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While U.S. heart failure readmissions fall, deaths rise
DALLAS – U.S. hospitals have recently shown a consistent and disturbing disconnect between reductions in their heart failure hospital readmission rates and heart failure mortality. Readmissions have dropped while mortality has risen.
“Despite reductions in 30-day heart failure readmissions in 89% of U.S. hospitals” during 2009-2016, “30-day heart failure mortality rates increased at 73%* of these ‘successful’ hospitals” during the same period,” Ahmad A. Abdul-Aziz, MD, said at the annual scientific meeting of the Heart Failure Society of America.
These shifts in the outcomes of U.S. patients hospitalized for acute heart failure episodes are tied to the penalties that the Centers for Medicare & Medicaid Services began slapping on hospitals in 2013 for excess 30-day readmissions for heart failure patients and in 2014 for excess mortality. A problem with these two CMS programs is that the penalty on inferior readmissions performance is a lot stiffer than for excess mortality, Dr. Aziz noted: a 0.2% penalty on payments for high mortality, compared with a 3% penalty for excess readmissions, a disparity that can make hospitals focus more on the readmissions side, he suggested.
Dr. Aziz’s report isn’t the first to make this observation. Study results published earlier in 2017 used CMS Medicare data from 2008 to 2014 to show that during that period, heart failure 30-day mortality rates following hospital discharge rose by 1.3%, while 30-day readmissions fell by 2.1% (JAMA. 2017 July 18;318[3]:270-8). On the basis of these numbers, as many as 5,200 additional deaths to U.S. heart failure patients in 2014 “may be related to the Hospital Readmission Reduction Program” of CMS, Gregg C. Fonarow, MD, said during a separate talk at the meeting.
The analysis reported by Dr. Aziz included data from 3,265 U.S. hospitals for heart failure patients, and data from 1,621 hospitals that managed patients with acute MIs, another disease that the CMS has targeted for penalties based on 30-day readmissions and 30-day postdischarge mortality rates. During the 8-year period studied, heart failure 30-day readmissions fell by 2.2% while 30-day mortality rose by 1%. In contrast, among acute MI patients, readmissions fell by 3% and mortality also fell, by 2.2%, Dr. Abdul-Aziz reported.
Dr. Abdul-Aziz had no disclosures. Dr. Fonarow had been a consultant to Amgen, Janssen, Medtronic, Novartis, St. Jude, and ZS Pharma.
[email protected]
On Twitter @mitchelzoler
*This article was updated October 5, 2017
My colleagues and I have seen in results from recent trials a changing relationship between heart failure mortality and heart failure hospitalization. In the United States in particular, where penalties exist for high rates of hospital readmissions for heart failure, we are seeing more patients treated as outpatients and we see that these “outpatient” events are associated with the same risk for subsequent mortality as we had previously seen for heart failure hospitalization.
It may be that we are keeping patients out of the hospital to avoid a financial ding, but perhaps we are keeping out patients who really should be hospitalized.
What we have begun doing in trials is to look not just at hospitalizations but also consider the incidence of other heart failure events, such as patients treated for heart failure symptoms with an intravenous diuretic in the emergency department and patients who are kept in observation rooms and are not admitted. It’s not the same as a heart failure hospitalization, but some trials are now including these other heart failure events in their primary endpoint.
Scott D. Solomon, MD, professor of medicine at Harvard Medical School and director of noninvasive cardiology at Brigham and Women’s Hospital in Boston, made these comments as chair of the session where Dr. Aziz gave his report and in an interview. He has been a consultant to and/or received research support from Alnylam, Amgen, AstraZeneca, Bristol-Myers Squibb, Cytokinetics, GlaxoSmithKline, Ionis, Merck, Novartis, and Sanofi.
My colleagues and I have seen in results from recent trials a changing relationship between heart failure mortality and heart failure hospitalization. In the United States in particular, where penalties exist for high rates of hospital readmissions for heart failure, we are seeing more patients treated as outpatients and we see that these “outpatient” events are associated with the same risk for subsequent mortality as we had previously seen for heart failure hospitalization.
It may be that we are keeping patients out of the hospital to avoid a financial ding, but perhaps we are keeping out patients who really should be hospitalized.
What we have begun doing in trials is to look not just at hospitalizations but also consider the incidence of other heart failure events, such as patients treated for heart failure symptoms with an intravenous diuretic in the emergency department and patients who are kept in observation rooms and are not admitted. It’s not the same as a heart failure hospitalization, but some trials are now including these other heart failure events in their primary endpoint.
Scott D. Solomon, MD, professor of medicine at Harvard Medical School and director of noninvasive cardiology at Brigham and Women’s Hospital in Boston, made these comments as chair of the session where Dr. Aziz gave his report and in an interview. He has been a consultant to and/or received research support from Alnylam, Amgen, AstraZeneca, Bristol-Myers Squibb, Cytokinetics, GlaxoSmithKline, Ionis, Merck, Novartis, and Sanofi.
My colleagues and I have seen in results from recent trials a changing relationship between heart failure mortality and heart failure hospitalization. In the United States in particular, where penalties exist for high rates of hospital readmissions for heart failure, we are seeing more patients treated as outpatients and we see that these “outpatient” events are associated with the same risk for subsequent mortality as we had previously seen for heart failure hospitalization.
It may be that we are keeping patients out of the hospital to avoid a financial ding, but perhaps we are keeping out patients who really should be hospitalized.
What we have begun doing in trials is to look not just at hospitalizations but also consider the incidence of other heart failure events, such as patients treated for heart failure symptoms with an intravenous diuretic in the emergency department and patients who are kept in observation rooms and are not admitted. It’s not the same as a heart failure hospitalization, but some trials are now including these other heart failure events in their primary endpoint.
Scott D. Solomon, MD, professor of medicine at Harvard Medical School and director of noninvasive cardiology at Brigham and Women’s Hospital in Boston, made these comments as chair of the session where Dr. Aziz gave his report and in an interview. He has been a consultant to and/or received research support from Alnylam, Amgen, AstraZeneca, Bristol-Myers Squibb, Cytokinetics, GlaxoSmithKline, Ionis, Merck, Novartis, and Sanofi.
DALLAS – U.S. hospitals have recently shown a consistent and disturbing disconnect between reductions in their heart failure hospital readmission rates and heart failure mortality. Readmissions have dropped while mortality has risen.
“Despite reductions in 30-day heart failure readmissions in 89% of U.S. hospitals” during 2009-2016, “30-day heart failure mortality rates increased at 73%* of these ‘successful’ hospitals” during the same period,” Ahmad A. Abdul-Aziz, MD, said at the annual scientific meeting of the Heart Failure Society of America.
These shifts in the outcomes of U.S. patients hospitalized for acute heart failure episodes are tied to the penalties that the Centers for Medicare & Medicaid Services began slapping on hospitals in 2013 for excess 30-day readmissions for heart failure patients and in 2014 for excess mortality. A problem with these two CMS programs is that the penalty on inferior readmissions performance is a lot stiffer than for excess mortality, Dr. Aziz noted: a 0.2% penalty on payments for high mortality, compared with a 3% penalty for excess readmissions, a disparity that can make hospitals focus more on the readmissions side, he suggested.
Dr. Aziz’s report isn’t the first to make this observation. Study results published earlier in 2017 used CMS Medicare data from 2008 to 2014 to show that during that period, heart failure 30-day mortality rates following hospital discharge rose by 1.3%, while 30-day readmissions fell by 2.1% (JAMA. 2017 July 18;318[3]:270-8). On the basis of these numbers, as many as 5,200 additional deaths to U.S. heart failure patients in 2014 “may be related to the Hospital Readmission Reduction Program” of CMS, Gregg C. Fonarow, MD, said during a separate talk at the meeting.
The analysis reported by Dr. Aziz included data from 3,265 U.S. hospitals for heart failure patients, and data from 1,621 hospitals that managed patients with acute MIs, another disease that the CMS has targeted for penalties based on 30-day readmissions and 30-day postdischarge mortality rates. During the 8-year period studied, heart failure 30-day readmissions fell by 2.2% while 30-day mortality rose by 1%. In contrast, among acute MI patients, readmissions fell by 3% and mortality also fell, by 2.2%, Dr. Abdul-Aziz reported.
Dr. Abdul-Aziz had no disclosures. Dr. Fonarow had been a consultant to Amgen, Janssen, Medtronic, Novartis, St. Jude, and ZS Pharma.
[email protected]
On Twitter @mitchelzoler
*This article was updated October 5, 2017
DALLAS – U.S. hospitals have recently shown a consistent and disturbing disconnect between reductions in their heart failure hospital readmission rates and heart failure mortality. Readmissions have dropped while mortality has risen.
“Despite reductions in 30-day heart failure readmissions in 89% of U.S. hospitals” during 2009-2016, “30-day heart failure mortality rates increased at 73%* of these ‘successful’ hospitals” during the same period,” Ahmad A. Abdul-Aziz, MD, said at the annual scientific meeting of the Heart Failure Society of America.
These shifts in the outcomes of U.S. patients hospitalized for acute heart failure episodes are tied to the penalties that the Centers for Medicare & Medicaid Services began slapping on hospitals in 2013 for excess 30-day readmissions for heart failure patients and in 2014 for excess mortality. A problem with these two CMS programs is that the penalty on inferior readmissions performance is a lot stiffer than for excess mortality, Dr. Aziz noted: a 0.2% penalty on payments for high mortality, compared with a 3% penalty for excess readmissions, a disparity that can make hospitals focus more on the readmissions side, he suggested.
Dr. Aziz’s report isn’t the first to make this observation. Study results published earlier in 2017 used CMS Medicare data from 2008 to 2014 to show that during that period, heart failure 30-day mortality rates following hospital discharge rose by 1.3%, while 30-day readmissions fell by 2.1% (JAMA. 2017 July 18;318[3]:270-8). On the basis of these numbers, as many as 5,200 additional deaths to U.S. heart failure patients in 2014 “may be related to the Hospital Readmission Reduction Program” of CMS, Gregg C. Fonarow, MD, said during a separate talk at the meeting.
The analysis reported by Dr. Aziz included data from 3,265 U.S. hospitals for heart failure patients, and data from 1,621 hospitals that managed patients with acute MIs, another disease that the CMS has targeted for penalties based on 30-day readmissions and 30-day postdischarge mortality rates. During the 8-year period studied, heart failure 30-day readmissions fell by 2.2% while 30-day mortality rose by 1%. In contrast, among acute MI patients, readmissions fell by 3% and mortality also fell, by 2.2%, Dr. Abdul-Aziz reported.
Dr. Abdul-Aziz had no disclosures. Dr. Fonarow had been a consultant to Amgen, Janssen, Medtronic, Novartis, St. Jude, and ZS Pharma.
[email protected]
On Twitter @mitchelzoler
*This article was updated October 5, 2017
AT THE HFSA ANNUAL SCIENTIFIC MEETING
Key clinical point:
Major finding: From 2009 to 2016, U.S. 30-day heart failure readmissions fell by 2.2% while 30-day heart failure mortality rose by 1%.
Data source: Review of Medicare data for 3,265 U.S. hospitals managing heart failure patients.
Disclosures: Dr. Abdul-Aziz had no disclosures. Dr. Fonarow had been a consultant to Amgen, Janssen, Medtronic, Novartis, St. Jude, and ZS Pharma.
Sneak Peek: Journal of Hospital Medicine – Sept. 2017
BACKGROUND: Patient preferences regarding cardiopulmonary resuscitation (CPR) are important, especially during hospitalization when a patient’s health is changing, yet many patients are not adequately informed or involved in the decision-making process.
OBJECTIVES: We examined the effect of an informational video about CPR on hospitalized patients’ code status choices.
DESIGN: This was a prospective, randomized trial conducted at the Veteran’s Affairs Hospital in Minneapolis.
PARTICIPANTS: We enrolled 119 patients who were hospitalized on the general medicine service and at least 65 years old. The majority were men (97%) with a mean age of 75.
INTERVENTION: A video described code status choices: full code (CPR and intubation if required), do not resuscitate (DNR), and do not resuscitate/do not intubate (DNR/DNI). Participants were randomized to watch the video (n = 59) or usual care (n = 60).
MEASUREMENTS: The primary outcome was participants’ code status preferences. Secondary outcomes included a questionnaire designed to evaluate participants’ trust in their health care team and their knowledge and perceptions about CPR.
RESULTS: Participants who viewed the video were less likely to choose full code (37%), compared with participants in the usual-care group (71%), and were more likely to choose DNR/DNI (56% in the video group vs. 17% in the control group) (P < .00001). We did not see a difference in trust in their health care team or knowledge and perceptions about CPR as assessed by our questionnaire.
CONCLUSIONS: Hospitalized patients who watched a video about CPR and code status choices were less likely to choose full code and more likely to choose DNR/DNI.
Also in JHM this month
Influenza season hospitalization trends in Israel: A multi-year comparative analysis 2005/2006 through 2012/2013
AUTHORS: Aharona Glatman-Freedman, MD, MPH, Zalman Kaufman, MS, Yaniv Stein, BS, Hanna Sefty, MS, Hila Zadka, PhD, Barak Gordon, MD, MHA, Jill Meron, BSc, Ethel-Sherry Gordon, PhD, Rita Dichtiar, BSc, Ziona Haklai, MSc, Arnon Afek, MD, Tamy Shohat, MD, MPH
Appropriate reconciliation of cardiovascular medications after elective surgery and postdischarge acute hospital and ambulatory visits
AUTHORS: Jonathan S. Lee, MD, Ralph Gonzales, MD, MSPH, Eric Vittinghoff, PhD, Kitty K. Corbett, PhD, MPH, Kirsten E. Fleischmann, MD, Neil Sehgal, MD, MPH, Andrew D. Auerbach, MD, MPH
Patterns and appropriateness of thrombophilia testing in an academic medical center
AUTHORS: Nicholas Cox, PharmD, Stacy A. Johnson, MD, Sara Vazquez, PharmD, Ryan P. Fleming, PharmD, BCPS, Matthew T. Rondina, MD, David Kaplan, MD, Stephanie Chauv, PharmD, Gabriel V. Fontaine, PharmD, Scott M. Stevens, MD, Scott Woller, MD, Daniel M. Witt, PharmD, BCPS, FCCP
National trends (2007-2013) of Clostridium difficile infection in patients with septic shock: Impact on outcome
AUTHORS: Kshitij Chatterjee, MD, Abhinav Goyal, MD, Aditya Chada, MD, Krishna Siva Sai Kakkera, MD, Howard L Corwin, MD
Blood products provided to patients receiving inappropriate critical care
AUTHORS: Thanh H. Neville, MD, MSHS, Alyssa Ziman, MD, Neil S. Wenger, MD, MPH
BACKGROUND: Patient preferences regarding cardiopulmonary resuscitation (CPR) are important, especially during hospitalization when a patient’s health is changing, yet many patients are not adequately informed or involved in the decision-making process.
OBJECTIVES: We examined the effect of an informational video about CPR on hospitalized patients’ code status choices.
DESIGN: This was a prospective, randomized trial conducted at the Veteran’s Affairs Hospital in Minneapolis.
PARTICIPANTS: We enrolled 119 patients who were hospitalized on the general medicine service and at least 65 years old. The majority were men (97%) with a mean age of 75.
INTERVENTION: A video described code status choices: full code (CPR and intubation if required), do not resuscitate (DNR), and do not resuscitate/do not intubate (DNR/DNI). Participants were randomized to watch the video (n = 59) or usual care (n = 60).
MEASUREMENTS: The primary outcome was participants’ code status preferences. Secondary outcomes included a questionnaire designed to evaluate participants’ trust in their health care team and their knowledge and perceptions about CPR.
RESULTS: Participants who viewed the video were less likely to choose full code (37%), compared with participants in the usual-care group (71%), and were more likely to choose DNR/DNI (56% in the video group vs. 17% in the control group) (P < .00001). We did not see a difference in trust in their health care team or knowledge and perceptions about CPR as assessed by our questionnaire.
CONCLUSIONS: Hospitalized patients who watched a video about CPR and code status choices were less likely to choose full code and more likely to choose DNR/DNI.
Also in JHM this month
Influenza season hospitalization trends in Israel: A multi-year comparative analysis 2005/2006 through 2012/2013
AUTHORS: Aharona Glatman-Freedman, MD, MPH, Zalman Kaufman, MS, Yaniv Stein, BS, Hanna Sefty, MS, Hila Zadka, PhD, Barak Gordon, MD, MHA, Jill Meron, BSc, Ethel-Sherry Gordon, PhD, Rita Dichtiar, BSc, Ziona Haklai, MSc, Arnon Afek, MD, Tamy Shohat, MD, MPH
Appropriate reconciliation of cardiovascular medications after elective surgery and postdischarge acute hospital and ambulatory visits
AUTHORS: Jonathan S. Lee, MD, Ralph Gonzales, MD, MSPH, Eric Vittinghoff, PhD, Kitty K. Corbett, PhD, MPH, Kirsten E. Fleischmann, MD, Neil Sehgal, MD, MPH, Andrew D. Auerbach, MD, MPH
Patterns and appropriateness of thrombophilia testing in an academic medical center
AUTHORS: Nicholas Cox, PharmD, Stacy A. Johnson, MD, Sara Vazquez, PharmD, Ryan P. Fleming, PharmD, BCPS, Matthew T. Rondina, MD, David Kaplan, MD, Stephanie Chauv, PharmD, Gabriel V. Fontaine, PharmD, Scott M. Stevens, MD, Scott Woller, MD, Daniel M. Witt, PharmD, BCPS, FCCP
National trends (2007-2013) of Clostridium difficile infection in patients with septic shock: Impact on outcome
AUTHORS: Kshitij Chatterjee, MD, Abhinav Goyal, MD, Aditya Chada, MD, Krishna Siva Sai Kakkera, MD, Howard L Corwin, MD
Blood products provided to patients receiving inappropriate critical care
AUTHORS: Thanh H. Neville, MD, MSHS, Alyssa Ziman, MD, Neil S. Wenger, MD, MPH
BACKGROUND: Patient preferences regarding cardiopulmonary resuscitation (CPR) are important, especially during hospitalization when a patient’s health is changing, yet many patients are not adequately informed or involved in the decision-making process.
OBJECTIVES: We examined the effect of an informational video about CPR on hospitalized patients’ code status choices.
DESIGN: This was a prospective, randomized trial conducted at the Veteran’s Affairs Hospital in Minneapolis.
PARTICIPANTS: We enrolled 119 patients who were hospitalized on the general medicine service and at least 65 years old. The majority were men (97%) with a mean age of 75.
INTERVENTION: A video described code status choices: full code (CPR and intubation if required), do not resuscitate (DNR), and do not resuscitate/do not intubate (DNR/DNI). Participants were randomized to watch the video (n = 59) or usual care (n = 60).
MEASUREMENTS: The primary outcome was participants’ code status preferences. Secondary outcomes included a questionnaire designed to evaluate participants’ trust in their health care team and their knowledge and perceptions about CPR.
RESULTS: Participants who viewed the video were less likely to choose full code (37%), compared with participants in the usual-care group (71%), and were more likely to choose DNR/DNI (56% in the video group vs. 17% in the control group) (P < .00001). We did not see a difference in trust in their health care team or knowledge and perceptions about CPR as assessed by our questionnaire.
CONCLUSIONS: Hospitalized patients who watched a video about CPR and code status choices were less likely to choose full code and more likely to choose DNR/DNI.
Also in JHM this month
Influenza season hospitalization trends in Israel: A multi-year comparative analysis 2005/2006 through 2012/2013
AUTHORS: Aharona Glatman-Freedman, MD, MPH, Zalman Kaufman, MS, Yaniv Stein, BS, Hanna Sefty, MS, Hila Zadka, PhD, Barak Gordon, MD, MHA, Jill Meron, BSc, Ethel-Sherry Gordon, PhD, Rita Dichtiar, BSc, Ziona Haklai, MSc, Arnon Afek, MD, Tamy Shohat, MD, MPH
Appropriate reconciliation of cardiovascular medications after elective surgery and postdischarge acute hospital and ambulatory visits
AUTHORS: Jonathan S. Lee, MD, Ralph Gonzales, MD, MSPH, Eric Vittinghoff, PhD, Kitty K. Corbett, PhD, MPH, Kirsten E. Fleischmann, MD, Neil Sehgal, MD, MPH, Andrew D. Auerbach, MD, MPH
Patterns and appropriateness of thrombophilia testing in an academic medical center
AUTHORS: Nicholas Cox, PharmD, Stacy A. Johnson, MD, Sara Vazquez, PharmD, Ryan P. Fleming, PharmD, BCPS, Matthew T. Rondina, MD, David Kaplan, MD, Stephanie Chauv, PharmD, Gabriel V. Fontaine, PharmD, Scott M. Stevens, MD, Scott Woller, MD, Daniel M. Witt, PharmD, BCPS, FCCP
National trends (2007-2013) of Clostridium difficile infection in patients with septic shock: Impact on outcome
AUTHORS: Kshitij Chatterjee, MD, Abhinav Goyal, MD, Aditya Chada, MD, Krishna Siva Sai Kakkera, MD, Howard L Corwin, MD
Blood products provided to patients receiving inappropriate critical care
AUTHORS: Thanh H. Neville, MD, MSHS, Alyssa Ziman, MD, Neil S. Wenger, MD, MPH
VIDEO: Educational intervention boosts A fib anticoagulation
BARCELONA – A program promoting broader anticoagulation of patients with atrial fibrillation that used education and feedback from practice audits produced a substantial increase in sustained anticoagulant use and cut strokes in a multinational study with almost 2,300 patients in 48 practices.
Among atrial fibrillation (AF) patients who were not on an anticoagulant at baseline (34% of the enrolled group) 48% of patients in the intervention group began anticoagulant treatment and remained on it for a year with intervention compared with 18% of patients in the control arm without the intervention, Christopher B. Granger, MD, said at the annual congress of the European Society of Cardiology.
The intervention, which highlighted to health care providers the opportunity to start their AF patients on anticoagulant treatment, “transforms how care is provided to this population” of AF patients, Dr. Granger said in a video interview. “Doing something like this can have enormous public health implications.”
IMPACT AF (The Clinical Trial to Improve Treatment With Blood Thinners in Patients With Atrial Fibrillation) randomized 2,281 AF patients in 48 practices in five middle-income countries: Argentina, Brazil, China, India, and Romania. Randomization was by practice, and patients were assigned to either usual care or to an intervention that ran educational sessions for patients and providers on the benefits of and best practices for using anticoagulants. The intervention also monitored anticoagulant use by the patients in each practice and gave providers case-by-case feedback on the care patients received. The educational component customized the feedback to focus on overcoming treatment barriers specific for each patient. This audit and feedback process was a key part of the intervention, Dr. Granger said.
In an adjusted analysis, among patients not on an anticoagulant at baseline, the ones managed in practices that received the intervention had a greater than fourfold likelihood of receiving anticoagulant treatment, compared with patients in practices with no intervention. The intervention was especially successful in transitioning patients off of aspirin treatment, considered ineffective for AF stroke prevention, and onto an anticoagulant, most commonly warfarin.
Overall, anticoagulant use rose by 12 percentage points from baseline among patients in the intervention practices and by 3 percentage points over baseline among the control patients, a statistically significant difference for the study’s primary endpoint.
During 1-year follow-up, 11 strokes occurred among patients managed in practices that received the intervention and 21 in those in control practices, a 52% relative hazard reduction linked with the intervention that was statistically significant, Dr. Granger reported. Concurrently with his talk, the results also appeared online (Lancet. 2017. doi: 10.1016/S0140-6736[17]32165-7).
“How will we take what we have learned [in IMPACT AF] and have it available to people who want to replicate this?” asked Dr. Granger. “We have partnered with several national cardiology societies, and we are working with them to optimize the tools and provide the tools we’ve used,” he said. “We will develop a website for people who want to take this information and use it in their practices.” Dr. Granger and his associates also are working with the Food and Drug Administration and other groups to come up with interventions specially designed for U.S. practice.
IMPACT AF received partial funding from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, and Pfizer. Dr. Granger has received honoraria and research funding from all of these companies, and also from Janssen and Medtronic.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
IMPACT AF is an important study, with impressive results that confirm the value of integrated atrial fibrillation care. In the study, a comprehensive and continuous educational intervention with 11 distinct components aimed at health care professionals and patients increased the initiation of and adherence to oral anticoagulation in patients with AF. This effect linked with a significantly reduced incidence of strokes.
Digital tools are an important part of the intervention. They provide both information and feedback, and they create a platform that can involve all stakeholders in management of atrial fibrillation. Informing AF patients about their treatment can result in patients who take responsibility for their management. Integrated AF management models can improve continued delivery of chronic care.
Paulus Kirchhof, MD , is a professor and deputy director of the Institute of Cardiovascular Sciences at the University of Birmingham, England. He has received honoraria and research funding from several drug companies. He made these comments as designated discussant for the report.
IMPACT AF is an important study, with impressive results that confirm the value of integrated atrial fibrillation care. In the study, a comprehensive and continuous educational intervention with 11 distinct components aimed at health care professionals and patients increased the initiation of and adherence to oral anticoagulation in patients with AF. This effect linked with a significantly reduced incidence of strokes.
Digital tools are an important part of the intervention. They provide both information and feedback, and they create a platform that can involve all stakeholders in management of atrial fibrillation. Informing AF patients about their treatment can result in patients who take responsibility for their management. Integrated AF management models can improve continued delivery of chronic care.
Paulus Kirchhof, MD , is a professor and deputy director of the Institute of Cardiovascular Sciences at the University of Birmingham, England. He has received honoraria and research funding from several drug companies. He made these comments as designated discussant for the report.
IMPACT AF is an important study, with impressive results that confirm the value of integrated atrial fibrillation care. In the study, a comprehensive and continuous educational intervention with 11 distinct components aimed at health care professionals and patients increased the initiation of and adherence to oral anticoagulation in patients with AF. This effect linked with a significantly reduced incidence of strokes.
Digital tools are an important part of the intervention. They provide both information and feedback, and they create a platform that can involve all stakeholders in management of atrial fibrillation. Informing AF patients about their treatment can result in patients who take responsibility for their management. Integrated AF management models can improve continued delivery of chronic care.
Paulus Kirchhof, MD , is a professor and deputy director of the Institute of Cardiovascular Sciences at the University of Birmingham, England. He has received honoraria and research funding from several drug companies. He made these comments as designated discussant for the report.
BARCELONA – A program promoting broader anticoagulation of patients with atrial fibrillation that used education and feedback from practice audits produced a substantial increase in sustained anticoagulant use and cut strokes in a multinational study with almost 2,300 patients in 48 practices.
Among atrial fibrillation (AF) patients who were not on an anticoagulant at baseline (34% of the enrolled group) 48% of patients in the intervention group began anticoagulant treatment and remained on it for a year with intervention compared with 18% of patients in the control arm without the intervention, Christopher B. Granger, MD, said at the annual congress of the European Society of Cardiology.
The intervention, which highlighted to health care providers the opportunity to start their AF patients on anticoagulant treatment, “transforms how care is provided to this population” of AF patients, Dr. Granger said in a video interview. “Doing something like this can have enormous public health implications.”
IMPACT AF (The Clinical Trial to Improve Treatment With Blood Thinners in Patients With Atrial Fibrillation) randomized 2,281 AF patients in 48 practices in five middle-income countries: Argentina, Brazil, China, India, and Romania. Randomization was by practice, and patients were assigned to either usual care or to an intervention that ran educational sessions for patients and providers on the benefits of and best practices for using anticoagulants. The intervention also monitored anticoagulant use by the patients in each practice and gave providers case-by-case feedback on the care patients received. The educational component customized the feedback to focus on overcoming treatment barriers specific for each patient. This audit and feedback process was a key part of the intervention, Dr. Granger said.
In an adjusted analysis, among patients not on an anticoagulant at baseline, the ones managed in practices that received the intervention had a greater than fourfold likelihood of receiving anticoagulant treatment, compared with patients in practices with no intervention. The intervention was especially successful in transitioning patients off of aspirin treatment, considered ineffective for AF stroke prevention, and onto an anticoagulant, most commonly warfarin.
Overall, anticoagulant use rose by 12 percentage points from baseline among patients in the intervention practices and by 3 percentage points over baseline among the control patients, a statistically significant difference for the study’s primary endpoint.
During 1-year follow-up, 11 strokes occurred among patients managed in practices that received the intervention and 21 in those in control practices, a 52% relative hazard reduction linked with the intervention that was statistically significant, Dr. Granger reported. Concurrently with his talk, the results also appeared online (Lancet. 2017. doi: 10.1016/S0140-6736[17]32165-7).
“How will we take what we have learned [in IMPACT AF] and have it available to people who want to replicate this?” asked Dr. Granger. “We have partnered with several national cardiology societies, and we are working with them to optimize the tools and provide the tools we’ve used,” he said. “We will develop a website for people who want to take this information and use it in their practices.” Dr. Granger and his associates also are working with the Food and Drug Administration and other groups to come up with interventions specially designed for U.S. practice.
IMPACT AF received partial funding from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, and Pfizer. Dr. Granger has received honoraria and research funding from all of these companies, and also from Janssen and Medtronic.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @mitchelzoler
BARCELONA – A program promoting broader anticoagulation of patients with atrial fibrillation that used education and feedback from practice audits produced a substantial increase in sustained anticoagulant use and cut strokes in a multinational study with almost 2,300 patients in 48 practices.
Among atrial fibrillation (AF) patients who were not on an anticoagulant at baseline (34% of the enrolled group) 48% of patients in the intervention group began anticoagulant treatment and remained on it for a year with intervention compared with 18% of patients in the control arm without the intervention, Christopher B. Granger, MD, said at the annual congress of the European Society of Cardiology.
The intervention, which highlighted to health care providers the opportunity to start their AF patients on anticoagulant treatment, “transforms how care is provided to this population” of AF patients, Dr. Granger said in a video interview. “Doing something like this can have enormous public health implications.”
IMPACT AF (The Clinical Trial to Improve Treatment With Blood Thinners in Patients With Atrial Fibrillation) randomized 2,281 AF patients in 48 practices in five middle-income countries: Argentina, Brazil, China, India, and Romania. Randomization was by practice, and patients were assigned to either usual care or to an intervention that ran educational sessions for patients and providers on the benefits of and best practices for using anticoagulants. The intervention also monitored anticoagulant use by the patients in each practice and gave providers case-by-case feedback on the care patients received. The educational component customized the feedback to focus on overcoming treatment barriers specific for each patient. This audit and feedback process was a key part of the intervention, Dr. Granger said.
In an adjusted analysis, among patients not on an anticoagulant at baseline, the ones managed in practices that received the intervention had a greater than fourfold likelihood of receiving anticoagulant treatment, compared with patients in practices with no intervention. The intervention was especially successful in transitioning patients off of aspirin treatment, considered ineffective for AF stroke prevention, and onto an anticoagulant, most commonly warfarin.
Overall, anticoagulant use rose by 12 percentage points from baseline among patients in the intervention practices and by 3 percentage points over baseline among the control patients, a statistically significant difference for the study’s primary endpoint.
During 1-year follow-up, 11 strokes occurred among patients managed in practices that received the intervention and 21 in those in control practices, a 52% relative hazard reduction linked with the intervention that was statistically significant, Dr. Granger reported. Concurrently with his talk, the results also appeared online (Lancet. 2017. doi: 10.1016/S0140-6736[17]32165-7).
“How will we take what we have learned [in IMPACT AF] and have it available to people who want to replicate this?” asked Dr. Granger. “We have partnered with several national cardiology societies, and we are working with them to optimize the tools and provide the tools we’ve used,” he said. “We will develop a website for people who want to take this information and use it in their practices.” Dr. Granger and his associates also are working with the Food and Drug Administration and other groups to come up with interventions specially designed for U.S. practice.
IMPACT AF received partial funding from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, and Pfizer. Dr. Granger has received honoraria and research funding from all of these companies, and also from Janssen and Medtronic.
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AT THE ESC CONGRESS 2017
Key clinical point:
Major finding: Anticoagulation rose by 12 percentage points from baseline with intervention and by 3 percentage points among controls.
Data source: IMPACT AF, which randomized 2,281 AF patients for 1 year at 48 centers in five middle-income countries.
Disclosures: IMPACT AF received partial funding from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, and Pfizer. Dr. Granger has received honoraria and research funding from all of these companies, and also from Janssen and Medtronic.
Statins linked to lower death rates in COPD
Receiving a statin prescription within a year after diagnosis of chronic obstructive pulmonary disease was associated with a 21% decrease in the subsequent risk of all-cause mortality and a 45% drop in risk of pulmonary mortality, according to the results of a large retrospective administrative database study.
The findings belie those of the recent Simvastatin in the Prevention of COPD Exacerbation (STATCOPE) trial, in which daily simvastatin (40 mg) did not affect exacerbation rates or time to first exacerbation in high-risk COPD patients, wrote Adam Raymakers, MSc, a doctoral candidate at the University of British Columbia, Vancouver, and his associates. Their study was observational, but the association between statin use and decreased mortality “persisted across several measures of statin exposure,” they wrote. “Our findings, in conjunction with previously reported evidence, suggests that there may be a specific subtype of COPD patients that may benefit from statin use.” The study appears in the September issue of Chest (2017;152;486-93).
To further explore the question, the researchers analyzed linked health databases from nearly 40,000 patients aged 50 years and older who had received at least three prescriptions for an anticholinergic or a short-acting beta agonist in 12 months some time between 1998 and 2007. The first prescription was considered the date of COPD “diagnosis.” The average age of the patients was 71 years; 55% were female.
A total of 7,775 patients (19.6%) who met this definition of incident COPD were prescribed a statin at least once during the subsequent year. These patients had a significantly reduced risk of subsequent all-cause mortality in univariate and multivariate analyses, with hazard ratios of 0.79 (95% confidence intervals, 0.68 to 0.91; P less than .002). Statins also showed a protective effect against pulmonary mortality, with univariate and multivariate hazard ratios of 0.52 (P = .01) and 0.55 (P = .03), respectively.
The protective effect of statins held up when the investigators narrowed the exposure period to 6 months after COPD diagnosis and when they expanded it to 18 months. Exposure to statins for 80% of the 1-year window after COPD diagnosis – a proxy for statin adherence – also led to a reduced risk of all-cause mortality, but the 95% confidence interval for the hazard ratio did not reach statistical significance (0.71 to 1.01; P = .06).
The most common prescription was for atorvastatin (49%), usually for 90 days (23%), 100 days (20%), or 30 days (15%), the researchers said. While the “possibility of the ‘healthy user’ or the ‘healthy adherer’ cannot be ignored,” they adjusted for other prescriptions, comorbidities, and income level, which should have helped eliminate this effect, they added. However, they lacked data on smoking and lung function assessments, both of which are “important confounders and contributors to mortality,” they acknowledged.
Canadian Institutes of Health Research supported the study. One coinvestigator disclosed consulting relationships with Teva, Pfizer, and Novartis. The others had no conflicts of interest.
Despite [its] limitations, the study results are intriguing and in line with findings from other retrospective cohorts. How then can we reconcile the apparent benefits observed in retrospective studies with the lack of clinical effect seen in prospective trials, particularly the Simvastatin in the Prevention of COPD Exacerbation (STATCOPE) study? Could it be that both negative and positive studies are “correct”? Prospective studies have thus far not been adequately powered for mortality as an endpoint. Perhaps the choice of the particular statin matters? While STATCOPE involved simvastatin, the majority of the cohort reported by Raymakers et al. received atorvastatin. [Or perhaps] the negative results of STATCOPE could be related to careful selection of study participants with a low burden of systemic inflammation.
This most recent study reinforces the idea that statins may play a beneficial role in COPD, but it isn’t clear which patients to target for therapy. It is unlikely that the findings by Raymakers et al. will reverse recent recommendations by the American College of Chest Physicians and Canadian Thoracic Society against the use of statins for the purpose of prevention of COPD exacerbations, but the suggestion of survival advantage related to statins certainly may breathe new life into an enthusiasm greatly tempered by STATCOPE.
Or Kalchiem-Dekel, MD, and Robert M. Reed, MD, are at the pulmonary and critical care medicine division, University of Maryland, Baltimore. Neither editorialist had conflicts of interest (Chest. 2017;152:456-7. doi: 10.1016/j.chest.2017.04.156).
Despite [its] limitations, the study results are intriguing and in line with findings from other retrospective cohorts. How then can we reconcile the apparent benefits observed in retrospective studies with the lack of clinical effect seen in prospective trials, particularly the Simvastatin in the Prevention of COPD Exacerbation (STATCOPE) study? Could it be that both negative and positive studies are “correct”? Prospective studies have thus far not been adequately powered for mortality as an endpoint. Perhaps the choice of the particular statin matters? While STATCOPE involved simvastatin, the majority of the cohort reported by Raymakers et al. received atorvastatin. [Or perhaps] the negative results of STATCOPE could be related to careful selection of study participants with a low burden of systemic inflammation.
This most recent study reinforces the idea that statins may play a beneficial role in COPD, but it isn’t clear which patients to target for therapy. It is unlikely that the findings by Raymakers et al. will reverse recent recommendations by the American College of Chest Physicians and Canadian Thoracic Society against the use of statins for the purpose of prevention of COPD exacerbations, but the suggestion of survival advantage related to statins certainly may breathe new life into an enthusiasm greatly tempered by STATCOPE.
Or Kalchiem-Dekel, MD, and Robert M. Reed, MD, are at the pulmonary and critical care medicine division, University of Maryland, Baltimore. Neither editorialist had conflicts of interest (Chest. 2017;152:456-7. doi: 10.1016/j.chest.2017.04.156).
Despite [its] limitations, the study results are intriguing and in line with findings from other retrospective cohorts. How then can we reconcile the apparent benefits observed in retrospective studies with the lack of clinical effect seen in prospective trials, particularly the Simvastatin in the Prevention of COPD Exacerbation (STATCOPE) study? Could it be that both negative and positive studies are “correct”? Prospective studies have thus far not been adequately powered for mortality as an endpoint. Perhaps the choice of the particular statin matters? While STATCOPE involved simvastatin, the majority of the cohort reported by Raymakers et al. received atorvastatin. [Or perhaps] the negative results of STATCOPE could be related to careful selection of study participants with a low burden of systemic inflammation.
This most recent study reinforces the idea that statins may play a beneficial role in COPD, but it isn’t clear which patients to target for therapy. It is unlikely that the findings by Raymakers et al. will reverse recent recommendations by the American College of Chest Physicians and Canadian Thoracic Society against the use of statins for the purpose of prevention of COPD exacerbations, but the suggestion of survival advantage related to statins certainly may breathe new life into an enthusiasm greatly tempered by STATCOPE.
Or Kalchiem-Dekel, MD, and Robert M. Reed, MD, are at the pulmonary and critical care medicine division, University of Maryland, Baltimore. Neither editorialist had conflicts of interest (Chest. 2017;152:456-7. doi: 10.1016/j.chest.2017.04.156).
Receiving a statin prescription within a year after diagnosis of chronic obstructive pulmonary disease was associated with a 21% decrease in the subsequent risk of all-cause mortality and a 45% drop in risk of pulmonary mortality, according to the results of a large retrospective administrative database study.
The findings belie those of the recent Simvastatin in the Prevention of COPD Exacerbation (STATCOPE) trial, in which daily simvastatin (40 mg) did not affect exacerbation rates or time to first exacerbation in high-risk COPD patients, wrote Adam Raymakers, MSc, a doctoral candidate at the University of British Columbia, Vancouver, and his associates. Their study was observational, but the association between statin use and decreased mortality “persisted across several measures of statin exposure,” they wrote. “Our findings, in conjunction with previously reported evidence, suggests that there may be a specific subtype of COPD patients that may benefit from statin use.” The study appears in the September issue of Chest (2017;152;486-93).
To further explore the question, the researchers analyzed linked health databases from nearly 40,000 patients aged 50 years and older who had received at least three prescriptions for an anticholinergic or a short-acting beta agonist in 12 months some time between 1998 and 2007. The first prescription was considered the date of COPD “diagnosis.” The average age of the patients was 71 years; 55% were female.
A total of 7,775 patients (19.6%) who met this definition of incident COPD were prescribed a statin at least once during the subsequent year. These patients had a significantly reduced risk of subsequent all-cause mortality in univariate and multivariate analyses, with hazard ratios of 0.79 (95% confidence intervals, 0.68 to 0.91; P less than .002). Statins also showed a protective effect against pulmonary mortality, with univariate and multivariate hazard ratios of 0.52 (P = .01) and 0.55 (P = .03), respectively.
The protective effect of statins held up when the investigators narrowed the exposure period to 6 months after COPD diagnosis and when they expanded it to 18 months. Exposure to statins for 80% of the 1-year window after COPD diagnosis – a proxy for statin adherence – also led to a reduced risk of all-cause mortality, but the 95% confidence interval for the hazard ratio did not reach statistical significance (0.71 to 1.01; P = .06).
The most common prescription was for atorvastatin (49%), usually for 90 days (23%), 100 days (20%), or 30 days (15%), the researchers said. While the “possibility of the ‘healthy user’ or the ‘healthy adherer’ cannot be ignored,” they adjusted for other prescriptions, comorbidities, and income level, which should have helped eliminate this effect, they added. However, they lacked data on smoking and lung function assessments, both of which are “important confounders and contributors to mortality,” they acknowledged.
Canadian Institutes of Health Research supported the study. One coinvestigator disclosed consulting relationships with Teva, Pfizer, and Novartis. The others had no conflicts of interest.
Receiving a statin prescription within a year after diagnosis of chronic obstructive pulmonary disease was associated with a 21% decrease in the subsequent risk of all-cause mortality and a 45% drop in risk of pulmonary mortality, according to the results of a large retrospective administrative database study.
The findings belie those of the recent Simvastatin in the Prevention of COPD Exacerbation (STATCOPE) trial, in which daily simvastatin (40 mg) did not affect exacerbation rates or time to first exacerbation in high-risk COPD patients, wrote Adam Raymakers, MSc, a doctoral candidate at the University of British Columbia, Vancouver, and his associates. Their study was observational, but the association between statin use and decreased mortality “persisted across several measures of statin exposure,” they wrote. “Our findings, in conjunction with previously reported evidence, suggests that there may be a specific subtype of COPD patients that may benefit from statin use.” The study appears in the September issue of Chest (2017;152;486-93).
To further explore the question, the researchers analyzed linked health databases from nearly 40,000 patients aged 50 years and older who had received at least three prescriptions for an anticholinergic or a short-acting beta agonist in 12 months some time between 1998 and 2007. The first prescription was considered the date of COPD “diagnosis.” The average age of the patients was 71 years; 55% were female.
A total of 7,775 patients (19.6%) who met this definition of incident COPD were prescribed a statin at least once during the subsequent year. These patients had a significantly reduced risk of subsequent all-cause mortality in univariate and multivariate analyses, with hazard ratios of 0.79 (95% confidence intervals, 0.68 to 0.91; P less than .002). Statins also showed a protective effect against pulmonary mortality, with univariate and multivariate hazard ratios of 0.52 (P = .01) and 0.55 (P = .03), respectively.
The protective effect of statins held up when the investigators narrowed the exposure period to 6 months after COPD diagnosis and when they expanded it to 18 months. Exposure to statins for 80% of the 1-year window after COPD diagnosis – a proxy for statin adherence – also led to a reduced risk of all-cause mortality, but the 95% confidence interval for the hazard ratio did not reach statistical significance (0.71 to 1.01; P = .06).
The most common prescription was for atorvastatin (49%), usually for 90 days (23%), 100 days (20%), or 30 days (15%), the researchers said. While the “possibility of the ‘healthy user’ or the ‘healthy adherer’ cannot be ignored,” they adjusted for other prescriptions, comorbidities, and income level, which should have helped eliminate this effect, they added. However, they lacked data on smoking and lung function assessments, both of which are “important confounders and contributors to mortality,” they acknowledged.
Canadian Institutes of Health Research supported the study. One coinvestigator disclosed consulting relationships with Teva, Pfizer, and Novartis. The others had no conflicts of interest.
FROM CHEST
Key clinical point: Statins might reduce the risk of death among patients with chronic obstructive pulmonary disease.
Major finding: Statin use was associated with a 21% decrease in risk of all-cause mortality and a 45% decrease in risk of pulmonary mortality.
Data source: A retrospective cohort study of 39,678 patients with COPD, including 7,775 prescribed statins.
Disclosures: Canadian Institutes of Health Research supported the study. One coinvestigator disclosed consulting relationships with Teva, Pfizer, and Novartis. The others had no conflicts of interest.
Hospital readmissions penalties now in 5th year
With the Hospital Readmissions Reduction Program (HRRP) in its 5th year, what has been the impact on hospitals and on hospitalists?
First of all, a lot of penalties have been paid by hospitals. According to an analysis by Kaiser Health News,1 the Centers for Medicare and Medicaid Services will withhold $528 million from 2,597 hospitals in the current fiscal year, Oct. 1, 2016 to Sept. 30, 2017, for readmissions for six diagnoses that occurred between July 2012 and June 2015. The number of penalized hospitals is down slightly from 2,665 the year before, but the total annual withhold will go up by $108 million.
HRRP exacts Medicare payment penalties from hospitals that have rates of readmissions – within 30 days of discharge – that are higher than expected, based on national rates and the health of their patient population. The maximum penalty is now up to 3% of a hospital’s Medicare reimbursement. Hospitals are being penalized an average of 0.73% of their annual Medicare reimbursement, and cumulative HRRP penalties will reach nearly $1.9 billion by the end of the fiscal year, Kaiser Health News reports.2
“Basically, we chose to introduce the idea of measuring readmissions because we felt it represented an adverse outcome for many people that was being ignored; that risk could be reduced; and improvements would yield benefits for people as well as save money for the health care system,” he told The Hospitalist.
“More than anything, HRRP has sharpened the focus on considering the episode of care from the patient’s perspective – rather than just focusing on venues of care like the hospitalization alone,” Dr. Krumholz said. “The focus on readmission forced many of us in the health professions to consider what the experience was like to leave the acute setting – how information flowed, what kind of concerns people had, the degree to which they understood what had happened to them, the extent to which they were prepared for the next steps.”
Once the patient leaves the hospital, there are myriad factors that will influence their likelihood of returning, notes researcher Karen Joynt, MD, MPH, of the Department of Health Policy and Management at Harvard’s School of Public Health, Boston. “The proportion of patients readmitted to the hospital because of gross error is low, but sometimes we’re too optimistic about our patients’ ability to manage postdischarge,” she said.
“We all know we can do better at providing softer landings, and anyone who’s ever been a hospital patient or a family member of one knows that leaving the hospital is incredibly tumultuous. I experienced that with my own parents, and it’s frightening, even if everything is done right. It’s still a very vulnerable time.”
HRRP has fundamentally changed the conversation about hospital care, Dr. Joynt said. “I think we need to change the conversation even more and talk more about how to prevent admissions in the first place. As a clinician, I think we need to be more innovative, recognizing that the ways we’ll make a real difference probably has more to do with what happens outside of the hospital. My personal hope is that new alternate payment models like accountable care organizations will lead to more creative partnerships with other providers.”
What have we learned about readmissions in 5 years?
A lot of recently published research about readmissions has documented modest decreases in overall readmissions nationally, from over 21% to under 18% between 2007 and 2014, although most of the reduction occurred in the first couple of years after HRRP was announced and it has since largely leveled off.
Other research has tried to explore the relationship between readmissions rates and other outcomes that might matter more to patients or that might be better proxies for the quality of the hospital experience. Is readmission rate a true measure of quality, or just a utilization measure? Research has also tried to document what works: what are the best strategies for preventing avoidable readmissions by improving the discharge process, care transitions, and the coordination of care postdischarge in the community – although no silver bullet has yet been identified.
A recent effort to inject more equity into the penalties program, contained in the wide-ranging 21st Century Cures Act signed into law by President Obama in December 2016, requires Medicare to account for patients’ socio-economic backgrounds when it calculates reductions in its payments to hospitals under HRRP. The law directs the government to change the way pay for performance is applied to safety net hospitals by setting different penalty thresholds for hospitals based on the proportion of their patients who are dually eligible for Medicare and Medicaid.
It remains to be seen how this will be implemented and with what impact. But some critics have continued to question whether hospitals should be held accountable for readmissions, whether 30 days is the correct time frame for that accountability, and whether some hospitals might be simply taking the penalty hit rather than investing in the hard work of care transitions.
Impact on working hospitalists
One expert, Ashish Jha, MD, MPH, director of Harvard’s Global Health Institute, wants to see hospitalists get more engaged in the conversation about how to improve hospital care overall.
Experts say there aren’t metrics available that could allocate penalties to individual hospitalists for their performance in readmissions prevention. But hospitals, clearly, are paying attention, and hospitalist groups may find that part of their negotiation of quality and performance incentives with the hospital includes readmissions.
“There are so many other variables that go into transitions of care, and it would be unreasonable to try to hold the individual doctor responsible for all of them,” he said. But accountability can be passed on to the hospitalist group. “My hospital contracts with a national hospitalist company and our agreement has quality measures that we review with them. We ask them to focus on readmissions.”
Dr. Harte said that when patients are discharged from the hospital, they go from an environment where everything is taken care of for them, to total responsibility for their self-care. Yet we are asking ever more from patients in terms of self-management.
“We need to focus on the human side of the experience. The hospital is a place to be avoided wherever possible,” he said. Yet some readmissions are largely unpreventable. Hospitalists should focus on the patient’s greatest risk of preventable readmission. “Is it health literacy? Is it transportation?”
Readmissions at the front lines
Preetham Talari, MD, FACP, FHM, hospitalist at University of Kentucky HealthCare in Lexington, has an interest in health care safety, quality improvement, and value. He has led the university’s site participation in Project BOOST, the Society of Hospital Medicine’s national mentored quality improvement initiative for care transitions. Dr. Talari also led a quality initiative at the university called the Interprofessional Teamwork Innovation Model to systematize teamwork, first piloted on a 30-bed hospitalist unit where he is medical director.
“Readmissions are not just about doctors, they are more about patient factors, socioeconomic factors, where they live,” Dr. Talari said. “Those are harder to impact, but in my experience, it comes down to thinking about the patient’s needs before discharge – really from the time of admission: What are all the things we can do in the hospital to make sure the patient is safely transitioned home?”
According to Dr. Talari, complex issues like readmissions don’t depend on just one, two, or three factors. “But we do the interventions believing that it will improve processes and outcomes, and then add another intervention and another,” he said. “All of these interventions will add up like a jigsaw puzzle to achieve a final, sustainable outcome. One thing I believe is hospitalists should be leading these efforts.”
Better interventions, better infrastructure
Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at New York University School of Public Health, says the biggest change she has seen resulting from readmissions penalties is that transitions of care are now understood to be both important and the responsibility of front line hospitalists. “That was not true 5 or 10 years ago. We used to spend hours admitting patients to the hospital and then 5 minutes on their discharge.”
“We’ve also learned that the infrastructure can be built better. Historically, hospital discharge summaries have been abysmal. But we can automate the importation of pending labs into the electronic health record. These are things you can change for everybody by changing your template. Sit down in a room together every afternoon to talk about what will happen to the patients when they go home. That’s become standard at our hospital. That was never done before.”
Evidence for improved outcomes is mixed, Dr. Horwitz noted. However, she pointed out, is there any evidence that readmissions penalties have produced adverse outcomes? Did they increase mortality, or length of stay? “So far the evidence suggests that they did not,” she said.
“I think it’s generally likely that the work we have done has resulted in better care. Thousands of people haven’t had to go back to the hospital, and that’s a good thing.”
Recent research on readmissions penalties
A survey by Yale researchers, published in JAMA in December 2016, found that hospitals financially penalized under HRRP reduced their readmissions rates at a higher rate than nonpenalized hospitals, “which implies that penalties can improve quality and readmission performance for hospitals with the most room for improvement,” coauthor Kumar Dharmarajan, MD, MBA, said in a statement.4 The hospitals responded to external pressures – in other words, financial penalties worked. But most of the reduction happened in the 2 years before actual penalties went into effect, which suggests that further improvement will not be easy, the authors note.
A survey of the attitudes of hospital leaders on the HRRP found that it has had a major impact on their efforts to reduce readmissions rates, although the failure to take sociodemographic factors into account was a major complaint for these leaders.5 Most said the penalties were too large, but 42.5% believed HRRP was likely to improve quality.
Some have questioned whether readmissions penalties were just encouraging hospitals to reduce their rates by keeping returning patients in observation units rather than formally readmitting them. Zuckerman et al. in the New England Journal of Medicine found no evidence that changes in observation unit stays accounted for the documented decrease in readmissions.6
But according to Papanicolas et al. in Health Affairs, patient hospital experience has improved only modestly under hospital value-based purchasing for U.S. hospitals, with no evidence that the program has had a beneficial effect on overall patient experience.7 Another study from Harvard by Figueroa et al. found that evidence is lacking that hospital value-based purchasing leads to lower mortality rates.8
“Patients and caregivers tell us: Hey, you people are the experts. You’ve taken care of lots of people with my medical condition before. You should know what my needs are going to be postdischarge and help me anticipate them,” he said.
References
1. Rau J. Medicare’s Readmission Penalties Hit New High. Kaiser Health News. 2016 Aug 2.
2. Boccuti C, Casillas G. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program. Kaiser Health News, 2016 Sep 30.
3. Keenan PS, Normand SLT, Lin Z, et al. An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2008;1:29-37.
4. Desai NR, Ross JS, Kwon JY, et al. Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions. JAMA. 2016 Dec 27;316(24):2647-56.
5. Joynt KE, Figueroa JF, Orav EJ, Jha AK. Opinions on the Hospital Readmissions Reduction Program: Results of a national survey of hospital leaders. Am J Manag Care. 2016 Aug 1;222(8):e287-94.
6. Zuckerman RB, Sheingold SH, Orav EJ, et al. Readmissions, observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016 Apr 21;374(16):1543-51.
7. Papanicolas I, Figueroa JF, Orav EJ, Jha AK. Patient hospital experience improved modestly, but no evidence Medicare incentives promoted meaningful gain. Health Aff (Millwood). 2017 Jan;36(1):133-40.
8. Figueroa JF, Tsugawa Y, Zheng J, et al. Association between the value-based purchasing pay for performance program and patient mortality in US hospitals: observational study. BMJ. 2016;353:i2214.
With the Hospital Readmissions Reduction Program (HRRP) in its 5th year, what has been the impact on hospitals and on hospitalists?
First of all, a lot of penalties have been paid by hospitals. According to an analysis by Kaiser Health News,1 the Centers for Medicare and Medicaid Services will withhold $528 million from 2,597 hospitals in the current fiscal year, Oct. 1, 2016 to Sept. 30, 2017, for readmissions for six diagnoses that occurred between July 2012 and June 2015. The number of penalized hospitals is down slightly from 2,665 the year before, but the total annual withhold will go up by $108 million.
HRRP exacts Medicare payment penalties from hospitals that have rates of readmissions – within 30 days of discharge – that are higher than expected, based on national rates and the health of their patient population. The maximum penalty is now up to 3% of a hospital’s Medicare reimbursement. Hospitals are being penalized an average of 0.73% of their annual Medicare reimbursement, and cumulative HRRP penalties will reach nearly $1.9 billion by the end of the fiscal year, Kaiser Health News reports.2
“Basically, we chose to introduce the idea of measuring readmissions because we felt it represented an adverse outcome for many people that was being ignored; that risk could be reduced; and improvements would yield benefits for people as well as save money for the health care system,” he told The Hospitalist.
“More than anything, HRRP has sharpened the focus on considering the episode of care from the patient’s perspective – rather than just focusing on venues of care like the hospitalization alone,” Dr. Krumholz said. “The focus on readmission forced many of us in the health professions to consider what the experience was like to leave the acute setting – how information flowed, what kind of concerns people had, the degree to which they understood what had happened to them, the extent to which they were prepared for the next steps.”
Once the patient leaves the hospital, there are myriad factors that will influence their likelihood of returning, notes researcher Karen Joynt, MD, MPH, of the Department of Health Policy and Management at Harvard’s School of Public Health, Boston. “The proportion of patients readmitted to the hospital because of gross error is low, but sometimes we’re too optimistic about our patients’ ability to manage postdischarge,” she said.
“We all know we can do better at providing softer landings, and anyone who’s ever been a hospital patient or a family member of one knows that leaving the hospital is incredibly tumultuous. I experienced that with my own parents, and it’s frightening, even if everything is done right. It’s still a very vulnerable time.”
HRRP has fundamentally changed the conversation about hospital care, Dr. Joynt said. “I think we need to change the conversation even more and talk more about how to prevent admissions in the first place. As a clinician, I think we need to be more innovative, recognizing that the ways we’ll make a real difference probably has more to do with what happens outside of the hospital. My personal hope is that new alternate payment models like accountable care organizations will lead to more creative partnerships with other providers.”
What have we learned about readmissions in 5 years?
A lot of recently published research about readmissions has documented modest decreases in overall readmissions nationally, from over 21% to under 18% between 2007 and 2014, although most of the reduction occurred in the first couple of years after HRRP was announced and it has since largely leveled off.
Other research has tried to explore the relationship between readmissions rates and other outcomes that might matter more to patients or that might be better proxies for the quality of the hospital experience. Is readmission rate a true measure of quality, or just a utilization measure? Research has also tried to document what works: what are the best strategies for preventing avoidable readmissions by improving the discharge process, care transitions, and the coordination of care postdischarge in the community – although no silver bullet has yet been identified.
A recent effort to inject more equity into the penalties program, contained in the wide-ranging 21st Century Cures Act signed into law by President Obama in December 2016, requires Medicare to account for patients’ socio-economic backgrounds when it calculates reductions in its payments to hospitals under HRRP. The law directs the government to change the way pay for performance is applied to safety net hospitals by setting different penalty thresholds for hospitals based on the proportion of their patients who are dually eligible for Medicare and Medicaid.
It remains to be seen how this will be implemented and with what impact. But some critics have continued to question whether hospitals should be held accountable for readmissions, whether 30 days is the correct time frame for that accountability, and whether some hospitals might be simply taking the penalty hit rather than investing in the hard work of care transitions.
Impact on working hospitalists
One expert, Ashish Jha, MD, MPH, director of Harvard’s Global Health Institute, wants to see hospitalists get more engaged in the conversation about how to improve hospital care overall.
Experts say there aren’t metrics available that could allocate penalties to individual hospitalists for their performance in readmissions prevention. But hospitals, clearly, are paying attention, and hospitalist groups may find that part of their negotiation of quality and performance incentives with the hospital includes readmissions.
“There are so many other variables that go into transitions of care, and it would be unreasonable to try to hold the individual doctor responsible for all of them,” he said. But accountability can be passed on to the hospitalist group. “My hospital contracts with a national hospitalist company and our agreement has quality measures that we review with them. We ask them to focus on readmissions.”
Dr. Harte said that when patients are discharged from the hospital, they go from an environment where everything is taken care of for them, to total responsibility for their self-care. Yet we are asking ever more from patients in terms of self-management.
“We need to focus on the human side of the experience. The hospital is a place to be avoided wherever possible,” he said. Yet some readmissions are largely unpreventable. Hospitalists should focus on the patient’s greatest risk of preventable readmission. “Is it health literacy? Is it transportation?”
Readmissions at the front lines
Preetham Talari, MD, FACP, FHM, hospitalist at University of Kentucky HealthCare in Lexington, has an interest in health care safety, quality improvement, and value. He has led the university’s site participation in Project BOOST, the Society of Hospital Medicine’s national mentored quality improvement initiative for care transitions. Dr. Talari also led a quality initiative at the university called the Interprofessional Teamwork Innovation Model to systematize teamwork, first piloted on a 30-bed hospitalist unit where he is medical director.
“Readmissions are not just about doctors, they are more about patient factors, socioeconomic factors, where they live,” Dr. Talari said. “Those are harder to impact, but in my experience, it comes down to thinking about the patient’s needs before discharge – really from the time of admission: What are all the things we can do in the hospital to make sure the patient is safely transitioned home?”
According to Dr. Talari, complex issues like readmissions don’t depend on just one, two, or three factors. “But we do the interventions believing that it will improve processes and outcomes, and then add another intervention and another,” he said. “All of these interventions will add up like a jigsaw puzzle to achieve a final, sustainable outcome. One thing I believe is hospitalists should be leading these efforts.”
Better interventions, better infrastructure
Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at New York University School of Public Health, says the biggest change she has seen resulting from readmissions penalties is that transitions of care are now understood to be both important and the responsibility of front line hospitalists. “That was not true 5 or 10 years ago. We used to spend hours admitting patients to the hospital and then 5 minutes on their discharge.”
“We’ve also learned that the infrastructure can be built better. Historically, hospital discharge summaries have been abysmal. But we can automate the importation of pending labs into the electronic health record. These are things you can change for everybody by changing your template. Sit down in a room together every afternoon to talk about what will happen to the patients when they go home. That’s become standard at our hospital. That was never done before.”
Evidence for improved outcomes is mixed, Dr. Horwitz noted. However, she pointed out, is there any evidence that readmissions penalties have produced adverse outcomes? Did they increase mortality, or length of stay? “So far the evidence suggests that they did not,” she said.
“I think it’s generally likely that the work we have done has resulted in better care. Thousands of people haven’t had to go back to the hospital, and that’s a good thing.”
Recent research on readmissions penalties
A survey by Yale researchers, published in JAMA in December 2016, found that hospitals financially penalized under HRRP reduced their readmissions rates at a higher rate than nonpenalized hospitals, “which implies that penalties can improve quality and readmission performance for hospitals with the most room for improvement,” coauthor Kumar Dharmarajan, MD, MBA, said in a statement.4 The hospitals responded to external pressures – in other words, financial penalties worked. But most of the reduction happened in the 2 years before actual penalties went into effect, which suggests that further improvement will not be easy, the authors note.
A survey of the attitudes of hospital leaders on the HRRP found that it has had a major impact on their efforts to reduce readmissions rates, although the failure to take sociodemographic factors into account was a major complaint for these leaders.5 Most said the penalties were too large, but 42.5% believed HRRP was likely to improve quality.
Some have questioned whether readmissions penalties were just encouraging hospitals to reduce their rates by keeping returning patients in observation units rather than formally readmitting them. Zuckerman et al. in the New England Journal of Medicine found no evidence that changes in observation unit stays accounted for the documented decrease in readmissions.6
But according to Papanicolas et al. in Health Affairs, patient hospital experience has improved only modestly under hospital value-based purchasing for U.S. hospitals, with no evidence that the program has had a beneficial effect on overall patient experience.7 Another study from Harvard by Figueroa et al. found that evidence is lacking that hospital value-based purchasing leads to lower mortality rates.8
“Patients and caregivers tell us: Hey, you people are the experts. You’ve taken care of lots of people with my medical condition before. You should know what my needs are going to be postdischarge and help me anticipate them,” he said.
References
1. Rau J. Medicare’s Readmission Penalties Hit New High. Kaiser Health News. 2016 Aug 2.
2. Boccuti C, Casillas G. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program. Kaiser Health News, 2016 Sep 30.
3. Keenan PS, Normand SLT, Lin Z, et al. An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2008;1:29-37.
4. Desai NR, Ross JS, Kwon JY, et al. Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions. JAMA. 2016 Dec 27;316(24):2647-56.
5. Joynt KE, Figueroa JF, Orav EJ, Jha AK. Opinions on the Hospital Readmissions Reduction Program: Results of a national survey of hospital leaders. Am J Manag Care. 2016 Aug 1;222(8):e287-94.
6. Zuckerman RB, Sheingold SH, Orav EJ, et al. Readmissions, observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016 Apr 21;374(16):1543-51.
7. Papanicolas I, Figueroa JF, Orav EJ, Jha AK. Patient hospital experience improved modestly, but no evidence Medicare incentives promoted meaningful gain. Health Aff (Millwood). 2017 Jan;36(1):133-40.
8. Figueroa JF, Tsugawa Y, Zheng J, et al. Association between the value-based purchasing pay for performance program and patient mortality in US hospitals: observational study. BMJ. 2016;353:i2214.
With the Hospital Readmissions Reduction Program (HRRP) in its 5th year, what has been the impact on hospitals and on hospitalists?
First of all, a lot of penalties have been paid by hospitals. According to an analysis by Kaiser Health News,1 the Centers for Medicare and Medicaid Services will withhold $528 million from 2,597 hospitals in the current fiscal year, Oct. 1, 2016 to Sept. 30, 2017, for readmissions for six diagnoses that occurred between July 2012 and June 2015. The number of penalized hospitals is down slightly from 2,665 the year before, but the total annual withhold will go up by $108 million.
HRRP exacts Medicare payment penalties from hospitals that have rates of readmissions – within 30 days of discharge – that are higher than expected, based on national rates and the health of their patient population. The maximum penalty is now up to 3% of a hospital’s Medicare reimbursement. Hospitals are being penalized an average of 0.73% of their annual Medicare reimbursement, and cumulative HRRP penalties will reach nearly $1.9 billion by the end of the fiscal year, Kaiser Health News reports.2
“Basically, we chose to introduce the idea of measuring readmissions because we felt it represented an adverse outcome for many people that was being ignored; that risk could be reduced; and improvements would yield benefits for people as well as save money for the health care system,” he told The Hospitalist.
“More than anything, HRRP has sharpened the focus on considering the episode of care from the patient’s perspective – rather than just focusing on venues of care like the hospitalization alone,” Dr. Krumholz said. “The focus on readmission forced many of us in the health professions to consider what the experience was like to leave the acute setting – how information flowed, what kind of concerns people had, the degree to which they understood what had happened to them, the extent to which they were prepared for the next steps.”
Once the patient leaves the hospital, there are myriad factors that will influence their likelihood of returning, notes researcher Karen Joynt, MD, MPH, of the Department of Health Policy and Management at Harvard’s School of Public Health, Boston. “The proportion of patients readmitted to the hospital because of gross error is low, but sometimes we’re too optimistic about our patients’ ability to manage postdischarge,” she said.
“We all know we can do better at providing softer landings, and anyone who’s ever been a hospital patient or a family member of one knows that leaving the hospital is incredibly tumultuous. I experienced that with my own parents, and it’s frightening, even if everything is done right. It’s still a very vulnerable time.”
HRRP has fundamentally changed the conversation about hospital care, Dr. Joynt said. “I think we need to change the conversation even more and talk more about how to prevent admissions in the first place. As a clinician, I think we need to be more innovative, recognizing that the ways we’ll make a real difference probably has more to do with what happens outside of the hospital. My personal hope is that new alternate payment models like accountable care organizations will lead to more creative partnerships with other providers.”
What have we learned about readmissions in 5 years?
A lot of recently published research about readmissions has documented modest decreases in overall readmissions nationally, from over 21% to under 18% between 2007 and 2014, although most of the reduction occurred in the first couple of years after HRRP was announced and it has since largely leveled off.
Other research has tried to explore the relationship between readmissions rates and other outcomes that might matter more to patients or that might be better proxies for the quality of the hospital experience. Is readmission rate a true measure of quality, or just a utilization measure? Research has also tried to document what works: what are the best strategies for preventing avoidable readmissions by improving the discharge process, care transitions, and the coordination of care postdischarge in the community – although no silver bullet has yet been identified.
A recent effort to inject more equity into the penalties program, contained in the wide-ranging 21st Century Cures Act signed into law by President Obama in December 2016, requires Medicare to account for patients’ socio-economic backgrounds when it calculates reductions in its payments to hospitals under HRRP. The law directs the government to change the way pay for performance is applied to safety net hospitals by setting different penalty thresholds for hospitals based on the proportion of their patients who are dually eligible for Medicare and Medicaid.
It remains to be seen how this will be implemented and with what impact. But some critics have continued to question whether hospitals should be held accountable for readmissions, whether 30 days is the correct time frame for that accountability, and whether some hospitals might be simply taking the penalty hit rather than investing in the hard work of care transitions.
Impact on working hospitalists
One expert, Ashish Jha, MD, MPH, director of Harvard’s Global Health Institute, wants to see hospitalists get more engaged in the conversation about how to improve hospital care overall.
Experts say there aren’t metrics available that could allocate penalties to individual hospitalists for their performance in readmissions prevention. But hospitals, clearly, are paying attention, and hospitalist groups may find that part of their negotiation of quality and performance incentives with the hospital includes readmissions.
“There are so many other variables that go into transitions of care, and it would be unreasonable to try to hold the individual doctor responsible for all of them,” he said. But accountability can be passed on to the hospitalist group. “My hospital contracts with a national hospitalist company and our agreement has quality measures that we review with them. We ask them to focus on readmissions.”
Dr. Harte said that when patients are discharged from the hospital, they go from an environment where everything is taken care of for them, to total responsibility for their self-care. Yet we are asking ever more from patients in terms of self-management.
“We need to focus on the human side of the experience. The hospital is a place to be avoided wherever possible,” he said. Yet some readmissions are largely unpreventable. Hospitalists should focus on the patient’s greatest risk of preventable readmission. “Is it health literacy? Is it transportation?”
Readmissions at the front lines
Preetham Talari, MD, FACP, FHM, hospitalist at University of Kentucky HealthCare in Lexington, has an interest in health care safety, quality improvement, and value. He has led the university’s site participation in Project BOOST, the Society of Hospital Medicine’s national mentored quality improvement initiative for care transitions. Dr. Talari also led a quality initiative at the university called the Interprofessional Teamwork Innovation Model to systematize teamwork, first piloted on a 30-bed hospitalist unit where he is medical director.
“Readmissions are not just about doctors, they are more about patient factors, socioeconomic factors, where they live,” Dr. Talari said. “Those are harder to impact, but in my experience, it comes down to thinking about the patient’s needs before discharge – really from the time of admission: What are all the things we can do in the hospital to make sure the patient is safely transitioned home?”
According to Dr. Talari, complex issues like readmissions don’t depend on just one, two, or three factors. “But we do the interventions believing that it will improve processes and outcomes, and then add another intervention and another,” he said. “All of these interventions will add up like a jigsaw puzzle to achieve a final, sustainable outcome. One thing I believe is hospitalists should be leading these efforts.”
Better interventions, better infrastructure
Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at New York University School of Public Health, says the biggest change she has seen resulting from readmissions penalties is that transitions of care are now understood to be both important and the responsibility of front line hospitalists. “That was not true 5 or 10 years ago. We used to spend hours admitting patients to the hospital and then 5 minutes on their discharge.”
“We’ve also learned that the infrastructure can be built better. Historically, hospital discharge summaries have been abysmal. But we can automate the importation of pending labs into the electronic health record. These are things you can change for everybody by changing your template. Sit down in a room together every afternoon to talk about what will happen to the patients when they go home. That’s become standard at our hospital. That was never done before.”
Evidence for improved outcomes is mixed, Dr. Horwitz noted. However, she pointed out, is there any evidence that readmissions penalties have produced adverse outcomes? Did they increase mortality, or length of stay? “So far the evidence suggests that they did not,” she said.
“I think it’s generally likely that the work we have done has resulted in better care. Thousands of people haven’t had to go back to the hospital, and that’s a good thing.”
Recent research on readmissions penalties
A survey by Yale researchers, published in JAMA in December 2016, found that hospitals financially penalized under HRRP reduced their readmissions rates at a higher rate than nonpenalized hospitals, “which implies that penalties can improve quality and readmission performance for hospitals with the most room for improvement,” coauthor Kumar Dharmarajan, MD, MBA, said in a statement.4 The hospitals responded to external pressures – in other words, financial penalties worked. But most of the reduction happened in the 2 years before actual penalties went into effect, which suggests that further improvement will not be easy, the authors note.
A survey of the attitudes of hospital leaders on the HRRP found that it has had a major impact on their efforts to reduce readmissions rates, although the failure to take sociodemographic factors into account was a major complaint for these leaders.5 Most said the penalties were too large, but 42.5% believed HRRP was likely to improve quality.
Some have questioned whether readmissions penalties were just encouraging hospitals to reduce their rates by keeping returning patients in observation units rather than formally readmitting them. Zuckerman et al. in the New England Journal of Medicine found no evidence that changes in observation unit stays accounted for the documented decrease in readmissions.6
But according to Papanicolas et al. in Health Affairs, patient hospital experience has improved only modestly under hospital value-based purchasing for U.S. hospitals, with no evidence that the program has had a beneficial effect on overall patient experience.7 Another study from Harvard by Figueroa et al. found that evidence is lacking that hospital value-based purchasing leads to lower mortality rates.8
“Patients and caregivers tell us: Hey, you people are the experts. You’ve taken care of lots of people with my medical condition before. You should know what my needs are going to be postdischarge and help me anticipate them,” he said.
References
1. Rau J. Medicare’s Readmission Penalties Hit New High. Kaiser Health News. 2016 Aug 2.
2. Boccuti C, Casillas G. Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program. Kaiser Health News, 2016 Sep 30.
3. Keenan PS, Normand SLT, Lin Z, et al. An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2008;1:29-37.
4. Desai NR, Ross JS, Kwon JY, et al. Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions. JAMA. 2016 Dec 27;316(24):2647-56.
5. Joynt KE, Figueroa JF, Orav EJ, Jha AK. Opinions on the Hospital Readmissions Reduction Program: Results of a national survey of hospital leaders. Am J Manag Care. 2016 Aug 1;222(8):e287-94.
6. Zuckerman RB, Sheingold SH, Orav EJ, et al. Readmissions, observation, and the Hospital Readmissions Reduction Program. N Engl J Med. 2016 Apr 21;374(16):1543-51.
7. Papanicolas I, Figueroa JF, Orav EJ, Jha AK. Patient hospital experience improved modestly, but no evidence Medicare incentives promoted meaningful gain. Health Aff (Millwood). 2017 Jan;36(1):133-40.
8. Figueroa JF, Tsugawa Y, Zheng J, et al. Association between the value-based purchasing pay for performance program and patient mortality in US hospitals: observational study. BMJ. 2016;353:i2214.
Hospital-led interventions cut pediatric asthma hospitalizations
Hospital-driven interventions designed to improve management of asthma in children achieved significant reductions in monthly asthma-related hospitalizations and emergency department visits, according to a paper published online Sept. 18 in JAMA Pediatrics.
Long-term management of pediatric asthma is challenging, and around 40% of children and adolescents hospitalized with the disease tend to be rehospitalized or revisit the emergency department (ED) within 12 months, according to Carolyn M. Kercsmar, MD, of Children’s Hospital Medical Center in Cincinnati, and her coauthors.
“Traditional care models do not adequately address underlying risk factors, propagating disparities and costly health care use,” they wrote (JAMA Pediatrics 2017, Sep 18. doi: 10.1001/jamapediatrics.2017.2600).
This study, initiated by Cincinnati Children’s Hospital Medical Center, involved a range of interventions implemented with inpatients and outpatients and through the community setting, targeting the region’s more than 36,000 children and adolescents with asthma, approximately 13,000 of whom were Medicaid insured.
Over the 5-year study, researchers saw a 41.8% relative reduction in asthma-related hospitalizations – from 8.1 to 4.7 per 10,000 Medicaid patients per month. Asthma-related visits to the ED decreased by 42.4%, from 21.5 to 12.4 per 10,000 Medicaid patients per month, and the percentage of patients rehospitalized or who returned to the ED for asthma within 30 days declined from 12% to 7%, “within 3 years of implementation of the inpatient care interventions,” the researchers noted.
There was also a significant increase in the percentage of patients discharged with a 30-day supply of inhaled controller medications, from 50% in May 2008 to 90% in May 2010, and the percentage of patients discharged with a short course of oral corticosteroids increased from 0% to 70% by March 2011.
Outpatient processes ensured that Asthma Control Test scores were collected and that patients were provided with asthma action plans. This was associated with an increase in the percentage of patients with well-controlled asthma from 48% to 54%.
“Implementation of an integrated, multilevel approach focused on enhancing availability and accessibility of treatments, removing barriers to adherence, mitigating risks related to adverse exposures, and augmenting self-management and collaborative relationships between the family and the health care system was associated with improved asthma outcomes,” the authors wrote.
Noting that previous research has found 38%-70% of patients do not get their prescribed medications at hospital discharge, the authors said they believed giving a 30-day supply of all daily asthma medications at discharge was a key part of their success.
The study was supported by the Cincinnati Children’s Hospital Medical Center and one author received a grant from the National Institutes of Health. One author declared compensation for a committee role on a study of asthma treatments in children. No other conflicts of interest were declared.
Of importance, any future efforts to replicate this work in a patient-centered way should include consideration of how information on asthma management is communicated to and understood by patients. Standard tools such as asthma action plans often contain language and other information that is inaccessible to populations with low health literacy levels.
After years of elevated morbidity, the work of Kercsmar et al. is a demonstration of how interdisciplinary care focused within a biopsychosocial model can improve outcomes for vulnerable children. Future efforts to replicate these results in other communities should continue to emphasize this patient-centered, biopsychosocial philosophy, with heightened attention to the challenges that remain for children and families.
Dr. Sean M. Frey and Dr. Jill S. Halterman are in the department of pediatrics at the University of Rochester (N.Y.) School of Medicine and Dentistry. These comments are taken from an accompanying editorial (JAMA Pediatrics 2017, Sep 18. doi: 10.1001/jamapediatrics.2017.2609). No conflicts of interest were declared.
Of importance, any future efforts to replicate this work in a patient-centered way should include consideration of how information on asthma management is communicated to and understood by patients. Standard tools such as asthma action plans often contain language and other information that is inaccessible to populations with low health literacy levels.
After years of elevated morbidity, the work of Kercsmar et al. is a demonstration of how interdisciplinary care focused within a biopsychosocial model can improve outcomes for vulnerable children. Future efforts to replicate these results in other communities should continue to emphasize this patient-centered, biopsychosocial philosophy, with heightened attention to the challenges that remain for children and families.
Dr. Sean M. Frey and Dr. Jill S. Halterman are in the department of pediatrics at the University of Rochester (N.Y.) School of Medicine and Dentistry. These comments are taken from an accompanying editorial (JAMA Pediatrics 2017, Sep 18. doi: 10.1001/jamapediatrics.2017.2609). No conflicts of interest were declared.
Of importance, any future efforts to replicate this work in a patient-centered way should include consideration of how information on asthma management is communicated to and understood by patients. Standard tools such as asthma action plans often contain language and other information that is inaccessible to populations with low health literacy levels.
After years of elevated morbidity, the work of Kercsmar et al. is a demonstration of how interdisciplinary care focused within a biopsychosocial model can improve outcomes for vulnerable children. Future efforts to replicate these results in other communities should continue to emphasize this patient-centered, biopsychosocial philosophy, with heightened attention to the challenges that remain for children and families.
Dr. Sean M. Frey and Dr. Jill S. Halterman are in the department of pediatrics at the University of Rochester (N.Y.) School of Medicine and Dentistry. These comments are taken from an accompanying editorial (JAMA Pediatrics 2017, Sep 18. doi: 10.1001/jamapediatrics.2017.2609). No conflicts of interest were declared.
Hospital-driven interventions designed to improve management of asthma in children achieved significant reductions in monthly asthma-related hospitalizations and emergency department visits, according to a paper published online Sept. 18 in JAMA Pediatrics.
Long-term management of pediatric asthma is challenging, and around 40% of children and adolescents hospitalized with the disease tend to be rehospitalized or revisit the emergency department (ED) within 12 months, according to Carolyn M. Kercsmar, MD, of Children’s Hospital Medical Center in Cincinnati, and her coauthors.
“Traditional care models do not adequately address underlying risk factors, propagating disparities and costly health care use,” they wrote (JAMA Pediatrics 2017, Sep 18. doi: 10.1001/jamapediatrics.2017.2600).
This study, initiated by Cincinnati Children’s Hospital Medical Center, involved a range of interventions implemented with inpatients and outpatients and through the community setting, targeting the region’s more than 36,000 children and adolescents with asthma, approximately 13,000 of whom were Medicaid insured.
Over the 5-year study, researchers saw a 41.8% relative reduction in asthma-related hospitalizations – from 8.1 to 4.7 per 10,000 Medicaid patients per month. Asthma-related visits to the ED decreased by 42.4%, from 21.5 to 12.4 per 10,000 Medicaid patients per month, and the percentage of patients rehospitalized or who returned to the ED for asthma within 30 days declined from 12% to 7%, “within 3 years of implementation of the inpatient care interventions,” the researchers noted.
There was also a significant increase in the percentage of patients discharged with a 30-day supply of inhaled controller medications, from 50% in May 2008 to 90% in May 2010, and the percentage of patients discharged with a short course of oral corticosteroids increased from 0% to 70% by March 2011.
Outpatient processes ensured that Asthma Control Test scores were collected and that patients were provided with asthma action plans. This was associated with an increase in the percentage of patients with well-controlled asthma from 48% to 54%.
“Implementation of an integrated, multilevel approach focused on enhancing availability and accessibility of treatments, removing barriers to adherence, mitigating risks related to adverse exposures, and augmenting self-management and collaborative relationships between the family and the health care system was associated with improved asthma outcomes,” the authors wrote.
Noting that previous research has found 38%-70% of patients do not get their prescribed medications at hospital discharge, the authors said they believed giving a 30-day supply of all daily asthma medications at discharge was a key part of their success.
The study was supported by the Cincinnati Children’s Hospital Medical Center and one author received a grant from the National Institutes of Health. One author declared compensation for a committee role on a study of asthma treatments in children. No other conflicts of interest were declared.
Hospital-driven interventions designed to improve management of asthma in children achieved significant reductions in monthly asthma-related hospitalizations and emergency department visits, according to a paper published online Sept. 18 in JAMA Pediatrics.
Long-term management of pediatric asthma is challenging, and around 40% of children and adolescents hospitalized with the disease tend to be rehospitalized or revisit the emergency department (ED) within 12 months, according to Carolyn M. Kercsmar, MD, of Children’s Hospital Medical Center in Cincinnati, and her coauthors.
“Traditional care models do not adequately address underlying risk factors, propagating disparities and costly health care use,” they wrote (JAMA Pediatrics 2017, Sep 18. doi: 10.1001/jamapediatrics.2017.2600).
This study, initiated by Cincinnati Children’s Hospital Medical Center, involved a range of interventions implemented with inpatients and outpatients and through the community setting, targeting the region’s more than 36,000 children and adolescents with asthma, approximately 13,000 of whom were Medicaid insured.
Over the 5-year study, researchers saw a 41.8% relative reduction in asthma-related hospitalizations – from 8.1 to 4.7 per 10,000 Medicaid patients per month. Asthma-related visits to the ED decreased by 42.4%, from 21.5 to 12.4 per 10,000 Medicaid patients per month, and the percentage of patients rehospitalized or who returned to the ED for asthma within 30 days declined from 12% to 7%, “within 3 years of implementation of the inpatient care interventions,” the researchers noted.
There was also a significant increase in the percentage of patients discharged with a 30-day supply of inhaled controller medications, from 50% in May 2008 to 90% in May 2010, and the percentage of patients discharged with a short course of oral corticosteroids increased from 0% to 70% by March 2011.
Outpatient processes ensured that Asthma Control Test scores were collected and that patients were provided with asthma action plans. This was associated with an increase in the percentage of patients with well-controlled asthma from 48% to 54%.
“Implementation of an integrated, multilevel approach focused on enhancing availability and accessibility of treatments, removing barriers to adherence, mitigating risks related to adverse exposures, and augmenting self-management and collaborative relationships between the family and the health care system was associated with improved asthma outcomes,” the authors wrote.
Noting that previous research has found 38%-70% of patients do not get their prescribed medications at hospital discharge, the authors said they believed giving a 30-day supply of all daily asthma medications at discharge was a key part of their success.
The study was supported by the Cincinnati Children’s Hospital Medical Center and one author received a grant from the National Institutes of Health. One author declared compensation for a committee role on a study of asthma treatments in children. No other conflicts of interest were declared.
FROM JAMA PEDIATRICS
Key clinical point: A hospital-driven intervention to improve management of asthma in children has achieved significant reductions in asthma-related hospitalizations and emergency department visits and increased medication uptake.
Major finding: A multifactorial intervention to improve asthma management in children was associated with a 41.8% relative reduction in asthma-related hospitalizations and a 42.4% reduction in emergency department visits.
Data source: A hospital-based intervention.
Disclosures: The study was supported by the Cincinnati Children’s Hospital Medical Center and one author received a grant from the National Institutes of Health. One author declared compensation for a committee role on a study of asthma treatments in children. No other conflicts of interest were declared.
Acquiring a REDcap data entry skill set
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
To give a status update on my project, I am almost finished collecting data for the Emergency ICU Transfer cases in Cincinnati Children’s Hospital. The project timeline is going as planned, and I should be finishing my data collection within the next week or so. I have begun to match control subjects by age strata, time of transfer and hospital unit to the Emergency ICU Transfer cases, and hope to finish that within the next week as well.
To streamline data collection and make it available for analysis in the near future, I set up a REDcap data entry form for my project. This was initially a challenge because even though I have entered data using this online tool before, I had no experience creating my own forms. With a lot of help from Google, people who worked around me, and our campus REDcap administrators, I was able to set this up pretty quickly and independently. I have noticed that this tool is widely used for clinical research, and am glad that being able create project instruments within REDcap is now part of my skill set. This was a unique learning experience for me that I wasn’t expecting to gain. It helped me understand what needs to be done specifically in order to execute a clinical research project, such as the one I’m working on alongside my mentor.
I have also learned a little medical knowledge from reading patient charts as I’m collecting data. For example, for procedures such as intubation, I have been seeing what specific medications are being administered for the pediatric patient. It has been interesting to learn some medical details behind lifesaving procedures, before even having clinical exposure in my medical training.
Farah Hussain is a 2nd-year medical student at University of Cincinnati College of Medicine and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care to vulnerable populations.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
To give a status update on my project, I am almost finished collecting data for the Emergency ICU Transfer cases in Cincinnati Children’s Hospital. The project timeline is going as planned, and I should be finishing my data collection within the next week or so. I have begun to match control subjects by age strata, time of transfer and hospital unit to the Emergency ICU Transfer cases, and hope to finish that within the next week as well.
To streamline data collection and make it available for analysis in the near future, I set up a REDcap data entry form for my project. This was initially a challenge because even though I have entered data using this online tool before, I had no experience creating my own forms. With a lot of help from Google, people who worked around me, and our campus REDcap administrators, I was able to set this up pretty quickly and independently. I have noticed that this tool is widely used for clinical research, and am glad that being able create project instruments within REDcap is now part of my skill set. This was a unique learning experience for me that I wasn’t expecting to gain. It helped me understand what needs to be done specifically in order to execute a clinical research project, such as the one I’m working on alongside my mentor.
I have also learned a little medical knowledge from reading patient charts as I’m collecting data. For example, for procedures such as intubation, I have been seeing what specific medications are being administered for the pediatric patient. It has been interesting to learn some medical details behind lifesaving procedures, before even having clinical exposure in my medical training.
Farah Hussain is a 2nd-year medical student at University of Cincinnati College of Medicine and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care to vulnerable populations.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.
To give a status update on my project, I am almost finished collecting data for the Emergency ICU Transfer cases in Cincinnati Children’s Hospital. The project timeline is going as planned, and I should be finishing my data collection within the next week or so. I have begun to match control subjects by age strata, time of transfer and hospital unit to the Emergency ICU Transfer cases, and hope to finish that within the next week as well.
To streamline data collection and make it available for analysis in the near future, I set up a REDcap data entry form for my project. This was initially a challenge because even though I have entered data using this online tool before, I had no experience creating my own forms. With a lot of help from Google, people who worked around me, and our campus REDcap administrators, I was able to set this up pretty quickly and independently. I have noticed that this tool is widely used for clinical research, and am glad that being able create project instruments within REDcap is now part of my skill set. This was a unique learning experience for me that I wasn’t expecting to gain. It helped me understand what needs to be done specifically in order to execute a clinical research project, such as the one I’m working on alongside my mentor.
I have also learned a little medical knowledge from reading patient charts as I’m collecting data. For example, for procedures such as intubation, I have been seeing what specific medications are being administered for the pediatric patient. It has been interesting to learn some medical details behind lifesaving procedures, before even having clinical exposure in my medical training.
Farah Hussain is a 2nd-year medical student at University of Cincinnati College of Medicine and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care to vulnerable populations.
VIDEO: What’s new in AAP’s pediatric hypertension guidelines
SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.
Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
The prevalence of pediatric hypertension, he said, now rivals asthma.
SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.
Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
The prevalence of pediatric hypertension, he said, now rivals asthma.
SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.
Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
The prevalence of pediatric hypertension, he said, now rivals asthma.
EXPERT ANALYSIS FROM THE AHA/ASH JOINT SCIENTIFIC SESSIONS
Increase in sepsis incidence stable from 2009 to 2014
The trend for sepsis incidence from 2009 to 2014, “calculated relative to the observed 2014 rates,” was a stable increase of 0.6% per year using the more accurate of two forms of analysis, investigators reported.
The incidence of sepsis was an adjusted 5.9% among hospitalized adults in 2014, with in-hospital mortality of 15%, according to a retrospective cohort study published online Sept. 13 in JAMA.
“Most studies [of sepsis incidence] have used claims data, but increasing clinical awareness, changes in diagnosis and coding practices, and variable definitions have led to uncertainty about the accuracy of reported trends,” wrote Chanu Rhee, MD, of Harvard Medical School, Boston, and his associates (JAMA. 2017 Sep 13. doi: 10.1001/jama.2017.13836).
They used two methods – one involving claims-based estimates using ICD-9-CM codes and the other based on clinical data from electronic health records (EHRs) – to analyze data for more than 2.9 million adults admitted to 409 U.S. academic, community, and federal acute-care hospitals in 2014. The claims-based “explicit-codes” approach used discharge diagnoses of severe sepsis (995.92) or septic shock (785.52), while the EHR-based, clinical-criteria method included blood cultures, antibiotics, and concurrent organ dysfunction with or without the criterion of a lactate level of 2.0 mmol/L or greater, the investigators said.
The explicit-codes approach produced an increase of 10.3% per year in sepsis incidence from 2009 to 2014, compared with 0.6% per year for the clinical-criteria approach, while in-hospital mortality declined by 7% a year using explicit codes and 3.3% using clinical criteria, Dr. Rhee and his associates reported.
“EHR-based criteria were more sensitive than explicit sepsis codes on medical record review, with comparable [positive predictive value]; EHR-based criteria had similar sensitivity to implicit or explicit codes combined but higher [positive predictive value],” they said.
The estimates provided by Dr. Rhee and his associates provide “a clearer understanding of trends in the incidence and mortality of sepsis in the United States but also a better understanding of the challenges in improving ICD coding to accurately document the global burden of sepsis,” Kristina E. Rudd, MD, of the University of Washington, Seattle, and her associates said in an editorial (JAMA 2017 Sep 13. doi: 10.1001/jama.2017.13697).
The study was funded by the Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, National Institutes of Health, Department of Veterans Affairs, National Institutes of Health Clinical Center, and National Institute of Allergy and Infectious Diseases. Three of Dr. Rhee’s associates reported receiving personal fees from private companies or serving on advisory boards or as consultants. No other authors reported disclosures. Dr. Rudd and her associates had no conflicts of interest to report.
The trend for sepsis incidence from 2009 to 2014, “calculated relative to the observed 2014 rates,” was a stable increase of 0.6% per year using the more accurate of two forms of analysis, investigators reported.
The incidence of sepsis was an adjusted 5.9% among hospitalized adults in 2014, with in-hospital mortality of 15%, according to a retrospective cohort study published online Sept. 13 in JAMA.
“Most studies [of sepsis incidence] have used claims data, but increasing clinical awareness, changes in diagnosis and coding practices, and variable definitions have led to uncertainty about the accuracy of reported trends,” wrote Chanu Rhee, MD, of Harvard Medical School, Boston, and his associates (JAMA. 2017 Sep 13. doi: 10.1001/jama.2017.13836).
They used two methods – one involving claims-based estimates using ICD-9-CM codes and the other based on clinical data from electronic health records (EHRs) – to analyze data for more than 2.9 million adults admitted to 409 U.S. academic, community, and federal acute-care hospitals in 2014. The claims-based “explicit-codes” approach used discharge diagnoses of severe sepsis (995.92) or septic shock (785.52), while the EHR-based, clinical-criteria method included blood cultures, antibiotics, and concurrent organ dysfunction with or without the criterion of a lactate level of 2.0 mmol/L or greater, the investigators said.
The explicit-codes approach produced an increase of 10.3% per year in sepsis incidence from 2009 to 2014, compared with 0.6% per year for the clinical-criteria approach, while in-hospital mortality declined by 7% a year using explicit codes and 3.3% using clinical criteria, Dr. Rhee and his associates reported.
“EHR-based criteria were more sensitive than explicit sepsis codes on medical record review, with comparable [positive predictive value]; EHR-based criteria had similar sensitivity to implicit or explicit codes combined but higher [positive predictive value],” they said.
The estimates provided by Dr. Rhee and his associates provide “a clearer understanding of trends in the incidence and mortality of sepsis in the United States but also a better understanding of the challenges in improving ICD coding to accurately document the global burden of sepsis,” Kristina E. Rudd, MD, of the University of Washington, Seattle, and her associates said in an editorial (JAMA 2017 Sep 13. doi: 10.1001/jama.2017.13697).
The study was funded by the Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, National Institutes of Health, Department of Veterans Affairs, National Institutes of Health Clinical Center, and National Institute of Allergy and Infectious Diseases. Three of Dr. Rhee’s associates reported receiving personal fees from private companies or serving on advisory boards or as consultants. No other authors reported disclosures. Dr. Rudd and her associates had no conflicts of interest to report.
The trend for sepsis incidence from 2009 to 2014, “calculated relative to the observed 2014 rates,” was a stable increase of 0.6% per year using the more accurate of two forms of analysis, investigators reported.
The incidence of sepsis was an adjusted 5.9% among hospitalized adults in 2014, with in-hospital mortality of 15%, according to a retrospective cohort study published online Sept. 13 in JAMA.
“Most studies [of sepsis incidence] have used claims data, but increasing clinical awareness, changes in diagnosis and coding practices, and variable definitions have led to uncertainty about the accuracy of reported trends,” wrote Chanu Rhee, MD, of Harvard Medical School, Boston, and his associates (JAMA. 2017 Sep 13. doi: 10.1001/jama.2017.13836).
They used two methods – one involving claims-based estimates using ICD-9-CM codes and the other based on clinical data from electronic health records (EHRs) – to analyze data for more than 2.9 million adults admitted to 409 U.S. academic, community, and federal acute-care hospitals in 2014. The claims-based “explicit-codes” approach used discharge diagnoses of severe sepsis (995.92) or septic shock (785.52), while the EHR-based, clinical-criteria method included blood cultures, antibiotics, and concurrent organ dysfunction with or without the criterion of a lactate level of 2.0 mmol/L or greater, the investigators said.
The explicit-codes approach produced an increase of 10.3% per year in sepsis incidence from 2009 to 2014, compared with 0.6% per year for the clinical-criteria approach, while in-hospital mortality declined by 7% a year using explicit codes and 3.3% using clinical criteria, Dr. Rhee and his associates reported.
“EHR-based criteria were more sensitive than explicit sepsis codes on medical record review, with comparable [positive predictive value]; EHR-based criteria had similar sensitivity to implicit or explicit codes combined but higher [positive predictive value],” they said.
The estimates provided by Dr. Rhee and his associates provide “a clearer understanding of trends in the incidence and mortality of sepsis in the United States but also a better understanding of the challenges in improving ICD coding to accurately document the global burden of sepsis,” Kristina E. Rudd, MD, of the University of Washington, Seattle, and her associates said in an editorial (JAMA 2017 Sep 13. doi: 10.1001/jama.2017.13697).
The study was funded by the Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, National Institutes of Health, Department of Veterans Affairs, National Institutes of Health Clinical Center, and National Institute of Allergy and Infectious Diseases. Three of Dr. Rhee’s associates reported receiving personal fees from private companies or serving on advisory boards or as consultants. No other authors reported disclosures. Dr. Rudd and her associates had no conflicts of interest to report.
FROM JAMA
Identifying clinical pathways for injection drug–related infectious sequelae
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
It is not surprising that my medical school – home to a group of passionate thought leaders in health service and policy research, including the Dartmouth Atlas and Accountable Care Organization – required all first-year medical students to take a course called “health care delivery science.”
The course offered me the first glimpse into quality improvement. However, because of a lack of clinical context, much of the course remained theoretical until my clinical years. During the hospital medicine rotation, I took care of a 40-year old patient who was newly diagnosed with metastatic pancreatic cancer. It was challenging to deliver devastatingly bad news. The patient and family, however, were most confused and frustrated by the roles of different specialists and care providers, the purpose and scheduling of procedures, and diet arrangement. I wondered how I could make their experience better.
After several meetings with my mentor, Professor Jonathan Huntington, a hospitalist, MD-PhD researcher, and director of Care Coordination Center at Dartmouth-Hitchcock Medical Center (DHMC), we identified a research area that has rising interest, importance, and relevance to the rural New Hampshire population. It is about identifying a clinical pathway for injection drug–related infectious sequelae.
Because of the unique bio-socio-psycho needs of injection drug users, hospitalizations due to injection-related infection sequelae often contribute to increased length of stay, readmission rates, and expenses out of state and federal health care funding. Prolonged stays also result in the waste of tertiary care resources for nontertiary needs, underutilization of regional care resources such as community and critical access hospitals, and increased care burden, as most patients travel long distances to obtain care.
We will pilot and implement a clinical pathway in the medicine units and measure length of stay, readmission rate, patient satisfaction rating, infectious disease provider follow-up rate, and hospitalization cost. I appreciate the grant support from SHM, and am looking forward to working with Dr. Huntington and other providers at DHMC, as well as developing myself professionally.
Yun Li is an MD/MBA student attending Geisel School of Medicine and Tuck School of Business at Dartmouth, Hanover, N.H. She obtained her Bachelor of Arts degree from Hanover College double-majoring in Economics and Biological Chemistry. Ms. Li participated in research in injury epidemiology and genetics, and has conducted studies on traditional Tibetan medicine, rural health, health NGOs, and digital health. Her career interest is practicing hospital medicine and geriatrics as a clinician/administrator, either in the United States or China. Ms. Li is a student member of the Society of Hospital Medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
It is not surprising that my medical school – home to a group of passionate thought leaders in health service and policy research, including the Dartmouth Atlas and Accountable Care Organization – required all first-year medical students to take a course called “health care delivery science.”
The course offered me the first glimpse into quality improvement. However, because of a lack of clinical context, much of the course remained theoretical until my clinical years. During the hospital medicine rotation, I took care of a 40-year old patient who was newly diagnosed with metastatic pancreatic cancer. It was challenging to deliver devastatingly bad news. The patient and family, however, were most confused and frustrated by the roles of different specialists and care providers, the purpose and scheduling of procedures, and diet arrangement. I wondered how I could make their experience better.
After several meetings with my mentor, Professor Jonathan Huntington, a hospitalist, MD-PhD researcher, and director of Care Coordination Center at Dartmouth-Hitchcock Medical Center (DHMC), we identified a research area that has rising interest, importance, and relevance to the rural New Hampshire population. It is about identifying a clinical pathway for injection drug–related infectious sequelae.
Because of the unique bio-socio-psycho needs of injection drug users, hospitalizations due to injection-related infection sequelae often contribute to increased length of stay, readmission rates, and expenses out of state and federal health care funding. Prolonged stays also result in the waste of tertiary care resources for nontertiary needs, underutilization of regional care resources such as community and critical access hospitals, and increased care burden, as most patients travel long distances to obtain care.
We will pilot and implement a clinical pathway in the medicine units and measure length of stay, readmission rate, patient satisfaction rating, infectious disease provider follow-up rate, and hospitalization cost. I appreciate the grant support from SHM, and am looking forward to working with Dr. Huntington and other providers at DHMC, as well as developing myself professionally.
Yun Li is an MD/MBA student attending Geisel School of Medicine and Tuck School of Business at Dartmouth, Hanover, N.H. She obtained her Bachelor of Arts degree from Hanover College double-majoring in Economics and Biological Chemistry. Ms. Li participated in research in injury epidemiology and genetics, and has conducted studies on traditional Tibetan medicine, rural health, health NGOs, and digital health. Her career interest is practicing hospital medicine and geriatrics as a clinician/administrator, either in the United States or China. Ms. Li is a student member of the Society of Hospital Medicine.
Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
It is not surprising that my medical school – home to a group of passionate thought leaders in health service and policy research, including the Dartmouth Atlas and Accountable Care Organization – required all first-year medical students to take a course called “health care delivery science.”
The course offered me the first glimpse into quality improvement. However, because of a lack of clinical context, much of the course remained theoretical until my clinical years. During the hospital medicine rotation, I took care of a 40-year old patient who was newly diagnosed with metastatic pancreatic cancer. It was challenging to deliver devastatingly bad news. The patient and family, however, were most confused and frustrated by the roles of different specialists and care providers, the purpose and scheduling of procedures, and diet arrangement. I wondered how I could make their experience better.
After several meetings with my mentor, Professor Jonathan Huntington, a hospitalist, MD-PhD researcher, and director of Care Coordination Center at Dartmouth-Hitchcock Medical Center (DHMC), we identified a research area that has rising interest, importance, and relevance to the rural New Hampshire population. It is about identifying a clinical pathway for injection drug–related infectious sequelae.
Because of the unique bio-socio-psycho needs of injection drug users, hospitalizations due to injection-related infection sequelae often contribute to increased length of stay, readmission rates, and expenses out of state and federal health care funding. Prolonged stays also result in the waste of tertiary care resources for nontertiary needs, underutilization of regional care resources such as community and critical access hospitals, and increased care burden, as most patients travel long distances to obtain care.
We will pilot and implement a clinical pathway in the medicine units and measure length of stay, readmission rate, patient satisfaction rating, infectious disease provider follow-up rate, and hospitalization cost. I appreciate the grant support from SHM, and am looking forward to working with Dr. Huntington and other providers at DHMC, as well as developing myself professionally.
Yun Li is an MD/MBA student attending Geisel School of Medicine and Tuck School of Business at Dartmouth, Hanover, N.H. She obtained her Bachelor of Arts degree from Hanover College double-majoring in Economics and Biological Chemistry. Ms. Li participated in research in injury epidemiology and genetics, and has conducted studies on traditional Tibetan medicine, rural health, health NGOs, and digital health. Her career interest is practicing hospital medicine and geriatrics as a clinician/administrator, either in the United States or China. Ms. Li is a student member of the Society of Hospital Medicine.