians to have discharge orders in the chart by 9:30 a.m. and for case management to have communicated with any post-acute services the day before discharge. These specific accountability measures facilitate accomplishing the larger team goal.
• Developing a culture of safety and transparency. Effective teams promote an environment where all members are empowered and encouraged to speak and share their perspective and knowledge. Communication is based on the value it provides to accomplishing the team’s goals rather than based on a hierarchy which determines who contributes and when.
• Defining and then redefining the competencies required of the team to promote continued development and growth. In this time of dynamic change, the skill sets that helped us get where we are today may be different then the skill sets that are needed for success in the future. There will continue to be a need for functional and knowledge-based competencies in addition to the need to focus on competencies that engender a culture of team-based care. For example, hospitalist leaders will need to understand evidence-based medicine to support appropriate management of a septic patient and simultaneously understand evidence-based management/leadership to affect sepsis care across his or her health care system.

With this change in the health care environment come new and exciting opportunities. Hospital medicine has always elected to assume a leadership role in these times of change, these periods of “punctuation.” Development of effective team-based care is a great place for those of us working in hospital medicine to demonstrate our leadership as we care for our patients.

Dr. Frost is national medical director, hospital-based services, at LifePoint Health, Brentwood, Tenn. He is president-elect of the Society of Hospital Medicine.

The current health care environment is undergoing a rapid transformation. In evolutionary biology, a theory exists called punctuated equilibrium. This theory suggests there are long periods of little or no morphological change amongst species and then, geologically speaking, short periods of rapid change in response to pressures within the environment. This rapid period of change adds significant diversity to the landscape of existing species. In health care, we are undergoing a period of “punctuation.”

A testament to the degree of change is a scan of the various consolidation activities occurring across the health care space. Some are more traditional, such as mergers of health systems with different or competing geographical footprints or hospitalist management companies that provide similar services and desire to increase their market share. Others that are more interesting are those that include mergers of seemingly different business lines or offerings, like CVS Health and Aetna; Humana and Kindred; or even organizations such as Amazon, Berkshire Hathaway, and JP Morgan hiring Atul Gawande as the CEO of their newly formed health care venture. The latter examples serve as an illustration of the reorganization that is occurring within health care delivery. This represents, at the very least, a blurring of the lines – if not a deconstruction and complete rebuild – of traditional lines of separation between payers, providers, employers, and retailers.

In other words, the silos are coming down, significant diversity in the landscape of existing species. A common theme across these changes is that most – if not all – participants will share some portion of the financial risk associated with these evolving models. High-deductible health plans, alternative payment models (APMs), and advanced APMs are examples of tactics and models that distribute the financial risk. The consolidations referenced above will likely continue to encourage distribution of the financial risk across patients, providers, employers, and payers.

A key theme coming into focus is that the evolving care delivery system will not be defined by bricks and mortar. Rather, it will follow the patient and go wherever he or she goes to meet his or her specific needs. This is why we’re seeing mergers comprised of a variety of assets, including personnel, technology, critical supplies (such as pharmaceuticals), and funding resources. This very purposeful and deliberate melting pot phenomenon will restructure and reformat the care delivery model.

To be successful within this new landscape, there will need to be a renewed focus on working within a collaborative model. The days of a single entity or provider being able to serve as the “be all” or “do all” is over, and the days of practicing medicine as the Lone Ranger are anachronistic. Instead, there is a need for health care providers to embrace and lead a team-based care model. Team-based care should have the patient at the center of the care delivery model and leverage the expertise of the various team members to practice at the “top of their expertise.”

In hospital medicine, this includes a variety of team members – from physicians, nurse practitioners, physician assistants, and clinical pharmacists to case managers, physical therapists, subject matter experts in quality improvement, and analysts – who identify operational priorities from the data rather than reporting predefined goals on dashboards. Although possibly a good start, this is by no means an exhaustive list of team members. The team will be defined by the goals the health care team aspires to achieve. These goals may include closer alignment with payers, employers, and post-acute partners; the goals will influence the composition of the team. Once the team is defined, the challenge will be to effectively integrate team members, so they are contributing their expertise to the patient care being delivered.

Some ingredients for effective team-based care include the following:

• Developing an effective process for engagement and providing a voice for all team members. Interdisciplinary team rounds where there is an established time for team members to plan and operationalize their plans around patient care can serve as an example of this type of structured process.
• Creating well-defined roles and responsibilities with key performance indicators to promote accountability. The team will have outcomes they are measuring and striving to impact, and each team member will have a role in achieving those goals. Being able to parse out and measure how each team member contributes to the overall outcome can be beneficial. This provides an opportunity for each team member to play a meaningful role in accomplishing the overall goal and allows for a measurement process to track success. For example, an overall team goal may be to have a specific percentage of eligible discharges completed by 11:00 a.m. To accomplish this goal, there may be specific objectives for the clinicians to have discharge orders in the chart by 9:30 a.m. and for case management to have communicated with any post-acute services the day before discharge. These specific accountability measures facilitate accomplishing the larger team goal.
• Developing a culture of safety and transparency. Effective teams promote an environment where all members are empowered and encouraged to speak and share their perspective and knowledge. Communication is based on the value it provides to accomplishing the team’s goals rather than based on a hierarchy which determines who contributes and when.
• Defining and then redefining the competencies required of the team to promote continued development and growth. In this time of dynamic change, the skill sets that helped us get where we are today may be different then the skill sets that are needed for success in the future. There will continue to be a need for functional and knowledge-based competencies in addition to the need to focus on competencies that engender a culture of team-based care. For example, hospitalist leaders will need to understand evidence-based medicine to support appropriate management of a septic patient and simultaneously understand evidence-based management/leadership to affect sepsis care across his or her health care system.

With this change in the health care environment come new and exciting opportunities. Hospital medicine has always elected to assume a leadership role in these times of change, these periods of “punctuation.” Development of effective team-based care is a great place for those of us working in hospital medicine to demonstrate our leadership as we care for our patients.

Dr. Frost is national medical director, hospital-based services, at LifePoint Health, Brentwood, Tenn. He is president-elect of the Society of Hospital Medicine.

The current health care environment is undergoing a rapid transformation. In evolutionary biology, a theory exists called punctuated equilibrium. This theory suggests there are long periods of little or no morphological change amongst species and then, geologically speaking, short periods of rapid change in response to pressures within the environment. This rapid period of change adds significant diversity to the landscape of existing species. In health care, we are undergoing a period of “punctuation.”

A testament to the degree of change is a scan of the various consolidation activities occurring across the health care space. Some are more traditional, such as mergers of health systems with different or competing geographical footprints or hospitalist management companies that provide similar services and desire to increase their market share. Others that are more interesting are those that include mergers of seemingly different business lines or offerings, like CVS Health and Aetna; Humana and Kindred; or even organizations such as Amazon, Berkshire Hathaway, and JP Morgan hiring Atul Gawande as the CEO of their newly formed health care venture. The latter examples serve as an illustration of the reorganization that is occurring within health care delivery. This represents, at the very least, a blurring of the lines – if not a deconstruction and complete rebuild – of traditional lines of separation between payers, providers, employers, and retailers.

In other words, the silos are coming down, significant diversity in the landscape of existing species. A common theme across these changes is that most – if not all – participants will share some portion of the financial risk associated with these evolving models. High-deductible health plans, alternative payment models (APMs), and advanced APMs are examples of tactics and models that distribute the financial risk. The consolidations referenced above will likely continue to encourage distribution of the financial risk across patients, providers, employers, and payers.

A key theme coming into focus is that the evolving care delivery system will not be defined by bricks and mortar. Rather, it will follow the patient and go wherever he or she goes to meet his or her specific needs. This is why we’re seeing mergers comprised of a variety of assets, including personnel, technology, critical supplies (such as pharmaceuticals), and funding resources. This very purposeful and deliberate melting pot phenomenon will restructure and reformat the care delivery model.

To be successful within this new landscape, there will need to be a renewed focus on working within a collaborative model. The days of a single entity or provider being able to serve as the “be all” or “do all” is over, and the days of practicing medicine as the Lone Ranger are anachronistic. Instead, there is a need for health care providers to embrace and lead a team-based care model. Team-based care should have the patient at the center of the care delivery model and leverage the expertise of the various team members to practice at the “top of their expertise.”

In hospital medicine, this includes a variety of team members – from physicians, nurse practitioners, physician assistants, and clinical pharmacists to case managers, physical therapists, subject matter experts in quality improvement, and analysts – who identify operational priorities from the data rather than reporting predefined goals on dashboards. Although possibly a good start, this is by no means an exhaustive list of team members. The team will be defined by the goals the health care team aspires to achieve. These goals may include closer alignment with payers, employers, and post-acute partners; the goals will influence the composition of the team. Once the team is defined, the challenge will be to effectively integrate team members, so they are contributing their expertise to the patient care being delivered.

Some ingredients for effective team-based care include the following:

• Developing an effective process for engagement and providing a voice for all team members. Interdisciplinary team rounds where there is an established time for team members to plan and operationalize their plans around patient care can serve as an example of this type of structured process.
• Creating well-defined roles and responsibilities with key performance indicators to promote accountability. The team will have outcomes they are measuring and striving to impact, and each team member will have a role in achieving those goals. Being able to parse out and measure how each team member contributes to the overall outcome can be beneficial. This provides an opportunity for each team member to play a meaningful role in accomplishing the overall goal and allows for a measurement process to track success. For example, an overall team goal may be to have a specific percentage of eligible discharges completed by 11:00 a.m. To accomplish this goal, there may be specific objectives for the clinicians to have discharge orders in the chart by 9:30 a.m. and for case management to have communicated with any post-acute services the day before discharge. These specific accountability measures facilitate accomplishing the larger team goal.
• Developing a culture of safety and transparency. Effective teams promote an environment where all members are empowered and encouraged to speak and share their perspective and knowledge. Communication is based on the value it provides to accomplishing the team’s goals rather than based on a hierarchy which determines who contributes and when.
• Defining and then redefining the competencies required of the team to promote continued development and growth. In this time of dynamic change, the skill sets that helped us get where we are today may be different then the skill sets that are needed for success in the future. There will continue to be a need for functional and knowledge-based competencies in addition to the need to focus on competencies that engender a culture of team-based care. For example, hospitalist leaders will need to understand evidence-based medicine to support appropriate management of a septic patient and simultaneously understand evidence-based management/leadership to affect sepsis care across his or her health care system.

With this change in the health care environment come new and exciting opportunities. Hospital medicine has always elected to assume a leadership role in these times of change, these periods of “punctuation.” Development of effective team-based care is a great place for those of us working in hospital medicine to demonstrate our leadership as we care for our patients.

Dr. Frost is national medical director, hospital-based services, at LifePoint Health, Brentwood, Tenn. He is president-elect of the Society of Hospital Medicine.

Guideline-concordant antibiotic treatment for pediatric community-acquired pneumonia (CAP) was significantly less likely in a nonchildren’s hospital, according to new research.

©drpnncpp/thinkstockphotos.com

“This gap is concerning because approximately 70% of children hospitalized with pneumonia receive care in nonchildren’s hospitals,” wrote Alison C. Tribble, MD, of C. S. Mott Children’s Hospital, University of Michigan, Ann Arbor, and her associates. The report is in JAMA Pediatrics.

Data were collected from the Pediatric Health Information System (children’s hospitals) and Premier Perspectives (all hospitals) databases and included a total of 120,238 children aged 1-17 years diagnosed with CAP between Jan. 1, 2009, and Sept. 30, 2015. Before the publication of the new guideline in October 2011, the probability of receiving what would become guideline-concordant antibiotics was 0.25 in children’s hospitals and 0.06 in nonchildren’s hospitals.

By the end of the study period, the probability of receiving guideline-concordant antibiotics for pediatric CAP was 0.61 in children’s hospitals and 0.27 in nonchildren’s hospitals. Without the interventions, the probabilities would have been 0.31 and 0.08, respectively. The rate of growth over the 4-year postintervention period was similar in both children’s and nonchildren’s hospitals.

“Studies in children’s hospitals have suggested that local implementation efforts may be important in facilitating guideline uptake. Nonchildren’s hospitals likely have fewer resources to lead pediatric-specific efforts, and care may be influenced by adult CAP guidelines,” the authors noted.

No conflicts of interest were reported.

[email protected]

SOURCE: Tribble AC et al. JAMA Pediatr. 2018 Dec 10. doi: 10.1001/jamapediatrics.2018.4270.

Guideline-concordant antibiotic treatment for pediatric community-acquired pneumonia (CAP) was significantly less likely in a nonchildren’s hospital, according to new research.

©drpnncpp/thinkstockphotos.com

“This gap is concerning because approximately 70% of children hospitalized with pneumonia receive care in nonchildren’s hospitals,” wrote Alison C. Tribble, MD, of C. S. Mott Children’s Hospital, University of Michigan, Ann Arbor, and her associates. The report is in JAMA Pediatrics.

Data were collected from the Pediatric Health Information System (children’s hospitals) and Premier Perspectives (all hospitals) databases and included a total of 120,238 children aged 1-17 years diagnosed with CAP between Jan. 1, 2009, and Sept. 30, 2015. Before the publication of the new guideline in October 2011, the probability of receiving what would become guideline-concordant antibiotics was 0.25 in children’s hospitals and 0.06 in nonchildren’s hospitals.

By the end of the study period, the probability of receiving guideline-concordant antibiotics for pediatric CAP was 0.61 in children’s hospitals and 0.27 in nonchildren’s hospitals. Without the interventions, the probabilities would have been 0.31 and 0.08, respectively. The rate of growth over the 4-year postintervention period was similar in both children’s and nonchildren’s hospitals.

“Studies in children’s hospitals have suggested that local implementation efforts may be important in facilitating guideline uptake. Nonchildren’s hospitals likely have fewer resources to lead pediatric-specific efforts, and care may be influenced by adult CAP guidelines,” the authors noted.

No conflicts of interest were reported.

[email protected]

SOURCE: Tribble AC et al. JAMA Pediatr. 2018 Dec 10. doi: 10.1001/jamapediatrics.2018.4270.

Guideline-concordant antibiotic treatment for pediatric community-acquired pneumonia (CAP) was significantly less likely in a nonchildren’s hospital, according to new research.

©drpnncpp/thinkstockphotos.com

“This gap is concerning because approximately 70% of children hospitalized with pneumonia receive care in nonchildren’s hospitals,” wrote Alison C. Tribble, MD, of C. S. Mott Children’s Hospital, University of Michigan, Ann Arbor, and her associates. The report is in JAMA Pediatrics.

Data were collected from the Pediatric Health Information System (children’s hospitals) and Premier Perspectives (all hospitals) databases and included a total of 120,238 children aged 1-17 years diagnosed with CAP between Jan. 1, 2009, and Sept. 30, 2015. Before the publication of the new guideline in October 2011, the probability of receiving what would become guideline-concordant antibiotics was 0.25 in children’s hospitals and 0.06 in nonchildren’s hospitals.

By the end of the study period, the probability of receiving guideline-concordant antibiotics for pediatric CAP was 0.61 in children’s hospitals and 0.27 in nonchildren’s hospitals. Without the interventions, the probabilities would have been 0.31 and 0.08, respectively. The rate of growth over the 4-year postintervention period was similar in both children’s and nonchildren’s hospitals.

“Studies in children’s hospitals have suggested that local implementation efforts may be important in facilitating guideline uptake. Nonchildren’s hospitals likely have fewer resources to lead pediatric-specific efforts, and care may be influenced by adult CAP guidelines,” the authors noted.

No conflicts of interest were reported.

[email protected]

SOURCE: Tribble AC et al. JAMA Pediatr. 2018 Dec 10. doi: 10.1001/jamapediatrics.2018.4270.

A blood management initiative that reduced RBC transfusions in the hospital did not adversely impact long-term outcomes after discharge, a retrospective analysis of an extensive patient database suggested.

Vlad/Fotolia

Tolerating moderate in-hospital anemia did not increase subsequent RBC use, readmission, or mortality over the next 6 months, according to results of the study, which drew on nearly half a million patient records.

In fact, modest mortality decreases were seen over time for patients with moderate anemia, perhaps because of concomitant initiatives that targeted infectious and circulatory conditions, reported Nareg H. Roubinian, MD, of Kaiser Permanente Northern California in Oakland and the University of California, San Francisco, and coinvestigators.

“These data support the efficacy and safety of practice recommendations to limit red blood cell transfusion in patients with anemia during and after hospitalization,” Dr. Roubinian and colleagues wrote in their report, which appears in the Annals of Internal Medicine.

However, additional studies are needed to guide anemia management, they wrote, particularly since persistent anemia has impacts on quality of life that are “likely substantial” and linked to the severity of that anemia.

Dr. Roubinian and colleagues sought to evaluate the impact of blood management programs – initiated starting in 2010 – that included blood-sparing surgical and medical techniques, increased use of hemostatic and cell salvage agents, and treatment of suboptimal iron stores before surgery.

In previous retrospective cohort studies, the researchers had found that the blood conservation strategies did not impact in-hospital or 30-day mortality rates, which was consistent with short-term safety data from clinical trials and other observational studies.

Their latest report on longer-term outcomes was based on data from Kaiser Permanente Northern California for 445,371 adults who had 801,261 hospitalizations with discharges between 2010 and 2014. In this cohort, moderate anemia (hemoglobin between 7 g/dL and 10 g/dL) at discharge occurred in 119,489 patients (27%) and 187,440 hospitalizations overall (23%).

Over the 2010-2014 period, RBC transfusions decreased by more than 25% in the inpatient and outpatient settings; and in parallel, the prevalence of moderate anemia at hospital discharge increased from 20% to 25%.

However, the risks of subsequent RBC transfusions and rehospitalization after discharge with anemia decreased during the study period, and mortality rates stayed steady or decreased slightly.

Among patients with moderate anemia, the proportion with subsequent RBC transfusions within 6 months decreased from 18.9% in 2010 to 16.8% in 2014 (P less than .001), while the rate of rehospitalization within 6 months decreased from 36.5% to 32.8% over that same time period (P less than .001).

The adjusted 6-month mortality rate likewise decreased from 16.1% to 15.6% (P = .004) over that time period among patients with moderate anemia.

The study was supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Roubinian and several coauthors reported grants during the conduct of the study from the National Institutes of Health.

SOURCE: Roubinian NH et al. Ann Intern Med. 2018 Dec 18. doi: 10.7326/M17-3253.

A blood management initiative that reduced RBC transfusions in the hospital did not adversely impact long-term outcomes after discharge, a retrospective analysis of an extensive patient database suggested.

Vlad/Fotolia

Tolerating moderate in-hospital anemia did not increase subsequent RBC use, readmission, or mortality over the next 6 months, according to results of the study, which drew on nearly half a million patient records.

In fact, modest mortality decreases were seen over time for patients with moderate anemia, perhaps because of concomitant initiatives that targeted infectious and circulatory conditions, reported Nareg H. Roubinian, MD, of Kaiser Permanente Northern California in Oakland and the University of California, San Francisco, and coinvestigators.

“These data support the efficacy and safety of practice recommendations to limit red blood cell transfusion in patients with anemia during and after hospitalization,” Dr. Roubinian and colleagues wrote in their report, which appears in the Annals of Internal Medicine.

However, additional studies are needed to guide anemia management, they wrote, particularly since persistent anemia has impacts on quality of life that are “likely substantial” and linked to the severity of that anemia.

Dr. Roubinian and colleagues sought to evaluate the impact of blood management programs – initiated starting in 2010 – that included blood-sparing surgical and medical techniques, increased use of hemostatic and cell salvage agents, and treatment of suboptimal iron stores before surgery.

In previous retrospective cohort studies, the researchers had found that the blood conservation strategies did not impact in-hospital or 30-day mortality rates, which was consistent with short-term safety data from clinical trials and other observational studies.

Their latest report on longer-term outcomes was based on data from Kaiser Permanente Northern California for 445,371 adults who had 801,261 hospitalizations with discharges between 2010 and 2014. In this cohort, moderate anemia (hemoglobin between 7 g/dL and 10 g/dL) at discharge occurred in 119,489 patients (27%) and 187,440 hospitalizations overall (23%).

Over the 2010-2014 period, RBC transfusions decreased by more than 25% in the inpatient and outpatient settings; and in parallel, the prevalence of moderate anemia at hospital discharge increased from 20% to 25%.

However, the risks of subsequent RBC transfusions and rehospitalization after discharge with anemia decreased during the study period, and mortality rates stayed steady or decreased slightly.

Among patients with moderate anemia, the proportion with subsequent RBC transfusions within 6 months decreased from 18.9% in 2010 to 16.8% in 2014 (P less than .001), while the rate of rehospitalization within 6 months decreased from 36.5% to 32.8% over that same time period (P less than .001).

The adjusted 6-month mortality rate likewise decreased from 16.1% to 15.6% (P = .004) over that time period among patients with moderate anemia.

The study was supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Roubinian and several coauthors reported grants during the conduct of the study from the National Institutes of Health.

SOURCE: Roubinian NH et al. Ann Intern Med. 2018 Dec 18. doi: 10.7326/M17-3253.

A blood management initiative that reduced RBC transfusions in the hospital did not adversely impact long-term outcomes after discharge, a retrospective analysis of an extensive patient database suggested.

Vlad/Fotolia

Tolerating moderate in-hospital anemia did not increase subsequent RBC use, readmission, or mortality over the next 6 months, according to results of the study, which drew on nearly half a million patient records.

In fact, modest mortality decreases were seen over time for patients with moderate anemia, perhaps because of concomitant initiatives that targeted infectious and circulatory conditions, reported Nareg H. Roubinian, MD, of Kaiser Permanente Northern California in Oakland and the University of California, San Francisco, and coinvestigators.

“These data support the efficacy and safety of practice recommendations to limit red blood cell transfusion in patients with anemia during and after hospitalization,” Dr. Roubinian and colleagues wrote in their report, which appears in the Annals of Internal Medicine.

However, additional studies are needed to guide anemia management, they wrote, particularly since persistent anemia has impacts on quality of life that are “likely substantial” and linked to the severity of that anemia.

Dr. Roubinian and colleagues sought to evaluate the impact of blood management programs – initiated starting in 2010 – that included blood-sparing surgical and medical techniques, increased use of hemostatic and cell salvage agents, and treatment of suboptimal iron stores before surgery.

In previous retrospective cohort studies, the researchers had found that the blood conservation strategies did not impact in-hospital or 30-day mortality rates, which was consistent with short-term safety data from clinical trials and other observational studies.

Their latest report on longer-term outcomes was based on data from Kaiser Permanente Northern California for 445,371 adults who had 801,261 hospitalizations with discharges between 2010 and 2014. In this cohort, moderate anemia (hemoglobin between 7 g/dL and 10 g/dL) at discharge occurred in 119,489 patients (27%) and 187,440 hospitalizations overall (23%).

Over the 2010-2014 period, RBC transfusions decreased by more than 25% in the inpatient and outpatient settings; and in parallel, the prevalence of moderate anemia at hospital discharge increased from 20% to 25%.

However, the risks of subsequent RBC transfusions and rehospitalization after discharge with anemia decreased during the study period, and mortality rates stayed steady or decreased slightly.

Among patients with moderate anemia, the proportion with subsequent RBC transfusions within 6 months decreased from 18.9% in 2010 to 16.8% in 2014 (P less than .001), while the rate of rehospitalization within 6 months decreased from 36.5% to 32.8% over that same time period (P less than .001).

The adjusted 6-month mortality rate likewise decreased from 16.1% to 15.6% (P = .004) over that time period among patients with moderate anemia.

The study was supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Roubinian and several coauthors reported grants during the conduct of the study from the National Institutes of Health.

SOURCE: Roubinian NH et al. Ann Intern Med. 2018 Dec 18. doi: 10.7326/M17-3253.

Compared with placebo, opioids provide very modest improvements in chronic noncancer pain and physical functioning that decrease over time, according to the authors of a systematic review and meta-analysis of nearly 100 randomized clinical trials.

There was little difference in pain control between opioids and nonopioid alternatives such as NSAIDs in a subset of nine such comparative trials, reported the authors, led by Jason W. Busse, DC, PhD, of the department of anesthesia at McMaster University, Hamilton, Ont.

Pain benefits of opioids decreased over time in longer trials, possibly because of opioid tolerance or hyperalgesia, a condition marked by hypersensitivity to pain. “A reduced association with benefit over time might lead to prescription of higher opioid doses and consequent harms,” Dr. Busse and his coauthors wrote in JAMA.

The meta-analysis included 96 randomized clinical trials including 26,169 patients with chronic noncancer pain.

Opioid treatment did significantly improve pain and physical function versus placebo, though the magnitude of benefit was small, according to the investigators. The reduction in pain was –0.69 cm on a 10-cm visual analog scale (P less than .001), based on high-quality evidence from 42 randomized, controlled trials that followed patients for at least 3 months.

The improvement in physical functioning was likewise significant but small at 2.04 out of 100 points on the SF-36 physical component score (P less than .001). Emotional and role functioning were not significantly improved by opioid use.

Opioid use was linked to increased vomiting incidence versus placebo, with a relative risk of 4.12 (95% CI, 3.34-5.07; P less than .001) for patients in “nonenrichment” trials – those studies that included all patients regardless of whether or not they reported lack of improvement or had substantial adverse events during a study run-in period.

Nausea, constipation, dizziness, drowsiness, pruritus, and dry mouth were also linked to opioid use as compared with placebo, Dr. Busse and his colleagues reported.

The benefit of opioids and nonopioid alternatives appeared to be similar in this meta-analysis, though the available evidence from comparative studies was of low to moderate quality, the authors advised.

In moderate-quality evidence from nine clinical trials of opioids versus NSAIDs including 1,431 patients, there was no difference in pain relief between the two interventions, the investigators said. Moreover, comparisons of physician functioning also suggested no difference, while opioids were associated with more vomiting.

Both tricyclic antidepressants and synthetic cannabinoids offered similar pain relief, compared with opioids, based on low-quality clinical trial evidence, they added, while moderate-quality evidence suggested opioids offered superior pain relief, compared with anticonvulsants.

Support for the study came from the Canadian Institutes of Health Research and Health Canada. One study coauthor reported receiving personal fees from Purdue Pharma and the Nova Scotia College of Physicians and Surgeons.

SOURCE: Busse JW et al. JAMA. 2018;320(23):2448-60.

Compared with placebo, opioids provide very modest improvements in chronic noncancer pain and physical functioning that decrease over time, according to the authors of a systematic review and meta-analysis of nearly 100 randomized clinical trials.

There was little difference in pain control between opioids and nonopioid alternatives such as NSAIDs in a subset of nine such comparative trials, reported the authors, led by Jason W. Busse, DC, PhD, of the department of anesthesia at McMaster University, Hamilton, Ont.

Pain benefits of opioids decreased over time in longer trials, possibly because of opioid tolerance or hyperalgesia, a condition marked by hypersensitivity to pain. “A reduced association with benefit over time might lead to prescription of higher opioid doses and consequent harms,” Dr. Busse and his coauthors wrote in JAMA.

The meta-analysis included 96 randomized clinical trials including 26,169 patients with chronic noncancer pain.

Opioid treatment did significantly improve pain and physical function versus placebo, though the magnitude of benefit was small, according to the investigators. The reduction in pain was –0.69 cm on a 10-cm visual analog scale (P less than .001), based on high-quality evidence from 42 randomized, controlled trials that followed patients for at least 3 months.

The improvement in physical functioning was likewise significant but small at 2.04 out of 100 points on the SF-36 physical component score (P less than .001). Emotional and role functioning were not significantly improved by opioid use.

Opioid use was linked to increased vomiting incidence versus placebo, with a relative risk of 4.12 (95% CI, 3.34-5.07; P less than .001) for patients in “nonenrichment” trials – those studies that included all patients regardless of whether or not they reported lack of improvement or had substantial adverse events during a study run-in period.

Nausea, constipation, dizziness, drowsiness, pruritus, and dry mouth were also linked to opioid use as compared with placebo, Dr. Busse and his colleagues reported.

The benefit of opioids and nonopioid alternatives appeared to be similar in this meta-analysis, though the available evidence from comparative studies was of low to moderate quality, the authors advised.

In moderate-quality evidence from nine clinical trials of opioids versus NSAIDs including 1,431 patients, there was no difference in pain relief between the two interventions, the investigators said. Moreover, comparisons of physician functioning also suggested no difference, while opioids were associated with more vomiting.

Both tricyclic antidepressants and synthetic cannabinoids offered similar pain relief, compared with opioids, based on low-quality clinical trial evidence, they added, while moderate-quality evidence suggested opioids offered superior pain relief, compared with anticonvulsants.

Support for the study came from the Canadian Institutes of Health Research and Health Canada. One study coauthor reported receiving personal fees from Purdue Pharma and the Nova Scotia College of Physicians and Surgeons.

SOURCE: Busse JW et al. JAMA. 2018;320(23):2448-60.

Compared with placebo, opioids provide very modest improvements in chronic noncancer pain and physical functioning that decrease over time, according to the authors of a systematic review and meta-analysis of nearly 100 randomized clinical trials.

There was little difference in pain control between opioids and nonopioid alternatives such as NSAIDs in a subset of nine such comparative trials, reported the authors, led by Jason W. Busse, DC, PhD, of the department of anesthesia at McMaster University, Hamilton, Ont.

Pain benefits of opioids decreased over time in longer trials, possibly because of opioid tolerance or hyperalgesia, a condition marked by hypersensitivity to pain. “A reduced association with benefit over time might lead to prescription of higher opioid doses and consequent harms,” Dr. Busse and his coauthors wrote in JAMA.

The meta-analysis included 96 randomized clinical trials including 26,169 patients with chronic noncancer pain.

Opioid treatment did significantly improve pain and physical function versus placebo, though the magnitude of benefit was small, according to the investigators. The reduction in pain was –0.69 cm on a 10-cm visual analog scale (P less than .001), based on high-quality evidence from 42 randomized, controlled trials that followed patients for at least 3 months.

The improvement in physical functioning was likewise significant but small at 2.04 out of 100 points on the SF-36 physical component score (P less than .001). Emotional and role functioning were not significantly improved by opioid use.

Opioid use was linked to increased vomiting incidence versus placebo, with a relative risk of 4.12 (95% CI, 3.34-5.07; P less than .001) for patients in “nonenrichment” trials – those studies that included all patients regardless of whether or not they reported lack of improvement or had substantial adverse events during a study run-in period.

Nausea, constipation, dizziness, drowsiness, pruritus, and dry mouth were also linked to opioid use as compared with placebo, Dr. Busse and his colleagues reported.

The benefit of opioids and nonopioid alternatives appeared to be similar in this meta-analysis, though the available evidence from comparative studies was of low to moderate quality, the authors advised.

In moderate-quality evidence from nine clinical trials of opioids versus NSAIDs including 1,431 patients, there was no difference in pain relief between the two interventions, the investigators said. Moreover, comparisons of physician functioning also suggested no difference, while opioids were associated with more vomiting.

Both tricyclic antidepressants and synthetic cannabinoids offered similar pain relief, compared with opioids, based on low-quality clinical trial evidence, they added, while moderate-quality evidence suggested opioids offered superior pain relief, compared with anticonvulsants.

Support for the study came from the Canadian Institutes of Health Research and Health Canada. One study coauthor reported receiving personal fees from Purdue Pharma and the Nova Scotia College of Physicians and Surgeons.

SOURCE: Busse JW et al. JAMA. 2018;320(23):2448-60.

CHICAGO – High-risk hospitalized patients with atrial fibrillation (AF) whose doctors monitored them with a computerized alert system were more than twice as likely to be on anticoagulation and had significantly lower rates of death and other cardiovascular events, compared with patients on a standard admissions protocol, according to results of a randomized, controlled trial presented at the American Heart Association Scientific Sessions.

“Alert-based computerized decision support [CDS] increased the prescription of anticoagulation for stroke prevention in atrial fibrillation during hospitalization, at discharge, and at 90 days after randomization in high-risk patients,” said Gregory Piazza, MD, of Brigham and Women’s Hospital, Boston, in presenting results of the AF-ALERT trial. “The reductions in major cardiovascular events was attributable to reductions in MI and stroke/transient ischemic attack at 90 days in patients whose physicians received the alert.”

The trial evaluated 458 patients hospitalized for AF or flutter and with CHA2DS2-VASc scores of 1-8 randomly assigned to the alert (n = 258) or no-alert (n = 210) groups.

Dr. Piazza explained that for those in the alert group, the CDS system notified physicians when the patient’s CHA₂DS₂-VASc score increased. From there, the physician could choose to open an order template to prescribe evidence-based medications to prevent stroke, to elect to review evidence-based clinical practice guidelines, or to continue with the admissions order with an acknowledged reason for omitting anticoagulation (such as high bleeding risk, low stroke risk, high risk for falls, or patient refusal of anticoagulation).

“In patients for whom their providers were alerted, 35% elected to open the stroke-prevention order set, a very tiny percentage elected to read the AF guidelines, and about 64% exited but provided a rationale for omitting anticoagulation,” Dr. Piazza noted.

The alert group was far more likely to be prescribed anticoagulation during the hospitalization (25.8% vs. 9.5%; P less than .0001), at discharge (23.8% vs. 12.9%; P = .003), and at 90 days (27.7% vs. 17.1%; P = .007) than the control group. The alert resulted in a 55% relative risk reduction in a composite outcome of death, MI, cerebrovascular event, and systemic embolic event at 90 days (11.3% vs. 21.9%; P = .002). The alert group had an 87% lower incidence of MI at 90 days (1.2% vs. 8.6%, P = .0002) and 88% lower incidence of cerebrovascular events or systemic embolism at 90 days (0% vs. 2.4%; P = .02). Death at 90 days occurred in 10.1% in the alert group and 14.8% in the control group (P = .13).

One of the limitations of the study, Dr. Piazza noted, was that the most dramatic finding – reduction of major cardiovascular events – was a secondary, not a primary, endpoint. “CDS has the potential to be a powerful tool in prevention of cardiovascular events in patients with atrial fibrillation.”

Moderator Mintu Turakhia, MD, of Stanford (Calif.) University, questioned the low rate of anticoagulation in the study’s control arm – 9.5% – much lower than medians reported in many registries. He also asked Dr. Piazza to describe the mechanism of action for prescribing anticoagulation in these patients.

Dr. Piazza noted the study population was hospitalized patients whose providers had decided prior to their admissions not to prescribe anticoagulation; hence, the rate of anticoagulation in these patients was actually higher than expected.

Regarding the mechanism of action, “the electronic alert seems to preferentially increase the prescription of [direct oral anticoagulants] over warfarin, and that may have been one of the mechanisms,” Dr. Piazza said. Another explanation he offered were “off-target” effects whereby, if providers have a better idea of a patient’s risk for a stroke or MI, they’ll be more aggressive about managing other risk factors.

“There are a number of interventions that could be triggered if the alert prompted the provider to have a conversation with patients about their risk of stroke from AF,” he said. “This may have impact beyond what we can tell from this simple [Best Practice Advisory in the Epic EHR system]. I think we don’t have a great understanding of the full mechanisms of CDS.”

Dr. Piazza reported financial relationships with BTG, Janssen, Bristol-Myers Squibb, Daiichi Sankyo, Portola, and Bayer. Daiichi Sankyo funded the trial. Dr. Turakhia reported relationships with Apple, Janssen, AstraZeneca, VA, Boehringer Ingelheim, Cardiva Medical, Medtronic, Abbott, Precision Health Economics, iBeat, iRhythm, MyoKardia, Biotronik, and an ownership Interest in AliveCor.

CHICAGO – High-risk hospitalized patients with atrial fibrillation (AF) whose doctors monitored them with a computerized alert system were more than twice as likely to be on anticoagulation and had significantly lower rates of death and other cardiovascular events, compared with patients on a standard admissions protocol, according to results of a randomized, controlled trial presented at the American Heart Association Scientific Sessions.

“Alert-based computerized decision support [CDS] increased the prescription of anticoagulation for stroke prevention in atrial fibrillation during hospitalization, at discharge, and at 90 days after randomization in high-risk patients,” said Gregory Piazza, MD, of Brigham and Women’s Hospital, Boston, in presenting results of the AF-ALERT trial. “The reductions in major cardiovascular events was attributable to reductions in MI and stroke/transient ischemic attack at 90 days in patients whose physicians received the alert.”

The trial evaluated 458 patients hospitalized for AF or flutter and with CHA2DS2-VASc scores of 1-8 randomly assigned to the alert (n = 258) or no-alert (n = 210) groups.

Dr. Piazza explained that for those in the alert group, the CDS system notified physicians when the patient’s CHA₂DS₂-VASc score increased. From there, the physician could choose to open an order template to prescribe evidence-based medications to prevent stroke, to elect to review evidence-based clinical practice guidelines, or to continue with the admissions order with an acknowledged reason for omitting anticoagulation (such as high bleeding risk, low stroke risk, high risk for falls, or patient refusal of anticoagulation).

“In patients for whom their providers were alerted, 35% elected to open the stroke-prevention order set, a very tiny percentage elected to read the AF guidelines, and about 64% exited but provided a rationale for omitting anticoagulation,” Dr. Piazza noted.

The alert group was far more likely to be prescribed anticoagulation during the hospitalization (25.8% vs. 9.5%; P less than .0001), at discharge (23.8% vs. 12.9%; P = .003), and at 90 days (27.7% vs. 17.1%; P = .007) than the control group. The alert resulted in a 55% relative risk reduction in a composite outcome of death, MI, cerebrovascular event, and systemic embolic event at 90 days (11.3% vs. 21.9%; P = .002). The alert group had an 87% lower incidence of MI at 90 days (1.2% vs. 8.6%, P = .0002) and 88% lower incidence of cerebrovascular events or systemic embolism at 90 days (0% vs. 2.4%; P = .02). Death at 90 days occurred in 10.1% in the alert group and 14.8% in the control group (P = .13).

One of the limitations of the study, Dr. Piazza noted, was that the most dramatic finding – reduction of major cardiovascular events – was a secondary, not a primary, endpoint. “CDS has the potential to be a powerful tool in prevention of cardiovascular events in patients with atrial fibrillation.”

Moderator Mintu Turakhia, MD, of Stanford (Calif.) University, questioned the low rate of anticoagulation in the study’s control arm – 9.5% – much lower than medians reported in many registries. He also asked Dr. Piazza to describe the mechanism of action for prescribing anticoagulation in these patients.

Dr. Piazza noted the study population was hospitalized patients whose providers had decided prior to their admissions not to prescribe anticoagulation; hence, the rate of anticoagulation in these patients was actually higher than expected.

Regarding the mechanism of action, “the electronic alert seems to preferentially increase the prescription of [direct oral anticoagulants] over warfarin, and that may have been one of the mechanisms,” Dr. Piazza said. Another explanation he offered were “off-target” effects whereby, if providers have a better idea of a patient’s risk for a stroke or MI, they’ll be more aggressive about managing other risk factors.

“There are a number of interventions that could be triggered if the alert prompted the provider to have a conversation with patients about their risk of stroke from AF,” he said. “This may have impact beyond what we can tell from this simple [Best Practice Advisory in the Epic EHR system]. I think we don’t have a great understanding of the full mechanisms of CDS.”

Dr. Piazza reported financial relationships with BTG, Janssen, Bristol-Myers Squibb, Daiichi Sankyo, Portola, and Bayer. Daiichi Sankyo funded the trial. Dr. Turakhia reported relationships with Apple, Janssen, AstraZeneca, VA, Boehringer Ingelheim, Cardiva Medical, Medtronic, Abbott, Precision Health Economics, iBeat, iRhythm, MyoKardia, Biotronik, and an ownership Interest in AliveCor.

CHICAGO – High-risk hospitalized patients with atrial fibrillation (AF) whose doctors monitored them with a computerized alert system were more than twice as likely to be on anticoagulation and had significantly lower rates of death and other cardiovascular events, compared with patients on a standard admissions protocol, according to results of a randomized, controlled trial presented at the American Heart Association Scientific Sessions.

“Alert-based computerized decision support [CDS] increased the prescription of anticoagulation for stroke prevention in atrial fibrillation during hospitalization, at discharge, and at 90 days after randomization in high-risk patients,” said Gregory Piazza, MD, of Brigham and Women’s Hospital, Boston, in presenting results of the AF-ALERT trial. “The reductions in major cardiovascular events was attributable to reductions in MI and stroke/transient ischemic attack at 90 days in patients whose physicians received the alert.”

The trial evaluated 458 patients hospitalized for AF or flutter and with CHA2DS2-VASc scores of 1-8 randomly assigned to the alert (n = 258) or no-alert (n = 210) groups.

Dr. Piazza explained that for those in the alert group, the CDS system notified physicians when the patient’s CHA₂DS₂-VASc score increased. From there, the physician could choose to open an order template to prescribe evidence-based medications to prevent stroke, to elect to review evidence-based clinical practice guidelines, or to continue with the admissions order with an acknowledged reason for omitting anticoagulation (such as high bleeding risk, low stroke risk, high risk for falls, or patient refusal of anticoagulation).

“In patients for whom their providers were alerted, 35% elected to open the stroke-prevention order set, a very tiny percentage elected to read the AF guidelines, and about 64% exited but provided a rationale for omitting anticoagulation,” Dr. Piazza noted.

The alert group was far more likely to be prescribed anticoagulation during the hospitalization (25.8% vs. 9.5%; P less than .0001), at discharge (23.8% vs. 12.9%; P = .003), and at 90 days (27.7% vs. 17.1%; P = .007) than the control group. The alert resulted in a 55% relative risk reduction in a composite outcome of death, MI, cerebrovascular event, and systemic embolic event at 90 days (11.3% vs. 21.9%; P = .002). The alert group had an 87% lower incidence of MI at 90 days (1.2% vs. 8.6%, P = .0002) and 88% lower incidence of cerebrovascular events or systemic embolism at 90 days (0% vs. 2.4%; P = .02). Death at 90 days occurred in 10.1% in the alert group and 14.8% in the control group (P = .13).

One of the limitations of the study, Dr. Piazza noted, was that the most dramatic finding – reduction of major cardiovascular events – was a secondary, not a primary, endpoint. “CDS has the potential to be a powerful tool in prevention of cardiovascular events in patients with atrial fibrillation.”

Moderator Mintu Turakhia, MD, of Stanford (Calif.) University, questioned the low rate of anticoagulation in the study’s control arm – 9.5% – much lower than medians reported in many registries. He also asked Dr. Piazza to describe the mechanism of action for prescribing anticoagulation in these patients.

Dr. Piazza noted the study population was hospitalized patients whose providers had decided prior to their admissions not to prescribe anticoagulation; hence, the rate of anticoagulation in these patients was actually higher than expected.

Regarding the mechanism of action, “the electronic alert seems to preferentially increase the prescription of [direct oral anticoagulants] over warfarin, and that may have been one of the mechanisms,” Dr. Piazza said. Another explanation he offered were “off-target” effects whereby, if providers have a better idea of a patient’s risk for a stroke or MI, they’ll be more aggressive about managing other risk factors.

“There are a number of interventions that could be triggered if the alert prompted the provider to have a conversation with patients about their risk of stroke from AF,” he said. “This may have impact beyond what we can tell from this simple [Best Practice Advisory in the Epic EHR system]. I think we don’t have a great understanding of the full mechanisms of CDS.”

Dr. Piazza reported financial relationships with BTG, Janssen, Bristol-Myers Squibb, Daiichi Sankyo, Portola, and Bayer. Daiichi Sankyo funded the trial. Dr. Turakhia reported relationships with Apple, Janssen, AstraZeneca, VA, Boehringer Ingelheim, Cardiva Medical, Medtronic, Abbott, Precision Health Economics, iBeat, iRhythm, MyoKardia, Biotronik, and an ownership Interest in AliveCor.

The U.S. Preventive Services Task Force posted a draft research plan on opioid use disorder prevention for public comment on Dec. 13, according to a USPSTF bulletin.

An estimated 2.1 million persons aged 12 years and older had an opioid use disorder in 2017, and opioids were involved in nearly two-thirds of more than 70,000 fatal drug overdoses, according to the task force. Prevention of unnecessary opioid use, opioid misuse, and opioid use disorder in primary care settings is necessary to effectively respond to the ongoing crisis.

In an extensive literature review, an independent research team will look for evidence on strategies for people not currently receiving opioids that can be implemented on the primary care level. The public is invited to submit comments on the research plan that will help focus and guide the literature review.

The USPSTF also will be updating the current 2008 recommendation statement on screening for illicit drugs and nonmedical prescription drugs in adolescents and young adults, including pregnant and postpartum women.

Comments can be submitted until Jan. 16, 2019, on the USPSTF website.

[email protected]

The U.S. Preventive Services Task Force posted a draft research plan on opioid use disorder prevention for public comment on Dec. 13, according to a USPSTF bulletin.

An estimated 2.1 million persons aged 12 years and older had an opioid use disorder in 2017, and opioids were involved in nearly two-thirds of more than 70,000 fatal drug overdoses, according to the task force. Prevention of unnecessary opioid use, opioid misuse, and opioid use disorder in primary care settings is necessary to effectively respond to the ongoing crisis.

In an extensive literature review, an independent research team will look for evidence on strategies for people not currently receiving opioids that can be implemented on the primary care level. The public is invited to submit comments on the research plan that will help focus and guide the literature review.

The USPSTF also will be updating the current 2008 recommendation statement on screening for illicit drugs and nonmedical prescription drugs in adolescents and young adults, including pregnant and postpartum women.

Comments can be submitted until Jan. 16, 2019, on the USPSTF website.

[email protected]

The U.S. Preventive Services Task Force posted a draft research plan on opioid use disorder prevention for public comment on Dec. 13, according to a USPSTF bulletin.

An estimated 2.1 million persons aged 12 years and older had an opioid use disorder in 2017, and opioids were involved in nearly two-thirds of more than 70,000 fatal drug overdoses, according to the task force. Prevention of unnecessary opioid use, opioid misuse, and opioid use disorder in primary care settings is necessary to effectively respond to the ongoing crisis.

In an extensive literature review, an independent research team will look for evidence on strategies for people not currently receiving opioids that can be implemented on the primary care level. The public is invited to submit comments on the research plan that will help focus and guide the literature review.

The USPSTF also will be updating the current 2008 recommendation statement on screening for illicit drugs and nonmedical prescription drugs in adolescents and young adults, including pregnant and postpartum women.

Comments can be submitted until Jan. 16, 2019, on the USPSTF website.

[email protected]

The world’s largest gay dating app, Grindr, changed its software earlier this year to create reminders for users to get regular HIV tests.

jarun011/Thinkstock

According to Grindr, 3.3 million users around the world visit the site daily; it sends those who opt into the service a reminder every 3-6 months to get a test. The message also directs them to the nearest testing site. Grindr also plans to give clinics, gay community centers, and other testing sites free advertising.

Among health care providers, the decision has been widely applauded. “This will ‘demedicalize’ testing and destigmatize it,” Perry N. Halkitis, PhD, dean of the Rutgers School of Public Health, in Newark, N.J., told the New York Times. “The more you make it normal, the more people are going to access it.”

Studies have shown that reminders by text or phone can triple or quadruple the chance that the recipient will get tested.
 

Reference

McNeil Jr. DG. Grindr App to Offer H.I.V. Test Reminders. The New York Times. March 26, 2018. Accessed April 5, 2018.






 

The world’s largest gay dating app, Grindr, changed its software earlier this year to create reminders for users to get regular HIV tests.

jarun011/Thinkstock

According to Grindr, 3.3 million users around the world visit the site daily; it sends those who opt into the service a reminder every 3-6 months to get a test. The message also directs them to the nearest testing site. Grindr also plans to give clinics, gay community centers, and other testing sites free advertising.

Among health care providers, the decision has been widely applauded. “This will ‘demedicalize’ testing and destigmatize it,” Perry N. Halkitis, PhD, dean of the Rutgers School of Public Health, in Newark, N.J., told the New York Times. “The more you make it normal, the more people are going to access it.”

Studies have shown that reminders by text or phone can triple or quadruple the chance that the recipient will get tested.
 

Reference

McNeil Jr. DG. Grindr App to Offer H.I.V. Test Reminders. The New York Times. March 26, 2018. Accessed April 5, 2018.






 

The world’s largest gay dating app, Grindr, changed its software earlier this year to create reminders for users to get regular HIV tests.

jarun011/Thinkstock

According to Grindr, 3.3 million users around the world visit the site daily; it sends those who opt into the service a reminder every 3-6 months to get a test. The message also directs them to the nearest testing site. Grindr also plans to give clinics, gay community centers, and other testing sites free advertising.

Among health care providers, the decision has been widely applauded. “This will ‘demedicalize’ testing and destigmatize it,” Perry N. Halkitis, PhD, dean of the Rutgers School of Public Health, in Newark, N.J., told the New York Times. “The more you make it normal, the more people are going to access it.”

Studies have shown that reminders by text or phone can triple or quadruple the chance that the recipient will get tested.
 

Reference

McNeil Jr. DG. Grindr App to Offer H.I.V. Test Reminders. The New York Times. March 26, 2018. Accessed April 5, 2018.