User login
Readmission rates after passage of the hospital readmissions reduction program
CLINICAL QUESTION: Did hospitals receiving the highest penalties for readmissions have accelerated improvement in this metric after passage of Medicare Hospital Readmissions Reduction Program (HRRP)?
BACKGROUND: Medicare passed the HRRP to incentivize reductions in readmission rates. The impact of penalties on relative hospital improvement rates remains unknown.
SETTING: Query of national Medicare Provider Analysis and Review files.
SYNOPSIS: 2,868 hospitals were identified as candidates for analysis and were stratified into four risk groups based on penalty size under HRRP: highest-performing, average-performing, low-performing, and lowest-performing. The primary outcomes were hospital-specific, 30-day, all-cause risk-standardized readmission rates (RSRRs) for patients discharged with acute MI, HF, or pneumonia. The investigators separated data into a pre-law period and post-law period. They fitted a logistic regression model to pre-law RSRRs and developed a piecewise linear model on post-law RSRRs with pre-law data as the dependent variable. All hospital groups had reductions in RSRRs, with the lowest quartile demonstrating greatest improvement.
BOTTOM LINE: HRRP has resulted in reductions in RSRRs with greatest improvement in hospitals with lowest pre-law performance.
CITATIONS: Wasfy JH, Zigler CM, Choirat C, et al. Readmission rates after passage of the hospital readmissions reduction program: a pre-post analysis. Ann Intern Med. 2017 Mar;166(5):324-31.
Dr. Patil is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Did hospitals receiving the highest penalties for readmissions have accelerated improvement in this metric after passage of Medicare Hospital Readmissions Reduction Program (HRRP)?
BACKGROUND: Medicare passed the HRRP to incentivize reductions in readmission rates. The impact of penalties on relative hospital improvement rates remains unknown.
SETTING: Query of national Medicare Provider Analysis and Review files.
SYNOPSIS: 2,868 hospitals were identified as candidates for analysis and were stratified into four risk groups based on penalty size under HRRP: highest-performing, average-performing, low-performing, and lowest-performing. The primary outcomes were hospital-specific, 30-day, all-cause risk-standardized readmission rates (RSRRs) for patients discharged with acute MI, HF, or pneumonia. The investigators separated data into a pre-law period and post-law period. They fitted a logistic regression model to pre-law RSRRs and developed a piecewise linear model on post-law RSRRs with pre-law data as the dependent variable. All hospital groups had reductions in RSRRs, with the lowest quartile demonstrating greatest improvement.
BOTTOM LINE: HRRP has resulted in reductions in RSRRs with greatest improvement in hospitals with lowest pre-law performance.
CITATIONS: Wasfy JH, Zigler CM, Choirat C, et al. Readmission rates after passage of the hospital readmissions reduction program: a pre-post analysis. Ann Intern Med. 2017 Mar;166(5):324-31.
Dr. Patil is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Did hospitals receiving the highest penalties for readmissions have accelerated improvement in this metric after passage of Medicare Hospital Readmissions Reduction Program (HRRP)?
BACKGROUND: Medicare passed the HRRP to incentivize reductions in readmission rates. The impact of penalties on relative hospital improvement rates remains unknown.
SETTING: Query of national Medicare Provider Analysis and Review files.
SYNOPSIS: 2,868 hospitals were identified as candidates for analysis and were stratified into four risk groups based on penalty size under HRRP: highest-performing, average-performing, low-performing, and lowest-performing. The primary outcomes were hospital-specific, 30-day, all-cause risk-standardized readmission rates (RSRRs) for patients discharged with acute MI, HF, or pneumonia. The investigators separated data into a pre-law period and post-law period. They fitted a logistic regression model to pre-law RSRRs and developed a piecewise linear model on post-law RSRRs with pre-law data as the dependent variable. All hospital groups had reductions in RSRRs, with the lowest quartile demonstrating greatest improvement.
BOTTOM LINE: HRRP has resulted in reductions in RSRRs with greatest improvement in hospitals with lowest pre-law performance.
CITATIONS: Wasfy JH, Zigler CM, Choirat C, et al. Readmission rates after passage of the hospital readmissions reduction program: a pre-post analysis. Ann Intern Med. 2017 Mar;166(5):324-31.
Dr. Patil is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Assessment of goals of care in nursing home reduces hospitalization for patients with dementia
CLINICAL QUESTION: For patients with advanced dementia, does a goals-of-care intervention improve communication and care outcomes?
STUDY DESIGN: Single-blind cluster randomized trial.
SETTING: Twenty-two nursing homes in North Carolina.
SYNOPSIS: Three hundred and two patient/families enrolled. Intervention included video and print decision aids followed by a structured goals of care discussion with trained nursing home staff. Quality of communication results, the primary outcome, at 3 months were mixed. Family perception of communication with nursing home staff was better in the intervention. Family–health care provider concordance on primary goal of care and treatment consistent with preferences were not significantly different. By the end of the study at 9 months there was no difference in symptom control but some secondary outcomes were encouraging including greater completion of MOST advanced directives (35% vs. 16%; P = .05) and half as many hospital transfers. Multiple comparisons merits future verification of secondary outcome findings.
BOTTOM LINE: Goals of care discussions for patients with advanced dementia appears to reduce hospitalizations.
CITATIONS: Hanson LC, Zimmerman S, Song MK, et al. Effect of the goals of care intervention for advanced dementia: a randomized clinical trial. JAMA Intern Med. 2017 Jan;177:24-31.
Dr. Cumbler is the associate chief of hospital medicine, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: For patients with advanced dementia, does a goals-of-care intervention improve communication and care outcomes?
STUDY DESIGN: Single-blind cluster randomized trial.
SETTING: Twenty-two nursing homes in North Carolina.
SYNOPSIS: Three hundred and two patient/families enrolled. Intervention included video and print decision aids followed by a structured goals of care discussion with trained nursing home staff. Quality of communication results, the primary outcome, at 3 months were mixed. Family perception of communication with nursing home staff was better in the intervention. Family–health care provider concordance on primary goal of care and treatment consistent with preferences were not significantly different. By the end of the study at 9 months there was no difference in symptom control but some secondary outcomes were encouraging including greater completion of MOST advanced directives (35% vs. 16%; P = .05) and half as many hospital transfers. Multiple comparisons merits future verification of secondary outcome findings.
BOTTOM LINE: Goals of care discussions for patients with advanced dementia appears to reduce hospitalizations.
CITATIONS: Hanson LC, Zimmerman S, Song MK, et al. Effect of the goals of care intervention for advanced dementia: a randomized clinical trial. JAMA Intern Med. 2017 Jan;177:24-31.
Dr. Cumbler is the associate chief of hospital medicine, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: For patients with advanced dementia, does a goals-of-care intervention improve communication and care outcomes?
STUDY DESIGN: Single-blind cluster randomized trial.
SETTING: Twenty-two nursing homes in North Carolina.
SYNOPSIS: Three hundred and two patient/families enrolled. Intervention included video and print decision aids followed by a structured goals of care discussion with trained nursing home staff. Quality of communication results, the primary outcome, at 3 months were mixed. Family perception of communication with nursing home staff was better in the intervention. Family–health care provider concordance on primary goal of care and treatment consistent with preferences were not significantly different. By the end of the study at 9 months there was no difference in symptom control but some secondary outcomes were encouraging including greater completion of MOST advanced directives (35% vs. 16%; P = .05) and half as many hospital transfers. Multiple comparisons merits future verification of secondary outcome findings.
BOTTOM LINE: Goals of care discussions for patients with advanced dementia appears to reduce hospitalizations.
CITATIONS: Hanson LC, Zimmerman S, Song MK, et al. Effect of the goals of care intervention for advanced dementia: a randomized clinical trial. JAMA Intern Med. 2017 Jan;177:24-31.
Dr. Cumbler is the associate chief of hospital medicine, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Presenters hand out tips for better handoffs
LAS VEGAS – When the resident in the handoff training video approached another resident, she first vented about her “really crazy day” and how she’d been hoping to “get out of here on time for once.” Then, she tore through a case like an auctioneer, leaving out important details. At the end, she got a page and, of course, didn’t finish the handoff.
In Wednesday’s Quality Track session, “Strategies for Implementing a Successful Handoff” – with lessons from SHM’s I-PASS mentored implementation project – some attendees were eager to point out all of the flaws in the handoff. They were, however, slower to point to the good. For instance, the resident in the video made the effort to meet face-to-face and asked whether her colleague had any questions.
The audience had learned an important lesson about how to foster better handoffs, said Glenn Rosenbluth, MD, director of quality and safety programs at the University of California, San Francisco. He noted that it can be difficult to find the positives when the negatives are so glaring.
“This is one of the hard parts about doing feedback,” he said.
It was just one of many lessons taught in the session, also led by Amy Starmer, MD, MPH, a lecturer on pediatrics at Harvard Medical School, and Courtney Edgar-Zarate, MD, a pediatric hospitalist at Arkansas Children’s Hospital who was one of the I-PASS site leaders.
I-PASS was a nine-site study in the United States and Canada that found that using a bundle of interventions while doing handoffs resulted in a 30% reduction in preventable adverse events, meaning less harm to patients. The hallmark is the “I-PASS” mnemonic. It stands for:
- Illness severity – describing the stability level of a patient.
- Patient summary, including general information, such as the events leading to admission.
- Action list – essentially a to-do list for the patient.
- Situation awareness and contingency planning, which involves having a plan for what might happen.
- Synthesis by the receiver, in which the recipient of the information summarizes what was heard and asks questions.
Beyond that, the I-PASS system involves an introductory workshop, simulation exercises, structured observation and feedback, among other elements, Dr. Starmer said.
“This intervention was certainly not just a five-letter mnemonic,” she said.
The I-PASS Mentored Implementation Program, a collaboration with SHM that is funded by the Agency for Healthcare Research and Quality, is an effort to help implement a similar program in 32 hospitals in the United States.
Dr. Edgar-Zarate outlined the steps that worked at her site to make their I-PASS project successful. She said that project managers have to establish institutional support; assess a given center’s needs; gauge where to begin by identifying the most vulnerable transition points; find providers who will champion the project; establish good communication, in part by incorporating I-PASS into previously scheduled meetings; and collect data as time goes on.
Dr. Starmer directed attendees to www.ipassstudygroup.com, where anyone can download the material for free.
“This mentored implementation process,” she said, “has really been a helpful vehicle for disseminating the curriculum and implementation across different areas.”
LAS VEGAS – When the resident in the handoff training video approached another resident, she first vented about her “really crazy day” and how she’d been hoping to “get out of here on time for once.” Then, she tore through a case like an auctioneer, leaving out important details. At the end, she got a page and, of course, didn’t finish the handoff.
In Wednesday’s Quality Track session, “Strategies for Implementing a Successful Handoff” – with lessons from SHM’s I-PASS mentored implementation project – some attendees were eager to point out all of the flaws in the handoff. They were, however, slower to point to the good. For instance, the resident in the video made the effort to meet face-to-face and asked whether her colleague had any questions.
The audience had learned an important lesson about how to foster better handoffs, said Glenn Rosenbluth, MD, director of quality and safety programs at the University of California, San Francisco. He noted that it can be difficult to find the positives when the negatives are so glaring.
“This is one of the hard parts about doing feedback,” he said.
It was just one of many lessons taught in the session, also led by Amy Starmer, MD, MPH, a lecturer on pediatrics at Harvard Medical School, and Courtney Edgar-Zarate, MD, a pediatric hospitalist at Arkansas Children’s Hospital who was one of the I-PASS site leaders.
I-PASS was a nine-site study in the United States and Canada that found that using a bundle of interventions while doing handoffs resulted in a 30% reduction in preventable adverse events, meaning less harm to patients. The hallmark is the “I-PASS” mnemonic. It stands for:
- Illness severity – describing the stability level of a patient.
- Patient summary, including general information, such as the events leading to admission.
- Action list – essentially a to-do list for the patient.
- Situation awareness and contingency planning, which involves having a plan for what might happen.
- Synthesis by the receiver, in which the recipient of the information summarizes what was heard and asks questions.
Beyond that, the I-PASS system involves an introductory workshop, simulation exercises, structured observation and feedback, among other elements, Dr. Starmer said.
“This intervention was certainly not just a five-letter mnemonic,” she said.
The I-PASS Mentored Implementation Program, a collaboration with SHM that is funded by the Agency for Healthcare Research and Quality, is an effort to help implement a similar program in 32 hospitals in the United States.
Dr. Edgar-Zarate outlined the steps that worked at her site to make their I-PASS project successful. She said that project managers have to establish institutional support; assess a given center’s needs; gauge where to begin by identifying the most vulnerable transition points; find providers who will champion the project; establish good communication, in part by incorporating I-PASS into previously scheduled meetings; and collect data as time goes on.
Dr. Starmer directed attendees to www.ipassstudygroup.com, where anyone can download the material for free.
“This mentored implementation process,” she said, “has really been a helpful vehicle for disseminating the curriculum and implementation across different areas.”
LAS VEGAS – When the resident in the handoff training video approached another resident, she first vented about her “really crazy day” and how she’d been hoping to “get out of here on time for once.” Then, she tore through a case like an auctioneer, leaving out important details. At the end, she got a page and, of course, didn’t finish the handoff.
In Wednesday’s Quality Track session, “Strategies for Implementing a Successful Handoff” – with lessons from SHM’s I-PASS mentored implementation project – some attendees were eager to point out all of the flaws in the handoff. They were, however, slower to point to the good. For instance, the resident in the video made the effort to meet face-to-face and asked whether her colleague had any questions.
The audience had learned an important lesson about how to foster better handoffs, said Glenn Rosenbluth, MD, director of quality and safety programs at the University of California, San Francisco. He noted that it can be difficult to find the positives when the negatives are so glaring.
“This is one of the hard parts about doing feedback,” he said.
It was just one of many lessons taught in the session, also led by Amy Starmer, MD, MPH, a lecturer on pediatrics at Harvard Medical School, and Courtney Edgar-Zarate, MD, a pediatric hospitalist at Arkansas Children’s Hospital who was one of the I-PASS site leaders.
I-PASS was a nine-site study in the United States and Canada that found that using a bundle of interventions while doing handoffs resulted in a 30% reduction in preventable adverse events, meaning less harm to patients. The hallmark is the “I-PASS” mnemonic. It stands for:
- Illness severity – describing the stability level of a patient.
- Patient summary, including general information, such as the events leading to admission.
- Action list – essentially a to-do list for the patient.
- Situation awareness and contingency planning, which involves having a plan for what might happen.
- Synthesis by the receiver, in which the recipient of the information summarizes what was heard and asks questions.
Beyond that, the I-PASS system involves an introductory workshop, simulation exercises, structured observation and feedback, among other elements, Dr. Starmer said.
“This intervention was certainly not just a five-letter mnemonic,” she said.
The I-PASS Mentored Implementation Program, a collaboration with SHM that is funded by the Agency for Healthcare Research and Quality, is an effort to help implement a similar program in 32 hospitals in the United States.
Dr. Edgar-Zarate outlined the steps that worked at her site to make their I-PASS project successful. She said that project managers have to establish institutional support; assess a given center’s needs; gauge where to begin by identifying the most vulnerable transition points; find providers who will champion the project; establish good communication, in part by incorporating I-PASS into previously scheduled meetings; and collect data as time goes on.
Dr. Starmer directed attendees to www.ipassstudygroup.com, where anyone can download the material for free.
“This mentored implementation process,” she said, “has really been a helpful vehicle for disseminating the curriculum and implementation across different areas.”
AT HM17
VIDEO: NPs, PAs weigh common issues in hospitalist practice
Practicing at the top of your license, billing and reimbursement, recruiting and orientation – Those were some of the hot topics discussed by more than 50 attendees of HM17’s Special Interest Forum for nurse practitioners (NPs) and physician assistants (PAs).
“Every year, we are seeing more and more HM groups integrating NPs and PAs into their practice,” said forum moderator Emilie Thornhill, PA-C, a certified PA, who works for Oschner Health in New Orleans, La.
Ms. Thornhill emphasized that a common issue among attendees is restrictive HM policies in dictating the scope of practice for NP/PAs in hospitalist groups.
“That seems to be the thing that is holding us back the most,” she said. “SHM is really going to be the home for these individuals to find the resources they need to address these issues.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Practicing at the top of your license, billing and reimbursement, recruiting and orientation – Those were some of the hot topics discussed by more than 50 attendees of HM17’s Special Interest Forum for nurse practitioners (NPs) and physician assistants (PAs).
“Every year, we are seeing more and more HM groups integrating NPs and PAs into their practice,” said forum moderator Emilie Thornhill, PA-C, a certified PA, who works for Oschner Health in New Orleans, La.
Ms. Thornhill emphasized that a common issue among attendees is restrictive HM policies in dictating the scope of practice for NP/PAs in hospitalist groups.
“That seems to be the thing that is holding us back the most,” she said. “SHM is really going to be the home for these individuals to find the resources they need to address these issues.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Practicing at the top of your license, billing and reimbursement, recruiting and orientation – Those were some of the hot topics discussed by more than 50 attendees of HM17’s Special Interest Forum for nurse practitioners (NPs) and physician assistants (PAs).
“Every year, we are seeing more and more HM groups integrating NPs and PAs into their practice,” said forum moderator Emilie Thornhill, PA-C, a certified PA, who works for Oschner Health in New Orleans, La.
Ms. Thornhill emphasized that a common issue among attendees is restrictive HM policies in dictating the scope of practice for NP/PAs in hospitalist groups.
“That seems to be the thing that is holding us back the most,” she said. “SHM is really going to be the home for these individuals to find the resources they need to address these issues.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Connect: Community hospitalists brainstorm ways to be stronger as a group
Coping with disjointed administrative goals, demonstrating value to hospital leadership, and strengthening support networks for one another were hot-button topics during the Special Interest Group for Community Hospitalists at this year’s HM17.
A mix of hospitalists from rural, urban, and suburban facilities with an average 200-500 beds joined in the discussion, moderated by Stephen Behnke, MD, an internist and president of MedOne in Columbus, Ohio, and Jason Robertson, MD, an internist with HealthPartners in Bloomington, Minn.
Burnout was seen by several in the crowd of about two dozen physicians as being related in part to poor staffing and scheduling decisions at the administrative level, and not allocating clerical work to other staff, often forcing hospitalists to perform tasks not at the top of their license. One solution offered was to amortize the cost of physicians doing paperwork according to their salaries, and to bring those numbers to the attention of hospital leadership.
The group called on the Society of Hospital Medicine to create and disseminate evidence-based resources to help demonstrate their value to hospital administration. Many in the group expressed interest in learning how to communicate their value effectively to their respective C-suites to underscore the essential nature HM has to the core business. In an interview directly after the session, Dr. Behnke explained that hospital leaders often underfund HM programs, only to find that the decision ends up costing them more in the long run.
Lots of upset was vented by session attendees over patient discharge protocols that often resulted in higher lengths of stay or increased readmissions, which then reflected poorly on the hospitalist. The group agreed that since there was no one-size-fits-all approach to this, it would be helpful to start a listserv of community hospitalists in the SHM that was organized by hospital size, location, and types of staffing, so it would be easier to find solutions by connecting with others with similar concerns.
Many in the group also shared how their respective facilities promoted wellness through togetherness activities: staff retreats, movie nights, book clubs, group family outings, and forming alliances with hospitalists at other local hospitals. The general consensus was that this helped improve staff morale.
Coping with disjointed administrative goals, demonstrating value to hospital leadership, and strengthening support networks for one another were hot-button topics during the Special Interest Group for Community Hospitalists at this year’s HM17.
A mix of hospitalists from rural, urban, and suburban facilities with an average 200-500 beds joined in the discussion, moderated by Stephen Behnke, MD, an internist and president of MedOne in Columbus, Ohio, and Jason Robertson, MD, an internist with HealthPartners in Bloomington, Minn.
Burnout was seen by several in the crowd of about two dozen physicians as being related in part to poor staffing and scheduling decisions at the administrative level, and not allocating clerical work to other staff, often forcing hospitalists to perform tasks not at the top of their license. One solution offered was to amortize the cost of physicians doing paperwork according to their salaries, and to bring those numbers to the attention of hospital leadership.
The group called on the Society of Hospital Medicine to create and disseminate evidence-based resources to help demonstrate their value to hospital administration. Many in the group expressed interest in learning how to communicate their value effectively to their respective C-suites to underscore the essential nature HM has to the core business. In an interview directly after the session, Dr. Behnke explained that hospital leaders often underfund HM programs, only to find that the decision ends up costing them more in the long run.
Lots of upset was vented by session attendees over patient discharge protocols that often resulted in higher lengths of stay or increased readmissions, which then reflected poorly on the hospitalist. The group agreed that since there was no one-size-fits-all approach to this, it would be helpful to start a listserv of community hospitalists in the SHM that was organized by hospital size, location, and types of staffing, so it would be easier to find solutions by connecting with others with similar concerns.
Many in the group also shared how their respective facilities promoted wellness through togetherness activities: staff retreats, movie nights, book clubs, group family outings, and forming alliances with hospitalists at other local hospitals. The general consensus was that this helped improve staff morale.
Coping with disjointed administrative goals, demonstrating value to hospital leadership, and strengthening support networks for one another were hot-button topics during the Special Interest Group for Community Hospitalists at this year’s HM17.
A mix of hospitalists from rural, urban, and suburban facilities with an average 200-500 beds joined in the discussion, moderated by Stephen Behnke, MD, an internist and president of MedOne in Columbus, Ohio, and Jason Robertson, MD, an internist with HealthPartners in Bloomington, Minn.
Burnout was seen by several in the crowd of about two dozen physicians as being related in part to poor staffing and scheduling decisions at the administrative level, and not allocating clerical work to other staff, often forcing hospitalists to perform tasks not at the top of their license. One solution offered was to amortize the cost of physicians doing paperwork according to their salaries, and to bring those numbers to the attention of hospital leadership.
The group called on the Society of Hospital Medicine to create and disseminate evidence-based resources to help demonstrate their value to hospital administration. Many in the group expressed interest in learning how to communicate their value effectively to their respective C-suites to underscore the essential nature HM has to the core business. In an interview directly after the session, Dr. Behnke explained that hospital leaders often underfund HM programs, only to find that the decision ends up costing them more in the long run.
Lots of upset was vented by session attendees over patient discharge protocols that often resulted in higher lengths of stay or increased readmissions, which then reflected poorly on the hospitalist. The group agreed that since there was no one-size-fits-all approach to this, it would be helpful to start a listserv of community hospitalists in the SHM that was organized by hospital size, location, and types of staffing, so it would be easier to find solutions by connecting with others with similar concerns.
Many in the group also shared how their respective facilities promoted wellness through togetherness activities: staff retreats, movie nights, book clubs, group family outings, and forming alliances with hospitalists at other local hospitals. The general consensus was that this helped improve staff morale.
Keys to de-escalating endocrine emergencies
It’s a fine line between compensated and decompensated endocrine conditions, and often, there is an underlying non–endocrine component complicating the diagnosis.
That’s according to Marilyn Tan, MD, a clinical assistant professor of medicine at Stanford (Calif.) University, where she is chief of the endocrinology clinic. She spoke about endocrinology emergencies during a case-based, rapid-fire session at HM17.
“Endocrine emergencies are usually due to an excess or a deficiency of a hormone,” Dr. Tan said, noting that these can take time to bring into balance. This is one reason Dr. Tan counseled not waiting for laboratory results before administering treatment.
To diagnose and treat diabetic ketoacidosis, combined with a hyperosmolar hyperglycemic state, Dr. Tan recommended checking hypoglycemia levels, which she said are often mild, and to check anion gap, pH, and ketones. It’s also important to be generous with IV fluids, to administer insulin only if the ketoacidosis level is greater than 3.3 mEq/L, and to not take the patient off an insulin drip too early or inappropriately. To prevent readmissions, the patient on discharge should have adequate diabetes supplies, education on their condition, and timely follow-up, Dr. Tan recommended.
For patients experiencing a thyroid storm, Dr. Tan advised that thyroid function tests are a poor surrogate for predicting who will decompensate. The clinical distinction is made by documentation of acute organ dysfunction. Reducing T3 to T4 conversion means propylthiouracil is preferred over methimazole.
Ongoing management of a myxedema coma means monitoring the clinical parameters of the patient’s mental status, cardiac and pulmonary functions, while keeping the levothyroxine dose steady and checking lab values every 1-2 days to ensure the patient is progressing.
Suspect pituitary apoplexy in cases of hypertension, major surgery, trauma, anticoagulation, pregnancy, or if there is a large sellar mass. If choosing to image a patient, Dr. Tan recommended using an MRI rather than a CT scan, which she said is less sensitive. Immediate hydrocortisone treatment must be administered, she said. About 90% of cases of acute hypercalcemia are caused by hyperparathyroidism in the outpatient setting, and malignancy in the inpatient setting, Dr. Tan said. Also, these patients tend to be volume depleted, so assessment of their ability to tolerate hydration is essential.
Regarding all endocrine emergencies, Dr. Tan said, “When in doubt, be more aggressive with treatment.”
Dr. Tan had no relevant financial disclosures.
It’s a fine line between compensated and decompensated endocrine conditions, and often, there is an underlying non–endocrine component complicating the diagnosis.
That’s according to Marilyn Tan, MD, a clinical assistant professor of medicine at Stanford (Calif.) University, where she is chief of the endocrinology clinic. She spoke about endocrinology emergencies during a case-based, rapid-fire session at HM17.
“Endocrine emergencies are usually due to an excess or a deficiency of a hormone,” Dr. Tan said, noting that these can take time to bring into balance. This is one reason Dr. Tan counseled not waiting for laboratory results before administering treatment.
To diagnose and treat diabetic ketoacidosis, combined with a hyperosmolar hyperglycemic state, Dr. Tan recommended checking hypoglycemia levels, which she said are often mild, and to check anion gap, pH, and ketones. It’s also important to be generous with IV fluids, to administer insulin only if the ketoacidosis level is greater than 3.3 mEq/L, and to not take the patient off an insulin drip too early or inappropriately. To prevent readmissions, the patient on discharge should have adequate diabetes supplies, education on their condition, and timely follow-up, Dr. Tan recommended.
For patients experiencing a thyroid storm, Dr. Tan advised that thyroid function tests are a poor surrogate for predicting who will decompensate. The clinical distinction is made by documentation of acute organ dysfunction. Reducing T3 to T4 conversion means propylthiouracil is preferred over methimazole.
Ongoing management of a myxedema coma means monitoring the clinical parameters of the patient’s mental status, cardiac and pulmonary functions, while keeping the levothyroxine dose steady and checking lab values every 1-2 days to ensure the patient is progressing.
Suspect pituitary apoplexy in cases of hypertension, major surgery, trauma, anticoagulation, pregnancy, or if there is a large sellar mass. If choosing to image a patient, Dr. Tan recommended using an MRI rather than a CT scan, which she said is less sensitive. Immediate hydrocortisone treatment must be administered, she said. About 90% of cases of acute hypercalcemia are caused by hyperparathyroidism in the outpatient setting, and malignancy in the inpatient setting, Dr. Tan said. Also, these patients tend to be volume depleted, so assessment of their ability to tolerate hydration is essential.
Regarding all endocrine emergencies, Dr. Tan said, “When in doubt, be more aggressive with treatment.”
Dr. Tan had no relevant financial disclosures.
It’s a fine line between compensated and decompensated endocrine conditions, and often, there is an underlying non–endocrine component complicating the diagnosis.
That’s according to Marilyn Tan, MD, a clinical assistant professor of medicine at Stanford (Calif.) University, where she is chief of the endocrinology clinic. She spoke about endocrinology emergencies during a case-based, rapid-fire session at HM17.
“Endocrine emergencies are usually due to an excess or a deficiency of a hormone,” Dr. Tan said, noting that these can take time to bring into balance. This is one reason Dr. Tan counseled not waiting for laboratory results before administering treatment.
To diagnose and treat diabetic ketoacidosis, combined with a hyperosmolar hyperglycemic state, Dr. Tan recommended checking hypoglycemia levels, which she said are often mild, and to check anion gap, pH, and ketones. It’s also important to be generous with IV fluids, to administer insulin only if the ketoacidosis level is greater than 3.3 mEq/L, and to not take the patient off an insulin drip too early or inappropriately. To prevent readmissions, the patient on discharge should have adequate diabetes supplies, education on their condition, and timely follow-up, Dr. Tan recommended.
For patients experiencing a thyroid storm, Dr. Tan advised that thyroid function tests are a poor surrogate for predicting who will decompensate. The clinical distinction is made by documentation of acute organ dysfunction. Reducing T3 to T4 conversion means propylthiouracil is preferred over methimazole.
Ongoing management of a myxedema coma means monitoring the clinical parameters of the patient’s mental status, cardiac and pulmonary functions, while keeping the levothyroxine dose steady and checking lab values every 1-2 days to ensure the patient is progressing.
Suspect pituitary apoplexy in cases of hypertension, major surgery, trauma, anticoagulation, pregnancy, or if there is a large sellar mass. If choosing to image a patient, Dr. Tan recommended using an MRI rather than a CT scan, which she said is less sensitive. Immediate hydrocortisone treatment must be administered, she said. About 90% of cases of acute hypercalcemia are caused by hyperparathyroidism in the outpatient setting, and malignancy in the inpatient setting, Dr. Tan said. Also, these patients tend to be volume depleted, so assessment of their ability to tolerate hydration is essential.
Regarding all endocrine emergencies, Dr. Tan said, “When in doubt, be more aggressive with treatment.”
Dr. Tan had no relevant financial disclosures.
Highlights of Day 4
Sometimes the final day of a convention is nothing more than the “getaway day.”
But not at HM17. Not this year.
The finale of the 2017 annual meeting is capped off, as has become tradition, by a speech from the dean of hospital medicine: Robert Wachter, MD, MHM. The last time Dr. Wachter gave his address from a Vegas stage, it ended with him in head-to-toe Elton John regalia. While there’s no guarantee of a wardrobe reprisal, the annual address from the man who helped name the specialty promises to entertain and inform, said HM17 course director Lenny Feldman, MD, SFHM.
However, Dr. Wachter’s words – this year titled “Planning for the Future in a World of Constant Change: What Should Hospitalists Do?” – aren’t the final day’s only lure.
Two of this year’s newest educational tracks – Health Policy and Medical Education – debut today and offer five courses focusing on niche areas interesting to many hospitalists. Also today is the annual Potpurri track, which highlights off-beat topics such as “Case-Based Approach to Difficult Conversations” and “The History of Medicine: Discoveries that Shaped Our Profession.”
“These sessions are unique but have a wide range of appeal,” Dr. Feldman said. “Attendees are going to have a great time delving into these topics.”
Sometimes the final day of a convention is nothing more than the “getaway day.”
But not at HM17. Not this year.
The finale of the 2017 annual meeting is capped off, as has become tradition, by a speech from the dean of hospital medicine: Robert Wachter, MD, MHM. The last time Dr. Wachter gave his address from a Vegas stage, it ended with him in head-to-toe Elton John regalia. While there’s no guarantee of a wardrobe reprisal, the annual address from the man who helped name the specialty promises to entertain and inform, said HM17 course director Lenny Feldman, MD, SFHM.
However, Dr. Wachter’s words – this year titled “Planning for the Future in a World of Constant Change: What Should Hospitalists Do?” – aren’t the final day’s only lure.
Two of this year’s newest educational tracks – Health Policy and Medical Education – debut today and offer five courses focusing on niche areas interesting to many hospitalists. Also today is the annual Potpurri track, which highlights off-beat topics such as “Case-Based Approach to Difficult Conversations” and “The History of Medicine: Discoveries that Shaped Our Profession.”
“These sessions are unique but have a wide range of appeal,” Dr. Feldman said. “Attendees are going to have a great time delving into these topics.”
Sometimes the final day of a convention is nothing more than the “getaway day.”
But not at HM17. Not this year.
The finale of the 2017 annual meeting is capped off, as has become tradition, by a speech from the dean of hospital medicine: Robert Wachter, MD, MHM. The last time Dr. Wachter gave his address from a Vegas stage, it ended with him in head-to-toe Elton John regalia. While there’s no guarantee of a wardrobe reprisal, the annual address from the man who helped name the specialty promises to entertain and inform, said HM17 course director Lenny Feldman, MD, SFHM.
However, Dr. Wachter’s words – this year titled “Planning for the Future in a World of Constant Change: What Should Hospitalists Do?” – aren’t the final day’s only lure.
Two of this year’s newest educational tracks – Health Policy and Medical Education – debut today and offer five courses focusing on niche areas interesting to many hospitalists. Also today is the annual Potpurri track, which highlights off-beat topics such as “Case-Based Approach to Difficult Conversations” and “The History of Medicine: Discoveries that Shaped Our Profession.”
“These sessions are unique but have a wide range of appeal,” Dr. Feldman said. “Attendees are going to have a great time delving into these topics.”
Hope and change
Robert M. Wachter, MD, MHM, has given the last plenary address at every SHM annual meeting since 2007. The talks are peppered with his one-of-a-kind take on the confluence of medicine, politics, and policy. Then there was the time when he broke into an Elton John parody.
Where does that point of view come from? Well, as the dean of hospital medicine says in his ever-popular Twitter bio, he is “what happens when a poli-sci major becomes an academic physician.”
That’s a needed perspective this year, as the level of political upheaval in the United States has added to the tumult in the health care field. Questions surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the continued struggles that doctors face when using electronic health records (EHRs) are among the topics that he will address in his this final discussion.
“While [President Donald] Trump brings massive uncertainly, the shift to value and the increasing importance of building a strong culture, a method to continuously improve, and a way to use the EHR to make things better is unlikely to go away,” said Dr. Wachter, whose address is titled, “Mergers, MACRA, and Mission-Creep: Can Hospitalists Thrive in the New World of Healthcare?”
Dr. Wachter, chair of the department of medicine at the University of California, San Francisco, said that the Trump administration is a once-in-a-lifetime anomaly that understandably has made both physicians and patients nervous – particularly at a time when health care reform appeared to be stabilizing.
The new president “adds an amazing wild card, at every level,” he said. “If it weren’t for his administration, I think we’d be on a fairly stable, predictable path. Not that that path doesn’t include a ton of change, but at least it had a predictable path.”
The defeat of Republicans’ plan to replace the Affordable Care Act (ACA) with the American Health Care Act (AHCA) showed that the divide over health care extends even to intraparty discussions.
“The implosion of the AHCA shows how difficult health reform is and how quickly the ACA became the de facto standard,” Dr. Wachter said. “It is now that status quo that is so difficult to change.”
Dr. Wachter, who famously helped coined the term “hospitalist” in the 1996 New England Journal of Medicine paper that propelled the nascent specialty, said that one big challenge to HM is determining the future of how hospitals get paid – and how they pay their workers (335[7]:514-7).
“The business model for hospitals will be massively challenged, and it could get worse if a lot of your patients lose insurance or [if] their payments go way down,” he predicted.
What that means for the daily schedules of hospitalists remains to be seen, but Dr. Wachter doesn’t expect much in the short term.
“The job will be the same,” he said. “Take care of patients well, make them happy, satisfy your bosses and colleagues, and do it for less money. The biggest shift is likely to be that more and more people/systems – doing the same thing – will find that they don’t need as many hospital days, which means that we’ll have fewer patients and fewer hospitals. But we knew that.”
Dr. Wachter is more interested to see what will happen in postacute and other nonhospital facilities, how quickly technology continues to disrupt, and who hospitalists will work for (be it staffing companies, medical groups, or “something new”).
The veteran physician in him says not to get too distracted “by all of the zigs and zags,” he noted, while the political idealist in him says not to ever forget that the “core values and imperatives remain.”
If the past decade of wise words ending SHM’s annual meeting are any indication, Dr. Wachter’s message of trepidation and concern will end on a high note for attendees.
Robert M. Wachter, MD, MHM, has given the last plenary address at every SHM annual meeting since 2007. The talks are peppered with his one-of-a-kind take on the confluence of medicine, politics, and policy. Then there was the time when he broke into an Elton John parody.
Where does that point of view come from? Well, as the dean of hospital medicine says in his ever-popular Twitter bio, he is “what happens when a poli-sci major becomes an academic physician.”
That’s a needed perspective this year, as the level of political upheaval in the United States has added to the tumult in the health care field. Questions surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the continued struggles that doctors face when using electronic health records (EHRs) are among the topics that he will address in his this final discussion.
“While [President Donald] Trump brings massive uncertainly, the shift to value and the increasing importance of building a strong culture, a method to continuously improve, and a way to use the EHR to make things better is unlikely to go away,” said Dr. Wachter, whose address is titled, “Mergers, MACRA, and Mission-Creep: Can Hospitalists Thrive in the New World of Healthcare?”
Dr. Wachter, chair of the department of medicine at the University of California, San Francisco, said that the Trump administration is a once-in-a-lifetime anomaly that understandably has made both physicians and patients nervous – particularly at a time when health care reform appeared to be stabilizing.
The new president “adds an amazing wild card, at every level,” he said. “If it weren’t for his administration, I think we’d be on a fairly stable, predictable path. Not that that path doesn’t include a ton of change, but at least it had a predictable path.”
The defeat of Republicans’ plan to replace the Affordable Care Act (ACA) with the American Health Care Act (AHCA) showed that the divide over health care extends even to intraparty discussions.
“The implosion of the AHCA shows how difficult health reform is and how quickly the ACA became the de facto standard,” Dr. Wachter said. “It is now that status quo that is so difficult to change.”
Dr. Wachter, who famously helped coined the term “hospitalist” in the 1996 New England Journal of Medicine paper that propelled the nascent specialty, said that one big challenge to HM is determining the future of how hospitals get paid – and how they pay their workers (335[7]:514-7).
“The business model for hospitals will be massively challenged, and it could get worse if a lot of your patients lose insurance or [if] their payments go way down,” he predicted.
What that means for the daily schedules of hospitalists remains to be seen, but Dr. Wachter doesn’t expect much in the short term.
“The job will be the same,” he said. “Take care of patients well, make them happy, satisfy your bosses and colleagues, and do it for less money. The biggest shift is likely to be that more and more people/systems – doing the same thing – will find that they don’t need as many hospital days, which means that we’ll have fewer patients and fewer hospitals. But we knew that.”
Dr. Wachter is more interested to see what will happen in postacute and other nonhospital facilities, how quickly technology continues to disrupt, and who hospitalists will work for (be it staffing companies, medical groups, or “something new”).
The veteran physician in him says not to get too distracted “by all of the zigs and zags,” he noted, while the political idealist in him says not to ever forget that the “core values and imperatives remain.”
If the past decade of wise words ending SHM’s annual meeting are any indication, Dr. Wachter’s message of trepidation and concern will end on a high note for attendees.
Robert M. Wachter, MD, MHM, has given the last plenary address at every SHM annual meeting since 2007. The talks are peppered with his one-of-a-kind take on the confluence of medicine, politics, and policy. Then there was the time when he broke into an Elton John parody.
Where does that point of view come from? Well, as the dean of hospital medicine says in his ever-popular Twitter bio, he is “what happens when a poli-sci major becomes an academic physician.”
That’s a needed perspective this year, as the level of political upheaval in the United States has added to the tumult in the health care field. Questions surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the continued struggles that doctors face when using electronic health records (EHRs) are among the topics that he will address in his this final discussion.
“While [President Donald] Trump brings massive uncertainly, the shift to value and the increasing importance of building a strong culture, a method to continuously improve, and a way to use the EHR to make things better is unlikely to go away,” said Dr. Wachter, whose address is titled, “Mergers, MACRA, and Mission-Creep: Can Hospitalists Thrive in the New World of Healthcare?”
Dr. Wachter, chair of the department of medicine at the University of California, San Francisco, said that the Trump administration is a once-in-a-lifetime anomaly that understandably has made both physicians and patients nervous – particularly at a time when health care reform appeared to be stabilizing.
The new president “adds an amazing wild card, at every level,” he said. “If it weren’t for his administration, I think we’d be on a fairly stable, predictable path. Not that that path doesn’t include a ton of change, but at least it had a predictable path.”
The defeat of Republicans’ plan to replace the Affordable Care Act (ACA) with the American Health Care Act (AHCA) showed that the divide over health care extends even to intraparty discussions.
“The implosion of the AHCA shows how difficult health reform is and how quickly the ACA became the de facto standard,” Dr. Wachter said. “It is now that status quo that is so difficult to change.”
Dr. Wachter, who famously helped coined the term “hospitalist” in the 1996 New England Journal of Medicine paper that propelled the nascent specialty, said that one big challenge to HM is determining the future of how hospitals get paid – and how they pay their workers (335[7]:514-7).
“The business model for hospitals will be massively challenged, and it could get worse if a lot of your patients lose insurance or [if] their payments go way down,” he predicted.
What that means for the daily schedules of hospitalists remains to be seen, but Dr. Wachter doesn’t expect much in the short term.
“The job will be the same,” he said. “Take care of patients well, make them happy, satisfy your bosses and colleagues, and do it for less money. The biggest shift is likely to be that more and more people/systems – doing the same thing – will find that they don’t need as many hospital days, which means that we’ll have fewer patients and fewer hospitals. But we knew that.”
Dr. Wachter is more interested to see what will happen in postacute and other nonhospital facilities, how quickly technology continues to disrupt, and who hospitalists will work for (be it staffing companies, medical groups, or “something new”).
The veteran physician in him says not to get too distracted “by all of the zigs and zags,” he noted, while the political idealist in him says not to ever forget that the “core values and imperatives remain.”
If the past decade of wise words ending SHM’s annual meeting are any indication, Dr. Wachter’s message of trepidation and concern will end on a high note for attendees.
Welcome to the third and final day of HM17!
Welcome to the third and final day of HM17!
Although it is the shortest day of the conference, day 3 is full of quality content, starting at 7:40 a.m. with a mini-track.
If you are interested in hearing about the impact of November’s election on health care reform, join me at the Health Policy Mini-Track starting first thing in the morning. The mini-track will begin with a session called “Hot Topics in Health Policy for Hospitalists” and will be followed by a panel of visitors from our nation’s capital who will weigh in on events in D.C. that will have an impact on our careers.
There are also three workshops in the morning including one on negotiation that I hope to attend. The second set of workshops includes one with the provocative title of “Cutting Out Things We Do for No Reason.”
And while there are too many great sessions to be able to call out each one, the prize for most creative title clearly goes to “Take Your PICC: Choosing the Right Vascular Access.”
The day, and the meeting, ends as it traditionally does with a talk by the venerable Bob Wachter, MD, MHM, who will treat us to a discussion on “Planning for the Future in a World of Constant Change: What Should Hospitalists Do?” We may even see some of his famed humor and wit as we have in past years. Everyone who has ever heard Bob speak knows that this is a session that should not be missed!
Your afternoon is free to travel home or to hit the casinos one last time.
As I begin my year as SHM President, I continue to be energized by the opportunity to meet so many of you at our Annual Meeting and to be part of an organization that continues to have such a positive impact on our nation’s health care system.
The coming year will see a continued reshaping of our delivery system, driven by emerging federal policy including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and anticipated changes in the Affordable Care Act. It will continue to be a priority for SHM to make sure that the voice of Hospital Medicine is heard loud and clear as decisions are made that will affect our patients and our careers. I will be asking our members to help ensure that we have a prominent place in these decision making processes. We will continue to strive to make sure that our patients get the care they deserve and that we continue to help build and maintain a sustainable health care delivery system.
This year, you will also see a focused effort to strengthen our system of state and local chapters. The vitality of these local organizations is important to our efforts to effectively serve our members by engaging them along with their colleagues.
And, of course, SHM will continue to be the only organization created to represent our nation’s hospitalists and to be totally committed to providing our members with clinical and administrative education, dedicated publications, leadership training, research opportunities, and advocacy.
I hope you enjoyed what turned out to be the largest and best Annual Meeting in our history. And I hope to see you at Hospital Medicine 2018 in Orlando.
Welcome to the third and final day of HM17!
Although it is the shortest day of the conference, day 3 is full of quality content, starting at 7:40 a.m. with a mini-track.
If you are interested in hearing about the impact of November’s election on health care reform, join me at the Health Policy Mini-Track starting first thing in the morning. The mini-track will begin with a session called “Hot Topics in Health Policy for Hospitalists” and will be followed by a panel of visitors from our nation’s capital who will weigh in on events in D.C. that will have an impact on our careers.
There are also three workshops in the morning including one on negotiation that I hope to attend. The second set of workshops includes one with the provocative title of “Cutting Out Things We Do for No Reason.”
And while there are too many great sessions to be able to call out each one, the prize for most creative title clearly goes to “Take Your PICC: Choosing the Right Vascular Access.”
The day, and the meeting, ends as it traditionally does with a talk by the venerable Bob Wachter, MD, MHM, who will treat us to a discussion on “Planning for the Future in a World of Constant Change: What Should Hospitalists Do?” We may even see some of his famed humor and wit as we have in past years. Everyone who has ever heard Bob speak knows that this is a session that should not be missed!
Your afternoon is free to travel home or to hit the casinos one last time.
As I begin my year as SHM President, I continue to be energized by the opportunity to meet so many of you at our Annual Meeting and to be part of an organization that continues to have such a positive impact on our nation’s health care system.
The coming year will see a continued reshaping of our delivery system, driven by emerging federal policy including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and anticipated changes in the Affordable Care Act. It will continue to be a priority for SHM to make sure that the voice of Hospital Medicine is heard loud and clear as decisions are made that will affect our patients and our careers. I will be asking our members to help ensure that we have a prominent place in these decision making processes. We will continue to strive to make sure that our patients get the care they deserve and that we continue to help build and maintain a sustainable health care delivery system.
This year, you will also see a focused effort to strengthen our system of state and local chapters. The vitality of these local organizations is important to our efforts to effectively serve our members by engaging them along with their colleagues.
And, of course, SHM will continue to be the only organization created to represent our nation’s hospitalists and to be totally committed to providing our members with clinical and administrative education, dedicated publications, leadership training, research opportunities, and advocacy.
I hope you enjoyed what turned out to be the largest and best Annual Meeting in our history. And I hope to see you at Hospital Medicine 2018 in Orlando.
Welcome to the third and final day of HM17!
Although it is the shortest day of the conference, day 3 is full of quality content, starting at 7:40 a.m. with a mini-track.
If you are interested in hearing about the impact of November’s election on health care reform, join me at the Health Policy Mini-Track starting first thing in the morning. The mini-track will begin with a session called “Hot Topics in Health Policy for Hospitalists” and will be followed by a panel of visitors from our nation’s capital who will weigh in on events in D.C. that will have an impact on our careers.
There are also three workshops in the morning including one on negotiation that I hope to attend. The second set of workshops includes one with the provocative title of “Cutting Out Things We Do for No Reason.”
And while there are too many great sessions to be able to call out each one, the prize for most creative title clearly goes to “Take Your PICC: Choosing the Right Vascular Access.”
The day, and the meeting, ends as it traditionally does with a talk by the venerable Bob Wachter, MD, MHM, who will treat us to a discussion on “Planning for the Future in a World of Constant Change: What Should Hospitalists Do?” We may even see some of his famed humor and wit as we have in past years. Everyone who has ever heard Bob speak knows that this is a session that should not be missed!
Your afternoon is free to travel home or to hit the casinos one last time.
As I begin my year as SHM President, I continue to be energized by the opportunity to meet so many of you at our Annual Meeting and to be part of an organization that continues to have such a positive impact on our nation’s health care system.
The coming year will see a continued reshaping of our delivery system, driven by emerging federal policy including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and anticipated changes in the Affordable Care Act. It will continue to be a priority for SHM to make sure that the voice of Hospital Medicine is heard loud and clear as decisions are made that will affect our patients and our careers. I will be asking our members to help ensure that we have a prominent place in these decision making processes. We will continue to strive to make sure that our patients get the care they deserve and that we continue to help build and maintain a sustainable health care delivery system.
This year, you will also see a focused effort to strengthen our system of state and local chapters. The vitality of these local organizations is important to our efforts to effectively serve our members by engaging them along with their colleagues.
And, of course, SHM will continue to be the only organization created to represent our nation’s hospitalists and to be totally committed to providing our members with clinical and administrative education, dedicated publications, leadership training, research opportunities, and advocacy.
I hope you enjoyed what turned out to be the largest and best Annual Meeting in our history. And I hope to see you at Hospital Medicine 2018 in Orlando.
Antipsychotics ineffective for symptoms of delirium in palliative care
CLINICAL QUESTION: Do antipsychotics provide symptomatic benefit for delirium in palliative care?
BACKGROUND: Antipsychotics are frequently used for the treatment of delirium and guideline recommended for delirium-associated distress. However, a 2016 meta-analysis found antipsychotics are not associated with change in delirium duration or severity. Antipsychotics for palliative management of delirium at end of life is not well studied.
STUDY DESIGN: Double-blind randomized controlled trial with placebo, haloperidol, and risperidone arms.
SETTING: Eleven Australian inpatient hospice or palliative care services.
SYNOPSIS: 247 patients (mean age, 74.9 years; 88.3% with cancer) with advanced incurable disease and active delirium were studied. Most had mild-moderate severity delirium. All received nonpharmacological measures and plan to address reversible precipitants. Patients were randomized to placebo (84), haloperidol (81), or risperidone (82) for 72 hours. Dose titration was allowed based on delirium symptoms. In intention to treat analysis the delirium severity scores were statistically higher in haloperidol and risperidone arms, compared with placebo. This reached statistical significance although less than the minimum clinically significant difference. Mortality, use of rescue medicines, and extrapyramidal symptoms were higher in antipsychotic groups.
BOTTOM LINE: Antipsychotics cause side effects without efficacy in palliation of symptoms of delirium.
CITATIONS: Agar MR, Lawlor PG, Quinn S, et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA Intern Med. 2017 Jan;177:34-42.
Dr. Cumbler is the associate chief of hospital medicine, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Do antipsychotics provide symptomatic benefit for delirium in palliative care?
BACKGROUND: Antipsychotics are frequently used for the treatment of delirium and guideline recommended for delirium-associated distress. However, a 2016 meta-analysis found antipsychotics are not associated with change in delirium duration or severity. Antipsychotics for palliative management of delirium at end of life is not well studied.
STUDY DESIGN: Double-blind randomized controlled trial with placebo, haloperidol, and risperidone arms.
SETTING: Eleven Australian inpatient hospice or palliative care services.
SYNOPSIS: 247 patients (mean age, 74.9 years; 88.3% with cancer) with advanced incurable disease and active delirium were studied. Most had mild-moderate severity delirium. All received nonpharmacological measures and plan to address reversible precipitants. Patients were randomized to placebo (84), haloperidol (81), or risperidone (82) for 72 hours. Dose titration was allowed based on delirium symptoms. In intention to treat analysis the delirium severity scores were statistically higher in haloperidol and risperidone arms, compared with placebo. This reached statistical significance although less than the minimum clinically significant difference. Mortality, use of rescue medicines, and extrapyramidal symptoms were higher in antipsychotic groups.
BOTTOM LINE: Antipsychotics cause side effects without efficacy in palliation of symptoms of delirium.
CITATIONS: Agar MR, Lawlor PG, Quinn S, et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA Intern Med. 2017 Jan;177:34-42.
Dr. Cumbler is the associate chief of hospital medicine, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Do antipsychotics provide symptomatic benefit for delirium in palliative care?
BACKGROUND: Antipsychotics are frequently used for the treatment of delirium and guideline recommended for delirium-associated distress. However, a 2016 meta-analysis found antipsychotics are not associated with change in delirium duration or severity. Antipsychotics for palliative management of delirium at end of life is not well studied.
STUDY DESIGN: Double-blind randomized controlled trial with placebo, haloperidol, and risperidone arms.
SETTING: Eleven Australian inpatient hospice or palliative care services.
SYNOPSIS: 247 patients (mean age, 74.9 years; 88.3% with cancer) with advanced incurable disease and active delirium were studied. Most had mild-moderate severity delirium. All received nonpharmacological measures and plan to address reversible precipitants. Patients were randomized to placebo (84), haloperidol (81), or risperidone (82) for 72 hours. Dose titration was allowed based on delirium symptoms. In intention to treat analysis the delirium severity scores were statistically higher in haloperidol and risperidone arms, compared with placebo. This reached statistical significance although less than the minimum clinically significant difference. Mortality, use of rescue medicines, and extrapyramidal symptoms were higher in antipsychotic groups.
BOTTOM LINE: Antipsychotics cause side effects without efficacy in palliation of symptoms of delirium.
CITATIONS: Agar MR, Lawlor PG, Quinn S, et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA Intern Med. 2017 Jan;177:34-42.
Dr. Cumbler is the associate chief of hospital medicine, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.