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Study: Don’t separate NAS infants from moms
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
AT PHM 2017
Key clinical point:
Major finding: Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from, in one study, a mean of almost $45,000 per NAS infant stay to just over $10,000.
Data source: A meta-analysis of six studies.
Disclosures: The investigators had no relevant financial disclosures.
Ivabradine cut mortality in HFrEF patients not on beta-blocker
BARCELONA – The time is right for a placebo-controlled, randomized trial of ivabradine in patients with heart failure with reduced ejection fraction who are unwilling or unable to take a beta-blocker as recommended in the guidelines, John G.F. Cleland, MD, asserted at the annual congress of the European Society of Cardiology.
He cited as the rationale for such a study a new post-hoc analysis of data from the SHIFT trial showing that ivabradine (Corlanor) significantly reduced both cardiovascular and all-cause mortality, as well as hospitalizations for heart failure, in the subset of study participants who weren’t on beta-blocker therapy.
“I think there would be ethical equipoise,” he added. “If patients are unwilling or unable to take a beta-blocker, or their cardiologist feels it’s not in their best interest, then I certainly think a placebo-controlled trial would not only be appropriate, but there’s also an onus on the cardiology community to do such a trial.”
Ivabradine slows heart rate by a unique mechanism that doesn’t involve blockade of adrenergic receptors. In the SHIFT trial (Lancet. 2010 Sep 11;376[9744]:875-85), more than 6,500 patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm and with a heart rate greater than 70 bpm were randomized to ivabradine or placebo on top of guideline-directed medical therapy for heart failure. During a median 23 months of follow-up, heart failure hospitalizations were significantly reduced by 26% in the ivabradine group, although cardiovascular deaths were not significantly affected.
As a result of the SHIFT findings, the drug was approved with an indication for use only in combination with a beta-blocker in patients with HFrEF whose on-treatment heart rate exceeds 70 bpm. Ivabradine is not currently recommended as an alternative to beta-blocker therapy. However, in real-world clinical practice a large number of heart failure patients are not managed with a beta-blocker, the cardiologist noted.
His post-hoc analysis focused on the 685 SHIFT participants who were not on a beta-blocker at randomization. During follow-up, there were 93 deaths among patients who were on placebo and only 71 in those randomized to ivabradine, for a statistically significant 30% reduction in all-cause mortality. Cardiovascular mortality was reduced to a similar extent. These hazard ratios remained similar after adjusting for differences in heart rate and other clinical characteristics.
“Beta-blockers are a highly effective therapy for heart failure with reduced ejection fraction, but the mechanism of benefit remains uncertain. It might simply be due to heart rate reduction. And I would point out that we have no evidence of a dose response for beta-blockers: It may well be that you get most of the effect of a beta-blocker with the lowest dose. Titrating to the full dose of a beta-blocker might only be helpful in that it lowers your heart rate. I would argue that 6.25 mg/day of carvedilol plus ivabradine might be as good as 50 mg twice daily of carvedilol but with much higher patient acceptability. We don’t know,” said Dr. Cleland.
“This is an interesting, hypothesis-generating analysis, and we need confirmation now that ivabradine reduces mortality in heart failure patients who are unwilling or unable to take a beta-blocker,” he concluded.
The SHIFT trial was sponsored by Servier. Dr. Cleland reported serving as a consultant to and receiving research funding from that company and others.
BARCELONA – The time is right for a placebo-controlled, randomized trial of ivabradine in patients with heart failure with reduced ejection fraction who are unwilling or unable to take a beta-blocker as recommended in the guidelines, John G.F. Cleland, MD, asserted at the annual congress of the European Society of Cardiology.
He cited as the rationale for such a study a new post-hoc analysis of data from the SHIFT trial showing that ivabradine (Corlanor) significantly reduced both cardiovascular and all-cause mortality, as well as hospitalizations for heart failure, in the subset of study participants who weren’t on beta-blocker therapy.
“I think there would be ethical equipoise,” he added. “If patients are unwilling or unable to take a beta-blocker, or their cardiologist feels it’s not in their best interest, then I certainly think a placebo-controlled trial would not only be appropriate, but there’s also an onus on the cardiology community to do such a trial.”
Ivabradine slows heart rate by a unique mechanism that doesn’t involve blockade of adrenergic receptors. In the SHIFT trial (Lancet. 2010 Sep 11;376[9744]:875-85), more than 6,500 patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm and with a heart rate greater than 70 bpm were randomized to ivabradine or placebo on top of guideline-directed medical therapy for heart failure. During a median 23 months of follow-up, heart failure hospitalizations were significantly reduced by 26% in the ivabradine group, although cardiovascular deaths were not significantly affected.
As a result of the SHIFT findings, the drug was approved with an indication for use only in combination with a beta-blocker in patients with HFrEF whose on-treatment heart rate exceeds 70 bpm. Ivabradine is not currently recommended as an alternative to beta-blocker therapy. However, in real-world clinical practice a large number of heart failure patients are not managed with a beta-blocker, the cardiologist noted.
His post-hoc analysis focused on the 685 SHIFT participants who were not on a beta-blocker at randomization. During follow-up, there were 93 deaths among patients who were on placebo and only 71 in those randomized to ivabradine, for a statistically significant 30% reduction in all-cause mortality. Cardiovascular mortality was reduced to a similar extent. These hazard ratios remained similar after adjusting for differences in heart rate and other clinical characteristics.
“Beta-blockers are a highly effective therapy for heart failure with reduced ejection fraction, but the mechanism of benefit remains uncertain. It might simply be due to heart rate reduction. And I would point out that we have no evidence of a dose response for beta-blockers: It may well be that you get most of the effect of a beta-blocker with the lowest dose. Titrating to the full dose of a beta-blocker might only be helpful in that it lowers your heart rate. I would argue that 6.25 mg/day of carvedilol plus ivabradine might be as good as 50 mg twice daily of carvedilol but with much higher patient acceptability. We don’t know,” said Dr. Cleland.
“This is an interesting, hypothesis-generating analysis, and we need confirmation now that ivabradine reduces mortality in heart failure patients who are unwilling or unable to take a beta-blocker,” he concluded.
The SHIFT trial was sponsored by Servier. Dr. Cleland reported serving as a consultant to and receiving research funding from that company and others.
BARCELONA – The time is right for a placebo-controlled, randomized trial of ivabradine in patients with heart failure with reduced ejection fraction who are unwilling or unable to take a beta-blocker as recommended in the guidelines, John G.F. Cleland, MD, asserted at the annual congress of the European Society of Cardiology.
He cited as the rationale for such a study a new post-hoc analysis of data from the SHIFT trial showing that ivabradine (Corlanor) significantly reduced both cardiovascular and all-cause mortality, as well as hospitalizations for heart failure, in the subset of study participants who weren’t on beta-blocker therapy.
“I think there would be ethical equipoise,” he added. “If patients are unwilling or unable to take a beta-blocker, or their cardiologist feels it’s not in their best interest, then I certainly think a placebo-controlled trial would not only be appropriate, but there’s also an onus on the cardiology community to do such a trial.”
Ivabradine slows heart rate by a unique mechanism that doesn’t involve blockade of adrenergic receptors. In the SHIFT trial (Lancet. 2010 Sep 11;376[9744]:875-85), more than 6,500 patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm and with a heart rate greater than 70 bpm were randomized to ivabradine or placebo on top of guideline-directed medical therapy for heart failure. During a median 23 months of follow-up, heart failure hospitalizations were significantly reduced by 26% in the ivabradine group, although cardiovascular deaths were not significantly affected.
As a result of the SHIFT findings, the drug was approved with an indication for use only in combination with a beta-blocker in patients with HFrEF whose on-treatment heart rate exceeds 70 bpm. Ivabradine is not currently recommended as an alternative to beta-blocker therapy. However, in real-world clinical practice a large number of heart failure patients are not managed with a beta-blocker, the cardiologist noted.
His post-hoc analysis focused on the 685 SHIFT participants who were not on a beta-blocker at randomization. During follow-up, there were 93 deaths among patients who were on placebo and only 71 in those randomized to ivabradine, for a statistically significant 30% reduction in all-cause mortality. Cardiovascular mortality was reduced to a similar extent. These hazard ratios remained similar after adjusting for differences in heart rate and other clinical characteristics.
“Beta-blockers are a highly effective therapy for heart failure with reduced ejection fraction, but the mechanism of benefit remains uncertain. It might simply be due to heart rate reduction. And I would point out that we have no evidence of a dose response for beta-blockers: It may well be that you get most of the effect of a beta-blocker with the lowest dose. Titrating to the full dose of a beta-blocker might only be helpful in that it lowers your heart rate. I would argue that 6.25 mg/day of carvedilol plus ivabradine might be as good as 50 mg twice daily of carvedilol but with much higher patient acceptability. We don’t know,” said Dr. Cleland.
“This is an interesting, hypothesis-generating analysis, and we need confirmation now that ivabradine reduces mortality in heart failure patients who are unwilling or unable to take a beta-blocker,” he concluded.
The SHIFT trial was sponsored by Servier. Dr. Cleland reported serving as a consultant to and receiving research funding from that company and others.
AT THE ESC CONGRESS 2017
Key clinical point:
Major finding: All-cause mortality was reduced by 30%, compared with placebo, in ivabradine-treated patients with heart failure with reduced ejection fraction who were not on a beta-blocker.
Data source: A post-hoc analysis of the 685 patients in a much larger randomized, placebo-controlled clinical trial of ivabradine in patients with heart failure with reduced ejection fraction.
Disclosures: The SHIFT trial was funded by Servier. The presenter reported serving as a consultant to and recipient of research grants from that and other companies.
Short Takes
Hospitalized-patient one-year mortality risk (HOMR) score an excellent prognostic tool
The HOMR score, derived from administrative data, accurately predicts mortality. This study derived the score from medical records which providers can access and found it still accurately determines 1-year mortality.
Citation: Casey G, van Walraven C. Prognosticating with the hospitalized-patient one-year mortality risk score using information abstracted from the medical record. J Hosp Med. 2017 April; 12(4):224-30.
New drug for C. difficile recurrence
Bezlotoxumab is now approved to reduce recurrence of Clostridium difficile. This is an injectable human monoclonal antibody to C. difficile toxin and must be used in conjunction with antibiotics.
Citation: U.S. Food and Drug Administration. Drug Label. Available online at https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/761046s000lbl.pdf. Accessed 7 May 2017.
Hospitalized-patient one-year mortality risk (HOMR) score an excellent prognostic tool
The HOMR score, derived from administrative data, accurately predicts mortality. This study derived the score from medical records which providers can access and found it still accurately determines 1-year mortality.
Citation: Casey G, van Walraven C. Prognosticating with the hospitalized-patient one-year mortality risk score using information abstracted from the medical record. J Hosp Med. 2017 April; 12(4):224-30.
New drug for C. difficile recurrence
Bezlotoxumab is now approved to reduce recurrence of Clostridium difficile. This is an injectable human monoclonal antibody to C. difficile toxin and must be used in conjunction with antibiotics.
Citation: U.S. Food and Drug Administration. Drug Label. Available online at https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/761046s000lbl.pdf. Accessed 7 May 2017.
Hospitalized-patient one-year mortality risk (HOMR) score an excellent prognostic tool
The HOMR score, derived from administrative data, accurately predicts mortality. This study derived the score from medical records which providers can access and found it still accurately determines 1-year mortality.
Citation: Casey G, van Walraven C. Prognosticating with the hospitalized-patient one-year mortality risk score using information abstracted from the medical record. J Hosp Med. 2017 April; 12(4):224-30.
New drug for C. difficile recurrence
Bezlotoxumab is now approved to reduce recurrence of Clostridium difficile. This is an injectable human monoclonal antibody to C. difficile toxin and must be used in conjunction with antibiotics.
Citation: U.S. Food and Drug Administration. Drug Label. Available online at https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/761046s000lbl.pdf. Accessed 7 May 2017.
Heart failure guidelines updated
Clinical Question: What new evidence is available to guide heart failure (HF) management?
Background: New data has become available since the 2013 HF guidelines.
Study Design: A focused update.
Setting: Ongoing review of HF literature.
Synopsis: Beta-natriuretic peptide (BNP) is recommended to screen at risk patients (IIaB), on admission (IA), and prior to discharge (IIaB). The combination of ARB and neprilysin inhibitor (ARB-NI) is recommended in symptomatic patients with HF with reduced ejection fraction (HFrEF) who are tolerant of ACE inhibition (IB). For these patients, transitioning from ACE-inhibitor to the ARB-NI combination, valsartan-sacubitril significantly reduced hospitalization and mortality. Optimal dose and titration strategies remain unclear. ARB-NIs should not be used in patients with a history of angioedema (IIIC) or within 36 hours of receiving ACE-inhibitors (IIIB). Ivabradine, a selective inhibitor of the If current in the sinoatrial node, is recommended to reduce hospitalizations for patients with HFrEF with stable symptoms with resting sinus heart rate greater than or equal to 70 despite maximally-tolerated beta-blockade (IIaB). Intravenous iron replacement is recommended to improve function and quality of life for patients with symptomatic HF and iron deficiency (IIbB).
Bottom Line: Updates support use of BNP, ARB-NIs, ivabradine, and IV iron for HFrEF.
Citation: Yancy CW, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart failure society of America. Published online, 2017 Apr 28. Circulation. doi: 10.1161/CIR.0000000000000509.
Dr. Sweigart is an assistant professor in the University of Kentucky division of hospital medicine and Lexington VA Medical Center.
Clinical Question: What new evidence is available to guide heart failure (HF) management?
Background: New data has become available since the 2013 HF guidelines.
Study Design: A focused update.
Setting: Ongoing review of HF literature.
Synopsis: Beta-natriuretic peptide (BNP) is recommended to screen at risk patients (IIaB), on admission (IA), and prior to discharge (IIaB). The combination of ARB and neprilysin inhibitor (ARB-NI) is recommended in symptomatic patients with HF with reduced ejection fraction (HFrEF) who are tolerant of ACE inhibition (IB). For these patients, transitioning from ACE-inhibitor to the ARB-NI combination, valsartan-sacubitril significantly reduced hospitalization and mortality. Optimal dose and titration strategies remain unclear. ARB-NIs should not be used in patients with a history of angioedema (IIIC) or within 36 hours of receiving ACE-inhibitors (IIIB). Ivabradine, a selective inhibitor of the If current in the sinoatrial node, is recommended to reduce hospitalizations for patients with HFrEF with stable symptoms with resting sinus heart rate greater than or equal to 70 despite maximally-tolerated beta-blockade (IIaB). Intravenous iron replacement is recommended to improve function and quality of life for patients with symptomatic HF and iron deficiency (IIbB).
Bottom Line: Updates support use of BNP, ARB-NIs, ivabradine, and IV iron for HFrEF.
Citation: Yancy CW, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart failure society of America. Published online, 2017 Apr 28. Circulation. doi: 10.1161/CIR.0000000000000509.
Dr. Sweigart is an assistant professor in the University of Kentucky division of hospital medicine and Lexington VA Medical Center.
Clinical Question: What new evidence is available to guide heart failure (HF) management?
Background: New data has become available since the 2013 HF guidelines.
Study Design: A focused update.
Setting: Ongoing review of HF literature.
Synopsis: Beta-natriuretic peptide (BNP) is recommended to screen at risk patients (IIaB), on admission (IA), and prior to discharge (IIaB). The combination of ARB and neprilysin inhibitor (ARB-NI) is recommended in symptomatic patients with HF with reduced ejection fraction (HFrEF) who are tolerant of ACE inhibition (IB). For these patients, transitioning from ACE-inhibitor to the ARB-NI combination, valsartan-sacubitril significantly reduced hospitalization and mortality. Optimal dose and titration strategies remain unclear. ARB-NIs should not be used in patients with a history of angioedema (IIIC) or within 36 hours of receiving ACE-inhibitors (IIIB). Ivabradine, a selective inhibitor of the If current in the sinoatrial node, is recommended to reduce hospitalizations for patients with HFrEF with stable symptoms with resting sinus heart rate greater than or equal to 70 despite maximally-tolerated beta-blockade (IIaB). Intravenous iron replacement is recommended to improve function and quality of life for patients with symptomatic HF and iron deficiency (IIbB).
Bottom Line: Updates support use of BNP, ARB-NIs, ivabradine, and IV iron for HFrEF.
Citation: Yancy CW, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart failure society of America. Published online, 2017 Apr 28. Circulation. doi: 10.1161/CIR.0000000000000509.
Dr. Sweigart is an assistant professor in the University of Kentucky division of hospital medicine and Lexington VA Medical Center.
Triple therapy reduces exacerbations in patients with symptomatic COPD
Clinical Question: Does triple therapy (long-acting beta2-agonist, long-acting muscarinic antagonist, and inhaled corticosteroid) reduce exacerbations in patients with symptomatic chronic obstructive pulmonary disease (COPD)?
Background: Guidelines from GOLD and NICE recommend considering a step-up to triple therapy for patients with refractory COPD symptoms or exacerbations. However, it is unknown if this reduces the long term risk of exacerbations.
Study Design: A randomized controlled trial.
Synopsis: This study enrolled 2,691 patients with COPD, severe airflow restriction (FEV1 less than 50%), significant symptoms (CAT score greater than or equal to 10), and at least one exacerbation in the past year. Participants were randomized to a novel three-agent inhaler (containing an extrafine formulation of beclomethasone, formoterol, and glycopyrronium), an “open triple” regimen including beclomethasone/formoterol plus tiotropium, or to tiotropium alone.
During 52 weeks of treatment, the triple therapy regimens significantly reduced moderate to severe COPD exacerbations, compared with tiotropium alone, with annualized exacerbation rates of 0.46 (95% confidence interval, 0.41-0.51), 0.45 (0.39-0.52), and 0.57 (0.52-0.63), respectively. Rates of adverse events were similar between all three groups.
Bottom Line: Triple therapy was superior to tiotropium alone for reducing exacerbations in patients with symptomatic COPD. The two triple therapy regimens studied did not significantly differ in efficacy.
Citation: Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): A double-blind, parallel group, randomized controlled trial. Lancet. 2017;389(10082):1919-29.
Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.
Clinical Question: Does triple therapy (long-acting beta2-agonist, long-acting muscarinic antagonist, and inhaled corticosteroid) reduce exacerbations in patients with symptomatic chronic obstructive pulmonary disease (COPD)?
Background: Guidelines from GOLD and NICE recommend considering a step-up to triple therapy for patients with refractory COPD symptoms or exacerbations. However, it is unknown if this reduces the long term risk of exacerbations.
Study Design: A randomized controlled trial.
Synopsis: This study enrolled 2,691 patients with COPD, severe airflow restriction (FEV1 less than 50%), significant symptoms (CAT score greater than or equal to 10), and at least one exacerbation in the past year. Participants were randomized to a novel three-agent inhaler (containing an extrafine formulation of beclomethasone, formoterol, and glycopyrronium), an “open triple” regimen including beclomethasone/formoterol plus tiotropium, or to tiotropium alone.
During 52 weeks of treatment, the triple therapy regimens significantly reduced moderate to severe COPD exacerbations, compared with tiotropium alone, with annualized exacerbation rates of 0.46 (95% confidence interval, 0.41-0.51), 0.45 (0.39-0.52), and 0.57 (0.52-0.63), respectively. Rates of adverse events were similar between all three groups.
Bottom Line: Triple therapy was superior to tiotropium alone for reducing exacerbations in patients with symptomatic COPD. The two triple therapy regimens studied did not significantly differ in efficacy.
Citation: Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): A double-blind, parallel group, randomized controlled trial. Lancet. 2017;389(10082):1919-29.
Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.
Clinical Question: Does triple therapy (long-acting beta2-agonist, long-acting muscarinic antagonist, and inhaled corticosteroid) reduce exacerbations in patients with symptomatic chronic obstructive pulmonary disease (COPD)?
Background: Guidelines from GOLD and NICE recommend considering a step-up to triple therapy for patients with refractory COPD symptoms or exacerbations. However, it is unknown if this reduces the long term risk of exacerbations.
Study Design: A randomized controlled trial.
Synopsis: This study enrolled 2,691 patients with COPD, severe airflow restriction (FEV1 less than 50%), significant symptoms (CAT score greater than or equal to 10), and at least one exacerbation in the past year. Participants were randomized to a novel three-agent inhaler (containing an extrafine formulation of beclomethasone, formoterol, and glycopyrronium), an “open triple” regimen including beclomethasone/formoterol plus tiotropium, or to tiotropium alone.
During 52 weeks of treatment, the triple therapy regimens significantly reduced moderate to severe COPD exacerbations, compared with tiotropium alone, with annualized exacerbation rates of 0.46 (95% confidence interval, 0.41-0.51), 0.45 (0.39-0.52), and 0.57 (0.52-0.63), respectively. Rates of adverse events were similar between all three groups.
Bottom Line: Triple therapy was superior to tiotropium alone for reducing exacerbations in patients with symptomatic COPD. The two triple therapy regimens studied did not significantly differ in efficacy.
Citation: Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): A double-blind, parallel group, randomized controlled trial. Lancet. 2017;389(10082):1919-29.
Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.
Bridging clinical medicine, research, and quality
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 longitudinal (18-month) program, recipients are required to write about their experiences on a monthly basis.
I am a third-year medical student at the University of California, San Diego, as well as a recipient of the SHM Longitudinal Scholar Grant. Ultimately, I intend to pursue a career in academic medicine as a clinician-scientist, where I hope to bridge my interests in neuroscience, research, and clinical medicine.
Prior to entering medical school, I participated in a wide array of basic science, translational, and clinical research projects, but none in the area of quality improvement (QI). Given the breadth of my previous research experiences, an attractive feature of the SHM Hospitalist grant was the opportunity to complement this breadth of research exposure with increasing depth by exploring a QI project.
This year, I’ll be getting my first exposure to a QI project under the fine mentorship of Ian Jenkins, MD, SFHM, an attending in the division of hospital medicine at UCSD, who is working on an ongoing effort to combat catheter–associated urinary tract infections (CAUTI). Methods for reducing CAUTI include reducing indwelling urinary catheter (IUC) placement, performing proper maintenance of IUCs, and ensuring prompt removal of unnecessary urinary catheters.
Our project aims to combine all three approaches, along with staff education on IUC management and IUC alternatives. We plan to perform a “measure-vention,” or real-time monitoring and correction of defects by examining the rate of CAUTI as well as the percentage IUC utilization rate in participating units. Ultimately, we hope to optimize patient comfort and publicize our experience to help other health care facilities reduce IUC use and CAUTI.
I am excited to see how basic interventions, such as education and measure-vention can drive the development of improved health outcomes and quality patient care.
Victor Ekuta is a third-year medical student at the University of California, San Diego.
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 longitudinal (18-month) program, recipients are required to write about their experiences on a monthly basis.
I am a third-year medical student at the University of California, San Diego, as well as a recipient of the SHM Longitudinal Scholar Grant. Ultimately, I intend to pursue a career in academic medicine as a clinician-scientist, where I hope to bridge my interests in neuroscience, research, and clinical medicine.
Prior to entering medical school, I participated in a wide array of basic science, translational, and clinical research projects, but none in the area of quality improvement (QI). Given the breadth of my previous research experiences, an attractive feature of the SHM Hospitalist grant was the opportunity to complement this breadth of research exposure with increasing depth by exploring a QI project.
This year, I’ll be getting my first exposure to a QI project under the fine mentorship of Ian Jenkins, MD, SFHM, an attending in the division of hospital medicine at UCSD, who is working on an ongoing effort to combat catheter–associated urinary tract infections (CAUTI). Methods for reducing CAUTI include reducing indwelling urinary catheter (IUC) placement, performing proper maintenance of IUCs, and ensuring prompt removal of unnecessary urinary catheters.
Our project aims to combine all three approaches, along with staff education on IUC management and IUC alternatives. We plan to perform a “measure-vention,” or real-time monitoring and correction of defects by examining the rate of CAUTI as well as the percentage IUC utilization rate in participating units. Ultimately, we hope to optimize patient comfort and publicize our experience to help other health care facilities reduce IUC use and CAUTI.
I am excited to see how basic interventions, such as education and measure-vention can drive the development of improved health outcomes and quality patient care.
Victor Ekuta is a third-year medical student at the University of California, San Diego.
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 longitudinal (18-month) program, recipients are required to write about their experiences on a monthly basis.
I am a third-year medical student at the University of California, San Diego, as well as a recipient of the SHM Longitudinal Scholar Grant. Ultimately, I intend to pursue a career in academic medicine as a clinician-scientist, where I hope to bridge my interests in neuroscience, research, and clinical medicine.
Prior to entering medical school, I participated in a wide array of basic science, translational, and clinical research projects, but none in the area of quality improvement (QI). Given the breadth of my previous research experiences, an attractive feature of the SHM Hospitalist grant was the opportunity to complement this breadth of research exposure with increasing depth by exploring a QI project.
This year, I’ll be getting my first exposure to a QI project under the fine mentorship of Ian Jenkins, MD, SFHM, an attending in the division of hospital medicine at UCSD, who is working on an ongoing effort to combat catheter–associated urinary tract infections (CAUTI). Methods for reducing CAUTI include reducing indwelling urinary catheter (IUC) placement, performing proper maintenance of IUCs, and ensuring prompt removal of unnecessary urinary catheters.
Our project aims to combine all three approaches, along with staff education on IUC management and IUC alternatives. We plan to perform a “measure-vention,” or real-time monitoring and correction of defects by examining the rate of CAUTI as well as the percentage IUC utilization rate in participating units. Ultimately, we hope to optimize patient comfort and publicize our experience to help other health care facilities reduce IUC use and CAUTI.
I am excited to see how basic interventions, such as education and measure-vention can drive the development of improved health outcomes and quality patient care.
Victor Ekuta is a third-year medical student at the University of California, San Diego.
HEART score can safely identify low risk chest pain
Clinical Question: Can the HEART score risk stratify emergency department patients with chest pain?
Background: Many patients with chest pain are subjected to unnecessary admission and testing. The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score can accurately predict outcomes in chest pain patients, though it has undergone limited evaluation in real world settings.
Setting: Nine emergency departments in the Netherlands.
Synopsis: All sites started by providing usual care, then sequentially switched over to use of the HEART score to guide treatment. HEART care recommended early discharge if low risk (HEART score, 0-3), admission and further testing if intermediate risk (4-6), and early invasive testing if high risk (7-10).
The study included 3,648 adults presenting with chest pain. The HEART score was noninferior to usual care for the safety outcome of major adverse cardiovascular events (MACE) within 6 weeks. Only 2.0% of low risk patients experienced MACE, though 41% of these patients were still admitted or sent for further testing, and reduction in health care cost was minimal.
Bottom Line: The HEART score accurately predicted risk in patients with chest pain, but a significant portion of low risk patients underwent further testing anyway.
Citation: Poldervaart JM, Reitsma JB, Backus BE, et al. Effect of using the HEART score in patients with chest pain in the emergency department. Ann Intern Med. 2017 May 16;166(10):689-97.
Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.
Clinical Question: Can the HEART score risk stratify emergency department patients with chest pain?
Background: Many patients with chest pain are subjected to unnecessary admission and testing. The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score can accurately predict outcomes in chest pain patients, though it has undergone limited evaluation in real world settings.
Setting: Nine emergency departments in the Netherlands.
Synopsis: All sites started by providing usual care, then sequentially switched over to use of the HEART score to guide treatment. HEART care recommended early discharge if low risk (HEART score, 0-3), admission and further testing if intermediate risk (4-6), and early invasive testing if high risk (7-10).
The study included 3,648 adults presenting with chest pain. The HEART score was noninferior to usual care for the safety outcome of major adverse cardiovascular events (MACE) within 6 weeks. Only 2.0% of low risk patients experienced MACE, though 41% of these patients were still admitted or sent for further testing, and reduction in health care cost was minimal.
Bottom Line: The HEART score accurately predicted risk in patients with chest pain, but a significant portion of low risk patients underwent further testing anyway.
Citation: Poldervaart JM, Reitsma JB, Backus BE, et al. Effect of using the HEART score in patients with chest pain in the emergency department. Ann Intern Med. 2017 May 16;166(10):689-97.
Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.
Clinical Question: Can the HEART score risk stratify emergency department patients with chest pain?
Background: Many patients with chest pain are subjected to unnecessary admission and testing. The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score can accurately predict outcomes in chest pain patients, though it has undergone limited evaluation in real world settings.
Setting: Nine emergency departments in the Netherlands.
Synopsis: All sites started by providing usual care, then sequentially switched over to use of the HEART score to guide treatment. HEART care recommended early discharge if low risk (HEART score, 0-3), admission and further testing if intermediate risk (4-6), and early invasive testing if high risk (7-10).
The study included 3,648 adults presenting with chest pain. The HEART score was noninferior to usual care for the safety outcome of major adverse cardiovascular events (MACE) within 6 weeks. Only 2.0% of low risk patients experienced MACE, though 41% of these patients were still admitted or sent for further testing, and reduction in health care cost was minimal.
Bottom Line: The HEART score accurately predicted risk in patients with chest pain, but a significant portion of low risk patients underwent further testing anyway.
Citation: Poldervaart JM, Reitsma JB, Backus BE, et al. Effect of using the HEART score in patients with chest pain in the emergency department. Ann Intern Med. 2017 May 16;166(10):689-97.
Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.
Using EHR data to predict post-acute care placement
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 longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
When patients are admitted to the hospital, the focus for the first 24 hours is on the work-up: What do the data point values tell you about how sick this patient is, and what will they need to get better? While the goal for this information is to develop the appropriate treatment and management for the patient’s acute problem, it could be leveraged to help with other parts of the patient’s hospital stay as well. In particular, it could help avoid unnecessarily long stays in the hospital caused by patients’ waiting for a bed at a lower level of care.
My research mentor, Eduard Vasilevskis, MD, created a rough scoring system for predicting post-acute care placement using admission data, just based on his clinical gestalt. Even at this preliminary stage, the model has already functioned well without much refinement; however a validated, statistically robust model could potentially transform the way that we initiate the discharge planning process. Jesse Ehrenfeld, MD has helped us develop it further by giving us access to a curated database of deidentified EHR data, which contains all of the variables we would like to assess.
The strengths of this potential model are manifold. First, it relies on data collected early in the patient’s hospital course. Second, it relies on routinely collected information (both at our home institution and elsewhere, making it potentially generalizable). And third, it relies on objective patient data rather than requiring providers use their impressions of the patients’ functional status to guess whether they will require discharge planning services. Although such prediction models have been generated before, this model would be among the first to incorporate information routinely collected by nursing staff, such as the Braden Scale, instead of relying on additional instruments or surveys. In addition to predicting placement destination, the model may also be predictive of in-hospital mortality.
With this information, we hope to give hospital teams an additional tool to help mobilize resources toward patients who need the most attention – not just while they’re in the hospital, but also on their way out.
Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.
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 longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
When patients are admitted to the hospital, the focus for the first 24 hours is on the work-up: What do the data point values tell you about how sick this patient is, and what will they need to get better? While the goal for this information is to develop the appropriate treatment and management for the patient’s acute problem, it could be leveraged to help with other parts of the patient’s hospital stay as well. In particular, it could help avoid unnecessarily long stays in the hospital caused by patients’ waiting for a bed at a lower level of care.
My research mentor, Eduard Vasilevskis, MD, created a rough scoring system for predicting post-acute care placement using admission data, just based on his clinical gestalt. Even at this preliminary stage, the model has already functioned well without much refinement; however a validated, statistically robust model could potentially transform the way that we initiate the discharge planning process. Jesse Ehrenfeld, MD has helped us develop it further by giving us access to a curated database of deidentified EHR data, which contains all of the variables we would like to assess.
The strengths of this potential model are manifold. First, it relies on data collected early in the patient’s hospital course. Second, it relies on routinely collected information (both at our home institution and elsewhere, making it potentially generalizable). And third, it relies on objective patient data rather than requiring providers use their impressions of the patients’ functional status to guess whether they will require discharge planning services. Although such prediction models have been generated before, this model would be among the first to incorporate information routinely collected by nursing staff, such as the Braden Scale, instead of relying on additional instruments or surveys. In addition to predicting placement destination, the model may also be predictive of in-hospital mortality.
With this information, we hope to give hospital teams an additional tool to help mobilize resources toward patients who need the most attention – not just while they’re in the hospital, but also on their way out.
Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.
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 longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
When patients are admitted to the hospital, the focus for the first 24 hours is on the work-up: What do the data point values tell you about how sick this patient is, and what will they need to get better? While the goal for this information is to develop the appropriate treatment and management for the patient’s acute problem, it could be leveraged to help with other parts of the patient’s hospital stay as well. In particular, it could help avoid unnecessarily long stays in the hospital caused by patients’ waiting for a bed at a lower level of care.
My research mentor, Eduard Vasilevskis, MD, created a rough scoring system for predicting post-acute care placement using admission data, just based on his clinical gestalt. Even at this preliminary stage, the model has already functioned well without much refinement; however a validated, statistically robust model could potentially transform the way that we initiate the discharge planning process. Jesse Ehrenfeld, MD has helped us develop it further by giving us access to a curated database of deidentified EHR data, which contains all of the variables we would like to assess.
The strengths of this potential model are manifold. First, it relies on data collected early in the patient’s hospital course. Second, it relies on routinely collected information (both at our home institution and elsewhere, making it potentially generalizable). And third, it relies on objective patient data rather than requiring providers use their impressions of the patients’ functional status to guess whether they will require discharge planning services. Although such prediction models have been generated before, this model would be among the first to incorporate information routinely collected by nursing staff, such as the Braden Scale, instead of relying on additional instruments or surveys. In addition to predicting placement destination, the model may also be predictive of in-hospital mortality.
With this information, we hope to give hospital teams an additional tool to help mobilize resources toward patients who need the most attention – not just while they’re in the hospital, but also on their way out.
Monisha Bhatia, a native of Nashville, Tenn., is a fourth-year medical student at Vanderbilt University in Nashville. She is hoping to pursue either a residency in internal medicine or a combined internal medicine/emergency medicine program. Prior to medical school, she completed a JD/MPH program at Boston University, and she hopes to use her legal training in working with regulatory authorities to improve access to health care for all Americans.
Prediction tool for mortality after respiratory compromise
Background: Scoring systems exist to predict outcomes following cardiac arrest. There is currently no reliable model to predict outcome of patients who have survived acute respiratory compromise (ARC).
Study Design: A retrospective cohort study.
Setting: Get with the Guidelines Resuscitation (GWTG-R) is an online medical registry that tracks ARC data from more than 300 hospitals.
Synopsis: Using the GWTG-R database of ARC, researchers identified 13,193 cases of ARC to study the variables affecting prognosis. They randomized the group into derivation (75% of patients) and validation (25% of patients) cohorts and used c-statistics to create the prognostic scoring system. The greatest predictors of in-hospital mortality were age greater than 80 years, hypotension in the four hours preceding the ARC event, and the need for intubation.
This scoring system did not take into account any comorbidities (such as organ failure) that occurred shortly after the ARC event, although these likely affect mortality.
Bottom Line: Predicting in-hospital mortality for survivors of ARC events may help clinical prognostication. Such tools could also facilitate comparisons between hospitals and guide quality improvement projects.
Citation: Moskowitz A, Anderson LW, Karlsson M, et. al. Predicting in-hospital mortality for initial survivors of acute respiratory compromise (ARC) events: Development and validation of the ARC score. Resuscitation. 2017 Jun;115:5-10.
Dr. Suman is clinical instructor of medicine in the University of Kentucky division of hospital medicine.
Background: Scoring systems exist to predict outcomes following cardiac arrest. There is currently no reliable model to predict outcome of patients who have survived acute respiratory compromise (ARC).
Study Design: A retrospective cohort study.
Setting: Get with the Guidelines Resuscitation (GWTG-R) is an online medical registry that tracks ARC data from more than 300 hospitals.
Synopsis: Using the GWTG-R database of ARC, researchers identified 13,193 cases of ARC to study the variables affecting prognosis. They randomized the group into derivation (75% of patients) and validation (25% of patients) cohorts and used c-statistics to create the prognostic scoring system. The greatest predictors of in-hospital mortality were age greater than 80 years, hypotension in the four hours preceding the ARC event, and the need for intubation.
This scoring system did not take into account any comorbidities (such as organ failure) that occurred shortly after the ARC event, although these likely affect mortality.
Bottom Line: Predicting in-hospital mortality for survivors of ARC events may help clinical prognostication. Such tools could also facilitate comparisons between hospitals and guide quality improvement projects.
Citation: Moskowitz A, Anderson LW, Karlsson M, et. al. Predicting in-hospital mortality for initial survivors of acute respiratory compromise (ARC) events: Development and validation of the ARC score. Resuscitation. 2017 Jun;115:5-10.
Dr. Suman is clinical instructor of medicine in the University of Kentucky division of hospital medicine.
Background: Scoring systems exist to predict outcomes following cardiac arrest. There is currently no reliable model to predict outcome of patients who have survived acute respiratory compromise (ARC).
Study Design: A retrospective cohort study.
Setting: Get with the Guidelines Resuscitation (GWTG-R) is an online medical registry that tracks ARC data from more than 300 hospitals.
Synopsis: Using the GWTG-R database of ARC, researchers identified 13,193 cases of ARC to study the variables affecting prognosis. They randomized the group into derivation (75% of patients) and validation (25% of patients) cohorts and used c-statistics to create the prognostic scoring system. The greatest predictors of in-hospital mortality were age greater than 80 years, hypotension in the four hours preceding the ARC event, and the need for intubation.
This scoring system did not take into account any comorbidities (such as organ failure) that occurred shortly after the ARC event, although these likely affect mortality.
Bottom Line: Predicting in-hospital mortality for survivors of ARC events may help clinical prognostication. Such tools could also facilitate comparisons between hospitals and guide quality improvement projects.
Citation: Moskowitz A, Anderson LW, Karlsson M, et. al. Predicting in-hospital mortality for initial survivors of acute respiratory compromise (ARC) events: Development and validation of the ARC score. Resuscitation. 2017 Jun;115:5-10.
Dr. Suman is clinical instructor of medicine in the University of Kentucky division of hospital medicine.
VIP services linked to unnecessary care
Clinical Question: Does “very important person” (VIP) status impact physician decision making and lead to unnecessary care?
Background: In many centers, VIP patients avail VIP services, which involve extra services beyond the standard of care. No prior studies assess the impact of such VIP services on these patients.
Setting: Centers associated with the Hospital Medicine Reengineering Network (HOMERuN).
Synopsis: Of the 160 hospitalists across eight sites, 45% felt that VIP services were present at their hospital. These patients often had personal ties with the hospital. The majority of hospitalists (78%) felt VIP patients received similar medical care, compared with non-VIP patients. However, 63% felt pressured by VIP patients or families to order unnecessary tests. Moreover, 36% perceived pressure from hospital administration to comply with VIP patient wishes. Most hospitalists (56%) reported being more likely to comply with requests from VIP patients than from other patients.
The survey questions were not validated, so the responses might not reflect actual perceptions of hospitalists. These results are purely qualitative, so the burden of unnecessary care cannot be quantified.
Bottom Line: Most hospitalists perceive VIP services to lead to pressure to deliver unnecessary care.
Citation: Allen-Dicker J, Auerbach A, Herzig SJ. Perceived Safety and Value of Inpatient “Very Important Person” Services. J Hosp Med. 2017 Mar;12(3):177-179.
Dr. Suman is clinical instructor of medicine in the University of Kentucky division of hospital medicine.
Clinical Question: Does “very important person” (VIP) status impact physician decision making and lead to unnecessary care?
Background: In many centers, VIP patients avail VIP services, which involve extra services beyond the standard of care. No prior studies assess the impact of such VIP services on these patients.
Setting: Centers associated with the Hospital Medicine Reengineering Network (HOMERuN).
Synopsis: Of the 160 hospitalists across eight sites, 45% felt that VIP services were present at their hospital. These patients often had personal ties with the hospital. The majority of hospitalists (78%) felt VIP patients received similar medical care, compared with non-VIP patients. However, 63% felt pressured by VIP patients or families to order unnecessary tests. Moreover, 36% perceived pressure from hospital administration to comply with VIP patient wishes. Most hospitalists (56%) reported being more likely to comply with requests from VIP patients than from other patients.
The survey questions were not validated, so the responses might not reflect actual perceptions of hospitalists. These results are purely qualitative, so the burden of unnecessary care cannot be quantified.
Bottom Line: Most hospitalists perceive VIP services to lead to pressure to deliver unnecessary care.
Citation: Allen-Dicker J, Auerbach A, Herzig SJ. Perceived Safety and Value of Inpatient “Very Important Person” Services. J Hosp Med. 2017 Mar;12(3):177-179.
Dr. Suman is clinical instructor of medicine in the University of Kentucky division of hospital medicine.
Clinical Question: Does “very important person” (VIP) status impact physician decision making and lead to unnecessary care?
Background: In many centers, VIP patients avail VIP services, which involve extra services beyond the standard of care. No prior studies assess the impact of such VIP services on these patients.
Setting: Centers associated with the Hospital Medicine Reengineering Network (HOMERuN).
Synopsis: Of the 160 hospitalists across eight sites, 45% felt that VIP services were present at their hospital. These patients often had personal ties with the hospital. The majority of hospitalists (78%) felt VIP patients received similar medical care, compared with non-VIP patients. However, 63% felt pressured by VIP patients or families to order unnecessary tests. Moreover, 36% perceived pressure from hospital administration to comply with VIP patient wishes. Most hospitalists (56%) reported being more likely to comply with requests from VIP patients than from other patients.
The survey questions were not validated, so the responses might not reflect actual perceptions of hospitalists. These results are purely qualitative, so the burden of unnecessary care cannot be quantified.
Bottom Line: Most hospitalists perceive VIP services to lead to pressure to deliver unnecessary care.
Citation: Allen-Dicker J, Auerbach A, Herzig SJ. Perceived Safety and Value of Inpatient “Very Important Person” Services. J Hosp Med. 2017 Mar;12(3):177-179.
Dr. Suman is clinical instructor of medicine in the University of Kentucky division of hospital medicine.