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Non–private clinical encounters tied to diagnostic error and delays in delivery of care.
In a cross-sectional survey of 409 emergency physicians attending the American College of Emergency Physicians Scientific Assembly conference, a majority of respondents reported deviating from their standard history-taking and physical exam practices when practicing in a hallway location or when a patient had a companion present during the clinical encounter. Of those physicians who reported changing their practices during non–private clinical encounters, a significant proportion reported that these changes had led to a delay in patient care or diagnostic error.
Citation: Stoklosa H et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg Med J. 2018 Feb 13. doi: 10.1136/emermed-2017-207119.
Retrospective case series of fluoroquinolone-induced acute interstitial nephritis (AIN).
A 23-year retrospective review of biopsy-proven cases of acute interstitial nephritis secondary to fluoroquinolones revealed that only 17% of cases presented with the typical triad of fever, rash, and eosinophilia, but that discontinuation of the offending agent resulted in complete or partial recovery in a majority of patients, with a median time to recovery of 20.5 days.
Citation: Farid S et al. Clinical manifestations and outcomes of fluoroquinolone-related acute interstitial nephritis. Mayo Clin Proc. 2018 Jan;93(1):25-31.
Trimethoprim associated with increased risk of AKI and hyperkalemia.
In a cohort study of older patients with urinary tract infections, trimethoprim was associated with increased risk of acute kidney injury and hyperkalemia, but not increased risk of death, in comparison to other antibiotics for UTIs. These risks were amplified for patients simultaneously taking renin-angiotensin system blockers or spironolactone.
Citation: Crellin E et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ. 2018;360:k341.
Mortality of in-hospital cardiac arrest is decreasing, but disparities between on- and off-hours persist.
An analysis of 151,071 in-hospital cardiac arrests (IHCA) during 2000-2014 found that patient survival to hospital discharge increased from 13.6% to 22.0%, but return of spontaneous circulation, post-resuscitation survival, and overall survival to hospital discharge were all significantly lower for IHCA that occurred during nights or weekends, compared with weekday IHCA. The difference in on- and off-hours post-resuscitation survival rates did not significantly change over the 14-year study period.
Citation: Ofoma UR et al. Trends in survival after in-hospital cardiac arrest during nights and weekends. J Am Coll Cardiol. 2018;71(4):402-11.
Young women with acute myocardial infarction present differently than young men.
Interviews of 2,009 young women and 976 young men hospitalized for acute MI at U.S. hospitals revealed that, while both groups of patients reported chest pain as the predominant symptom, women were more likely to report a greater number of additional, non–chest pain symptoms.
Citation: Lichtman JH et al. Sex difference in the presentation and perception of symptoms among young patients with myocardial infarction. Circulation. 2018;137(8):781-90.
Non–private clinical encounters tied to diagnostic error and delays in delivery of care.
In a cross-sectional survey of 409 emergency physicians attending the American College of Emergency Physicians Scientific Assembly conference, a majority of respondents reported deviating from their standard history-taking and physical exam practices when practicing in a hallway location or when a patient had a companion present during the clinical encounter. Of those physicians who reported changing their practices during non–private clinical encounters, a significant proportion reported that these changes had led to a delay in patient care or diagnostic error.
Citation: Stoklosa H et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg Med J. 2018 Feb 13. doi: 10.1136/emermed-2017-207119.
Retrospective case series of fluoroquinolone-induced acute interstitial nephritis (AIN).
A 23-year retrospective review of biopsy-proven cases of acute interstitial nephritis secondary to fluoroquinolones revealed that only 17% of cases presented with the typical triad of fever, rash, and eosinophilia, but that discontinuation of the offending agent resulted in complete or partial recovery in a majority of patients, with a median time to recovery of 20.5 days.
Citation: Farid S et al. Clinical manifestations and outcomes of fluoroquinolone-related acute interstitial nephritis. Mayo Clin Proc. 2018 Jan;93(1):25-31.
Trimethoprim associated with increased risk of AKI and hyperkalemia.
In a cohort study of older patients with urinary tract infections, trimethoprim was associated with increased risk of acute kidney injury and hyperkalemia, but not increased risk of death, in comparison to other antibiotics for UTIs. These risks were amplified for patients simultaneously taking renin-angiotensin system blockers or spironolactone.
Citation: Crellin E et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ. 2018;360:k341.
Mortality of in-hospital cardiac arrest is decreasing, but disparities between on- and off-hours persist.
An analysis of 151,071 in-hospital cardiac arrests (IHCA) during 2000-2014 found that patient survival to hospital discharge increased from 13.6% to 22.0%, but return of spontaneous circulation, post-resuscitation survival, and overall survival to hospital discharge were all significantly lower for IHCA that occurred during nights or weekends, compared with weekday IHCA. The difference in on- and off-hours post-resuscitation survival rates did not significantly change over the 14-year study period.
Citation: Ofoma UR et al. Trends in survival after in-hospital cardiac arrest during nights and weekends. J Am Coll Cardiol. 2018;71(4):402-11.
Young women with acute myocardial infarction present differently than young men.
Interviews of 2,009 young women and 976 young men hospitalized for acute MI at U.S. hospitals revealed that, while both groups of patients reported chest pain as the predominant symptom, women were more likely to report a greater number of additional, non–chest pain symptoms.
Citation: Lichtman JH et al. Sex difference in the presentation and perception of symptoms among young patients with myocardial infarction. Circulation. 2018;137(8):781-90.
Non–private clinical encounters tied to diagnostic error and delays in delivery of care.
In a cross-sectional survey of 409 emergency physicians attending the American College of Emergency Physicians Scientific Assembly conference, a majority of respondents reported deviating from their standard history-taking and physical exam practices when practicing in a hallway location or when a patient had a companion present during the clinical encounter. Of those physicians who reported changing their practices during non–private clinical encounters, a significant proportion reported that these changes had led to a delay in patient care or diagnostic error.
Citation: Stoklosa H et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg Med J. 2018 Feb 13. doi: 10.1136/emermed-2017-207119.
Retrospective case series of fluoroquinolone-induced acute interstitial nephritis (AIN).
A 23-year retrospective review of biopsy-proven cases of acute interstitial nephritis secondary to fluoroquinolones revealed that only 17% of cases presented with the typical triad of fever, rash, and eosinophilia, but that discontinuation of the offending agent resulted in complete or partial recovery in a majority of patients, with a median time to recovery of 20.5 days.
Citation: Farid S et al. Clinical manifestations and outcomes of fluoroquinolone-related acute interstitial nephritis. Mayo Clin Proc. 2018 Jan;93(1):25-31.
Trimethoprim associated with increased risk of AKI and hyperkalemia.
In a cohort study of older patients with urinary tract infections, trimethoprim was associated with increased risk of acute kidney injury and hyperkalemia, but not increased risk of death, in comparison to other antibiotics for UTIs. These risks were amplified for patients simultaneously taking renin-angiotensin system blockers or spironolactone.
Citation: Crellin E et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ. 2018;360:k341.
Mortality of in-hospital cardiac arrest is decreasing, but disparities between on- and off-hours persist.
An analysis of 151,071 in-hospital cardiac arrests (IHCA) during 2000-2014 found that patient survival to hospital discharge increased from 13.6% to 22.0%, but return of spontaneous circulation, post-resuscitation survival, and overall survival to hospital discharge were all significantly lower for IHCA that occurred during nights or weekends, compared with weekday IHCA. The difference in on- and off-hours post-resuscitation survival rates did not significantly change over the 14-year study period.
Citation: Ofoma UR et al. Trends in survival after in-hospital cardiac arrest during nights and weekends. J Am Coll Cardiol. 2018;71(4):402-11.
Young women with acute myocardial infarction present differently than young men.
Interviews of 2,009 young women and 976 young men hospitalized for acute MI at U.S. hospitals revealed that, while both groups of patients reported chest pain as the predominant symptom, women were more likely to report a greater number of additional, non–chest pain symptoms.
Citation: Lichtman JH et al. Sex difference in the presentation and perception of symptoms among young patients with myocardial infarction. Circulation. 2018;137(8):781-90.
Who are the 'high-need, high-cost' patients?
Among patients hospitalized with gastrointestinal and liver diseases, a clearly identifiable subset uses significantly more health care resources, which incurs significantly greater costs, according to the results of a national database analysis published in the August issue of Clinical Gastroenterology and Hepatology.
Compared with otherwise similar inpatients, these “high-need, high-cost” individuals are significantly more likely to be enrolled in Medicare or Medicaid, to have lower income, to initially be admitted to a large, rural hospital, to have multiple comorbidities, to be obese, or to be hospitalized for infection, said Nghia Nguyen, MD, and his associates. “[A] small fraction of high-need, high-cost patients contribute disproportionately to hospitalization costs,” they wrote. “Population health management directed toward these patients would facilitate high-value care.”
Gastrointestinal and liver diseases incur more than $100 billion in health care expenses annually in the United States, of which more than 60% is related to inpatient care, the researchers noted. However, few studies have comprehensively evaluated the annual burden and costs of hospitalization in patients with chronic gastrointestinal and liver diseases. Therefore, using the Nationwide Readmissions Database, the investigators studied patients with inflammatory bowel disease (IBD), chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases who were hospitalized at least once during the first 6 months of 2013. All patients were diagnosed with IBD, chronic liver diseases, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases and followed for at least 6 months. The researchers stratified hospital days and costs and characterized the subset of patients who fell into the highest decile of days spent in the hospital per month.
The most common reason for hospitalization was chronic liver disease (nearly 377,000 patients), followed by functional gastrointestinal disorders (more than 351,000 patients), gastrointestinal hemorrhage (nearly 191,000 patients), pancreatic diseases (more than 98,000 patients), and IBD (more than 47,000 patients). Patients spent a median of 6-7 days in the hospital per year, with an interquartile range of 3-14 days. Compared with patients in the lowest decile for annual hospital stay (median, 0.13-0.14 days per month), patients in the highest decile spent a median of 3.7-5.1 days in the hospital per month. In this high-cost, high-need subset of patients, the costs of each hospitalization ranged from $7,438 per month to $11,425 per month, and they were typically hospitalized once every 2 months.
“Gastrointestinal diseases, infections, and cardiopulmonary causes were leading reasons for hospitalization of these patients,” the researchers wrote. “At a patient level, modifiable risk factors may include tackling the obesity epidemic and mental health issues and minimizing risk of iatrogenic or health care–associated infections, whereas at a health system level, interventions may include better access to care and connectivity between rural and specialty hospitals.”
Funders included the American College of Gastroenterology, the Crohn’s and Colitis Foundation, and the National Institutes of Health. Senior author Siddharth Singh disclosed unrelated grant funding from Pifzer and AbbVie. The other investigators reported having no conflicts of interest.
SOURCE: Nguyen NH et al. Clin Gastroenterol Hepatol. 2018 Feb 20. doi: 10.1016/j.cgh.2018.02.015.
Understanding the reasons underlying variations in health care utilization is central to any plan to reduce costs at the population level. To this end, Nguyen et al. provide crucial data for the patients for whom we care as gastroenterologists. Studying a longitudinal database of hospitalizations in 2013, the authors provide comprehensive demographic data for the top decile of inpatient health care utilizers (defined by hospital-days/month) with inflammatory bowel disease, chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, and pancreatic diseases. Although constrained by the limits of administrative data and the lack of outpatient/pharmaceutical data linkage, these findings are strengthened by their consistency across conditions. Indeed, despite the heterogeneous disorders surveyed, a remarkably consistent high-need/high-cost "phenotype" emerges: publicly insured, low-income, rural, obese but malnourished, and beset by infections and the complications of diabetes.
What are the next steps?
When a minority of the patients are responsible for a substantial portion of the costs (i.e., the 80/20 rule), one strategy for cost containment is "hot-spotting." Hot-spotting is a two-step process: Identify high-need, high-cost patients, and then deploy interventions tailored to their needs. Nguyen and colleague's work is a landmark for the first step. However, before these findings may be translated into policy or intervention, we need granular data to explain these associations and suggest clear action items. Solutions will likely be multifactorial including early, intensified care for obesity and diabetes (before end-stage complications arise), novel care delivery methods for gastroenterology specialty care in rural hospitals, and intensified outpatient resources for high-need patients in order to coordinate alternatives to hospitalization.
Elliot B. Tapper, MD, is assistant professor, division of gastroenterology and hepatology, University of Michigan, Ann Arbor. He reports consulting for Novartis and receiving unrestricted research grants from Valeant and Gilead, all unrelated to this work.
Understanding the reasons underlying variations in health care utilization is central to any plan to reduce costs at the population level. To this end, Nguyen et al. provide crucial data for the patients for whom we care as gastroenterologists. Studying a longitudinal database of hospitalizations in 2013, the authors provide comprehensive demographic data for the top decile of inpatient health care utilizers (defined by hospital-days/month) with inflammatory bowel disease, chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, and pancreatic diseases. Although constrained by the limits of administrative data and the lack of outpatient/pharmaceutical data linkage, these findings are strengthened by their consistency across conditions. Indeed, despite the heterogeneous disorders surveyed, a remarkably consistent high-need/high-cost "phenotype" emerges: publicly insured, low-income, rural, obese but malnourished, and beset by infections and the complications of diabetes.
What are the next steps?
When a minority of the patients are responsible for a substantial portion of the costs (i.e., the 80/20 rule), one strategy for cost containment is "hot-spotting." Hot-spotting is a two-step process: Identify high-need, high-cost patients, and then deploy interventions tailored to their needs. Nguyen and colleague's work is a landmark for the first step. However, before these findings may be translated into policy or intervention, we need granular data to explain these associations and suggest clear action items. Solutions will likely be multifactorial including early, intensified care for obesity and diabetes (before end-stage complications arise), novel care delivery methods for gastroenterology specialty care in rural hospitals, and intensified outpatient resources for high-need patients in order to coordinate alternatives to hospitalization.
Elliot B. Tapper, MD, is assistant professor, division of gastroenterology and hepatology, University of Michigan, Ann Arbor. He reports consulting for Novartis and receiving unrestricted research grants from Valeant and Gilead, all unrelated to this work.
Understanding the reasons underlying variations in health care utilization is central to any plan to reduce costs at the population level. To this end, Nguyen et al. provide crucial data for the patients for whom we care as gastroenterologists. Studying a longitudinal database of hospitalizations in 2013, the authors provide comprehensive demographic data for the top decile of inpatient health care utilizers (defined by hospital-days/month) with inflammatory bowel disease, chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, and pancreatic diseases. Although constrained by the limits of administrative data and the lack of outpatient/pharmaceutical data linkage, these findings are strengthened by their consistency across conditions. Indeed, despite the heterogeneous disorders surveyed, a remarkably consistent high-need/high-cost "phenotype" emerges: publicly insured, low-income, rural, obese but malnourished, and beset by infections and the complications of diabetes.
What are the next steps?
When a minority of the patients are responsible for a substantial portion of the costs (i.e., the 80/20 rule), one strategy for cost containment is "hot-spotting." Hot-spotting is a two-step process: Identify high-need, high-cost patients, and then deploy interventions tailored to their needs. Nguyen and colleague's work is a landmark for the first step. However, before these findings may be translated into policy or intervention, we need granular data to explain these associations and suggest clear action items. Solutions will likely be multifactorial including early, intensified care for obesity and diabetes (before end-stage complications arise), novel care delivery methods for gastroenterology specialty care in rural hospitals, and intensified outpatient resources for high-need patients in order to coordinate alternatives to hospitalization.
Elliot B. Tapper, MD, is assistant professor, division of gastroenterology and hepatology, University of Michigan, Ann Arbor. He reports consulting for Novartis and receiving unrestricted research grants from Valeant and Gilead, all unrelated to this work.
Among patients hospitalized with gastrointestinal and liver diseases, a clearly identifiable subset uses significantly more health care resources, which incurs significantly greater costs, according to the results of a national database analysis published in the August issue of Clinical Gastroenterology and Hepatology.
Compared with otherwise similar inpatients, these “high-need, high-cost” individuals are significantly more likely to be enrolled in Medicare or Medicaid, to have lower income, to initially be admitted to a large, rural hospital, to have multiple comorbidities, to be obese, or to be hospitalized for infection, said Nghia Nguyen, MD, and his associates. “[A] small fraction of high-need, high-cost patients contribute disproportionately to hospitalization costs,” they wrote. “Population health management directed toward these patients would facilitate high-value care.”
Gastrointestinal and liver diseases incur more than $100 billion in health care expenses annually in the United States, of which more than 60% is related to inpatient care, the researchers noted. However, few studies have comprehensively evaluated the annual burden and costs of hospitalization in patients with chronic gastrointestinal and liver diseases. Therefore, using the Nationwide Readmissions Database, the investigators studied patients with inflammatory bowel disease (IBD), chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases who were hospitalized at least once during the first 6 months of 2013. All patients were diagnosed with IBD, chronic liver diseases, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases and followed for at least 6 months. The researchers stratified hospital days and costs and characterized the subset of patients who fell into the highest decile of days spent in the hospital per month.
The most common reason for hospitalization was chronic liver disease (nearly 377,000 patients), followed by functional gastrointestinal disorders (more than 351,000 patients), gastrointestinal hemorrhage (nearly 191,000 patients), pancreatic diseases (more than 98,000 patients), and IBD (more than 47,000 patients). Patients spent a median of 6-7 days in the hospital per year, with an interquartile range of 3-14 days. Compared with patients in the lowest decile for annual hospital stay (median, 0.13-0.14 days per month), patients in the highest decile spent a median of 3.7-5.1 days in the hospital per month. In this high-cost, high-need subset of patients, the costs of each hospitalization ranged from $7,438 per month to $11,425 per month, and they were typically hospitalized once every 2 months.
“Gastrointestinal diseases, infections, and cardiopulmonary causes were leading reasons for hospitalization of these patients,” the researchers wrote. “At a patient level, modifiable risk factors may include tackling the obesity epidemic and mental health issues and minimizing risk of iatrogenic or health care–associated infections, whereas at a health system level, interventions may include better access to care and connectivity between rural and specialty hospitals.”
Funders included the American College of Gastroenterology, the Crohn’s and Colitis Foundation, and the National Institutes of Health. Senior author Siddharth Singh disclosed unrelated grant funding from Pifzer and AbbVie. The other investigators reported having no conflicts of interest.
SOURCE: Nguyen NH et al. Clin Gastroenterol Hepatol. 2018 Feb 20. doi: 10.1016/j.cgh.2018.02.015.
Among patients hospitalized with gastrointestinal and liver diseases, a clearly identifiable subset uses significantly more health care resources, which incurs significantly greater costs, according to the results of a national database analysis published in the August issue of Clinical Gastroenterology and Hepatology.
Compared with otherwise similar inpatients, these “high-need, high-cost” individuals are significantly more likely to be enrolled in Medicare or Medicaid, to have lower income, to initially be admitted to a large, rural hospital, to have multiple comorbidities, to be obese, or to be hospitalized for infection, said Nghia Nguyen, MD, and his associates. “[A] small fraction of high-need, high-cost patients contribute disproportionately to hospitalization costs,” they wrote. “Population health management directed toward these patients would facilitate high-value care.”
Gastrointestinal and liver diseases incur more than $100 billion in health care expenses annually in the United States, of which more than 60% is related to inpatient care, the researchers noted. However, few studies have comprehensively evaluated the annual burden and costs of hospitalization in patients with chronic gastrointestinal and liver diseases. Therefore, using the Nationwide Readmissions Database, the investigators studied patients with inflammatory bowel disease (IBD), chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases who were hospitalized at least once during the first 6 months of 2013. All patients were diagnosed with IBD, chronic liver diseases, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases and followed for at least 6 months. The researchers stratified hospital days and costs and characterized the subset of patients who fell into the highest decile of days spent in the hospital per month.
The most common reason for hospitalization was chronic liver disease (nearly 377,000 patients), followed by functional gastrointestinal disorders (more than 351,000 patients), gastrointestinal hemorrhage (nearly 191,000 patients), pancreatic diseases (more than 98,000 patients), and IBD (more than 47,000 patients). Patients spent a median of 6-7 days in the hospital per year, with an interquartile range of 3-14 days. Compared with patients in the lowest decile for annual hospital stay (median, 0.13-0.14 days per month), patients in the highest decile spent a median of 3.7-5.1 days in the hospital per month. In this high-cost, high-need subset of patients, the costs of each hospitalization ranged from $7,438 per month to $11,425 per month, and they were typically hospitalized once every 2 months.
“Gastrointestinal diseases, infections, and cardiopulmonary causes were leading reasons for hospitalization of these patients,” the researchers wrote. “At a patient level, modifiable risk factors may include tackling the obesity epidemic and mental health issues and minimizing risk of iatrogenic or health care–associated infections, whereas at a health system level, interventions may include better access to care and connectivity between rural and specialty hospitals.”
Funders included the American College of Gastroenterology, the Crohn’s and Colitis Foundation, and the National Institutes of Health. Senior author Siddharth Singh disclosed unrelated grant funding from Pifzer and AbbVie. The other investigators reported having no conflicts of interest.
SOURCE: Nguyen NH et al. Clin Gastroenterol Hepatol. 2018 Feb 20. doi: 10.1016/j.cgh.2018.02.015.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: For patients with gastrointestinal or liver disease, significant predictors of high need and cost during hospitalization included Medicare or Medicaid insurance, lower income, first hospitalization in a large rural hospital, high comorbidity burden, obesity, and hospitalization for infection.
Major finding: Patients in the highest decile spent a median of 3.7-4.1 days in the hospital per month for all causes. Gastrointestinal disease, infections, and cardiopulmonary morbidity were the most common reasons for hospitalization.
Study details: Analysis of patients with inflammatory bowel disease, chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases hospitalized at least once during 2013.
Disclosures: Funders included the American College of Gastroenterology, the Crohn’s and Colitis Foundation, and the National Institutes of Health. Senior author Siddharth Singh disclosed unrelated grant funding from Pifzer and AbbVie. The other investigators reported having no conflicts of interest.
Source: Nguyen NH et al. Clin Gastroenterol Hepatol. 2018 Feb 20. doi: 10.1016/j.cgh.2018.02.015.
Pulmonary Embolism Rule-Out Criteria Strategy is noninferior when clinical probability is low
Background: There is an alarming trend toward overuse of computed tomographic pulmonary angiography (CTPA) for the rule-out of low clinical probability PE. The eight-item Pulmonary Embolism Rule-Out Criteria (PERC) rule was devised to be used in populations of patients with low clinical probability of PE to guide which patients would likely not benefit from CTPA imaging. Recent concerns have been raised that the use of the PERC rule could result in high false-negative rates.
Study design: Crossover cluster–randomized clinical noninferiority trial.
Setting: 14 EDs in France from August 2015 to September 2016.
Synopsis: 1,916 emergency department patients with low clinical probability of PE were cluster-randomized to usual care or to a PERC strategy where, if the PERC score was zero, PE was ruled out without additional testing. The primary outcome was diagnosis of a symptomatic PE within 3 months that had not been diagnosed initially. Primary outcome results met prespecified noninferiority criteria for the PERC group, compared with the usual-care group (0.1% in the PERC group, 0% in the control group). The PERC group had significantly lower median length of ED stay and lower likelihood of admission.
Limitations of this study include its younger average patient age (44 years) and its cluster, as opposed to per-patient, randomization design.
Bottom line: In patients for whom the clinical probability of PE is low, use of the PERC rule is noninferior to a conventional d-dimer and CTPA strategy for ruling out symptomatic PE.
Citation: Freund Y et al. Effect of the pulmonary embolism rule-out criteria on subsequent thromboembolic events among low-risk emergency department patients. JAMA. 2018;319(6):559-66.
Dr. Abdallah is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Background: There is an alarming trend toward overuse of computed tomographic pulmonary angiography (CTPA) for the rule-out of low clinical probability PE. The eight-item Pulmonary Embolism Rule-Out Criteria (PERC) rule was devised to be used in populations of patients with low clinical probability of PE to guide which patients would likely not benefit from CTPA imaging. Recent concerns have been raised that the use of the PERC rule could result in high false-negative rates.
Study design: Crossover cluster–randomized clinical noninferiority trial.
Setting: 14 EDs in France from August 2015 to September 2016.
Synopsis: 1,916 emergency department patients with low clinical probability of PE were cluster-randomized to usual care or to a PERC strategy where, if the PERC score was zero, PE was ruled out without additional testing. The primary outcome was diagnosis of a symptomatic PE within 3 months that had not been diagnosed initially. Primary outcome results met prespecified noninferiority criteria for the PERC group, compared with the usual-care group (0.1% in the PERC group, 0% in the control group). The PERC group had significantly lower median length of ED stay and lower likelihood of admission.
Limitations of this study include its younger average patient age (44 years) and its cluster, as opposed to per-patient, randomization design.
Bottom line: In patients for whom the clinical probability of PE is low, use of the PERC rule is noninferior to a conventional d-dimer and CTPA strategy for ruling out symptomatic PE.
Citation: Freund Y et al. Effect of the pulmonary embolism rule-out criteria on subsequent thromboembolic events among low-risk emergency department patients. JAMA. 2018;319(6):559-66.
Dr. Abdallah is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Background: There is an alarming trend toward overuse of computed tomographic pulmonary angiography (CTPA) for the rule-out of low clinical probability PE. The eight-item Pulmonary Embolism Rule-Out Criteria (PERC) rule was devised to be used in populations of patients with low clinical probability of PE to guide which patients would likely not benefit from CTPA imaging. Recent concerns have been raised that the use of the PERC rule could result in high false-negative rates.
Study design: Crossover cluster–randomized clinical noninferiority trial.
Setting: 14 EDs in France from August 2015 to September 2016.
Synopsis: 1,916 emergency department patients with low clinical probability of PE were cluster-randomized to usual care or to a PERC strategy where, if the PERC score was zero, PE was ruled out without additional testing. The primary outcome was diagnosis of a symptomatic PE within 3 months that had not been diagnosed initially. Primary outcome results met prespecified noninferiority criteria for the PERC group, compared with the usual-care group (0.1% in the PERC group, 0% in the control group). The PERC group had significantly lower median length of ED stay and lower likelihood of admission.
Limitations of this study include its younger average patient age (44 years) and its cluster, as opposed to per-patient, randomization design.
Bottom line: In patients for whom the clinical probability of PE is low, use of the PERC rule is noninferior to a conventional d-dimer and CTPA strategy for ruling out symptomatic PE.
Citation: Freund Y et al. Effect of the pulmonary embolism rule-out criteria on subsequent thromboembolic events among low-risk emergency department patients. JAMA. 2018;319(6):559-66.
Dr. Abdallah is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Timely culture reports lower LOS for neonatal fever
ATLANTA – An adjustment in the culture reporting schedule at Texas Children’s Hospital, Houston, helped reduce the average length of stay for neonatal fever from 48 to 43 hours, without increasing readmissions for serious bacterial infections, according to a review presented at the Pediatric Hospital Medicine meeting.
Investigators there were working to meet the goals of the Reducing Excessive Variability in Infant Sepsis Evaluation project (REVISE), a national collaboration aimed at improving care. One of the goals is to reduce the length of stay (LOS) for neonatal fever to fewer than 30 hours for low-risk infants and fewer than 42 hours among high-risk infants.
The traditional standard is to keep children in the hospital for 48 hours to rule out sepsis, but that thinking has begun to change amid evidence that blood cultures generally do not need that long to turn positive, among other findings, said investigator Huay-Ying Lo, MD, a pediatrician at Texas Children’s.
“At our institution,” which admits more than 200 NF cases annually, “we have order sets for neonatal fever, and we’re actually doing pretty well” meeting most of the REVISE goals, “so we decided to focus on reducing length of stay,” she said at the meeting.
Evidence of the safety and cost savings of earlier discharge was presented to providers, and weekly emails reminded them of the early discharge goal and updated them on the current average LOS for NF.
Dr. Lo and her team also brainstormed with providers to identify problems. “One of the barriers they consistently mentioned was the timing of cultures being reported out from the microbiology lab. A lot of time, people were just waiting for the report to say no growth for 36 hours or whatever it was going to be,” she said.
That led to talks with the microbiology department. Blood cultures were already automated, so there wasn’t much that needed to be done. Urine cultures were read manually three to four times a day after the initial incubation period. However, after an initial Gram stain, CSF cultures were read manually only one or two times a day – whenever somebody had time. The hours were random, and sometimes results were not reported until the evening, which meant the child had to spend another night in the hospital.
The lab director agreed that it was a problem, and standardized procedures to read cultures twice a day, at 7 a.m. and 2 p.m. “The times we agreed upon; 7 a.m. works really well for morning discharge, and at 2 p.m., the day team is still there and can get kids out that day,” Dr. Lo explained.
. Among infants 7-60 days old admitted with NF – excluding ill-appearing children and those with comorbidities that increased the risk of infections – the mean LOS fell from 48 hours among 144 infants treated before the intervention, to 43 hours among 157 treated afterward (P = .001), and “we didn’t have any more readmission for serious bacterial infections,” Dr. Lo said.
“We want to reduce it further. If we get to 42 hours, we’ll be pretty happy.” Updating discharge criteria, and letting providers know how their LOS’s compare with their peers’ might help. “I’m sure some people are more conservative and some a little more liberal,” she said.
There was no industry funding for the work, and the investigators had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
ATLANTA – An adjustment in the culture reporting schedule at Texas Children’s Hospital, Houston, helped reduce the average length of stay for neonatal fever from 48 to 43 hours, without increasing readmissions for serious bacterial infections, according to a review presented at the Pediatric Hospital Medicine meeting.
Investigators there were working to meet the goals of the Reducing Excessive Variability in Infant Sepsis Evaluation project (REVISE), a national collaboration aimed at improving care. One of the goals is to reduce the length of stay (LOS) for neonatal fever to fewer than 30 hours for low-risk infants and fewer than 42 hours among high-risk infants.
The traditional standard is to keep children in the hospital for 48 hours to rule out sepsis, but that thinking has begun to change amid evidence that blood cultures generally do not need that long to turn positive, among other findings, said investigator Huay-Ying Lo, MD, a pediatrician at Texas Children’s.
“At our institution,” which admits more than 200 NF cases annually, “we have order sets for neonatal fever, and we’re actually doing pretty well” meeting most of the REVISE goals, “so we decided to focus on reducing length of stay,” she said at the meeting.
Evidence of the safety and cost savings of earlier discharge was presented to providers, and weekly emails reminded them of the early discharge goal and updated them on the current average LOS for NF.
Dr. Lo and her team also brainstormed with providers to identify problems. “One of the barriers they consistently mentioned was the timing of cultures being reported out from the microbiology lab. A lot of time, people were just waiting for the report to say no growth for 36 hours or whatever it was going to be,” she said.
That led to talks with the microbiology department. Blood cultures were already automated, so there wasn’t much that needed to be done. Urine cultures were read manually three to four times a day after the initial incubation period. However, after an initial Gram stain, CSF cultures were read manually only one or two times a day – whenever somebody had time. The hours were random, and sometimes results were not reported until the evening, which meant the child had to spend another night in the hospital.
The lab director agreed that it was a problem, and standardized procedures to read cultures twice a day, at 7 a.m. and 2 p.m. “The times we agreed upon; 7 a.m. works really well for morning discharge, and at 2 p.m., the day team is still there and can get kids out that day,” Dr. Lo explained.
. Among infants 7-60 days old admitted with NF – excluding ill-appearing children and those with comorbidities that increased the risk of infections – the mean LOS fell from 48 hours among 144 infants treated before the intervention, to 43 hours among 157 treated afterward (P = .001), and “we didn’t have any more readmission for serious bacterial infections,” Dr. Lo said.
“We want to reduce it further. If we get to 42 hours, we’ll be pretty happy.” Updating discharge criteria, and letting providers know how their LOS’s compare with their peers’ might help. “I’m sure some people are more conservative and some a little more liberal,” she said.
There was no industry funding for the work, and the investigators had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
ATLANTA – An adjustment in the culture reporting schedule at Texas Children’s Hospital, Houston, helped reduce the average length of stay for neonatal fever from 48 to 43 hours, without increasing readmissions for serious bacterial infections, according to a review presented at the Pediatric Hospital Medicine meeting.
Investigators there were working to meet the goals of the Reducing Excessive Variability in Infant Sepsis Evaluation project (REVISE), a national collaboration aimed at improving care. One of the goals is to reduce the length of stay (LOS) for neonatal fever to fewer than 30 hours for low-risk infants and fewer than 42 hours among high-risk infants.
The traditional standard is to keep children in the hospital for 48 hours to rule out sepsis, but that thinking has begun to change amid evidence that blood cultures generally do not need that long to turn positive, among other findings, said investigator Huay-Ying Lo, MD, a pediatrician at Texas Children’s.
“At our institution,” which admits more than 200 NF cases annually, “we have order sets for neonatal fever, and we’re actually doing pretty well” meeting most of the REVISE goals, “so we decided to focus on reducing length of stay,” she said at the meeting.
Evidence of the safety and cost savings of earlier discharge was presented to providers, and weekly emails reminded them of the early discharge goal and updated them on the current average LOS for NF.
Dr. Lo and her team also brainstormed with providers to identify problems. “One of the barriers they consistently mentioned was the timing of cultures being reported out from the microbiology lab. A lot of time, people were just waiting for the report to say no growth for 36 hours or whatever it was going to be,” she said.
That led to talks with the microbiology department. Blood cultures were already automated, so there wasn’t much that needed to be done. Urine cultures were read manually three to four times a day after the initial incubation period. However, after an initial Gram stain, CSF cultures were read manually only one or two times a day – whenever somebody had time. The hours were random, and sometimes results were not reported until the evening, which meant the child had to spend another night in the hospital.
The lab director agreed that it was a problem, and standardized procedures to read cultures twice a day, at 7 a.m. and 2 p.m. “The times we agreed upon; 7 a.m. works really well for morning discharge, and at 2 p.m., the day team is still there and can get kids out that day,” Dr. Lo explained.
. Among infants 7-60 days old admitted with NF – excluding ill-appearing children and those with comorbidities that increased the risk of infections – the mean LOS fell from 48 hours among 144 infants treated before the intervention, to 43 hours among 157 treated afterward (P = .001), and “we didn’t have any more readmission for serious bacterial infections,” Dr. Lo said.
“We want to reduce it further. If we get to 42 hours, we’ll be pretty happy.” Updating discharge criteria, and letting providers know how their LOS’s compare with their peers’ might help. “I’m sure some people are more conservative and some a little more liberal,” she said.
There was no industry funding for the work, and the investigators had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
REPORTING FROM PHM 2018
Key clinical point: An adjustment in the culture reporting schedule at Texas Children’s Hospital, Houston, helped reduce the average length of stay for neonatal fever, without increasing readmissions for serious bacterial infections.
Major finding: The mean length of stay fell from 48 hours among 144 infants treated before the intervention, to 43 hours among 157 treated afterward (P = .001).
Study details: Pre/post analysis of quality improvement project.
Disclosures: There was no industry funding for the work, and the investigators had no disclosures.
Asthma medication ratio identifies high-risk pediatric patients
ATLANTA – An according to researchers from the Medical University of South Carolina (MUSC), Charleston.
The asthma medication ratio (AMR) – the number of prescriptions for controller medications divided by the number of prescriptions for both controller and rescue medications – has been around for a while, but it’s mostly been used as a quality metric. The new study shows that it’s also useful in the clinic to identify children who could benefit from extra attention.
A perfect ratio of 1 means that control is good without rescue inhalers. The ratio falls as the number of rescue inhalers goes up, signaling poorer control. Children with a ratio below 0.5 are considered high risk; they’d hit that mark if, for instance, they were prescribed one control medication such as fluticasone propionate (Flovent) and two albuterol rescue inhalers in a month.
If control is good, “you should only need a rescue inhaler very, very sporadically;” high-risk children probably need a higher dose of their controller, or help with compliance, explained lead investigator Annie L. Andrews, MD, associate professor of pediatrics at MUSC.
The university uses the EPIC records system, which incorporates prescription data from Surescripts, so the number of asthma medication fills is already available. The system just needs to be adjusted to calculate and report AMRs monthly, something Dr. Andrews and her team are working on. “The information is right there, but it’s an untapped resource,” she said. “We just need to crunch the numbers, and operationalize it. Why are we waiting until kids are in the hospital” to intervene?
Dr. Andrews presented a proof-of-concept study at the Pediatric Hospital Medicine meeting. Her team identified 214,452 asthma patients aged 2-17 years with at least one claim for an inhaled corticosteroid in the Truven MarketScan Medicaid database from 2013-14.
They calculated AMRs for each child every 3 months over a 15-month period. About 9% of children at any given time had AMRs below 0.5.
The first AMR was at or above 0.5 in 93,512 children; 18.1% had a subsequent asthma-related event, meaning an ED visit or hospitalization, during the course of the study. Among the 17,635 children with an initial AMR below 0.5, 25% had asthma-related events. The initial AMR couldn’t be calculated in 103,305 children, which likely meant they had less-active disease. Those children had the lowest proportion of asthma events, at 13.9%.
An AMR below 0.5 nearly doubled the risk of an asthma-related hospitalization or ED visit in the subsequent 3 months, with an odds ratios ranging from 1.7 to 1.9, compared with other children. The findings were statistically significant.
In short, serial AMRs helped predict exacerbations among Medicaid children. The team showed the same trend among commercially insured children in a recently published study. The only difference was that Medicaid children had a higher proportion of high-risk AMRs, and a higher number of asthma events (Am J Manag Care. 2018 Jun;24[6]:294-300). Together, the studies validate “the rolling 3-month AMR as an appropriate method for identifying children at high risk for imminent exacerbation,” the investigators concluded.
With automatic AMR reporting already in the works at MUSC, “we are now trying to figure out how to intervene. Do we just tell providers who their high-risk kids are and let them figure out how to contact families, or do we use this information to contact families directly? That’s kind of what I favor: ‘Hey, your kid just popped up as high risk, so let’s figure out what you need. Do you need a new prescription or a reminder to see your doctor?’ ” Dr. Andrews said.
Her team is developing a mobile app to communicate with families.
The mean age in the study was 7.9 years; 59% of the children were boys, and 41% were black.
The work was funded by the National Institutes of Health, among others. Dr. Andrews had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
ATLANTA – An according to researchers from the Medical University of South Carolina (MUSC), Charleston.
The asthma medication ratio (AMR) – the number of prescriptions for controller medications divided by the number of prescriptions for both controller and rescue medications – has been around for a while, but it’s mostly been used as a quality metric. The new study shows that it’s also useful in the clinic to identify children who could benefit from extra attention.
A perfect ratio of 1 means that control is good without rescue inhalers. The ratio falls as the number of rescue inhalers goes up, signaling poorer control. Children with a ratio below 0.5 are considered high risk; they’d hit that mark if, for instance, they were prescribed one control medication such as fluticasone propionate (Flovent) and two albuterol rescue inhalers in a month.
If control is good, “you should only need a rescue inhaler very, very sporadically;” high-risk children probably need a higher dose of their controller, or help with compliance, explained lead investigator Annie L. Andrews, MD, associate professor of pediatrics at MUSC.
The university uses the EPIC records system, which incorporates prescription data from Surescripts, so the number of asthma medication fills is already available. The system just needs to be adjusted to calculate and report AMRs monthly, something Dr. Andrews and her team are working on. “The information is right there, but it’s an untapped resource,” she said. “We just need to crunch the numbers, and operationalize it. Why are we waiting until kids are in the hospital” to intervene?
Dr. Andrews presented a proof-of-concept study at the Pediatric Hospital Medicine meeting. Her team identified 214,452 asthma patients aged 2-17 years with at least one claim for an inhaled corticosteroid in the Truven MarketScan Medicaid database from 2013-14.
They calculated AMRs for each child every 3 months over a 15-month period. About 9% of children at any given time had AMRs below 0.5.
The first AMR was at or above 0.5 in 93,512 children; 18.1% had a subsequent asthma-related event, meaning an ED visit or hospitalization, during the course of the study. Among the 17,635 children with an initial AMR below 0.5, 25% had asthma-related events. The initial AMR couldn’t be calculated in 103,305 children, which likely meant they had less-active disease. Those children had the lowest proportion of asthma events, at 13.9%.
An AMR below 0.5 nearly doubled the risk of an asthma-related hospitalization or ED visit in the subsequent 3 months, with an odds ratios ranging from 1.7 to 1.9, compared with other children. The findings were statistically significant.
In short, serial AMRs helped predict exacerbations among Medicaid children. The team showed the same trend among commercially insured children in a recently published study. The only difference was that Medicaid children had a higher proportion of high-risk AMRs, and a higher number of asthma events (Am J Manag Care. 2018 Jun;24[6]:294-300). Together, the studies validate “the rolling 3-month AMR as an appropriate method for identifying children at high risk for imminent exacerbation,” the investigators concluded.
With automatic AMR reporting already in the works at MUSC, “we are now trying to figure out how to intervene. Do we just tell providers who their high-risk kids are and let them figure out how to contact families, or do we use this information to contact families directly? That’s kind of what I favor: ‘Hey, your kid just popped up as high risk, so let’s figure out what you need. Do you need a new prescription or a reminder to see your doctor?’ ” Dr. Andrews said.
Her team is developing a mobile app to communicate with families.
The mean age in the study was 7.9 years; 59% of the children were boys, and 41% were black.
The work was funded by the National Institutes of Health, among others. Dr. Andrews had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
ATLANTA – An according to researchers from the Medical University of South Carolina (MUSC), Charleston.
The asthma medication ratio (AMR) – the number of prescriptions for controller medications divided by the number of prescriptions for both controller and rescue medications – has been around for a while, but it’s mostly been used as a quality metric. The new study shows that it’s also useful in the clinic to identify children who could benefit from extra attention.
A perfect ratio of 1 means that control is good without rescue inhalers. The ratio falls as the number of rescue inhalers goes up, signaling poorer control. Children with a ratio below 0.5 are considered high risk; they’d hit that mark if, for instance, they were prescribed one control medication such as fluticasone propionate (Flovent) and two albuterol rescue inhalers in a month.
If control is good, “you should only need a rescue inhaler very, very sporadically;” high-risk children probably need a higher dose of their controller, or help with compliance, explained lead investigator Annie L. Andrews, MD, associate professor of pediatrics at MUSC.
The university uses the EPIC records system, which incorporates prescription data from Surescripts, so the number of asthma medication fills is already available. The system just needs to be adjusted to calculate and report AMRs monthly, something Dr. Andrews and her team are working on. “The information is right there, but it’s an untapped resource,” she said. “We just need to crunch the numbers, and operationalize it. Why are we waiting until kids are in the hospital” to intervene?
Dr. Andrews presented a proof-of-concept study at the Pediatric Hospital Medicine meeting. Her team identified 214,452 asthma patients aged 2-17 years with at least one claim for an inhaled corticosteroid in the Truven MarketScan Medicaid database from 2013-14.
They calculated AMRs for each child every 3 months over a 15-month period. About 9% of children at any given time had AMRs below 0.5.
The first AMR was at or above 0.5 in 93,512 children; 18.1% had a subsequent asthma-related event, meaning an ED visit or hospitalization, during the course of the study. Among the 17,635 children with an initial AMR below 0.5, 25% had asthma-related events. The initial AMR couldn’t be calculated in 103,305 children, which likely meant they had less-active disease. Those children had the lowest proportion of asthma events, at 13.9%.
An AMR below 0.5 nearly doubled the risk of an asthma-related hospitalization or ED visit in the subsequent 3 months, with an odds ratios ranging from 1.7 to 1.9, compared with other children. The findings were statistically significant.
In short, serial AMRs helped predict exacerbations among Medicaid children. The team showed the same trend among commercially insured children in a recently published study. The only difference was that Medicaid children had a higher proportion of high-risk AMRs, and a higher number of asthma events (Am J Manag Care. 2018 Jun;24[6]:294-300). Together, the studies validate “the rolling 3-month AMR as an appropriate method for identifying children at high risk for imminent exacerbation,” the investigators concluded.
With automatic AMR reporting already in the works at MUSC, “we are now trying to figure out how to intervene. Do we just tell providers who their high-risk kids are and let them figure out how to contact families, or do we use this information to contact families directly? That’s kind of what I favor: ‘Hey, your kid just popped up as high risk, so let’s figure out what you need. Do you need a new prescription or a reminder to see your doctor?’ ” Dr. Andrews said.
Her team is developing a mobile app to communicate with families.
The mean age in the study was 7.9 years; 59% of the children were boys, and 41% were black.
The work was funded by the National Institutes of Health, among others. Dr. Andrews had no disclosures. The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
REPORTING FROM PHM 2018
Key clinical point: The asthma medication ratio is useful in the clinic to identify children who could benefit from extra attention.
Major finding: About 9% of children at any given time had AMRs below 0.5, meaning they were at high risk for acute exacerbations.
Study details: Review of more than 200,000 pediatric asthma patients on Medicaid
Disclosures: The work was funded by the National Institutes of Health, among others. The study lead had no disclosures.
After initial rivaroxaban, aspirin is noninferior to rivaroxaban for thromboprophylaxis following joint arthroplasty
Background: While there is a consensus on the need for chemoprophylaxis to reduce the rates of postoperative VTE, there is wide variation in choice of agents recommended. Aspirin, while cheap and widely available, has never been directly compared with a direct oral anticoagulant in randomized, controlled trials.
Study design: Multicenter, double-blind, randomized, controlled noninferiority trial.
Setting: 15 university-affiliated health centers in Canada from January 2013 through April 2016.
Synopsis: 3,224 patients who received daily rivaroxaban for 5 days following joint arthroplasty were randomized to either receive aspirin 81 mg daily or continue daily rivaroxaban. Duration of therapy was determined by type of surgery (9 days for knee, 17 days for hip). The primary effectiveness outcome was defined as symptomatic pulmonary embolism or proximal deep venous thrombosis diagnosed in the 90-day follow-up period. The primary outcome results met the predetermined criterion for noninferiority with similar rates of symptomatic VTE in the aspirin and rivaroxaban group (0.64% vs. 0.7%; P less than .001). There was no significant difference in bleeding rates between the groups. Given that patients with prior VTE, morbid obesity, or cancer were not well represented in this study, these results should not be extrapolated to those populations felt to be at highest risk for VTE.
Bottom line: For thromboprophylaxis after joint arthroplasty, rivaroxaban followed by aspirin may be noninferior to extended rivaroxaban.
Citation: Anderson D et al. Aspirin or rivaroxaban for VTE prophylaxis after hip or knee arthroplasty. N Eng J Med. 2018 Feb 22;378(8):699-707.
Dr. Abdallah is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Background: While there is a consensus on the need for chemoprophylaxis to reduce the rates of postoperative VTE, there is wide variation in choice of agents recommended. Aspirin, while cheap and widely available, has never been directly compared with a direct oral anticoagulant in randomized, controlled trials.
Study design: Multicenter, double-blind, randomized, controlled noninferiority trial.
Setting: 15 university-affiliated health centers in Canada from January 2013 through April 2016.
Synopsis: 3,224 patients who received daily rivaroxaban for 5 days following joint arthroplasty were randomized to either receive aspirin 81 mg daily or continue daily rivaroxaban. Duration of therapy was determined by type of surgery (9 days for knee, 17 days for hip). The primary effectiveness outcome was defined as symptomatic pulmonary embolism or proximal deep venous thrombosis diagnosed in the 90-day follow-up period. The primary outcome results met the predetermined criterion for noninferiority with similar rates of symptomatic VTE in the aspirin and rivaroxaban group (0.64% vs. 0.7%; P less than .001). There was no significant difference in bleeding rates between the groups. Given that patients with prior VTE, morbid obesity, or cancer were not well represented in this study, these results should not be extrapolated to those populations felt to be at highest risk for VTE.
Bottom line: For thromboprophylaxis after joint arthroplasty, rivaroxaban followed by aspirin may be noninferior to extended rivaroxaban.
Citation: Anderson D et al. Aspirin or rivaroxaban for VTE prophylaxis after hip or knee arthroplasty. N Eng J Med. 2018 Feb 22;378(8):699-707.
Dr. Abdallah is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Background: While there is a consensus on the need for chemoprophylaxis to reduce the rates of postoperative VTE, there is wide variation in choice of agents recommended. Aspirin, while cheap and widely available, has never been directly compared with a direct oral anticoagulant in randomized, controlled trials.
Study design: Multicenter, double-blind, randomized, controlled noninferiority trial.
Setting: 15 university-affiliated health centers in Canada from January 2013 through April 2016.
Synopsis: 3,224 patients who received daily rivaroxaban for 5 days following joint arthroplasty were randomized to either receive aspirin 81 mg daily or continue daily rivaroxaban. Duration of therapy was determined by type of surgery (9 days for knee, 17 days for hip). The primary effectiveness outcome was defined as symptomatic pulmonary embolism or proximal deep venous thrombosis diagnosed in the 90-day follow-up period. The primary outcome results met the predetermined criterion for noninferiority with similar rates of symptomatic VTE in the aspirin and rivaroxaban group (0.64% vs. 0.7%; P less than .001). There was no significant difference in bleeding rates between the groups. Given that patients with prior VTE, morbid obesity, or cancer were not well represented in this study, these results should not be extrapolated to those populations felt to be at highest risk for VTE.
Bottom line: For thromboprophylaxis after joint arthroplasty, rivaroxaban followed by aspirin may be noninferior to extended rivaroxaban.
Citation: Anderson D et al. Aspirin or rivaroxaban for VTE prophylaxis after hip or knee arthroplasty. N Eng J Med. 2018 Feb 22;378(8):699-707.
Dr. Abdallah is a hospitalist at Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.
Short-course IV antibiotics okay for newborn bacteremic UTI
ATLANTA – A short course of IV antibiotics – 7 days or less – is fine for most infants with uncomplicated bacteremic urinary tract infections, according to a review of 116 children younger than 60 days.
How long to treat bacteremic UTIs in the very young has been debated in pediatrics for a while, with some centers opting for a few days and others for 2 weeks or more. Shorter courses reduce length of stay, costs, and complications, but there hasn’t been much research to see whether they work as well.
The new investigation has suggested they do. “Young infants with bacteremic UTI who received less than or equal to 7 days of IV antibiotic therapy did not have more recurrent UTIs,” compared “to infants who received longer courses. Short course IV therapy with early conversion to oral antibiotics may be considered in this population,” said lead investigator Sanyukta Desai, MD, at the Pediatric Hospital Medicine meeting.
The team compared outcomes of 58 infants treated for 7 days or less to outcomes of 58 infants treated for more than 7 days at 11 children’s hospitals scattered across the United States.
Urine was collected by catheter, and each child grew the same organism in their blood and urine cultures, confirming the diagnosis of bacteremic UTI. Children with bacterial meningitis, or suspected of having it, were excluded. The subjects had all been admitted through the ED.
There was quite a bit of variation among the 11 hospitals, with the proportion of children treated with short courses ranging from 10% to 81%.
As for the results, two patients in the short-course group (3%) and four in the long-course group (7%) had recurrent UTIs within 30 days. None of them developed meningitis, and none required ICU admission. Propensity-score matching revealed an odds ratio for recurrence that favored shorter treatment, but it wasn’t statistically significant.
The mean length of stay was 5 days in the short-course arm and 11 days in the long-course arm. There were no serious adverse events within 30 days of the index admission in either group.
Among the recurrences, the two children in the short-course arm were initially treated for 3 and 5 days. Both were older than 28 days at their initial presentation, and both had vesicoureteral reflux of at least grade 2, which was not diagnosed in one child until after the recurrence. The other child had been on prophylactic trimethoprim/sulfamethoxazole before the recurrence.
The four recurrent cases in the long arm initially received either 10 or 14 days of IV antibiotics. Two children had grade 4 vesicoureteral reflux and had been on prophylactic amoxicillin.
Infants treated with longer antibiotic courses were more likely to be under 28 days old, appear ill at presentation, have had bacteremia for more than 24 hours, and have and grow out pathogens other than Escherichia coli. The two groups were otherwise balanced for sex, prematurity, complex chronic conditions, and known genitourinary anomalies.
With such low event rates, the study wasn’t powered to detect small but potentially meaningful differences in outcomes, and further work is needed to define which children would benefit from longer treatment courses. Even so, “it was reassuring that patients did well in both arms,” said Dr. Desai, a clinical fellow in the division of hospital medicine at Cincinnati Children’s Hospital.
“At our institution with uncomplicated UTI, we wait to see what the culture grows.” If there’s an oral antibiotic that will work, “we send [infants] home in 3-4 days. We haven’t had any poor outcomes, even when they’re bacteremic,” she said.
The work was funded by the National Institutes of Health. The investigators didn’t have any disclosures.
ATLANTA – A short course of IV antibiotics – 7 days or less – is fine for most infants with uncomplicated bacteremic urinary tract infections, according to a review of 116 children younger than 60 days.
How long to treat bacteremic UTIs in the very young has been debated in pediatrics for a while, with some centers opting for a few days and others for 2 weeks or more. Shorter courses reduce length of stay, costs, and complications, but there hasn’t been much research to see whether they work as well.
The new investigation has suggested they do. “Young infants with bacteremic UTI who received less than or equal to 7 days of IV antibiotic therapy did not have more recurrent UTIs,” compared “to infants who received longer courses. Short course IV therapy with early conversion to oral antibiotics may be considered in this population,” said lead investigator Sanyukta Desai, MD, at the Pediatric Hospital Medicine meeting.
The team compared outcomes of 58 infants treated for 7 days or less to outcomes of 58 infants treated for more than 7 days at 11 children’s hospitals scattered across the United States.
Urine was collected by catheter, and each child grew the same organism in their blood and urine cultures, confirming the diagnosis of bacteremic UTI. Children with bacterial meningitis, or suspected of having it, were excluded. The subjects had all been admitted through the ED.
There was quite a bit of variation among the 11 hospitals, with the proportion of children treated with short courses ranging from 10% to 81%.
As for the results, two patients in the short-course group (3%) and four in the long-course group (7%) had recurrent UTIs within 30 days. None of them developed meningitis, and none required ICU admission. Propensity-score matching revealed an odds ratio for recurrence that favored shorter treatment, but it wasn’t statistically significant.
The mean length of stay was 5 days in the short-course arm and 11 days in the long-course arm. There were no serious adverse events within 30 days of the index admission in either group.
Among the recurrences, the two children in the short-course arm were initially treated for 3 and 5 days. Both were older than 28 days at their initial presentation, and both had vesicoureteral reflux of at least grade 2, which was not diagnosed in one child until after the recurrence. The other child had been on prophylactic trimethoprim/sulfamethoxazole before the recurrence.
The four recurrent cases in the long arm initially received either 10 or 14 days of IV antibiotics. Two children had grade 4 vesicoureteral reflux and had been on prophylactic amoxicillin.
Infants treated with longer antibiotic courses were more likely to be under 28 days old, appear ill at presentation, have had bacteremia for more than 24 hours, and have and grow out pathogens other than Escherichia coli. The two groups were otherwise balanced for sex, prematurity, complex chronic conditions, and known genitourinary anomalies.
With such low event rates, the study wasn’t powered to detect small but potentially meaningful differences in outcomes, and further work is needed to define which children would benefit from longer treatment courses. Even so, “it was reassuring that patients did well in both arms,” said Dr. Desai, a clinical fellow in the division of hospital medicine at Cincinnati Children’s Hospital.
“At our institution with uncomplicated UTI, we wait to see what the culture grows.” If there’s an oral antibiotic that will work, “we send [infants] home in 3-4 days. We haven’t had any poor outcomes, even when they’re bacteremic,” she said.
The work was funded by the National Institutes of Health. The investigators didn’t have any disclosures.
ATLANTA – A short course of IV antibiotics – 7 days or less – is fine for most infants with uncomplicated bacteremic urinary tract infections, according to a review of 116 children younger than 60 days.
How long to treat bacteremic UTIs in the very young has been debated in pediatrics for a while, with some centers opting for a few days and others for 2 weeks or more. Shorter courses reduce length of stay, costs, and complications, but there hasn’t been much research to see whether they work as well.
The new investigation has suggested they do. “Young infants with bacteremic UTI who received less than or equal to 7 days of IV antibiotic therapy did not have more recurrent UTIs,” compared “to infants who received longer courses. Short course IV therapy with early conversion to oral antibiotics may be considered in this population,” said lead investigator Sanyukta Desai, MD, at the Pediatric Hospital Medicine meeting.
The team compared outcomes of 58 infants treated for 7 days or less to outcomes of 58 infants treated for more than 7 days at 11 children’s hospitals scattered across the United States.
Urine was collected by catheter, and each child grew the same organism in their blood and urine cultures, confirming the diagnosis of bacteremic UTI. Children with bacterial meningitis, or suspected of having it, were excluded. The subjects had all been admitted through the ED.
There was quite a bit of variation among the 11 hospitals, with the proportion of children treated with short courses ranging from 10% to 81%.
As for the results, two patients in the short-course group (3%) and four in the long-course group (7%) had recurrent UTIs within 30 days. None of them developed meningitis, and none required ICU admission. Propensity-score matching revealed an odds ratio for recurrence that favored shorter treatment, but it wasn’t statistically significant.
The mean length of stay was 5 days in the short-course arm and 11 days in the long-course arm. There were no serious adverse events within 30 days of the index admission in either group.
Among the recurrences, the two children in the short-course arm were initially treated for 3 and 5 days. Both were older than 28 days at their initial presentation, and both had vesicoureteral reflux of at least grade 2, which was not diagnosed in one child until after the recurrence. The other child had been on prophylactic trimethoprim/sulfamethoxazole before the recurrence.
The four recurrent cases in the long arm initially received either 10 or 14 days of IV antibiotics. Two children had grade 4 vesicoureteral reflux and had been on prophylactic amoxicillin.
Infants treated with longer antibiotic courses were more likely to be under 28 days old, appear ill at presentation, have had bacteremia for more than 24 hours, and have and grow out pathogens other than Escherichia coli. The two groups were otherwise balanced for sex, prematurity, complex chronic conditions, and known genitourinary anomalies.
With such low event rates, the study wasn’t powered to detect small but potentially meaningful differences in outcomes, and further work is needed to define which children would benefit from longer treatment courses. Even so, “it was reassuring that patients did well in both arms,” said Dr. Desai, a clinical fellow in the division of hospital medicine at Cincinnati Children’s Hospital.
“At our institution with uncomplicated UTI, we wait to see what the culture grows.” If there’s an oral antibiotic that will work, “we send [infants] home in 3-4 days. We haven’t had any poor outcomes, even when they’re bacteremic,” she said.
The work was funded by the National Institutes of Health. The investigators didn’t have any disclosures.
REPORTING FROM PHM 2018
Key clinical point:
Major finding: Two patients in the short-course group (3%) and four in the long-course group (7%) had recurrent UTIs within 30 days.
Study details: Review of 116 infants.
Disclosures: The work was funded by the National Institutes of Health. The investigators didn’t have any disclosures.
CMS proposes site-neutral payments for hospital outpatient setting
In the proposed update to the Outpatient Prospective Payment System (OPPS) for 2019, released July 27 and scheduled to be published July 31 in the Federal Register, the CMS is proposing to apply a physician fee schedule–equivalent for the clinic visit service when provided at an off-campus, provider-based department that is paid under the OPPS.
“The clinic visit is the most common service billed under the OPPS and is often furnished in the physician office setting,” the CMS said in a fact sheet detailing its proposal.
According to the CMS, the average current clinical visit paid by the CMS is $116 with $23 being the average copay by the patient. If the proposal is finalized, the payment would drop to about $46 with an average patient copay of $9.
“This is intended to address concerns about recent consolidations in the market that reduce competition,” CMS Administrator Seema Verma said during a July 25 press conference.
The American Hospital Association already is pushing back on this proposal.
“With today’s proposed rule, CMS has once again showed a lack of understanding about the reality in which hospitals and health systems operate daily to serve the needs of their communities,” AHA Executive Vice President Tom Nickels said in a statement. “In 2015, Congress clearly intended to provide current off-campus hospital clinics with the existing outpatient payment rate in recognition of the critical role they play in their communities. But CMS’s proposal runs counter to this and will instead impede access to care for the most vulnerable patients.”
However, Farzad Mostashari, MD, founder of the health care technology company Aledade and National Coordinator for Health IT under President Obama, suggested that this could actually be a good thing for hospitals.
“The truth is that this proposal could help hospitals be more competitive in value-based contracts/alternative-payment models, and they should embrace the changes,” he said in a tweet.
The OPPS update also includes proposals to expand the list of covered surgical procedures that can be performed in an ambulatory surgical center, a move that Ms. Verma said would “provide patients with more choices and options for lower-priced care.”
“For CY 2019, CMS is proposing to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the [covered procedure list] and is proposing to add certain cardiovascular codes to the ASC [covered procedure list] as a result,” the CMS fact sheet notes.
The CMS also will review all procedures added to the covered procedure list in the past 3 years to determine whether such procedures should continue to be covered.
In addition, the OPPS is seeking feedback on a number of topics.
One is related to price transparency. The agency is asking “whether providers and suppliers can and should be required to inform patients about charges and payment information for healthcare services and out-of-pocket costs, what data elements the public would find most useful, and what other charges are needed to empower patients,” according to the fact sheet.
The CMS also is seeking information about relaunching a revamped competitive acquisition program that would have private vendors administer payment arrangements for Part B drugs. The agency is soliciting feedback on ways to design a model for testing.
Finally, the agency is seeking more information on solutions to better promote interoperability.
In the proposed update to the Outpatient Prospective Payment System (OPPS) for 2019, released July 27 and scheduled to be published July 31 in the Federal Register, the CMS is proposing to apply a physician fee schedule–equivalent for the clinic visit service when provided at an off-campus, provider-based department that is paid under the OPPS.
“The clinic visit is the most common service billed under the OPPS and is often furnished in the physician office setting,” the CMS said in a fact sheet detailing its proposal.
According to the CMS, the average current clinical visit paid by the CMS is $116 with $23 being the average copay by the patient. If the proposal is finalized, the payment would drop to about $46 with an average patient copay of $9.
“This is intended to address concerns about recent consolidations in the market that reduce competition,” CMS Administrator Seema Verma said during a July 25 press conference.
The American Hospital Association already is pushing back on this proposal.
“With today’s proposed rule, CMS has once again showed a lack of understanding about the reality in which hospitals and health systems operate daily to serve the needs of their communities,” AHA Executive Vice President Tom Nickels said in a statement. “In 2015, Congress clearly intended to provide current off-campus hospital clinics with the existing outpatient payment rate in recognition of the critical role they play in their communities. But CMS’s proposal runs counter to this and will instead impede access to care for the most vulnerable patients.”
However, Farzad Mostashari, MD, founder of the health care technology company Aledade and National Coordinator for Health IT under President Obama, suggested that this could actually be a good thing for hospitals.
“The truth is that this proposal could help hospitals be more competitive in value-based contracts/alternative-payment models, and they should embrace the changes,” he said in a tweet.
The OPPS update also includes proposals to expand the list of covered surgical procedures that can be performed in an ambulatory surgical center, a move that Ms. Verma said would “provide patients with more choices and options for lower-priced care.”
“For CY 2019, CMS is proposing to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the [covered procedure list] and is proposing to add certain cardiovascular codes to the ASC [covered procedure list] as a result,” the CMS fact sheet notes.
The CMS also will review all procedures added to the covered procedure list in the past 3 years to determine whether such procedures should continue to be covered.
In addition, the OPPS is seeking feedback on a number of topics.
One is related to price transparency. The agency is asking “whether providers and suppliers can and should be required to inform patients about charges and payment information for healthcare services and out-of-pocket costs, what data elements the public would find most useful, and what other charges are needed to empower patients,” according to the fact sheet.
The CMS also is seeking information about relaunching a revamped competitive acquisition program that would have private vendors administer payment arrangements for Part B drugs. The agency is soliciting feedback on ways to design a model for testing.
Finally, the agency is seeking more information on solutions to better promote interoperability.
In the proposed update to the Outpatient Prospective Payment System (OPPS) for 2019, released July 27 and scheduled to be published July 31 in the Federal Register, the CMS is proposing to apply a physician fee schedule–equivalent for the clinic visit service when provided at an off-campus, provider-based department that is paid under the OPPS.
“The clinic visit is the most common service billed under the OPPS and is often furnished in the physician office setting,” the CMS said in a fact sheet detailing its proposal.
According to the CMS, the average current clinical visit paid by the CMS is $116 with $23 being the average copay by the patient. If the proposal is finalized, the payment would drop to about $46 with an average patient copay of $9.
“This is intended to address concerns about recent consolidations in the market that reduce competition,” CMS Administrator Seema Verma said during a July 25 press conference.
The American Hospital Association already is pushing back on this proposal.
“With today’s proposed rule, CMS has once again showed a lack of understanding about the reality in which hospitals and health systems operate daily to serve the needs of their communities,” AHA Executive Vice President Tom Nickels said in a statement. “In 2015, Congress clearly intended to provide current off-campus hospital clinics with the existing outpatient payment rate in recognition of the critical role they play in their communities. But CMS’s proposal runs counter to this and will instead impede access to care for the most vulnerable patients.”
However, Farzad Mostashari, MD, founder of the health care technology company Aledade and National Coordinator for Health IT under President Obama, suggested that this could actually be a good thing for hospitals.
“The truth is that this proposal could help hospitals be more competitive in value-based contracts/alternative-payment models, and they should embrace the changes,” he said in a tweet.
The OPPS update also includes proposals to expand the list of covered surgical procedures that can be performed in an ambulatory surgical center, a move that Ms. Verma said would “provide patients with more choices and options for lower-priced care.”
“For CY 2019, CMS is proposing to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the [covered procedure list] and is proposing to add certain cardiovascular codes to the ASC [covered procedure list] as a result,” the CMS fact sheet notes.
The CMS also will review all procedures added to the covered procedure list in the past 3 years to determine whether such procedures should continue to be covered.
In addition, the OPPS is seeking feedback on a number of topics.
One is related to price transparency. The agency is asking “whether providers and suppliers can and should be required to inform patients about charges and payment information for healthcare services and out-of-pocket costs, what data elements the public would find most useful, and what other charges are needed to empower patients,” according to the fact sheet.
The CMS also is seeking information about relaunching a revamped competitive acquisition program that would have private vendors administer payment arrangements for Part B drugs. The agency is soliciting feedback on ways to design a model for testing.
Finally, the agency is seeking more information on solutions to better promote interoperability.
Ten tips for managing patients with both heart failure and COPD
Patients with both are prone to hospital readmissions that detract from quality of life and dramatically drive up care costs.
Because the two chronic diseases spring from the same root cause and share overlapping symptoms, strategies that improve clinical outcomes in one can also benefit the other, Ravi Kalhan, MD, and R. Kannan Mutharasan, MD, wrote in CHEST Journal (doi: 10.1016/j.chest.2018.06.001).
“Both conditions are characterized by periods of clinical stability punctuated by episodes of exacerbation and are typified by gradual functional decline,” wrote the colleagues, both of Northwestern University, Chicago. “From a patient perspective, both conditions lead to highly overlapping patterns of symptoms, involve complicated medication regimens, and have courses highly sensitive to adherence and lifestyle modification. Therefore, disease management strategies for both conditions can be synergistic.”
The team came up with a “Top 10 list” of practical tips for reducing readmissions in patients with this challenging combination.
Diagnose accurately
An acute hospitalization is often the first time these patients pop up on the radar. This is a great time to employ spirometry to accurately diagnose COPD. It’s also appropriate to conduct a chest CT and check right heart size, diameter of the pulmonary artery, and the presence of coronary calcification. The authors noted that relatively little is known about the course of patients with combined asthma and HF in contrast to COPD and HF.
Detect admissions for exacerbations early
Check soon to find out if this is a readmission, get an acute plan going, and don’t wait to implement multidisciplinary interventions. “First, specialist involvement can occur more rapidly, allowing for faster identification of any root causes driving the HF or COPD syndromes, and allowing for more rapid institution of treatment plans to control the acute exacerbation. Second, early identification during hospitalization allows time to deploy multidisciplinary interventions, such as disease management education, social work evaluation, follow-up appointment scheduling, and coordination of home services. These interventions are less effective, and are often not implemented, if initiated toward the end of hospitalization.”
Use specialist management in the hospital
Get experts on board fast. An integrated team means a coordinated treatment plan that’s easier to follow and more effective therapeutically. Specialist care may impact rates of readmission: weight loss with diuretics; discharge doses of guideline-directed medical therapy for heart failure; and higher rates of discharge on long-acting beta-agonists, long-acting muscarinic antagonists, inhaled corticosteroids, and home supplemental oxygen.
Modify the underlying disease substrate
Heart failure is more likely to arise from a correctable pathophysiology, so find it early and treat it thoroughly – especially in younger patients. Ischemic heart disease, valvular heart disease, systemic hypertension, and pulmonary hypertension all have potential to make the HF syndrome more tractable.
Apply and intensify evidence-based therapies
Start in the hospital if possible; if not, begin upon discharge. “The order of application of these therapies can be bewildering, as many strategies for initiation and up-titration of these medications are reasonable. Not only are there long-term outcome benefits for these therapies, evidence suggests early initiation of HF therapies can reduce 30-day readmissions.”
Activate the patient and develop critical health behaviors
Medical regimens for these diseases can be complex, and they must be supported by patient engagement. “Many strategies for engaging patients in care have been tested, including teaching to goal, motivational interviewing, and teach-back methods of activation and engagement. Often these methods are time intensive. Because physician time is increasingly constrained, a team approach is particularly useful.”
Set up feedback loops
“Course correction should the patient decompensate is critically important to maintaining outpatient success. Feedback loops can allow for clinical stabilization before rehospitalization is necessary.” Self-monitoring with individually set benchmarks is critical.
Arrange an early follow-up appointment prior to discharge
About half of Medicare patients with these conditions are readmitted before they’ve even had a postdischarge follow-up appointment. Ideally this should occur within 7 days. The purpose of early follow-up is to identify and address gaps in the discharge plan of care, revise the discharge plan of care to adapt to the outpatient environment, and reinforce critical health behaviors.
Consider and address other comorbidities
Comorbidities are the rule rather than the exception and contribute to many readmissions. Get primary care on the team and enlist their help in managing these issues before they lead to an exacerbation. “Meticulous control – even perfect control were it possible – of cardiopulmonary disease would still leave patients vulnerable to significant risk of readmission from other causes.”
Consider ancillary supportive services at home
Patients may be overwhelmed by the complexity of postdischarge care. Home health assistance can help in getting patients to physical therapy, continuing patient education, and providing a home clinical assessment.
Neither of the authors had any financial disclosures.
Patients with both are prone to hospital readmissions that detract from quality of life and dramatically drive up care costs.
Because the two chronic diseases spring from the same root cause and share overlapping symptoms, strategies that improve clinical outcomes in one can also benefit the other, Ravi Kalhan, MD, and R. Kannan Mutharasan, MD, wrote in CHEST Journal (doi: 10.1016/j.chest.2018.06.001).
“Both conditions are characterized by periods of clinical stability punctuated by episodes of exacerbation and are typified by gradual functional decline,” wrote the colleagues, both of Northwestern University, Chicago. “From a patient perspective, both conditions lead to highly overlapping patterns of symptoms, involve complicated medication regimens, and have courses highly sensitive to adherence and lifestyle modification. Therefore, disease management strategies for both conditions can be synergistic.”
The team came up with a “Top 10 list” of practical tips for reducing readmissions in patients with this challenging combination.
Diagnose accurately
An acute hospitalization is often the first time these patients pop up on the radar. This is a great time to employ spirometry to accurately diagnose COPD. It’s also appropriate to conduct a chest CT and check right heart size, diameter of the pulmonary artery, and the presence of coronary calcification. The authors noted that relatively little is known about the course of patients with combined asthma and HF in contrast to COPD and HF.
Detect admissions for exacerbations early
Check soon to find out if this is a readmission, get an acute plan going, and don’t wait to implement multidisciplinary interventions. “First, specialist involvement can occur more rapidly, allowing for faster identification of any root causes driving the HF or COPD syndromes, and allowing for more rapid institution of treatment plans to control the acute exacerbation. Second, early identification during hospitalization allows time to deploy multidisciplinary interventions, such as disease management education, social work evaluation, follow-up appointment scheduling, and coordination of home services. These interventions are less effective, and are often not implemented, if initiated toward the end of hospitalization.”
Use specialist management in the hospital
Get experts on board fast. An integrated team means a coordinated treatment plan that’s easier to follow and more effective therapeutically. Specialist care may impact rates of readmission: weight loss with diuretics; discharge doses of guideline-directed medical therapy for heart failure; and higher rates of discharge on long-acting beta-agonists, long-acting muscarinic antagonists, inhaled corticosteroids, and home supplemental oxygen.
Modify the underlying disease substrate
Heart failure is more likely to arise from a correctable pathophysiology, so find it early and treat it thoroughly – especially in younger patients. Ischemic heart disease, valvular heart disease, systemic hypertension, and pulmonary hypertension all have potential to make the HF syndrome more tractable.
Apply and intensify evidence-based therapies
Start in the hospital if possible; if not, begin upon discharge. “The order of application of these therapies can be bewildering, as many strategies for initiation and up-titration of these medications are reasonable. Not only are there long-term outcome benefits for these therapies, evidence suggests early initiation of HF therapies can reduce 30-day readmissions.”
Activate the patient and develop critical health behaviors
Medical regimens for these diseases can be complex, and they must be supported by patient engagement. “Many strategies for engaging patients in care have been tested, including teaching to goal, motivational interviewing, and teach-back methods of activation and engagement. Often these methods are time intensive. Because physician time is increasingly constrained, a team approach is particularly useful.”
Set up feedback loops
“Course correction should the patient decompensate is critically important to maintaining outpatient success. Feedback loops can allow for clinical stabilization before rehospitalization is necessary.” Self-monitoring with individually set benchmarks is critical.
Arrange an early follow-up appointment prior to discharge
About half of Medicare patients with these conditions are readmitted before they’ve even had a postdischarge follow-up appointment. Ideally this should occur within 7 days. The purpose of early follow-up is to identify and address gaps in the discharge plan of care, revise the discharge plan of care to adapt to the outpatient environment, and reinforce critical health behaviors.
Consider and address other comorbidities
Comorbidities are the rule rather than the exception and contribute to many readmissions. Get primary care on the team and enlist their help in managing these issues before they lead to an exacerbation. “Meticulous control – even perfect control were it possible – of cardiopulmonary disease would still leave patients vulnerable to significant risk of readmission from other causes.”
Consider ancillary supportive services at home
Patients may be overwhelmed by the complexity of postdischarge care. Home health assistance can help in getting patients to physical therapy, continuing patient education, and providing a home clinical assessment.
Neither of the authors had any financial disclosures.
Patients with both are prone to hospital readmissions that detract from quality of life and dramatically drive up care costs.
Because the two chronic diseases spring from the same root cause and share overlapping symptoms, strategies that improve clinical outcomes in one can also benefit the other, Ravi Kalhan, MD, and R. Kannan Mutharasan, MD, wrote in CHEST Journal (doi: 10.1016/j.chest.2018.06.001).
“Both conditions are characterized by periods of clinical stability punctuated by episodes of exacerbation and are typified by gradual functional decline,” wrote the colleagues, both of Northwestern University, Chicago. “From a patient perspective, both conditions lead to highly overlapping patterns of symptoms, involve complicated medication regimens, and have courses highly sensitive to adherence and lifestyle modification. Therefore, disease management strategies for both conditions can be synergistic.”
The team came up with a “Top 10 list” of practical tips for reducing readmissions in patients with this challenging combination.
Diagnose accurately
An acute hospitalization is often the first time these patients pop up on the radar. This is a great time to employ spirometry to accurately diagnose COPD. It’s also appropriate to conduct a chest CT and check right heart size, diameter of the pulmonary artery, and the presence of coronary calcification. The authors noted that relatively little is known about the course of patients with combined asthma and HF in contrast to COPD and HF.
Detect admissions for exacerbations early
Check soon to find out if this is a readmission, get an acute plan going, and don’t wait to implement multidisciplinary interventions. “First, specialist involvement can occur more rapidly, allowing for faster identification of any root causes driving the HF or COPD syndromes, and allowing for more rapid institution of treatment plans to control the acute exacerbation. Second, early identification during hospitalization allows time to deploy multidisciplinary interventions, such as disease management education, social work evaluation, follow-up appointment scheduling, and coordination of home services. These interventions are less effective, and are often not implemented, if initiated toward the end of hospitalization.”
Use specialist management in the hospital
Get experts on board fast. An integrated team means a coordinated treatment plan that’s easier to follow and more effective therapeutically. Specialist care may impact rates of readmission: weight loss with diuretics; discharge doses of guideline-directed medical therapy for heart failure; and higher rates of discharge on long-acting beta-agonists, long-acting muscarinic antagonists, inhaled corticosteroids, and home supplemental oxygen.
Modify the underlying disease substrate
Heart failure is more likely to arise from a correctable pathophysiology, so find it early and treat it thoroughly – especially in younger patients. Ischemic heart disease, valvular heart disease, systemic hypertension, and pulmonary hypertension all have potential to make the HF syndrome more tractable.
Apply and intensify evidence-based therapies
Start in the hospital if possible; if not, begin upon discharge. “The order of application of these therapies can be bewildering, as many strategies for initiation and up-titration of these medications are reasonable. Not only are there long-term outcome benefits for these therapies, evidence suggests early initiation of HF therapies can reduce 30-day readmissions.”
Activate the patient and develop critical health behaviors
Medical regimens for these diseases can be complex, and they must be supported by patient engagement. “Many strategies for engaging patients in care have been tested, including teaching to goal, motivational interviewing, and teach-back methods of activation and engagement. Often these methods are time intensive. Because physician time is increasingly constrained, a team approach is particularly useful.”
Set up feedback loops
“Course correction should the patient decompensate is critically important to maintaining outpatient success. Feedback loops can allow for clinical stabilization before rehospitalization is necessary.” Self-monitoring with individually set benchmarks is critical.
Arrange an early follow-up appointment prior to discharge
About half of Medicare patients with these conditions are readmitted before they’ve even had a postdischarge follow-up appointment. Ideally this should occur within 7 days. The purpose of early follow-up is to identify and address gaps in the discharge plan of care, revise the discharge plan of care to adapt to the outpatient environment, and reinforce critical health behaviors.
Consider and address other comorbidities
Comorbidities are the rule rather than the exception and contribute to many readmissions. Get primary care on the team and enlist their help in managing these issues before they lead to an exacerbation. “Meticulous control – even perfect control were it possible – of cardiopulmonary disease would still leave patients vulnerable to significant risk of readmission from other causes.”
Consider ancillary supportive services at home
Patients may be overwhelmed by the complexity of postdischarge care. Home health assistance can help in getting patients to physical therapy, continuing patient education, and providing a home clinical assessment.
Neither of the authors had any financial disclosures.
EXPERT ANALYSIS FROM CHEST JOURNAL
Skip ultrasound in acute UTI in small children
MALMO, SWEDEN – Ultrasound of the kidneys and urinary tract in the acute phase of a first urinary tract infection in young children has an unacceptably high false-positive rate, Magdalena Okarska-Napierala, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.
“Sonography performed 2 weeks after treatment initiation seems to be more reliable,” said Dr. Okarska-Napierala, a pediatrician at the Medical University of Warsaw Children’s Hospital.
Broad agreement exists that imaging is warranted in all children with a first urinary tract infection (UTI), because this infection can be the first signal of a structural abnormality of the kidneys or urinary tract. Abdominal ultrasound is the first-choice imaging modality in this setting because it is noninvasive, widely available, and inexpensive. But there remains controversy – and guidelines differ – regarding when to perform the ultrasound in children with UTI who respond well to therapy. This was the impetus for Dr. Okarska-Napierala and her coinvestigators to launch a prospective, single-center study examining the issue.
“The theory beneath it is the possibility that diffuse inflammation affects the ultrasound picture of the kidneys and urinary tract and may give us false-positive results, so we shouldn’t base our decisions on those results,” she explained.
This theory has been provisionally confirmed by the preliminary results of the study, which is continuing to enroll patients.
To date, the study includes 48 children, mean age 10.4 months, hospitalized for their first UTI. Participation was restricted to patients with no known congenital abnormalities of the kidneys or urinary tract and who were not on antibiotics at enrollment. Of the 48 children, 44 had an Escherichia coli infection. The predominant treatment was a second-generation cephalosporin for a median of 10 days.
On day 1 of treatment all patients underwent an ultrasound exam evaluating kidney size, anterior-posterior renal pelvis diameter, and the urinary tract based upon a grading system for urinary tract dilation developed by multidisciplinary consensus (J Pediatr Urol. 2014 Dec;10[6]:982-98). The ultrasound exam was repeated 2 weeks later, and again 2 weeks after that.
The most striking findings were a significantly increased kidney size and more prevalent urinary tract dilation on the day 1 ultrasound exam than on repeat ultrasound 2 weeks later. The average length of the left and right kidneys was 67.0 and 64.5 mm, respectively, on day 1, dropping off to 64.3 and 62.0 mm at 2 weeks, with a smaller and statistically nonsignificant further drop-off to 61.9 and 60.0 mm on the week 4 ultrasound.
“We saw a strong correlation between initial kidney size and CRP [C-reactive protein] value: The higher the CRP you have initially, the bigger the kidneys. It’s an interesting finding, but not so very practical. The only practical conclusion is that if we perform ultrasound at this stage and the child has big kidneys, it doesn’t mean anything. We have to check it again later,” she said.
Also, the number of renal units with urinary tract dilation went from 29 on day 1 ultrasound to 20 at 2 weeks and 19 at 4 weeks. Of the 48 children, 28 had urinary tract dilation on day 1, compared with 18 at 2 weeks and 16 at 4 weeks.
“If we look at this practically, if we base our decision on the day 1 ultrasound we would qualify half of all children for voiding cystourethrography, which is harmful, but if we wait 2 weeks to do the ultrasound we would reduce this number by six children. So I think we can call this a clinically significant difference,” she continued.
Of the 48 children, 11 have undergone voiding cystourethrography, revealing 2 mild cases of vesicoureteral reflux, which is the most common congenital abnormality of the urinary tract.
“I would like to emphasize that there is no real benefit in performing an ultrasound exam in children in this acute phase of infection. And there is harm in that we have to repeat the exam later, the parents are worried, the doctor is worried,” Dr. Okarska-Napierala concluded.
She reported having no relevant financial conflicts, and the study was conducted free of commercial support.
MALMO, SWEDEN – Ultrasound of the kidneys and urinary tract in the acute phase of a first urinary tract infection in young children has an unacceptably high false-positive rate, Magdalena Okarska-Napierala, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.
“Sonography performed 2 weeks after treatment initiation seems to be more reliable,” said Dr. Okarska-Napierala, a pediatrician at the Medical University of Warsaw Children’s Hospital.
Broad agreement exists that imaging is warranted in all children with a first urinary tract infection (UTI), because this infection can be the first signal of a structural abnormality of the kidneys or urinary tract. Abdominal ultrasound is the first-choice imaging modality in this setting because it is noninvasive, widely available, and inexpensive. But there remains controversy – and guidelines differ – regarding when to perform the ultrasound in children with UTI who respond well to therapy. This was the impetus for Dr. Okarska-Napierala and her coinvestigators to launch a prospective, single-center study examining the issue.
“The theory beneath it is the possibility that diffuse inflammation affects the ultrasound picture of the kidneys and urinary tract and may give us false-positive results, so we shouldn’t base our decisions on those results,” she explained.
This theory has been provisionally confirmed by the preliminary results of the study, which is continuing to enroll patients.
To date, the study includes 48 children, mean age 10.4 months, hospitalized for their first UTI. Participation was restricted to patients with no known congenital abnormalities of the kidneys or urinary tract and who were not on antibiotics at enrollment. Of the 48 children, 44 had an Escherichia coli infection. The predominant treatment was a second-generation cephalosporin for a median of 10 days.
On day 1 of treatment all patients underwent an ultrasound exam evaluating kidney size, anterior-posterior renal pelvis diameter, and the urinary tract based upon a grading system for urinary tract dilation developed by multidisciplinary consensus (J Pediatr Urol. 2014 Dec;10[6]:982-98). The ultrasound exam was repeated 2 weeks later, and again 2 weeks after that.
The most striking findings were a significantly increased kidney size and more prevalent urinary tract dilation on the day 1 ultrasound exam than on repeat ultrasound 2 weeks later. The average length of the left and right kidneys was 67.0 and 64.5 mm, respectively, on day 1, dropping off to 64.3 and 62.0 mm at 2 weeks, with a smaller and statistically nonsignificant further drop-off to 61.9 and 60.0 mm on the week 4 ultrasound.
“We saw a strong correlation between initial kidney size and CRP [C-reactive protein] value: The higher the CRP you have initially, the bigger the kidneys. It’s an interesting finding, but not so very practical. The only practical conclusion is that if we perform ultrasound at this stage and the child has big kidneys, it doesn’t mean anything. We have to check it again later,” she said.
Also, the number of renal units with urinary tract dilation went from 29 on day 1 ultrasound to 20 at 2 weeks and 19 at 4 weeks. Of the 48 children, 28 had urinary tract dilation on day 1, compared with 18 at 2 weeks and 16 at 4 weeks.
“If we look at this practically, if we base our decision on the day 1 ultrasound we would qualify half of all children for voiding cystourethrography, which is harmful, but if we wait 2 weeks to do the ultrasound we would reduce this number by six children. So I think we can call this a clinically significant difference,” she continued.
Of the 48 children, 11 have undergone voiding cystourethrography, revealing 2 mild cases of vesicoureteral reflux, which is the most common congenital abnormality of the urinary tract.
“I would like to emphasize that there is no real benefit in performing an ultrasound exam in children in this acute phase of infection. And there is harm in that we have to repeat the exam later, the parents are worried, the doctor is worried,” Dr. Okarska-Napierala concluded.
She reported having no relevant financial conflicts, and the study was conducted free of commercial support.
MALMO, SWEDEN – Ultrasound of the kidneys and urinary tract in the acute phase of a first urinary tract infection in young children has an unacceptably high false-positive rate, Magdalena Okarska-Napierala, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.
“Sonography performed 2 weeks after treatment initiation seems to be more reliable,” said Dr. Okarska-Napierala, a pediatrician at the Medical University of Warsaw Children’s Hospital.
Broad agreement exists that imaging is warranted in all children with a first urinary tract infection (UTI), because this infection can be the first signal of a structural abnormality of the kidneys or urinary tract. Abdominal ultrasound is the first-choice imaging modality in this setting because it is noninvasive, widely available, and inexpensive. But there remains controversy – and guidelines differ – regarding when to perform the ultrasound in children with UTI who respond well to therapy. This was the impetus for Dr. Okarska-Napierala and her coinvestigators to launch a prospective, single-center study examining the issue.
“The theory beneath it is the possibility that diffuse inflammation affects the ultrasound picture of the kidneys and urinary tract and may give us false-positive results, so we shouldn’t base our decisions on those results,” she explained.
This theory has been provisionally confirmed by the preliminary results of the study, which is continuing to enroll patients.
To date, the study includes 48 children, mean age 10.4 months, hospitalized for their first UTI. Participation was restricted to patients with no known congenital abnormalities of the kidneys or urinary tract and who were not on antibiotics at enrollment. Of the 48 children, 44 had an Escherichia coli infection. The predominant treatment was a second-generation cephalosporin for a median of 10 days.
On day 1 of treatment all patients underwent an ultrasound exam evaluating kidney size, anterior-posterior renal pelvis diameter, and the urinary tract based upon a grading system for urinary tract dilation developed by multidisciplinary consensus (J Pediatr Urol. 2014 Dec;10[6]:982-98). The ultrasound exam was repeated 2 weeks later, and again 2 weeks after that.
The most striking findings were a significantly increased kidney size and more prevalent urinary tract dilation on the day 1 ultrasound exam than on repeat ultrasound 2 weeks later. The average length of the left and right kidneys was 67.0 and 64.5 mm, respectively, on day 1, dropping off to 64.3 and 62.0 mm at 2 weeks, with a smaller and statistically nonsignificant further drop-off to 61.9 and 60.0 mm on the week 4 ultrasound.
“We saw a strong correlation between initial kidney size and CRP [C-reactive protein] value: The higher the CRP you have initially, the bigger the kidneys. It’s an interesting finding, but not so very practical. The only practical conclusion is that if we perform ultrasound at this stage and the child has big kidneys, it doesn’t mean anything. We have to check it again later,” she said.
Also, the number of renal units with urinary tract dilation went from 29 on day 1 ultrasound to 20 at 2 weeks and 19 at 4 weeks. Of the 48 children, 28 had urinary tract dilation on day 1, compared with 18 at 2 weeks and 16 at 4 weeks.
“If we look at this practically, if we base our decision on the day 1 ultrasound we would qualify half of all children for voiding cystourethrography, which is harmful, but if we wait 2 weeks to do the ultrasound we would reduce this number by six children. So I think we can call this a clinically significant difference,” she continued.
Of the 48 children, 11 have undergone voiding cystourethrography, revealing 2 mild cases of vesicoureteral reflux, which is the most common congenital abnormality of the urinary tract.
“I would like to emphasize that there is no real benefit in performing an ultrasound exam in children in this acute phase of infection. And there is harm in that we have to repeat the exam later, the parents are worried, the doctor is worried,” Dr. Okarska-Napierala concluded.
She reported having no relevant financial conflicts, and the study was conducted free of commercial support.
REPORTING FROM ESPID 2018
Key clinical point:
Major finding: Average left kidney length dropped from 67.0 mm on treatment day 1 to 64.3 mm 2 weeks later.
Study details: This interim report from an ongoing, prospective, single-center study included 48 children up to age 3 years who were hospitalized for their first urinary tract infection.
Disclosures: The presenter reported no relevant financial conflicts.