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Background: Most GI endoscopies use sedation to keep patients comfortable during procedures, but sedation puts patients at increased risk of complications. Most of the available studies reporting sedation-related complications are retrospective and dated. There is a lack of prospective studies investigating sedation-related complications and their associated risk factors.

Study design: Prospective study.

Setting: Thirty-nine hospitals in Germany.

Synopsis: Using data collected from 314,190 adult endoscopies in which sedation was used, this study identified that there was only a 0.01% rate of major complications. Major complications for this study included intubation, ICU admission, resuscitation, or death. Propofol was the most commonly used sedative (61.7% of cases) and had the lowest risk of complications (odds ratio, 0.7509; P = .028). The top risk factors for complications were an American Society of Anesthesiologists class greater than 2 (OR, 2.2998; P less than .001), emergent need for the endoscopy (9 of the 13 fatal cases), and longer procedure length (P less than .001).

Bottom line: GI endoscopic procedures with sedation are tolerated well in the general population and have low risk of complications.

Citation: Behrens A et al. Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): Results from the prospective multicentre electronic registry of sedation-associated complications. Gut. 2018 Jan 3. doi: 10.1136/gutjnl-2015-311037.

Dr. Ally is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Background: Most GI endoscopies use sedation to keep patients comfortable during procedures, but sedation puts patients at increased risk of complications. Most of the available studies reporting sedation-related complications are retrospective and dated. There is a lack of prospective studies investigating sedation-related complications and their associated risk factors.

Study design: Prospective study.

Setting: Thirty-nine hospitals in Germany.

Synopsis: Using data collected from 314,190 adult endoscopies in which sedation was used, this study identified that there was only a 0.01% rate of major complications. Major complications for this study included intubation, ICU admission, resuscitation, or death. Propofol was the most commonly used sedative (61.7% of cases) and had the lowest risk of complications (odds ratio, 0.7509; P = .028). The top risk factors for complications were an American Society of Anesthesiologists class greater than 2 (OR, 2.2998; P less than .001), emergent need for the endoscopy (9 of the 13 fatal cases), and longer procedure length (P less than .001).

Bottom line: GI endoscopic procedures with sedation are tolerated well in the general population and have low risk of complications.

Citation: Behrens A et al. Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): Results from the prospective multicentre electronic registry of sedation-associated complications. Gut. 2018 Jan 3. doi: 10.1136/gutjnl-2015-311037.

Dr. Ally is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Background: Most GI endoscopies use sedation to keep patients comfortable during procedures, but sedation puts patients at increased risk of complications. Most of the available studies reporting sedation-related complications are retrospective and dated. There is a lack of prospective studies investigating sedation-related complications and their associated risk factors.

Study design: Prospective study.

Setting: Thirty-nine hospitals in Germany.

Synopsis: Using data collected from 314,190 adult endoscopies in which sedation was used, this study identified that there was only a 0.01% rate of major complications. Major complications for this study included intubation, ICU admission, resuscitation, or death. Propofol was the most commonly used sedative (61.7% of cases) and had the lowest risk of complications (odds ratio, 0.7509; P = .028). The top risk factors for complications were an American Society of Anesthesiologists class greater than 2 (OR, 2.2998; P less than .001), emergent need for the endoscopy (9 of the 13 fatal cases), and longer procedure length (P less than .001).

Bottom line: GI endoscopic procedures with sedation are tolerated well in the general population and have low risk of complications.

Citation: Behrens A et al. Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): Results from the prospective multicentre electronic registry of sedation-associated complications. Gut. 2018 Jan 3. doi: 10.1136/gutjnl-2015-311037.

Dr. Ally is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Background: Patients who complain of chest pain make up over a quarter of annual hospital admissions, but not all chest pain is attributable to acute coronary syndrome. The one-page CPC document was developed to facilitate joint decision making between low-risk patients and providers regarding the work-up for chest pain.

Study design: Parallel, randomized, controlled trial.

Setting: Six U.S. medical centers.

Synopsis: After reviewing the CPC tool, patients with low cardiac risk who presented to the ED with chest pain were given the option either to be admitted to the hospital for cardiac testing or to not be admitted and instead follow up with their primary care doctor or a cardiologist within 3 days to determine what further cardiac work-up might be warranted.

Upon reviewing data obtained from 898 patient diaries regarding use of health care services, as well as from billing data from the medical centers, the researchers found no statistically significant difference between patients who used the CPC tool and those treated under usual care with regard to hospital readmission rates, length of stay in the ED, repeat ED visits, or clinic visits. However, at the 45-day follow-up mark, those in the CPC group had undergone fewer tests and cardiac imaging studies (decrease of 125.6 tests/100 patients; 95% confidence interval, 29.3-221.6).

Bottom line: Shared decision making between providers and patients with low cardiac risk factors that used the Chest Pain Choice tool decreased some health care utilization without worsening outcomes.

Citation: Schaffer JT et al. Impact of a shared decision-making intervention on health care utilization: A secondary analysis of the Chest Pain Choice multicenter randomized trial. Acad Emerg Med. 2018 Mar;25(3):293-300.

Dr. Ally is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Background: Patients who complain of chest pain make up over a quarter of annual hospital admissions, but not all chest pain is attributable to acute coronary syndrome. The one-page CPC document was developed to facilitate joint decision making between low-risk patients and providers regarding the work-up for chest pain.

Study design: Parallel, randomized, controlled trial.

Setting: Six U.S. medical centers.

Synopsis: After reviewing the CPC tool, patients with low cardiac risk who presented to the ED with chest pain were given the option either to be admitted to the hospital for cardiac testing or to not be admitted and instead follow up with their primary care doctor or a cardiologist within 3 days to determine what further cardiac work-up might be warranted.

Upon reviewing data obtained from 898 patient diaries regarding use of health care services, as well as from billing data from the medical centers, the researchers found no statistically significant difference between patients who used the CPC tool and those treated under usual care with regard to hospital readmission rates, length of stay in the ED, repeat ED visits, or clinic visits. However, at the 45-day follow-up mark, those in the CPC group had undergone fewer tests and cardiac imaging studies (decrease of 125.6 tests/100 patients; 95% confidence interval, 29.3-221.6).

Bottom line: Shared decision making between providers and patients with low cardiac risk factors that used the Chest Pain Choice tool decreased some health care utilization without worsening outcomes.

Citation: Schaffer JT et al. Impact of a shared decision-making intervention on health care utilization: A secondary analysis of the Chest Pain Choice multicenter randomized trial. Acad Emerg Med. 2018 Mar;25(3):293-300.

Dr. Ally is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Background: Patients who complain of chest pain make up over a quarter of annual hospital admissions, but not all chest pain is attributable to acute coronary syndrome. The one-page CPC document was developed to facilitate joint decision making between low-risk patients and providers regarding the work-up for chest pain.

Study design: Parallel, randomized, controlled trial.

Setting: Six U.S. medical centers.

Synopsis: After reviewing the CPC tool, patients with low cardiac risk who presented to the ED with chest pain were given the option either to be admitted to the hospital for cardiac testing or to not be admitted and instead follow up with their primary care doctor or a cardiologist within 3 days to determine what further cardiac work-up might be warranted.

Upon reviewing data obtained from 898 patient diaries regarding use of health care services, as well as from billing data from the medical centers, the researchers found no statistically significant difference between patients who used the CPC tool and those treated under usual care with regard to hospital readmission rates, length of stay in the ED, repeat ED visits, or clinic visits. However, at the 45-day follow-up mark, those in the CPC group had undergone fewer tests and cardiac imaging studies (decrease of 125.6 tests/100 patients; 95% confidence interval, 29.3-221.6).

Bottom line: Shared decision making between providers and patients with low cardiac risk factors that used the Chest Pain Choice tool decreased some health care utilization without worsening outcomes.

Citation: Schaffer JT et al. Impact of a shared decision-making intervention on health care utilization: A secondary analysis of the Chest Pain Choice multicenter randomized trial. Acad Emerg Med. 2018 Mar;25(3):293-300.

Dr. Ally is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.

Clinical question: Among patients with septic shock undergoing mechanical ventilation, does hydrocortisone reduce 90-day mortality?

Background: Septic shock is associated with a significant mortality risk, and there is no proven pharmacologic treatment other than fluids, vasopressors, and antimicrobials. Prior randomized, controlled trials have resulted in mixed outcomes, and meta-analyses and clinical practice guidelines also have not provided consistent guidance.

Study design: Randomized, controlled, double-blinded trial.

Setting: Medical centers in Australia, Denmark, New Zealand, Saudi Arabia, and the United Kingdom.

Synopsis: Over a 4-year period from 2013 to 2017, 3,658 patients with septic shock undergoing mechanical ventilation were randomized to receive either a continuous infusion of 200 mg/day of hydrocortisone for 7 days or placebo. The primary outcome, death within 90 days, occurred in 511 patients (27.9%) in the hydrocortisone group and in 526 patients (28.8%) in the placebo group (P = .50).

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Among patients with septic shock undergoing mechanical ventilation, does hydrocortisone reduce 90-day mortality?

Background: Septic shock is associated with a significant mortality risk, and there is no proven pharmacologic treatment other than fluids, vasopressors, and antimicrobials. Prior randomized, controlled trials have resulted in mixed outcomes, and meta-analyses and clinical practice guidelines also have not provided consistent guidance.

Study design: Randomized, controlled, double-blinded trial.

Setting: Medical centers in Australia, Denmark, New Zealand, Saudi Arabia, and the United Kingdom.

Synopsis: Over a 4-year period from 2013 to 2017, 3,658 patients with septic shock undergoing mechanical ventilation were randomized to receive either a continuous infusion of 200 mg/day of hydrocortisone for 7 days or placebo. The primary outcome, death within 90 days, occurred in 511 patients (27.9%) in the hydrocortisone group and in 526 patients (28.8%) in the placebo group (P = .50).

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Among patients with septic shock undergoing mechanical ventilation, does hydrocortisone reduce 90-day mortality?

Background: Septic shock is associated with a significant mortality risk, and there is no proven pharmacologic treatment other than fluids, vasopressors, and antimicrobials. Prior randomized, controlled trials have resulted in mixed outcomes, and meta-analyses and clinical practice guidelines also have not provided consistent guidance.

Study design: Randomized, controlled, double-blinded trial.

Setting: Medical centers in Australia, Denmark, New Zealand, Saudi Arabia, and the United Kingdom.

Synopsis: Over a 4-year period from 2013 to 2017, 3,658 patients with septic shock undergoing mechanical ventilation were randomized to receive either a continuous infusion of 200 mg/day of hydrocortisone for 7 days or placebo. The primary outcome, death within 90 days, occurred in 511 patients (27.9%) in the hydrocortisone group and in 526 patients (28.8%) in the placebo group (P = .50).

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Does prompting hospitalists during interdisciplinary rounds to discontinue lab orders on patients nearing discharge result in a decrease in lab testing?

Background: The Society of Hospital Medicine, as part of the Choosing Wisely campaign, has recommended against “repetitive complete blood count and chemistry testing in the face of clinical and lab stability.” Repeated phlebotomy has been shown to increase iatrogenic anemia and patient discomfort. While past interventions have been effective in decreasing lab testing, this study focused on identifying and intervening on patients who were clinically stable and nearing discharge.

Study design: Prospective, observational study.

Setting: Tertiary care teaching hospital in New York.

Synopsis: As part of structured, bedside, interdisciplinary rounds, over the course of a year, this study incorporated an inquiry to identify patients who were likely to be discharged in the next 24-48 hours; the unit medical director or nurse manager then prompted staff to discontinue labs for these patients when appropriate. This was supplemented by education of clinicians and regular review of lab utilization data with hospitalists.

The percentage of patients with labs ordered in the 24 hours prior to discharge decreased from 50.1% in the preintervention period to 34.5% in the postintervention period (P = .004). The number of labs ordered per patient-day dropped from 1.96 to 1.83 (P = .01).

Bottom line: An intervention with prompting during structured interdisciplinary rounds decreased the frequency of labs ordered for patients nearing hospital discharge.

Citation: Tsega S et al. Bedside assessment of the necessity of daily lab testing for patients nearing discharge. J Hosp Med. 2018 Jan 1;13(1):38-40.
 

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Does prompting hospitalists during interdisciplinary rounds to discontinue lab orders on patients nearing discharge result in a decrease in lab testing?

Background: The Society of Hospital Medicine, as part of the Choosing Wisely campaign, has recommended against “repetitive complete blood count and chemistry testing in the face of clinical and lab stability.” Repeated phlebotomy has been shown to increase iatrogenic anemia and patient discomfort. While past interventions have been effective in decreasing lab testing, this study focused on identifying and intervening on patients who were clinically stable and nearing discharge.

Study design: Prospective, observational study.

Setting: Tertiary care teaching hospital in New York.

Synopsis: As part of structured, bedside, interdisciplinary rounds, over the course of a year, this study incorporated an inquiry to identify patients who were likely to be discharged in the next 24-48 hours; the unit medical director or nurse manager then prompted staff to discontinue labs for these patients when appropriate. This was supplemented by education of clinicians and regular review of lab utilization data with hospitalists.

The percentage of patients with labs ordered in the 24 hours prior to discharge decreased from 50.1% in the preintervention period to 34.5% in the postintervention period (P = .004). The number of labs ordered per patient-day dropped from 1.96 to 1.83 (P = .01).

Bottom line: An intervention with prompting during structured interdisciplinary rounds decreased the frequency of labs ordered for patients nearing hospital discharge.

Citation: Tsega S et al. Bedside assessment of the necessity of daily lab testing for patients nearing discharge. J Hosp Med. 2018 Jan 1;13(1):38-40.
 

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Clinical question: Does prompting hospitalists during interdisciplinary rounds to discontinue lab orders on patients nearing discharge result in a decrease in lab testing?

Background: The Society of Hospital Medicine, as part of the Choosing Wisely campaign, has recommended against “repetitive complete blood count and chemistry testing in the face of clinical and lab stability.” Repeated phlebotomy has been shown to increase iatrogenic anemia and patient discomfort. While past interventions have been effective in decreasing lab testing, this study focused on identifying and intervening on patients who were clinically stable and nearing discharge.

Study design: Prospective, observational study.

Setting: Tertiary care teaching hospital in New York.

Synopsis: As part of structured, bedside, interdisciplinary rounds, over the course of a year, this study incorporated an inquiry to identify patients who were likely to be discharged in the next 24-48 hours; the unit medical director or nurse manager then prompted staff to discontinue labs for these patients when appropriate. This was supplemented by education of clinicians and regular review of lab utilization data with hospitalists.

The percentage of patients with labs ordered in the 24 hours prior to discharge decreased from 50.1% in the preintervention period to 34.5% in the postintervention period (P = .004). The number of labs ordered per patient-day dropped from 1.96 to 1.83 (P = .01).

Bottom line: An intervention with prompting during structured interdisciplinary rounds decreased the frequency of labs ordered for patients nearing hospital discharge.

Citation: Tsega S et al. Bedside assessment of the necessity of daily lab testing for patients nearing discharge. J Hosp Med. 2018 Jan 1;13(1):38-40.
 

Dr. Huang is associate chief of the division of hospital medicine at UC San Diego Health and an associate professor of medicine at the University of California, San Diego.

Since 2000, Medicare beneficiaries have become less likely to die in hospitals, and more likely to die in their homes or in community health care facilities.

A review of Medicare records also determined that there was a decline in health care transitions in the final 3 days of life for these patients, Joan M. Teno, MD, and her colleagues wrote in JAMA.

It is not possible to identify a specific reason for the shift, wrote Dr. Teno, professor of medicine at the Oregon Health & Science University, Portland. Between the study years of 2000 and 2015, there were several large efforts to improve care at the end of life.

“Since 2009, programs ranging from ensuring informed patient decision making to enhanced care coordination have had the goal of improving care at the end of life. Specific interventions have included promoting conversations about the goals of care, continued growth of hospice services and palliative care, and the debate and passage of the Affordable Care Act … It is difficult to disentangle efforts such as public education, promotion of advance directives through the Patient Self- Determination Act, increased access to hospice and palliative care services, financial incentives of payment policies, and other secular changes.”

The study mined data from the Centers for Medicare & Medicaid Services, and examined end-of-life outcomes among two Medicare groups: Medicare fee-for-service recipients (1,361,870) during 2009-2015, and Medicare Advantage recipients (871,845), comparing 2011 and 2015. The mean age of both cohorts was 82 years.

Outcomes included site of death and “potentially burdensome transitions,” during the last days of life. These were defined as three or more hospitalizations in the previous 3 months, or two or more hospitalizations for pneumonia, urinary tract infection, dehydration, or sepsis during the last 120 days of life. Prolonged mechanical ventilation also was deemed potentially burdensome.

Among fee-for-service recipients, deaths in acute care hospitals declined from 32.6% to19.8%. Deaths in nursing homes remained steady, at 27.2% and 24.9%. Many of these deaths (42.9%) were preceded by a stay in an ICU. There was a transient increase in end-of-life ICU use, around 2009, but by 2015, the percentage was down to 29%, compared with 65.2% in 2000.

Transitions between a nursing home and hospital in the last 90 days of life were 0.49/person in 2000 and 0.33/person in 2015. Hospitalizations for infection or dehydration fell from 14.6% to12.2%. Hospitalization with prolonged ventilation fell from 3.1% to 2.5%.

Dying in hospice care increased from 21.6% to 50.4%, and people were taking advantage of hospice services longer: the proportion using short-term services (3 days or less) fell from 9.8% to 7.7%.

Among Medicare Advantage recipients, the numbers were somewhat different. More than 50% of recipients entered hospice care in both 2011 and 2015; in both years, 8% had services for more than 3 days. About 27% had ICU care in the last days of life, in both years. Compared to fee-for-service recipients, fewer Medicare Advantage patients were in nursing homes at the time of death, and that number declined from 2011 to 2015 (37.7% to 33.2%).

In each year, about 10% of these patients had a hospitalization for dehydration or infection, and 3% had a stay requiring prolonged mechanical ventilation in each year. The mean number of health care transitions remained steady, at 0.23 and 0.21 per person each year.

Dr. Teno had no financial disclosures.

[email protected]

SOURCE: Teno JM et al. JAMA. 2018 Jun 25. doi: 10.1001/jama.2018.8981.

Since 2000, Medicare beneficiaries have become less likely to die in hospitals, and more likely to die in their homes or in community health care facilities.

A review of Medicare records also determined that there was a decline in health care transitions in the final 3 days of life for these patients, Joan M. Teno, MD, and her colleagues wrote in JAMA.

It is not possible to identify a specific reason for the shift, wrote Dr. Teno, professor of medicine at the Oregon Health & Science University, Portland. Between the study years of 2000 and 2015, there were several large efforts to improve care at the end of life.

“Since 2009, programs ranging from ensuring informed patient decision making to enhanced care coordination have had the goal of improving care at the end of life. Specific interventions have included promoting conversations about the goals of care, continued growth of hospice services and palliative care, and the debate and passage of the Affordable Care Act … It is difficult to disentangle efforts such as public education, promotion of advance directives through the Patient Self- Determination Act, increased access to hospice and palliative care services, financial incentives of payment policies, and other secular changes.”

The study mined data from the Centers for Medicare & Medicaid Services, and examined end-of-life outcomes among two Medicare groups: Medicare fee-for-service recipients (1,361,870) during 2009-2015, and Medicare Advantage recipients (871,845), comparing 2011 and 2015. The mean age of both cohorts was 82 years.

Outcomes included site of death and “potentially burdensome transitions,” during the last days of life. These were defined as three or more hospitalizations in the previous 3 months, or two or more hospitalizations for pneumonia, urinary tract infection, dehydration, or sepsis during the last 120 days of life. Prolonged mechanical ventilation also was deemed potentially burdensome.

Among fee-for-service recipients, deaths in acute care hospitals declined from 32.6% to19.8%. Deaths in nursing homes remained steady, at 27.2% and 24.9%. Many of these deaths (42.9%) were preceded by a stay in an ICU. There was a transient increase in end-of-life ICU use, around 2009, but by 2015, the percentage was down to 29%, compared with 65.2% in 2000.

Transitions between a nursing home and hospital in the last 90 days of life were 0.49/person in 2000 and 0.33/person in 2015. Hospitalizations for infection or dehydration fell from 14.6% to12.2%. Hospitalization with prolonged ventilation fell from 3.1% to 2.5%.

Dying in hospice care increased from 21.6% to 50.4%, and people were taking advantage of hospice services longer: the proportion using short-term services (3 days or less) fell from 9.8% to 7.7%.

Among Medicare Advantage recipients, the numbers were somewhat different. More than 50% of recipients entered hospice care in both 2011 and 2015; in both years, 8% had services for more than 3 days. About 27% had ICU care in the last days of life, in both years. Compared to fee-for-service recipients, fewer Medicare Advantage patients were in nursing homes at the time of death, and that number declined from 2011 to 2015 (37.7% to 33.2%).

In each year, about 10% of these patients had a hospitalization for dehydration or infection, and 3% had a stay requiring prolonged mechanical ventilation in each year. The mean number of health care transitions remained steady, at 0.23 and 0.21 per person each year.

Dr. Teno had no financial disclosures.

[email protected]

SOURCE: Teno JM et al. JAMA. 2018 Jun 25. doi: 10.1001/jama.2018.8981.

Since 2000, Medicare beneficiaries have become less likely to die in hospitals, and more likely to die in their homes or in community health care facilities.

A review of Medicare records also determined that there was a decline in health care transitions in the final 3 days of life for these patients, Joan M. Teno, MD, and her colleagues wrote in JAMA.

It is not possible to identify a specific reason for the shift, wrote Dr. Teno, professor of medicine at the Oregon Health & Science University, Portland. Between the study years of 2000 and 2015, there were several large efforts to improve care at the end of life.

“Since 2009, programs ranging from ensuring informed patient decision making to enhanced care coordination have had the goal of improving care at the end of life. Specific interventions have included promoting conversations about the goals of care, continued growth of hospice services and palliative care, and the debate and passage of the Affordable Care Act … It is difficult to disentangle efforts such as public education, promotion of advance directives through the Patient Self- Determination Act, increased access to hospice and palliative care services, financial incentives of payment policies, and other secular changes.”

The study mined data from the Centers for Medicare & Medicaid Services, and examined end-of-life outcomes among two Medicare groups: Medicare fee-for-service recipients (1,361,870) during 2009-2015, and Medicare Advantage recipients (871,845), comparing 2011 and 2015. The mean age of both cohorts was 82 years.

Outcomes included site of death and “potentially burdensome transitions,” during the last days of life. These were defined as three or more hospitalizations in the previous 3 months, or two or more hospitalizations for pneumonia, urinary tract infection, dehydration, or sepsis during the last 120 days of life. Prolonged mechanical ventilation also was deemed potentially burdensome.

Among fee-for-service recipients, deaths in acute care hospitals declined from 32.6% to19.8%. Deaths in nursing homes remained steady, at 27.2% and 24.9%. Many of these deaths (42.9%) were preceded by a stay in an ICU. There was a transient increase in end-of-life ICU use, around 2009, but by 2015, the percentage was down to 29%, compared with 65.2% in 2000.

Transitions between a nursing home and hospital in the last 90 days of life were 0.49/person in 2000 and 0.33/person in 2015. Hospitalizations for infection or dehydration fell from 14.6% to12.2%. Hospitalization with prolonged ventilation fell from 3.1% to 2.5%.

Dying in hospice care increased from 21.6% to 50.4%, and people were taking advantage of hospice services longer: the proportion using short-term services (3 days or less) fell from 9.8% to 7.7%.

Among Medicare Advantage recipients, the numbers were somewhat different. More than 50% of recipients entered hospice care in both 2011 and 2015; in both years, 8% had services for more than 3 days. About 27% had ICU care in the last days of life, in both years. Compared to fee-for-service recipients, fewer Medicare Advantage patients were in nursing homes at the time of death, and that number declined from 2011 to 2015 (37.7% to 33.2%).

In each year, about 10% of these patients had a hospitalization for dehydration or infection, and 3% had a stay requiring prolonged mechanical ventilation in each year. The mean number of health care transitions remained steady, at 0.23 and 0.21 per person each year.

Dr. Teno had no financial disclosures.

[email protected]

SOURCE: Teno JM et al. JAMA. 2018 Jun 25. doi: 10.1001/jama.2018.8981.

Editor’s note: Each month, the Society of Hospital Medicine puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help improve the care of hospitalized patients.

Why did you become a member of SHM?

After being in a general pediatrics practice for a few years, I saw a lot of value in and got a lot of support from working with other outpatient pediatricians and the American Academy of Pediatrics. When I left that outpatient practice to focus on hospital pediatrics 13 years ago, I needed to find people who knew a lot more than I did about inpatient work and an organization that could support my growth and development in this new role. Of course, SHM was the answer.

I knew there was a ton I could learn from the internists who had been doing this work a lot longer and senior pediatric hospitalists who could share their experiences. I found all of that, and more, and was honored to join the Pediatrics Committee in 2012 to help serve the community that’s helped me so much.
 

During your time on the Pediatrics Committee, what goals were accomplished?

Over the years, this great committee has been very active at the direction of some fantastic leaders. We have had the privilege and responsibility to advise the SHM Board on pediatric issues and concerns, and we’ve developed some interesting pediatric-specific educational content in areas such as quality and safe handoffs. We’ve worked on the Choosing Wisely campaign and are now in the process of updating the Pediatric Hospital Medicine Core Competencies.

Each year we develop the content for the Pediatric Track of the SHM annual conference, and for several years, I was also on the Annual Conference Committee, which was a fantastic opportunity to bring the pediatric world to the broader work of SHM.
 

The Pediatrics Committee is transitioning from a committee to a Pediatric Special Interest Group. What can members look forward to in this transition?

I was asked to lead the subcommittee that is working on the SIG transition, and I must say, I am excited! You know, as great as the Pediatrics Committee is, it’s still only 15-20 people. And there are opportunities for pediatric hospitalists to join other SHM committees, but even at that, the footprint of active, engaged pediatric hospitalists within SHM is fairly small. The transition to a much more open-ended pediatric hospitalist SIG will allow many more hospitalists who take care of children to become involved. That’s more people, from more places, with more perspectives and ideas. It’s more energy, more collaboration, and hopefully, in the long run, a more visible and systemic pediatric presence within SHM.

Sure, there are questions and a few concerns, and I’m not sure all the details have been quite worked out, but in the big picture, I think it’s good for pediatric hospital medicine and good for SHM. Stay tuned as the process develops, but I think SHM members are going to see the new opportunity to get involved directly in SIG projects and goals, collaborate with more pediatric hospitalists, and see some real dynamic and forward-thinking leadership in the SIG executive council ... and opportunities to be on that Executive Council in a transparent, collegial way.
 

What were your main takeaways from Pediatric Hospital Medicine 2017? What can attendees expect at PHM 2018?

The annual Pediatric Hospital Medicine (PHM) meeting is always a bit of a whirlwind and our meeting in Nashville in 2017, hosted by SHM and our very own board member, Kris Rehm, MD, SFHM, was no different. There is always so much to experience and a diversity of offerings, which is really representative of how broad and rapidly growing our field is.

Of course, the “Top Articles in PHM” review is always popular and well received, and the poster and platform research sessions really show how far PHM has come and how much incredibly detailed and diligent work is being done to advance it further. There were some particularly thought-provoking plenary sessions last year on evidence-based health policy challenges and how some things we take as PHM dogma might not even be true! Left us all scratching our heads a bit. The final plenary on magic and pediatrics was inspiring and hilarious.

As far as PHM 2018, I suppose for full disclosure I should mention that I’m on the planning committee, so of course it’s going to be awesome! We really are putting together a fantastic experience. We had so many high-quality submissions for workshops, clinical sessions, research – truly spanning the whole range of PHM work. Whatever you’re coming to learn about, you’ll find it. We have some tremendously gifted plenary speakers lined up; some are sure to inspire, some will make you smile with pride about being a hospitalist, and at least one will almost certainly crack you up. We’ve shortened the length of many of the workshops to allow attendees to have more experiences while making sure the content is still meaningful. There will be several opportunities to mentor and be mentored in a comfortable, casual setting. I could go on and on, but if you take care of kids, come to Atlanta and see for yourself in July!
 

Do you have any advice for early-stage pediatric hospitalists looking to advance their careers?

This is an exciting time to be a pediatric hospitalist. Like it or hate it, subspecialty designation in PHM is around the corner, the new SHM pediatric SIG is going to open up a new era of opportunities, research in the field is gathering tremendous momentum, and fellowship training is only going to fuel that.

But PHM is still so far from becoming a single, one-size-fits-all path. There is still a huge range of practice locations, settings, responsibilities, and challenges. I tell my junior folks: “Put yourself out there. Try some things. Try a lot of things. If you have opportunities to practice in a few different settings, try it. If there are learners, teach. Join a research or quality improvement group. Go to some big meetings; talk to 50 new people. If you hear someone give a great talk that gets you fired up about something you have a passion for, stick around, go talk with them; they get it, they were you once, and probably not even that long ago. Throw your hat in a ring and help out with a project. It might turn out to not be your ‘thing,’ but it might lead you to your ‘thing.’ Or not, but you’ll come away with some experience and two new friends.”

That’s what makes this journey fun. There is no goal, no endgame. It’s all about the journey and the joy you find in the ride.
 

Ms. Steele is a marketing communications specialist at the Society of Hospital Medicine.

Editor’s note: Each month, the Society of Hospital Medicine puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help improve the care of hospitalized patients.

Why did you become a member of SHM?

After being in a general pediatrics practice for a few years, I saw a lot of value in and got a lot of support from working with other outpatient pediatricians and the American Academy of Pediatrics. When I left that outpatient practice to focus on hospital pediatrics 13 years ago, I needed to find people who knew a lot more than I did about inpatient work and an organization that could support my growth and development in this new role. Of course, SHM was the answer.

I knew there was a ton I could learn from the internists who had been doing this work a lot longer and senior pediatric hospitalists who could share their experiences. I found all of that, and more, and was honored to join the Pediatrics Committee in 2012 to help serve the community that’s helped me so much.
 

During your time on the Pediatrics Committee, what goals were accomplished?

Over the years, this great committee has been very active at the direction of some fantastic leaders. We have had the privilege and responsibility to advise the SHM Board on pediatric issues and concerns, and we’ve developed some interesting pediatric-specific educational content in areas such as quality and safe handoffs. We’ve worked on the Choosing Wisely campaign and are now in the process of updating the Pediatric Hospital Medicine Core Competencies.

Each year we develop the content for the Pediatric Track of the SHM annual conference, and for several years, I was also on the Annual Conference Committee, which was a fantastic opportunity to bring the pediatric world to the broader work of SHM.
 

The Pediatrics Committee is transitioning from a committee to a Pediatric Special Interest Group. What can members look forward to in this transition?

I was asked to lead the subcommittee that is working on the SIG transition, and I must say, I am excited! You know, as great as the Pediatrics Committee is, it’s still only 15-20 people. And there are opportunities for pediatric hospitalists to join other SHM committees, but even at that, the footprint of active, engaged pediatric hospitalists within SHM is fairly small. The transition to a much more open-ended pediatric hospitalist SIG will allow many more hospitalists who take care of children to become involved. That’s more people, from more places, with more perspectives and ideas. It’s more energy, more collaboration, and hopefully, in the long run, a more visible and systemic pediatric presence within SHM.

Sure, there are questions and a few concerns, and I’m not sure all the details have been quite worked out, but in the big picture, I think it’s good for pediatric hospital medicine and good for SHM. Stay tuned as the process develops, but I think SHM members are going to see the new opportunity to get involved directly in SIG projects and goals, collaborate with more pediatric hospitalists, and see some real dynamic and forward-thinking leadership in the SIG executive council ... and opportunities to be on that Executive Council in a transparent, collegial way.
 

What were your main takeaways from Pediatric Hospital Medicine 2017? What can attendees expect at PHM 2018?

The annual Pediatric Hospital Medicine (PHM) meeting is always a bit of a whirlwind and our meeting in Nashville in 2017, hosted by SHM and our very own board member, Kris Rehm, MD, SFHM, was no different. There is always so much to experience and a diversity of offerings, which is really representative of how broad and rapidly growing our field is.

Of course, the “Top Articles in PHM” review is always popular and well received, and the poster and platform research sessions really show how far PHM has come and how much incredibly detailed and diligent work is being done to advance it further. There were some particularly thought-provoking plenary sessions last year on evidence-based health policy challenges and how some things we take as PHM dogma might not even be true! Left us all scratching our heads a bit. The final plenary on magic and pediatrics was inspiring and hilarious.

As far as PHM 2018, I suppose for full disclosure I should mention that I’m on the planning committee, so of course it’s going to be awesome! We really are putting together a fantastic experience. We had so many high-quality submissions for workshops, clinical sessions, research – truly spanning the whole range of PHM work. Whatever you’re coming to learn about, you’ll find it. We have some tremendously gifted plenary speakers lined up; some are sure to inspire, some will make you smile with pride about being a hospitalist, and at least one will almost certainly crack you up. We’ve shortened the length of many of the workshops to allow attendees to have more experiences while making sure the content is still meaningful. There will be several opportunities to mentor and be mentored in a comfortable, casual setting. I could go on and on, but if you take care of kids, come to Atlanta and see for yourself in July!
 

Do you have any advice for early-stage pediatric hospitalists looking to advance their careers?

This is an exciting time to be a pediatric hospitalist. Like it or hate it, subspecialty designation in PHM is around the corner, the new SHM pediatric SIG is going to open up a new era of opportunities, research in the field is gathering tremendous momentum, and fellowship training is only going to fuel that.

But PHM is still so far from becoming a single, one-size-fits-all path. There is still a huge range of practice locations, settings, responsibilities, and challenges. I tell my junior folks: “Put yourself out there. Try some things. Try a lot of things. If you have opportunities to practice in a few different settings, try it. If there are learners, teach. Join a research or quality improvement group. Go to some big meetings; talk to 50 new people. If you hear someone give a great talk that gets you fired up about something you have a passion for, stick around, go talk with them; they get it, they were you once, and probably not even that long ago. Throw your hat in a ring and help out with a project. It might turn out to not be your ‘thing,’ but it might lead you to your ‘thing.’ Or not, but you’ll come away with some experience and two new friends.”

That’s what makes this journey fun. There is no goal, no endgame. It’s all about the journey and the joy you find in the ride.
 

Ms. Steele is a marketing communications specialist at the Society of Hospital Medicine.

Editor’s note: Each month, the Society of Hospital Medicine puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help improve the care of hospitalized patients.

Why did you become a member of SHM?

After being in a general pediatrics practice for a few years, I saw a lot of value in and got a lot of support from working with other outpatient pediatricians and the American Academy of Pediatrics. When I left that outpatient practice to focus on hospital pediatrics 13 years ago, I needed to find people who knew a lot more than I did about inpatient work and an organization that could support my growth and development in this new role. Of course, SHM was the answer.

I knew there was a ton I could learn from the internists who had been doing this work a lot longer and senior pediatric hospitalists who could share their experiences. I found all of that, and more, and was honored to join the Pediatrics Committee in 2012 to help serve the community that’s helped me so much.
 

During your time on the Pediatrics Committee, what goals were accomplished?

Over the years, this great committee has been very active at the direction of some fantastic leaders. We have had the privilege and responsibility to advise the SHM Board on pediatric issues and concerns, and we’ve developed some interesting pediatric-specific educational content in areas such as quality and safe handoffs. We’ve worked on the Choosing Wisely campaign and are now in the process of updating the Pediatric Hospital Medicine Core Competencies.

Each year we develop the content for the Pediatric Track of the SHM annual conference, and for several years, I was also on the Annual Conference Committee, which was a fantastic opportunity to bring the pediatric world to the broader work of SHM.
 

The Pediatrics Committee is transitioning from a committee to a Pediatric Special Interest Group. What can members look forward to in this transition?

I was asked to lead the subcommittee that is working on the SIG transition, and I must say, I am excited! You know, as great as the Pediatrics Committee is, it’s still only 15-20 people. And there are opportunities for pediatric hospitalists to join other SHM committees, but even at that, the footprint of active, engaged pediatric hospitalists within SHM is fairly small. The transition to a much more open-ended pediatric hospitalist SIG will allow many more hospitalists who take care of children to become involved. That’s more people, from more places, with more perspectives and ideas. It’s more energy, more collaboration, and hopefully, in the long run, a more visible and systemic pediatric presence within SHM.

Sure, there are questions and a few concerns, and I’m not sure all the details have been quite worked out, but in the big picture, I think it’s good for pediatric hospital medicine and good for SHM. Stay tuned as the process develops, but I think SHM members are going to see the new opportunity to get involved directly in SIG projects and goals, collaborate with more pediatric hospitalists, and see some real dynamic and forward-thinking leadership in the SIG executive council ... and opportunities to be on that Executive Council in a transparent, collegial way.
 

What were your main takeaways from Pediatric Hospital Medicine 2017? What can attendees expect at PHM 2018?

The annual Pediatric Hospital Medicine (PHM) meeting is always a bit of a whirlwind and our meeting in Nashville in 2017, hosted by SHM and our very own board member, Kris Rehm, MD, SFHM, was no different. There is always so much to experience and a diversity of offerings, which is really representative of how broad and rapidly growing our field is.

Of course, the “Top Articles in PHM” review is always popular and well received, and the poster and platform research sessions really show how far PHM has come and how much incredibly detailed and diligent work is being done to advance it further. There were some particularly thought-provoking plenary sessions last year on evidence-based health policy challenges and how some things we take as PHM dogma might not even be true! Left us all scratching our heads a bit. The final plenary on magic and pediatrics was inspiring and hilarious.

As far as PHM 2018, I suppose for full disclosure I should mention that I’m on the planning committee, so of course it’s going to be awesome! We really are putting together a fantastic experience. We had so many high-quality submissions for workshops, clinical sessions, research – truly spanning the whole range of PHM work. Whatever you’re coming to learn about, you’ll find it. We have some tremendously gifted plenary speakers lined up; some are sure to inspire, some will make you smile with pride about being a hospitalist, and at least one will almost certainly crack you up. We’ve shortened the length of many of the workshops to allow attendees to have more experiences while making sure the content is still meaningful. There will be several opportunities to mentor and be mentored in a comfortable, casual setting. I could go on and on, but if you take care of kids, come to Atlanta and see for yourself in July!
 

Do you have any advice for early-stage pediatric hospitalists looking to advance their careers?

This is an exciting time to be a pediatric hospitalist. Like it or hate it, subspecialty designation in PHM is around the corner, the new SHM pediatric SIG is going to open up a new era of opportunities, research in the field is gathering tremendous momentum, and fellowship training is only going to fuel that.

But PHM is still so far from becoming a single, one-size-fits-all path. There is still a huge range of practice locations, settings, responsibilities, and challenges. I tell my junior folks: “Put yourself out there. Try some things. Try a lot of things. If you have opportunities to practice in a few different settings, try it. If there are learners, teach. Join a research or quality improvement group. Go to some big meetings; talk to 50 new people. If you hear someone give a great talk that gets you fired up about something you have a passion for, stick around, go talk with them; they get it, they were you once, and probably not even that long ago. Throw your hat in a ring and help out with a project. It might turn out to not be your ‘thing,’ but it might lead you to your ‘thing.’ Or not, but you’ll come away with some experience and two new friends.”

That’s what makes this journey fun. There is no goal, no endgame. It’s all about the journey and the joy you find in the ride.
 

Ms. Steele is a marketing communications specialist at the Society of Hospital Medicine.

For the fourth consecutive year, Boston Children’s Hospital has been named the top children’s hospital by U.S. News & World Report.

The hospital finished among the top five in all 10 pediatric specialties included in the rankings: cancer (third), cardiology and heart surgery (second), diabetes and endocrinology (second), gastroenterology and GI surgery (second), neonatology (third), nephrology (first), neurology and neurosurgery (first), orthopedics (first), pulmonology (fourth), and urology (third), according to the 2018-2019 Best Children’s Hospitals rankings.

[email protected]

For the fourth consecutive year, Boston Children’s Hospital has been named the top children’s hospital by U.S. News & World Report.

The hospital finished among the top five in all 10 pediatric specialties included in the rankings: cancer (third), cardiology and heart surgery (second), diabetes and endocrinology (second), gastroenterology and GI surgery (second), neonatology (third), nephrology (first), neurology and neurosurgery (first), orthopedics (first), pulmonology (fourth), and urology (third), according to the 2018-2019 Best Children’s Hospitals rankings.

[email protected]

For the fourth consecutive year, Boston Children’s Hospital has been named the top children’s hospital by U.S. News & World Report.

The hospital finished among the top five in all 10 pediatric specialties included in the rankings: cancer (third), cardiology and heart surgery (second), diabetes and endocrinology (second), gastroenterology and GI surgery (second), neonatology (third), nephrology (first), neurology and neurosurgery (first), orthopedics (first), pulmonology (fourth), and urology (third), according to the 2018-2019 Best Children’s Hospitals rankings.

[email protected]

AMSTERDAM – Opioids cannot be justified for the routine treatment for musculoskeletal pain because risks outweigh benefits, according to a detailed review of published studies presented at the European Congress of Rheumatology.

“There is very little evidence of benefit for the long-term management of nonmalignant pain, but very good evidence for harm,” reported Blair Smith, MD, head of the population health sciences division, University of Dundee (Scotland).

Ted Bosworth/MDedge News

In the treatment of musculoskeletal pain, the goals are increased function and quality of life, rather than complete relief of pain, according to Dr. Smith. On this basis, opioids are not an appropriate routine therapy. He reported that pain relief is not well documented, while side effects such as sedation, dizziness, and constipation, are likely to be counterproductive to improved outcomes.

There is no absolute contraindication for opioids in the control of chronic musculoskeletal pain, but Dr. Smith’s summary of the data led him to conclude that they should be used judiciously and “only for carefully selected patients.”

Of the many studies he reviewed to draw this conclusion, one of the most recent was identified as the most persuasive. Published earlier this year, the SPACE study is “the first good-quality study of long-term opioid use” in patients with musculoskeletal complaints. It was negative.

“The pain intensity at the end of 12 months of treatment was slightly but significantly worse among those randomized to opioids,” reported Dr. Smith. “There was no difference in patient function, but there was an increased risk of adverse events.”

In the SPACE study, 240 patients with moderate to severe chronic back pain or hip or knee osteoarthritis were randomized to opioid or nonopioid pain management. In the nonopioid group, the first therapeutic step was acetaminophen, but medications could be changed, added, or adjusted within both groups to improve patient response.

At the end of 12 months, a lack of benefit on both pain control and functional improvement from opioids relative to nonopioid treatment was accompanied by a higher rate of adverse effects. This led the authors to conclude that opioids are not supported for musculoskeletal pain.

Not all the evidence argues against opioids for noncancer pain management, according to Dr. Smith, but he emphasized that those who support use of opioids do so for pain control only. They do not confirm an advantage for function and quality of life, which he suggested are the key endpoints. For example, a 2010 Cochrane review concluded from a systematic literature review that there is “weak evidence” for pain relief but inconclusive evidence of an improvement in functioning and quality of life.

Other investigators have drawn the same conclusion, according to Dr. Smith. He cited a statement from the International Association for Study of Pain that advises, “Caution should be used for prescribing opioids for chronic pain.” Although this statement was not specific to musculoskeletal pain, the IASP does specify that pain medications should be employed “to promote increased function and improved quality of life rather than complete relief of pain,” according to Dr. Smith.

Opioid prescriptions for chronic pain have been increasing in Europe as they have in the United States, but Dr. Smith indicated that opioids, if used at all, should be prescribed for very short periods and for very specific goals, particularly improvement in function.

“Probably most important for my [primary care] colleagues, patients prescribed opioids should be evaluated early and frequently to gauge benefit,” Dr. Smith said. Although he believes pain control is an important and worthwhile goal, it must be approached within the context of improved well-being rather than as an isolated endpoint.
 

SOURCE: Smith B et al. EULAR 2018, Abstract No. SP0073.

AMSTERDAM – Opioids cannot be justified for the routine treatment for musculoskeletal pain because risks outweigh benefits, according to a detailed review of published studies presented at the European Congress of Rheumatology.

“There is very little evidence of benefit for the long-term management of nonmalignant pain, but very good evidence for harm,” reported Blair Smith, MD, head of the population health sciences division, University of Dundee (Scotland).

Ted Bosworth/MDedge News

In the treatment of musculoskeletal pain, the goals are increased function and quality of life, rather than complete relief of pain, according to Dr. Smith. On this basis, opioids are not an appropriate routine therapy. He reported that pain relief is not well documented, while side effects such as sedation, dizziness, and constipation, are likely to be counterproductive to improved outcomes.

There is no absolute contraindication for opioids in the control of chronic musculoskeletal pain, but Dr. Smith’s summary of the data led him to conclude that they should be used judiciously and “only for carefully selected patients.”

Of the many studies he reviewed to draw this conclusion, one of the most recent was identified as the most persuasive. Published earlier this year, the SPACE study is “the first good-quality study of long-term opioid use” in patients with musculoskeletal complaints. It was negative.

“The pain intensity at the end of 12 months of treatment was slightly but significantly worse among those randomized to opioids,” reported Dr. Smith. “There was no difference in patient function, but there was an increased risk of adverse events.”

In the SPACE study, 240 patients with moderate to severe chronic back pain or hip or knee osteoarthritis were randomized to opioid or nonopioid pain management. In the nonopioid group, the first therapeutic step was acetaminophen, but medications could be changed, added, or adjusted within both groups to improve patient response.

At the end of 12 months, a lack of benefit on both pain control and functional improvement from opioids relative to nonopioid treatment was accompanied by a higher rate of adverse effects. This led the authors to conclude that opioids are not supported for musculoskeletal pain.

Not all the evidence argues against opioids for noncancer pain management, according to Dr. Smith, but he emphasized that those who support use of opioids do so for pain control only. They do not confirm an advantage for function and quality of life, which he suggested are the key endpoints. For example, a 2010 Cochrane review concluded from a systematic literature review that there is “weak evidence” for pain relief but inconclusive evidence of an improvement in functioning and quality of life.

Other investigators have drawn the same conclusion, according to Dr. Smith. He cited a statement from the International Association for Study of Pain that advises, “Caution should be used for prescribing opioids for chronic pain.” Although this statement was not specific to musculoskeletal pain, the IASP does specify that pain medications should be employed “to promote increased function and improved quality of life rather than complete relief of pain,” according to Dr. Smith.

Opioid prescriptions for chronic pain have been increasing in Europe as they have in the United States, but Dr. Smith indicated that opioids, if used at all, should be prescribed for very short periods and for very specific goals, particularly improvement in function.

“Probably most important for my [primary care] colleagues, patients prescribed opioids should be evaluated early and frequently to gauge benefit,” Dr. Smith said. Although he believes pain control is an important and worthwhile goal, it must be approached within the context of improved well-being rather than as an isolated endpoint.
 

SOURCE: Smith B et al. EULAR 2018, Abstract No. SP0073.

AMSTERDAM – Opioids cannot be justified for the routine treatment for musculoskeletal pain because risks outweigh benefits, according to a detailed review of published studies presented at the European Congress of Rheumatology.

“There is very little evidence of benefit for the long-term management of nonmalignant pain, but very good evidence for harm,” reported Blair Smith, MD, head of the population health sciences division, University of Dundee (Scotland).

Ted Bosworth/MDedge News

In the treatment of musculoskeletal pain, the goals are increased function and quality of life, rather than complete relief of pain, according to Dr. Smith. On this basis, opioids are not an appropriate routine therapy. He reported that pain relief is not well documented, while side effects such as sedation, dizziness, and constipation, are likely to be counterproductive to improved outcomes.

There is no absolute contraindication for opioids in the control of chronic musculoskeletal pain, but Dr. Smith’s summary of the data led him to conclude that they should be used judiciously and “only for carefully selected patients.”

Of the many studies he reviewed to draw this conclusion, one of the most recent was identified as the most persuasive. Published earlier this year, the SPACE study is “the first good-quality study of long-term opioid use” in patients with musculoskeletal complaints. It was negative.

“The pain intensity at the end of 12 months of treatment was slightly but significantly worse among those randomized to opioids,” reported Dr. Smith. “There was no difference in patient function, but there was an increased risk of adverse events.”

In the SPACE study, 240 patients with moderate to severe chronic back pain or hip or knee osteoarthritis were randomized to opioid or nonopioid pain management. In the nonopioid group, the first therapeutic step was acetaminophen, but medications could be changed, added, or adjusted within both groups to improve patient response.

At the end of 12 months, a lack of benefit on both pain control and functional improvement from opioids relative to nonopioid treatment was accompanied by a higher rate of adverse effects. This led the authors to conclude that opioids are not supported for musculoskeletal pain.

Not all the evidence argues against opioids for noncancer pain management, according to Dr. Smith, but he emphasized that those who support use of opioids do so for pain control only. They do not confirm an advantage for function and quality of life, which he suggested are the key endpoints. For example, a 2010 Cochrane review concluded from a systematic literature review that there is “weak evidence” for pain relief but inconclusive evidence of an improvement in functioning and quality of life.

Other investigators have drawn the same conclusion, according to Dr. Smith. He cited a statement from the International Association for Study of Pain that advises, “Caution should be used for prescribing opioids for chronic pain.” Although this statement was not specific to musculoskeletal pain, the IASP does specify that pain medications should be employed “to promote increased function and improved quality of life rather than complete relief of pain,” according to Dr. Smith.

Opioid prescriptions for chronic pain have been increasing in Europe as they have in the United States, but Dr. Smith indicated that opioids, if used at all, should be prescribed for very short periods and for very specific goals, particularly improvement in function.

“Probably most important for my [primary care] colleagues, patients prescribed opioids should be evaluated early and frequently to gauge benefit,” Dr. Smith said. Although he believes pain control is an important and worthwhile goal, it must be approached within the context of improved well-being rather than as an isolated endpoint.
 

SOURCE: Smith B et al. EULAR 2018, Abstract No. SP0073.

What will be the role of humans in the future health system?

At first blush, this is a peculiar question. Health care is all about humans. How could one doubt their presence or role? It is working with and for people that attracted many to this profession.

On the cusp of a significant health system reformulation, it is the very question that hospitalists now must ponder. Just as ATMs replaced bank cashiers, online shopping replaced retail stores, and autonomous cars will soon replace drivers, the human landscape of health care is about to change. What pressures will force the changes?

Hospitalist insight needed

What is the role of hospitalist leaders in this shifting equation? Hospitalists already can claim significant credit for introducing major changes in the landscape of hospital care in this country, with all the concomitant improvements in the efficiencies and quality of more integrated service delivery. Can you also guide the system in strategically selecting where and how technology can best be applied to automate and reconfigure service delivery?

The most important questions are: What is it that humans in health care uniquely do that cannot otherwise be accomplished? Are we able to hold onto the humane sides of health care, even as we seek to introduce cost-saving efficiencies?

Top of mind come the most personal sides of health service delivery: touch, empathy, understanding, and care itself. Next come human analysis, understanding, and translation. And beyond that, leadership, direction, and the vision to craft a health care system that meets our societal expectations – not just for the wealthy who cannot afford it – but for everyone.

It would be easy to dismiss this conversation. Society never decided whether those bank tellers, travel agents, or journalists were critical to our functioning. Along these same lines, you and your patients are more than mere algorithms.

As I often share in my leadership seminars, one key function of leaders is to identify and ask the right questions and to be at the decision-making table. What are those questions?

As a hospitalist leader, which part of your work and your activities could be eased by automation? Where might technology ease pressures and enhance your interactions with patients? How do we improve the efficiencies and effectiveness of health service delivery while we preserve the very human qualities that are fundamental to its values? No patient wants to speak to a physician who stares at a computer screen without eye contact, reassurance, or genuine interest. We can do better than that.

Business stakeholders in the system – and clearly, they are positioning and are powerful – will hold great sway on the contours of our future health care system. They could see humans – with all their costs, imperfections, and distractions – as replaceable.

Know that as you lead and pose your questions, there are people interested in listening. Certainly, the tech industry is looking for opportunities to generate broad market appeal. Similarly, health system decision makers looking to enhance how the system functions likewise seek guidance on what could – and could not – work. And who knows: Those decision makers could very well be you.

This is a conversation the country deserves. There is nothing more intimate, more personally important, and more professionally satisfying than the genuine person-to-person quality of what we do in health care. What we arrive at in the end should be achieved by intent, not by accident.
 

Dr. Marcus is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” 2nd ed. (San Francisco: Jossey-Bass Publishers, 2011) and is director of the program for health care negotiation and conflict resolution, Harvard T.H. Chan School of Public Health, Boston. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].

What will be the role of humans in the future health system?

At first blush, this is a peculiar question. Health care is all about humans. How could one doubt their presence or role? It is working with and for people that attracted many to this profession.

On the cusp of a significant health system reformulation, it is the very question that hospitalists now must ponder. Just as ATMs replaced bank cashiers, online shopping replaced retail stores, and autonomous cars will soon replace drivers, the human landscape of health care is about to change. What pressures will force the changes?

Hospitalist insight needed

What is the role of hospitalist leaders in this shifting equation? Hospitalists already can claim significant credit for introducing major changes in the landscape of hospital care in this country, with all the concomitant improvements in the efficiencies and quality of more integrated service delivery. Can you also guide the system in strategically selecting where and how technology can best be applied to automate and reconfigure service delivery?

The most important questions are: What is it that humans in health care uniquely do that cannot otherwise be accomplished? Are we able to hold onto the humane sides of health care, even as we seek to introduce cost-saving efficiencies?

Top of mind come the most personal sides of health service delivery: touch, empathy, understanding, and care itself. Next come human analysis, understanding, and translation. And beyond that, leadership, direction, and the vision to craft a health care system that meets our societal expectations – not just for the wealthy who cannot afford it – but for everyone.

It would be easy to dismiss this conversation. Society never decided whether those bank tellers, travel agents, or journalists were critical to our functioning. Along these same lines, you and your patients are more than mere algorithms.

As I often share in my leadership seminars, one key function of leaders is to identify and ask the right questions and to be at the decision-making table. What are those questions?

As a hospitalist leader, which part of your work and your activities could be eased by automation? Where might technology ease pressures and enhance your interactions with patients? How do we improve the efficiencies and effectiveness of health service delivery while we preserve the very human qualities that are fundamental to its values? No patient wants to speak to a physician who stares at a computer screen without eye contact, reassurance, or genuine interest. We can do better than that.

Business stakeholders in the system – and clearly, they are positioning and are powerful – will hold great sway on the contours of our future health care system. They could see humans – with all their costs, imperfections, and distractions – as replaceable.

Know that as you lead and pose your questions, there are people interested in listening. Certainly, the tech industry is looking for opportunities to generate broad market appeal. Similarly, health system decision makers looking to enhance how the system functions likewise seek guidance on what could – and could not – work. And who knows: Those decision makers could very well be you.

This is a conversation the country deserves. There is nothing more intimate, more personally important, and more professionally satisfying than the genuine person-to-person quality of what we do in health care. What we arrive at in the end should be achieved by intent, not by accident.
 

Dr. Marcus is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” 2nd ed. (San Francisco: Jossey-Bass Publishers, 2011) and is director of the program for health care negotiation and conflict resolution, Harvard T.H. Chan School of Public Health, Boston. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].

What will be the role of humans in the future health system?

At first blush, this is a peculiar question. Health care is all about humans. How could one doubt their presence or role? It is working with and for people that attracted many to this profession.

On the cusp of a significant health system reformulation, it is the very question that hospitalists now must ponder. Just as ATMs replaced bank cashiers, online shopping replaced retail stores, and autonomous cars will soon replace drivers, the human landscape of health care is about to change. What pressures will force the changes?

Hospitalist insight needed

What is the role of hospitalist leaders in this shifting equation? Hospitalists already can claim significant credit for introducing major changes in the landscape of hospital care in this country, with all the concomitant improvements in the efficiencies and quality of more integrated service delivery. Can you also guide the system in strategically selecting where and how technology can best be applied to automate and reconfigure service delivery?

The most important questions are: What is it that humans in health care uniquely do that cannot otherwise be accomplished? Are we able to hold onto the humane sides of health care, even as we seek to introduce cost-saving efficiencies?

Top of mind come the most personal sides of health service delivery: touch, empathy, understanding, and care itself. Next come human analysis, understanding, and translation. And beyond that, leadership, direction, and the vision to craft a health care system that meets our societal expectations – not just for the wealthy who cannot afford it – but for everyone.

It would be easy to dismiss this conversation. Society never decided whether those bank tellers, travel agents, or journalists were critical to our functioning. Along these same lines, you and your patients are more than mere algorithms.

As I often share in my leadership seminars, one key function of leaders is to identify and ask the right questions and to be at the decision-making table. What are those questions?

As a hospitalist leader, which part of your work and your activities could be eased by automation? Where might technology ease pressures and enhance your interactions with patients? How do we improve the efficiencies and effectiveness of health service delivery while we preserve the very human qualities that are fundamental to its values? No patient wants to speak to a physician who stares at a computer screen without eye contact, reassurance, or genuine interest. We can do better than that.

Business stakeholders in the system – and clearly, they are positioning and are powerful – will hold great sway on the contours of our future health care system. They could see humans – with all their costs, imperfections, and distractions – as replaceable.

Know that as you lead and pose your questions, there are people interested in listening. Certainly, the tech industry is looking for opportunities to generate broad market appeal. Similarly, health system decision makers looking to enhance how the system functions likewise seek guidance on what could – and could not – work. And who knows: Those decision makers could very well be you.

This is a conversation the country deserves. There is nothing more intimate, more personally important, and more professionally satisfying than the genuine person-to-person quality of what we do in health care. What we arrive at in the end should be achieved by intent, not by accident.
 

Dr. Marcus is coauthor of “Renegotiating Health Care: Resolving Conflict to Build Collaboration,” 2nd ed. (San Francisco: Jossey-Bass Publishers, 2011) and is director of the program for health care negotiation and conflict resolution, Harvard T.H. Chan School of Public Health, Boston. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].

Eleven children died from exposure to buprenorphine – a drug used to treat opioid exposure – from 2007 to 2016, mostly very young children who accidentally ingested the drug.

Four deaths, however, were teens who took buprenorphine recreationally or used it in a suicide attempt, according to a new database review by Sara Post, MS, of the Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, and her associates.

Fuse/thinkstockphotos.com

[email protected]

SOURCE: Post et al. Pediatrics. 2018;142:e20173652.

Eleven children died from exposure to buprenorphine – a drug used to treat opioid exposure – from 2007 to 2016, mostly very young children who accidentally ingested the drug.

Four deaths, however, were teens who took buprenorphine recreationally or used it in a suicide attempt, according to a new database review by Sara Post, MS, of the Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, and her associates.

Fuse/thinkstockphotos.com

[email protected]

SOURCE: Post et al. Pediatrics. 2018;142:e20173652.

Eleven children died from exposure to buprenorphine – a drug used to treat opioid exposure – from 2007 to 2016, mostly very young children who accidentally ingested the drug.

Four deaths, however, were teens who took buprenorphine recreationally or used it in a suicide attempt, according to a new database review by Sara Post, MS, of the Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, and her associates.

Fuse/thinkstockphotos.com

[email protected]

SOURCE: Post et al. Pediatrics. 2018;142:e20173652.