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Clinical Question: Are there particular groups of patients in which lower transfusion thresholds (transfusion only at lower hemoglobin levels) may be harmful?

Background: Previously published meta-analyses have examined transfusion thresholds for critically ill, surgical, and medical patients. By combining these patients, previous meta-analyses are limited in the identification of intervention effects. A more refined understanding of how transfusion thresholds impact outcomes for a variety of patients in different clinical settings is needed.

Study Design: Context-specific systematic review and meta-analysis of randomized clinical trials.

Setting: Adult patients in perioperative, emergency, or intensive-care settings.

Synopsis: Patient information was extracted from 31 randomized clinical trials. The authors found that among 3,465 elderly patients undergoing orthopedic surgery, those given restrictive transfusion strategies had significantly more events reflecting inadequate oxygen supply (relative risk, 1.41; 95% CI, 1.03–1.92). No statistically significant effect from restrictive transfusions was seen in 3,322 patients with cardiovascular disease undergoing cardiac or vascular procedures; 3,590 mixed medical-surgical patients in emergency and intensive-care settings; and 823 patients in a combined group of postpartum women, hematologic malignancy patients, and younger patients with neurologic injury.

The authors argue that even statistically nonsignificant differences in morbidity and mortality should encourage more liberal transfusion; apart from orthopedic surgery patients, this argument is not well-supported by the available data.

Bottom Line: It remains unclear whether restrictive transfusion strategies have a negative impact on certain types of patients, although the authors argue that there may be a trend in that direction. Further study is needed for specific patient populations.

Citation: Hovaguimian F, Myles PS. Restrictive versus liberal transfusion strategy in the perioperative and acute care settings: a context-specific systematic review and meta-analysis of randomized clinical trials. Anesthesiology. 2016;125(1):46-61.

Clinical Question: Are there particular groups of patients in which lower transfusion thresholds (transfusion only at lower hemoglobin levels) may be harmful?

Background: Previously published meta-analyses have examined transfusion thresholds for critically ill, surgical, and medical patients. By combining these patients, previous meta-analyses are limited in the identification of intervention effects. A more refined understanding of how transfusion thresholds impact outcomes for a variety of patients in different clinical settings is needed.

Study Design: Context-specific systematic review and meta-analysis of randomized clinical trials.

Setting: Adult patients in perioperative, emergency, or intensive-care settings.

Synopsis: Patient information was extracted from 31 randomized clinical trials. The authors found that among 3,465 elderly patients undergoing orthopedic surgery, those given restrictive transfusion strategies had significantly more events reflecting inadequate oxygen supply (relative risk, 1.41; 95% CI, 1.03–1.92). No statistically significant effect from restrictive transfusions was seen in 3,322 patients with cardiovascular disease undergoing cardiac or vascular procedures; 3,590 mixed medical-surgical patients in emergency and intensive-care settings; and 823 patients in a combined group of postpartum women, hematologic malignancy patients, and younger patients with neurologic injury.

The authors argue that even statistically nonsignificant differences in morbidity and mortality should encourage more liberal transfusion; apart from orthopedic surgery patients, this argument is not well-supported by the available data.

Bottom Line: It remains unclear whether restrictive transfusion strategies have a negative impact on certain types of patients, although the authors argue that there may be a trend in that direction. Further study is needed for specific patient populations.

Citation: Hovaguimian F, Myles PS. Restrictive versus liberal transfusion strategy in the perioperative and acute care settings: a context-specific systematic review and meta-analysis of randomized clinical trials. Anesthesiology. 2016;125(1):46-61.

Clinical Question: Are there particular groups of patients in which lower transfusion thresholds (transfusion only at lower hemoglobin levels) may be harmful?

Background: Previously published meta-analyses have examined transfusion thresholds for critically ill, surgical, and medical patients. By combining these patients, previous meta-analyses are limited in the identification of intervention effects. A more refined understanding of how transfusion thresholds impact outcomes for a variety of patients in different clinical settings is needed.

Study Design: Context-specific systematic review and meta-analysis of randomized clinical trials.

Setting: Adult patients in perioperative, emergency, or intensive-care settings.

Synopsis: Patient information was extracted from 31 randomized clinical trials. The authors found that among 3,465 elderly patients undergoing orthopedic surgery, those given restrictive transfusion strategies had significantly more events reflecting inadequate oxygen supply (relative risk, 1.41; 95% CI, 1.03–1.92). No statistically significant effect from restrictive transfusions was seen in 3,322 patients with cardiovascular disease undergoing cardiac or vascular procedures; 3,590 mixed medical-surgical patients in emergency and intensive-care settings; and 823 patients in a combined group of postpartum women, hematologic malignancy patients, and younger patients with neurologic injury.

The authors argue that even statistically nonsignificant differences in morbidity and mortality should encourage more liberal transfusion; apart from orthopedic surgery patients, this argument is not well-supported by the available data.

Bottom Line: It remains unclear whether restrictive transfusion strategies have a negative impact on certain types of patients, although the authors argue that there may be a trend in that direction. Further study is needed for specific patient populations.

Citation: Hovaguimian F, Myles PS. Restrictive versus liberal transfusion strategy in the perioperative and acute care settings: a context-specific systematic review and meta-analysis of randomized clinical trials. Anesthesiology. 2016;125(1):46-61.

Metrics used by the Centers for Medicare & Medicaid Services to determine penalties for heart failure hospital readmissions are not associated with quality of care or overall clinical outcomes, according to data presented at the annual scientific sessions of the American Heart Association.

Ambarish Pandey, MD, of the University of Texas Southwestern Medical Center in Dallas, and his colleagues analyzed data from centers participating in the American Heart Association’s Get With The Guidelines-Heart Failure (GWTG-HF) registry linked to Medicare claims from July 2008 to June 2011. Centers were stratified as having low risk-adjusted readmission rates and high risk-adjusted readmission rates based on publicly available data from 2013.

The study included 171 centers with 43,143 patients. Centers were almost evenly split between low- and high-risk–adjusted 30-day readmission rates, with just a few more (51%) falling in the low-risk–adjusted category.

Performance was nearly equal (95.7% for centers with a low risk-adjusted readmission rate vs. 96.5% for those with high risk-adjusted rate) for median adherence to all performance measures, as was the case for median percentage of defect-free care (90.0% vs. 91.1%, respectively) and composite 1-year outcome of death or all-cause readmission rates (median 62.9% vs. 65.3%, respectively). The higher readmission group had higher 1-year all-cause readmission rates (median, 59.1% vs. 54.7%), Dr. Pandey and his colleagues reported in the study that was published simultaneously in JACC: Heart Failure (2016 Nov 15. doi. org/10.1016/j.jchf.2016). One-year mortality rates were lower in the higher readmission group with a trend toward statistical significance (median, 28.2% vs. 31.7%; P = 0.07).

Taken together, the findings suggest the 30-day readmission metrics currently used by CMS to determine readmission penalties are not associated with quality of care or overall clinical outcomes, Dr. Pandey and his colleagues wrote. Results showing higher 30-day readmissions do not necessarily reflect poor quality of care and may be related to other factors.

“These findings question the usefulness of the [hospital readmission reduction program] metric in identifying and penalizing hospitals with low quality of care,” Dr. Pandey wrote, adding that the findings were consistent with previous studies that have demonstrated a lack of association between in-hospital quality of care and 30-day readmission rates.

CMS implemented the federal Hospital Readmissions Reduction Program (HRRP) in 2012 to provide financial incentives for hospitals to reduce readmissions. Under the program, CMS uses claims data to determine whether readmission rates for heart failure, acute myocardial infarction, and pneumonia at eligible hospitals are higher than would be predicted by CMS models. Centers with higher than expected readmission rates face up to a 3% reimbursement penalty.

[email protected]

On Twitter @legal_med

Metrics used by the Centers for Medicare & Medicaid Services to determine penalties for heart failure hospital readmissions are not associated with quality of care or overall clinical outcomes, according to data presented at the annual scientific sessions of the American Heart Association.

Ambarish Pandey, MD, of the University of Texas Southwestern Medical Center in Dallas, and his colleagues analyzed data from centers participating in the American Heart Association’s Get With The Guidelines-Heart Failure (GWTG-HF) registry linked to Medicare claims from July 2008 to June 2011. Centers were stratified as having low risk-adjusted readmission rates and high risk-adjusted readmission rates based on publicly available data from 2013.

The study included 171 centers with 43,143 patients. Centers were almost evenly split between low- and high-risk–adjusted 30-day readmission rates, with just a few more (51%) falling in the low-risk–adjusted category.

Performance was nearly equal (95.7% for centers with a low risk-adjusted readmission rate vs. 96.5% for those with high risk-adjusted rate) for median adherence to all performance measures, as was the case for median percentage of defect-free care (90.0% vs. 91.1%, respectively) and composite 1-year outcome of death or all-cause readmission rates (median 62.9% vs. 65.3%, respectively). The higher readmission group had higher 1-year all-cause readmission rates (median, 59.1% vs. 54.7%), Dr. Pandey and his colleagues reported in the study that was published simultaneously in JACC: Heart Failure (2016 Nov 15. doi. org/10.1016/j.jchf.2016). One-year mortality rates were lower in the higher readmission group with a trend toward statistical significance (median, 28.2% vs. 31.7%; P = 0.07).

Taken together, the findings suggest the 30-day readmission metrics currently used by CMS to determine readmission penalties are not associated with quality of care or overall clinical outcomes, Dr. Pandey and his colleagues wrote. Results showing higher 30-day readmissions do not necessarily reflect poor quality of care and may be related to other factors.

“These findings question the usefulness of the [hospital readmission reduction program] metric in identifying and penalizing hospitals with low quality of care,” Dr. Pandey wrote, adding that the findings were consistent with previous studies that have demonstrated a lack of association between in-hospital quality of care and 30-day readmission rates.

CMS implemented the federal Hospital Readmissions Reduction Program (HRRP) in 2012 to provide financial incentives for hospitals to reduce readmissions. Under the program, CMS uses claims data to determine whether readmission rates for heart failure, acute myocardial infarction, and pneumonia at eligible hospitals are higher than would be predicted by CMS models. Centers with higher than expected readmission rates face up to a 3% reimbursement penalty.

[email protected]

On Twitter @legal_med

Metrics used by the Centers for Medicare & Medicaid Services to determine penalties for heart failure hospital readmissions are not associated with quality of care or overall clinical outcomes, according to data presented at the annual scientific sessions of the American Heart Association.

Ambarish Pandey, MD, of the University of Texas Southwestern Medical Center in Dallas, and his colleagues analyzed data from centers participating in the American Heart Association’s Get With The Guidelines-Heart Failure (GWTG-HF) registry linked to Medicare claims from July 2008 to June 2011. Centers were stratified as having low risk-adjusted readmission rates and high risk-adjusted readmission rates based on publicly available data from 2013.

The study included 171 centers with 43,143 patients. Centers were almost evenly split between low- and high-risk–adjusted 30-day readmission rates, with just a few more (51%) falling in the low-risk–adjusted category.

Performance was nearly equal (95.7% for centers with a low risk-adjusted readmission rate vs. 96.5% for those with high risk-adjusted rate) for median adherence to all performance measures, as was the case for median percentage of defect-free care (90.0% vs. 91.1%, respectively) and composite 1-year outcome of death or all-cause readmission rates (median 62.9% vs. 65.3%, respectively). The higher readmission group had higher 1-year all-cause readmission rates (median, 59.1% vs. 54.7%), Dr. Pandey and his colleagues reported in the study that was published simultaneously in JACC: Heart Failure (2016 Nov 15. doi. org/10.1016/j.jchf.2016). One-year mortality rates were lower in the higher readmission group with a trend toward statistical significance (median, 28.2% vs. 31.7%; P = 0.07).

Taken together, the findings suggest the 30-day readmission metrics currently used by CMS to determine readmission penalties are not associated with quality of care or overall clinical outcomes, Dr. Pandey and his colleagues wrote. Results showing higher 30-day readmissions do not necessarily reflect poor quality of care and may be related to other factors.

“These findings question the usefulness of the [hospital readmission reduction program] metric in identifying and penalizing hospitals with low quality of care,” Dr. Pandey wrote, adding that the findings were consistent with previous studies that have demonstrated a lack of association between in-hospital quality of care and 30-day readmission rates.

CMS implemented the federal Hospital Readmissions Reduction Program (HRRP) in 2012 to provide financial incentives for hospitals to reduce readmissions. Under the program, CMS uses claims data to determine whether readmission rates for heart failure, acute myocardial infarction, and pneumonia at eligible hospitals are higher than would be predicted by CMS models. Centers with higher than expected readmission rates face up to a 3% reimbursement penalty.

[email protected]

On Twitter @legal_med

Editor’s note: As SHM celebrates the “Year of the Hospitalist,” we’re putting the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/yoth for more information on how you can join the yearlong celebration and help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Moises Auron, MD, SFHM, a dual internal medicine/pediatrics hospitalist at the Cleveland Clinic. He is board certified in internal medicine and pediatrics and serves as associate professor of medicine and pediatrics at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: I joined SHM as a third-year med-peds resident, influenced by my mentor and teacher, Dr. James C. Pile. I completed my medicine and perioperative consult rotation with him, and it was the first time in ages that anybody had served as such a motivating role model. He gave me a collection of The Hospitalist newsmagazines focused on perioperative medicine as well as a pack of articles around pertinent subjects for an internal medicine consultation service. It was a breath of fresh air; I found an entirely new niche in medicine. And in addition, he demonstrated to me how being a hospitalist was a fundamental pillar of patient care within the healthcare system. He showed me the elements of a thorough and pertinent system-based practice.

I met SHM CEO Dr. Larry Wellikson and the SHM team during a meeting in Philadelphia about 10 years ago and became even more acquainted with the society and its goals. I became a member on the spot. As a resident, I loved receiving both The Hospitalist and the Journal of Hospital Medicine. Both helped me also in my initial job search during my senior year of residency as well as with familiarizing myself with the latest hospital medicine literature. In short, being a member of SHM helped me cement my professional career path to hospital medicine.

Q: How has SHM provided you with resources to improve patient care and further your career?

I had the privilege of attending the Academic Hospitalist Academy and the Quality and Safety Educators Academy as well; both have helped me foster further goals in my career as well as achieve substantial professional and personal satisfaction.

The most important aspect of my membership has been becoming acquainted with a tremendous group of talented human beings, including both the SHM staff as well as hospitalist colleagues. The strength of SHM is its people: passionate providers and administrators who aim to make a better world for patients and doctors.

Q: What is your proudest moment working in hospital medicine?

A: Every single day of my job. As an academic hospitalist and a quality officer at my institution, I take tremendous pride in my job. I define ourselves as the super-internists; we are a quaternary medical center that cares for patients referred from all over the nation, and we need to elucidate obscure diagnoses and aim to offer a treatment and hope.

To me, what is more important is when I witness my residents being actively mindful about preventing harm: when they hardwire best practices such as good hand hygiene, precautions for prevention of falls, risk mitigation associated with any medical intervention … The list goes on. When I appreciate that behavior that becomes my proudest moment because I know that they will ensure the best outcomes for our patients and that I have made an impact.

Q: What do you see as the biggest opportunity for hospitalists as healthcare continues to evolve, and how can hospitalists rise to the challenge?

A: As the saying goes, “One of the tests of leadership is the ability to recognize a problem before it becomes an emergency.” We need to anticipate the way American healthcare is being delivered. The business model is changing, and the payment system is transitioning. Quality is being leveraged as a tool to decrease costs of care.

Hospitalists need to be creative in capitalizing on each individual patient encounter to maximize communication with other members of the healthcare team and use the patient’s hospitalization time strategically. We need to be the savings experts. We can recognize areas where unnecessary expenditure is used by having a lean mind and focusing on removing waste that will not impact our patients. We are the experts on the front line—we need to share the feedback to the leadership.

Q: What advice would you give to future providers considering a career in hospital medicine?

A: Become an SHM member early in your residency, aim to present a poster, participate at an SHM meeting, and engage in the networking process. SHM offers educational initiatives (e.g., Leadership Academy, Academic Hospitalist Academy, Quality and Safety Educators Academy), quality improvement programs (e.g., BOOST and Glycemic Control), and educational content to ensure your success in the Focused Practice in Hospital Medicine exam via the SHM SPARK tool.

Why so early? Because all of these resources help to build a sense of purpose and help to answer the question, “Where do I want to be five years from now?” Networking is fundamental, especially as it gives the opportunity to develop potential mentorship relationships and create teams for future collaboration endeavors.

Editor’s note: As SHM celebrates the “Year of the Hospitalist,” we’re putting the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/yoth for more information on how you can join the yearlong celebration and help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Moises Auron, MD, SFHM, a dual internal medicine/pediatrics hospitalist at the Cleveland Clinic. He is board certified in internal medicine and pediatrics and serves as associate professor of medicine and pediatrics at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: I joined SHM as a third-year med-peds resident, influenced by my mentor and teacher, Dr. James C. Pile. I completed my medicine and perioperative consult rotation with him, and it was the first time in ages that anybody had served as such a motivating role model. He gave me a collection of The Hospitalist newsmagazines focused on perioperative medicine as well as a pack of articles around pertinent subjects for an internal medicine consultation service. It was a breath of fresh air; I found an entirely new niche in medicine. And in addition, he demonstrated to me how being a hospitalist was a fundamental pillar of patient care within the healthcare system. He showed me the elements of a thorough and pertinent system-based practice.

I met SHM CEO Dr. Larry Wellikson and the SHM team during a meeting in Philadelphia about 10 years ago and became even more acquainted with the society and its goals. I became a member on the spot. As a resident, I loved receiving both The Hospitalist and the Journal of Hospital Medicine. Both helped me also in my initial job search during my senior year of residency as well as with familiarizing myself with the latest hospital medicine literature. In short, being a member of SHM helped me cement my professional career path to hospital medicine.

Q: How has SHM provided you with resources to improve patient care and further your career?

I had the privilege of attending the Academic Hospitalist Academy and the Quality and Safety Educators Academy as well; both have helped me foster further goals in my career as well as achieve substantial professional and personal satisfaction.

The most important aspect of my membership has been becoming acquainted with a tremendous group of talented human beings, including both the SHM staff as well as hospitalist colleagues. The strength of SHM is its people: passionate providers and administrators who aim to make a better world for patients and doctors.

Q: What is your proudest moment working in hospital medicine?

A: Every single day of my job. As an academic hospitalist and a quality officer at my institution, I take tremendous pride in my job. I define ourselves as the super-internists; we are a quaternary medical center that cares for patients referred from all over the nation, and we need to elucidate obscure diagnoses and aim to offer a treatment and hope.

To me, what is more important is when I witness my residents being actively mindful about preventing harm: when they hardwire best practices such as good hand hygiene, precautions for prevention of falls, risk mitigation associated with any medical intervention … The list goes on. When I appreciate that behavior that becomes my proudest moment because I know that they will ensure the best outcomes for our patients and that I have made an impact.

Q: What do you see as the biggest opportunity for hospitalists as healthcare continues to evolve, and how can hospitalists rise to the challenge?

A: As the saying goes, “One of the tests of leadership is the ability to recognize a problem before it becomes an emergency.” We need to anticipate the way American healthcare is being delivered. The business model is changing, and the payment system is transitioning. Quality is being leveraged as a tool to decrease costs of care.

Hospitalists need to be creative in capitalizing on each individual patient encounter to maximize communication with other members of the healthcare team and use the patient’s hospitalization time strategically. We need to be the savings experts. We can recognize areas where unnecessary expenditure is used by having a lean mind and focusing on removing waste that will not impact our patients. We are the experts on the front line—we need to share the feedback to the leadership.

Q: What advice would you give to future providers considering a career in hospital medicine?

A: Become an SHM member early in your residency, aim to present a poster, participate at an SHM meeting, and engage in the networking process. SHM offers educational initiatives (e.g., Leadership Academy, Academic Hospitalist Academy, Quality and Safety Educators Academy), quality improvement programs (e.g., BOOST and Glycemic Control), and educational content to ensure your success in the Focused Practice in Hospital Medicine exam via the SHM SPARK tool.

Why so early? Because all of these resources help to build a sense of purpose and help to answer the question, “Where do I want to be five years from now?” Networking is fundamental, especially as it gives the opportunity to develop potential mentorship relationships and create teams for future collaboration endeavors.

Editor’s note: As SHM celebrates the “Year of the Hospitalist,” we’re putting the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/yoth for more information on how you can join the yearlong celebration and help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Moises Auron, MD, SFHM, a dual internal medicine/pediatrics hospitalist at the Cleveland Clinic. He is board certified in internal medicine and pediatrics and serves as associate professor of medicine and pediatrics at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: I joined SHM as a third-year med-peds resident, influenced by my mentor and teacher, Dr. James C. Pile. I completed my medicine and perioperative consult rotation with him, and it was the first time in ages that anybody had served as such a motivating role model. He gave me a collection of The Hospitalist newsmagazines focused on perioperative medicine as well as a pack of articles around pertinent subjects for an internal medicine consultation service. It was a breath of fresh air; I found an entirely new niche in medicine. And in addition, he demonstrated to me how being a hospitalist was a fundamental pillar of patient care within the healthcare system. He showed me the elements of a thorough and pertinent system-based practice.

I met SHM CEO Dr. Larry Wellikson and the SHM team during a meeting in Philadelphia about 10 years ago and became even more acquainted with the society and its goals. I became a member on the spot. As a resident, I loved receiving both The Hospitalist and the Journal of Hospital Medicine. Both helped me also in my initial job search during my senior year of residency as well as with familiarizing myself with the latest hospital medicine literature. In short, being a member of SHM helped me cement my professional career path to hospital medicine.

Q: How has SHM provided you with resources to improve patient care and further your career?

I had the privilege of attending the Academic Hospitalist Academy and the Quality and Safety Educators Academy as well; both have helped me foster further goals in my career as well as achieve substantial professional and personal satisfaction.

The most important aspect of my membership has been becoming acquainted with a tremendous group of talented human beings, including both the SHM staff as well as hospitalist colleagues. The strength of SHM is its people: passionate providers and administrators who aim to make a better world for patients and doctors.

Q: What is your proudest moment working in hospital medicine?

A: Every single day of my job. As an academic hospitalist and a quality officer at my institution, I take tremendous pride in my job. I define ourselves as the super-internists; we are a quaternary medical center that cares for patients referred from all over the nation, and we need to elucidate obscure diagnoses and aim to offer a treatment and hope.

To me, what is more important is when I witness my residents being actively mindful about preventing harm: when they hardwire best practices such as good hand hygiene, precautions for prevention of falls, risk mitigation associated with any medical intervention … The list goes on. When I appreciate that behavior that becomes my proudest moment because I know that they will ensure the best outcomes for our patients and that I have made an impact.

Q: What do you see as the biggest opportunity for hospitalists as healthcare continues to evolve, and how can hospitalists rise to the challenge?

A: As the saying goes, “One of the tests of leadership is the ability to recognize a problem before it becomes an emergency.” We need to anticipate the way American healthcare is being delivered. The business model is changing, and the payment system is transitioning. Quality is being leveraged as a tool to decrease costs of care.

Hospitalists need to be creative in capitalizing on each individual patient encounter to maximize communication with other members of the healthcare team and use the patient’s hospitalization time strategically. We need to be the savings experts. We can recognize areas where unnecessary expenditure is used by having a lean mind and focusing on removing waste that will not impact our patients. We are the experts on the front line—we need to share the feedback to the leadership.

Q: What advice would you give to future providers considering a career in hospital medicine?

A: Become an SHM member early in your residency, aim to present a poster, participate at an SHM meeting, and engage in the networking process. SHM offers educational initiatives (e.g., Leadership Academy, Academic Hospitalist Academy, Quality and Safety Educators Academy), quality improvement programs (e.g., BOOST and Glycemic Control), and educational content to ensure your success in the Focused Practice in Hospital Medicine exam via the SHM SPARK tool.

Why so early? Because all of these resources help to build a sense of purpose and help to answer the question, “Where do I want to be five years from now?” Networking is fundamental, especially as it gives the opportunity to develop potential mentorship relationships and create teams for future collaboration endeavors.

Choosing hospital medicine as a specialty means choosing between practicing community HM or academic HM. Or does it? Elizabeth Cook, MD, of Hospital Medicine Associates in Lynchburg VA; Stella Fitzgibbon, MD, FACP, FHM, with Memorial Hermann Hospital in The Woodlands, TX; and Chris Moriates, MD, of Dell Medical School at UT Austin, talk about the options available in community and academic HM, and moving between them during an HM career.

Choosing hospital medicine as a specialty means choosing between practicing community HM or academic HM. Or does it? Elizabeth Cook, MD, of Hospital Medicine Associates in Lynchburg VA; Stella Fitzgibbon, MD, FACP, FHM, with Memorial Hermann Hospital in The Woodlands, TX; and Chris Moriates, MD, of Dell Medical School at UT Austin, talk about the options available in community and academic HM, and moving between them during an HM career.

Choosing hospital medicine as a specialty means choosing between practicing community HM or academic HM. Or does it? Elizabeth Cook, MD, of Hospital Medicine Associates in Lynchburg VA; Stella Fitzgibbon, MD, FACP, FHM, with Memorial Hermann Hospital in The Woodlands, TX; and Chris Moriates, MD, of Dell Medical School at UT Austin, talk about the options available in community and academic HM, and moving between them during an HM career.

WASHINGTON – Patients with traumatic injuries don’t appear to be at undue risk of sustained opioid use, a large database review has demonstrated.

More than half of the 13,000 patients in the study were discharged on opioids, but they were able to discontinue them fairly rapidly, Muhammad Chaudhary, MD, said at the annual clinical congress of the American College of Surgeons. Within 3 months, less than one-third were still using the drugs, and 1 year later, only 1% were still taking an opioid pain medication.

[email protected]

On Twitter @alz_gal

WASHINGTON – Patients with traumatic injuries don’t appear to be at undue risk of sustained opioid use, a large database review has demonstrated.

More than half of the 13,000 patients in the study were discharged on opioids, but they were able to discontinue them fairly rapidly, Muhammad Chaudhary, MD, said at the annual clinical congress of the American College of Surgeons. Within 3 months, less than one-third were still using the drugs, and 1 year later, only 1% were still taking an opioid pain medication.

[email protected]

On Twitter @alz_gal

WASHINGTON – Patients with traumatic injuries don’t appear to be at undue risk of sustained opioid use, a large database review has demonstrated.

More than half of the 13,000 patients in the study were discharged on opioids, but they were able to discontinue them fairly rapidly, Muhammad Chaudhary, MD, said at the annual clinical congress of the American College of Surgeons. Within 3 months, less than one-third were still using the drugs, and 1 year later, only 1% were still taking an opioid pain medication.

[email protected]

On Twitter @alz_gal

Clinical Question: What is the incidence of loss of independence (LOI) for older adults after surgery, and is there an association between LOI and readmission or death?

Background: LOI is being increasingly recognized as an important measure of patient-centered care and a potential opportunity for intervention to prevent disablement. This study is the first to examine links between LOI and rates of readmission or death following surgery.

Study Design: Retrospective cohort.

Setting: 26 U.S. hospitals participating in a national quality improvement project.

Synopsis: The authors examined data from 5,077 patients age 65 or older undergoing an inpatient surgical procedure. They examined ability to perform activities of daily living (ADLs), mobility, and living situation before and after surgery, and they defined LOI as a change in one or more of these factors at the time of discharge.

They found that LOI increased with age, with 49.9% of patients ages 65–74, 67.3% of patients ages 75–84, and 83.9% of patients age 85 or older experiencing LOI. The study also showed an association between LOI and negative outcomes, including readmission (odds ratio, 1.7) and death after discharge (odds ratio, 6.7).

Although this study was retrospective, the findings indicate that LOI is strongly correlated with negative short-term outcomes, especially in older populations. LOI related to surgery is a measure that deserves closer attention and greater future study as a potential target for clinical initiatives and intervention.

Bottom Line: LOI (functional ability, mobility, and living situation) after surgery increases with age and is associated with negative short-term outcomes including readmission and death.

Citation: Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.

Short Take

Transition to New Electronic Health Records Systems Does Not Increase Adverse Outcomes

An observational study comparing 17 hospitals implementing new electronic health records systems with 399 control hospitals showed no difference in the rate of adverse safety events or readmissions following implementation.

Citation: Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic health record system: observational study. BMJ. 2016;354:i3835.

Clinical Question: What is the incidence of loss of independence (LOI) for older adults after surgery, and is there an association between LOI and readmission or death?

Background: LOI is being increasingly recognized as an important measure of patient-centered care and a potential opportunity for intervention to prevent disablement. This study is the first to examine links between LOI and rates of readmission or death following surgery.

Study Design: Retrospective cohort.

Setting: 26 U.S. hospitals participating in a national quality improvement project.

Synopsis: The authors examined data from 5,077 patients age 65 or older undergoing an inpatient surgical procedure. They examined ability to perform activities of daily living (ADLs), mobility, and living situation before and after surgery, and they defined LOI as a change in one or more of these factors at the time of discharge.

They found that LOI increased with age, with 49.9% of patients ages 65–74, 67.3% of patients ages 75–84, and 83.9% of patients age 85 or older experiencing LOI. The study also showed an association between LOI and negative outcomes, including readmission (odds ratio, 1.7) and death after discharge (odds ratio, 6.7).

Although this study was retrospective, the findings indicate that LOI is strongly correlated with negative short-term outcomes, especially in older populations. LOI related to surgery is a measure that deserves closer attention and greater future study as a potential target for clinical initiatives and intervention.

Bottom Line: LOI (functional ability, mobility, and living situation) after surgery increases with age and is associated with negative short-term outcomes including readmission and death.

Citation: Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.

Short Take

Transition to New Electronic Health Records Systems Does Not Increase Adverse Outcomes

An observational study comparing 17 hospitals implementing new electronic health records systems with 399 control hospitals showed no difference in the rate of adverse safety events or readmissions following implementation.

Citation: Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic health record system: observational study. BMJ. 2016;354:i3835.

Clinical Question: What is the incidence of loss of independence (LOI) for older adults after surgery, and is there an association between LOI and readmission or death?

Background: LOI is being increasingly recognized as an important measure of patient-centered care and a potential opportunity for intervention to prevent disablement. This study is the first to examine links between LOI and rates of readmission or death following surgery.

Study Design: Retrospective cohort.

Setting: 26 U.S. hospitals participating in a national quality improvement project.

Synopsis: The authors examined data from 5,077 patients age 65 or older undergoing an inpatient surgical procedure. They examined ability to perform activities of daily living (ADLs), mobility, and living situation before and after surgery, and they defined LOI as a change in one or more of these factors at the time of discharge.

They found that LOI increased with age, with 49.9% of patients ages 65–74, 67.3% of patients ages 75–84, and 83.9% of patients age 85 or older experiencing LOI. The study also showed an association between LOI and negative outcomes, including readmission (odds ratio, 1.7) and death after discharge (odds ratio, 6.7).

Although this study was retrospective, the findings indicate that LOI is strongly correlated with negative short-term outcomes, especially in older populations. LOI related to surgery is a measure that deserves closer attention and greater future study as a potential target for clinical initiatives and intervention.

Bottom Line: LOI (functional ability, mobility, and living situation) after surgery increases with age and is associated with negative short-term outcomes including readmission and death.

Citation: Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.

Short Take

Transition to New Electronic Health Records Systems Does Not Increase Adverse Outcomes

An observational study comparing 17 hospitals implementing new electronic health records systems with 399 control hospitals showed no difference in the rate of adverse safety events or readmissions following implementation.

Citation: Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic health record system: observational study. BMJ. 2016;354:i3835.

Clinical Question: What data are available regarding the attitudes toward and the practice of euthanasia and physician-assisted suicide (PAS)?

Background: Although controversial, euthanasia and PAS are currently legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada, while PAS (but not euthanasia) is legal in Switzerland and five states (Oregon, Washington, Montana, Vermont, and California). Knowledge about current practices is limited as only a portion of these jurisdictions have reporting requirements.

Study Design: Literature review with a focus on original data.

Setting: Data from United States, Canada, and Europe.

Synopsis: Published data from 1947 to 2016 were reviewed. U.S. public opinion surveys show a recent decline in support of PAS, from a peak of 75% in 2005 to 64% in 2012. With the exception of the Netherlands and Belgium, physicians in the U.S., Europe, and Australia are less supportive than the general public.

In the U.S., <20% of physicians reported receiving a request for euthanasia or PAS, and <5% complied. Oncologists are most likely to receive a patient request. The typical patient is older, white, insured, well-educated, and enrolled in hospice. Seventy-five percent have cancer, while 15% have neurodegenerative conditions. Loss of autonomy and dignity are common motivators, while <33% of patients cite uncontrolled pain. PAS remains rare, accounting for <0.4% of all deaths. Existing data do not indicate abuse of these practices.

The authors emphasize that existing data are limited and recommend that all countries, not just those where euthanasia and/or PAS are legal, should formally collect information on end-of-life practices.

Bottom Line: Euthanasia and PAS remain relatively rare and primarily involve oncology patients despite increasing legalization.

Citation: Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90.

Short Take

Peer Support for Physicians May Curb Burnout

This perspective piece outlines a program of one-to-one peer outreach for physicians as a way to mitigate stress especially when dealing with adverse events or litigation, but no data are provided.

Citation: Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.

Clinical Question: What data are available regarding the attitudes toward and the practice of euthanasia and physician-assisted suicide (PAS)?

Background: Although controversial, euthanasia and PAS are currently legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada, while PAS (but not euthanasia) is legal in Switzerland and five states (Oregon, Washington, Montana, Vermont, and California). Knowledge about current practices is limited as only a portion of these jurisdictions have reporting requirements.

Study Design: Literature review with a focus on original data.

Setting: Data from United States, Canada, and Europe.

Synopsis: Published data from 1947 to 2016 were reviewed. U.S. public opinion surveys show a recent decline in support of PAS, from a peak of 75% in 2005 to 64% in 2012. With the exception of the Netherlands and Belgium, physicians in the U.S., Europe, and Australia are less supportive than the general public.

In the U.S., <20% of physicians reported receiving a request for euthanasia or PAS, and <5% complied. Oncologists are most likely to receive a patient request. The typical patient is older, white, insured, well-educated, and enrolled in hospice. Seventy-five percent have cancer, while 15% have neurodegenerative conditions. Loss of autonomy and dignity are common motivators, while <33% of patients cite uncontrolled pain. PAS remains rare, accounting for <0.4% of all deaths. Existing data do not indicate abuse of these practices.

The authors emphasize that existing data are limited and recommend that all countries, not just those where euthanasia and/or PAS are legal, should formally collect information on end-of-life practices.

Bottom Line: Euthanasia and PAS remain relatively rare and primarily involve oncology patients despite increasing legalization.

Citation: Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90.

Short Take

Peer Support for Physicians May Curb Burnout

This perspective piece outlines a program of one-to-one peer outreach for physicians as a way to mitigate stress especially when dealing with adverse events or litigation, but no data are provided.

Citation: Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.

Clinical Question: What data are available regarding the attitudes toward and the practice of euthanasia and physician-assisted suicide (PAS)?

Background: Although controversial, euthanasia and PAS are currently legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada, while PAS (but not euthanasia) is legal in Switzerland and five states (Oregon, Washington, Montana, Vermont, and California). Knowledge about current practices is limited as only a portion of these jurisdictions have reporting requirements.

Study Design: Literature review with a focus on original data.

Setting: Data from United States, Canada, and Europe.

Synopsis: Published data from 1947 to 2016 were reviewed. U.S. public opinion surveys show a recent decline in support of PAS, from a peak of 75% in 2005 to 64% in 2012. With the exception of the Netherlands and Belgium, physicians in the U.S., Europe, and Australia are less supportive than the general public.

In the U.S., <20% of physicians reported receiving a request for euthanasia or PAS, and <5% complied. Oncologists are most likely to receive a patient request. The typical patient is older, white, insured, well-educated, and enrolled in hospice. Seventy-five percent have cancer, while 15% have neurodegenerative conditions. Loss of autonomy and dignity are common motivators, while <33% of patients cite uncontrolled pain. PAS remains rare, accounting for <0.4% of all deaths. Existing data do not indicate abuse of these practices.

The authors emphasize that existing data are limited and recommend that all countries, not just those where euthanasia and/or PAS are legal, should formally collect information on end-of-life practices.

Bottom Line: Euthanasia and PAS remain relatively rare and primarily involve oncology patients despite increasing legalization.

Citation: Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90.

Short Take

Peer Support for Physicians May Curb Burnout

This perspective piece outlines a program of one-to-one peer outreach for physicians as a way to mitigate stress especially when dealing with adverse events or litigation, but no data are provided.

Citation: Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.

In conjunction with the Centers for Disease Control & Prevention’s Get Smart about Antibiotics Week, SHM is committed to promoting improved antibiotic-prescribing behaviors among the nation’s hospitalists through its “Fight the Resistance” awareness campaign.

Display SHM’s three downloadable “Fight the Resistance” posters, available at www.fighttheresistance.org. Hang them in your break rooms, hallways, or other high-profile locations to help remind your colleagues about the dangers of antibiotic resistance. SHM will be launching a mentored implementation program on antibiotics in early 2017. To be notified when the program becomes available, visit www.hospitalmedicine.org/ABX16.

In conjunction with the Centers for Disease Control & Prevention’s Get Smart about Antibiotics Week, SHM is committed to promoting improved antibiotic-prescribing behaviors among the nation’s hospitalists through its “Fight the Resistance” awareness campaign.

Display SHM’s three downloadable “Fight the Resistance” posters, available at www.fighttheresistance.org. Hang them in your break rooms, hallways, or other high-profile locations to help remind your colleagues about the dangers of antibiotic resistance. SHM will be launching a mentored implementation program on antibiotics in early 2017. To be notified when the program becomes available, visit www.hospitalmedicine.org/ABX16.

In conjunction with the Centers for Disease Control & Prevention’s Get Smart about Antibiotics Week, SHM is committed to promoting improved antibiotic-prescribing behaviors among the nation’s hospitalists through its “Fight the Resistance” awareness campaign.

Display SHM’s three downloadable “Fight the Resistance” posters, available at www.fighttheresistance.org. Hang them in your break rooms, hallways, or other high-profile locations to help remind your colleagues about the dangers of antibiotic resistance. SHM will be launching a mentored implementation program on antibiotics in early 2017. To be notified when the program becomes available, visit www.hospitalmedicine.org/ABX16.

There is no better time than American Diabetes Month to learn more about SHM’s Glycemic Control Program. Find out how your institution can submit point-of-care data to SHM’s Data Center, generate monthly reports, and be included in the national glucometrics benchmark report. Hospital systems are also encouraged to subscribe in order to track their individual performance as well as compare overall performance.

View a recent case study on three sites that demonstrated more rapid definitive improvements in measurable outcomes with the mentoring program, driving change through ongoing objective support, data collection, and analysis. Don’t wait: Be one of the 100 hospitals nationwide supported by SHM’s respected Glycemic Control Program. Learn more at www.hospitalmedicine.org/gc.

There is no better time than American Diabetes Month to learn more about SHM’s Glycemic Control Program. Find out how your institution can submit point-of-care data to SHM’s Data Center, generate monthly reports, and be included in the national glucometrics benchmark report. Hospital systems are also encouraged to subscribe in order to track their individual performance as well as compare overall performance.

View a recent case study on three sites that demonstrated more rapid definitive improvements in measurable outcomes with the mentoring program, driving change through ongoing objective support, data collection, and analysis. Don’t wait: Be one of the 100 hospitals nationwide supported by SHM’s respected Glycemic Control Program. Learn more at www.hospitalmedicine.org/gc.

There is no better time than American Diabetes Month to learn more about SHM’s Glycemic Control Program. Find out how your institution can submit point-of-care data to SHM’s Data Center, generate monthly reports, and be included in the national glucometrics benchmark report. Hospital systems are also encouraged to subscribe in order to track their individual performance as well as compare overall performance.

View a recent case study on three sites that demonstrated more rapid definitive improvements in measurable outcomes with the mentoring program, driving change through ongoing objective support, data collection, and analysis. Don’t wait: Be one of the 100 hospitals nationwide supported by SHM’s respected Glycemic Control Program. Learn more at www.hospitalmedicine.org/gc.

Now through December 31, 2016, all active SHM members can earn 2017–2018 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members. Active members will be eligible for:

• A $35 credit toward 2017–2018 dues when recruiting 1 new member.
• A $50 credit toward 2017–2018 dues when recruiting 2–4 new members.
• A $75 credit toward 2017–2018 dues when recruiting 5–9 new members.
• A $125 credit toward 2017–2018 dues when recruiting 10+ new members.

For each member recruited, referrers will receive one entry into a grand-prize drawing to receive complimentary registration to Hospital Medicine 2017 in Las Vegas.

Now through December 31, 2016, all active SHM members can earn 2017–2018 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members. Active members will be eligible for:

• A $35 credit toward 2017–2018 dues when recruiting 1 new member.
• A $50 credit toward 2017–2018 dues when recruiting 2–4 new members.
• A $75 credit toward 2017–2018 dues when recruiting 5–9 new members.
• A $125 credit toward 2017–2018 dues when recruiting 10+ new members.

For each member recruited, referrers will receive one entry into a grand-prize drawing to receive complimentary registration to Hospital Medicine 2017 in Las Vegas.

Now through December 31, 2016, all active SHM members can earn 2017–2018 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members. Active members will be eligible for:

• A $35 credit toward 2017–2018 dues when recruiting 1 new member.
• A $50 credit toward 2017–2018 dues when recruiting 2–4 new members.
• A $75 credit toward 2017–2018 dues when recruiting 5–9 new members.
• A $125 credit toward 2017–2018 dues when recruiting 10+ new members.

For each member recruited, referrers will receive one entry into a grand-prize drawing to receive complimentary registration to Hospital Medicine 2017 in Las Vegas.