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Clinical question: Does nasal high-flow (NHF) oxygen after extubation reduce reintubation rates in low-risk patients?

Background: NHF oxygen devices deliver warmed and humidified oxygen up to 60 liters per minutes. NHF provides positive end-expiratory pressure and dead-space washout. NHF in higher-risk post-extubation patients has been shown to have clinical benefits. Whether NHF post-extubation benefits patients at low risk of reintubation is unknown.

Study design: Randomized control trial (RCT).

Setting: Seven ICUs in Spain.

Synopsis: In this RCT, post-extubation NHF oxygen for 24 hours reduced the risk of reintubation among 527 ICU adults at low risk of reintubation when compared to conventional oxygen therapy (by nasal cannula or face mask). Patients with hypercapnia during weaning trials were excluded. The risk of reintubation was 4.9% versus 12.2% in NHF versus standard oxygen therapy, with an absolute difference of 7.2% (95% CI, 2.5–12.2%; P=0.004). ICU length of stay and mortality were not significantly different between the groups. The strengths of the study were adequate sample size, prespecified criteria for reintubation, and low number of crossover patients.

Limitations of the trial were the high percentage of surgical and neurologic cases, exclusion of patients with a variety of common comorbidities, and the inability to blind the physicians to the treatment arm of the subjects. Select patients may benefit from noninvasive ventilation to prevent reintubation, which was not studied. These results are highly relevant to post-extubation patients, with the optimum therapy for low-risk patients now appearing to be NHF.

Bottom line: NHF oxygen reduced reintubation compared to conventional oxygen therapy (nasal cannula or face mask) in extubated patients at low risk of reintubation.

Citation: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354-1361. doi:10.1001/jama.2016.2711.

Clinical question: Does nasal high-flow (NHF) oxygen after extubation reduce reintubation rates in low-risk patients?

Background: NHF oxygen devices deliver warmed and humidified oxygen up to 60 liters per minutes. NHF provides positive end-expiratory pressure and dead-space washout. NHF in higher-risk post-extubation patients has been shown to have clinical benefits. Whether NHF post-extubation benefits patients at low risk of reintubation is unknown.

Study design: Randomized control trial (RCT).

Setting: Seven ICUs in Spain.

Synopsis: In this RCT, post-extubation NHF oxygen for 24 hours reduced the risk of reintubation among 527 ICU adults at low risk of reintubation when compared to conventional oxygen therapy (by nasal cannula or face mask). Patients with hypercapnia during weaning trials were excluded. The risk of reintubation was 4.9% versus 12.2% in NHF versus standard oxygen therapy, with an absolute difference of 7.2% (95% CI, 2.5–12.2%; P=0.004). ICU length of stay and mortality were not significantly different between the groups. The strengths of the study were adequate sample size, prespecified criteria for reintubation, and low number of crossover patients.

Limitations of the trial were the high percentage of surgical and neurologic cases, exclusion of patients with a variety of common comorbidities, and the inability to blind the physicians to the treatment arm of the subjects. Select patients may benefit from noninvasive ventilation to prevent reintubation, which was not studied. These results are highly relevant to post-extubation patients, with the optimum therapy for low-risk patients now appearing to be NHF.

Bottom line: NHF oxygen reduced reintubation compared to conventional oxygen therapy (nasal cannula or face mask) in extubated patients at low risk of reintubation.

Citation: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354-1361. doi:10.1001/jama.2016.2711.

Clinical question: Does nasal high-flow (NHF) oxygen after extubation reduce reintubation rates in low-risk patients?

Background: NHF oxygen devices deliver warmed and humidified oxygen up to 60 liters per minutes. NHF provides positive end-expiratory pressure and dead-space washout. NHF in higher-risk post-extubation patients has been shown to have clinical benefits. Whether NHF post-extubation benefits patients at low risk of reintubation is unknown.

Study design: Randomized control trial (RCT).

Setting: Seven ICUs in Spain.

Synopsis: In this RCT, post-extubation NHF oxygen for 24 hours reduced the risk of reintubation among 527 ICU adults at low risk of reintubation when compared to conventional oxygen therapy (by nasal cannula or face mask). Patients with hypercapnia during weaning trials were excluded. The risk of reintubation was 4.9% versus 12.2% in NHF versus standard oxygen therapy, with an absolute difference of 7.2% (95% CI, 2.5–12.2%; P=0.004). ICU length of stay and mortality were not significantly different between the groups. The strengths of the study were adequate sample size, prespecified criteria for reintubation, and low number of crossover patients.

Limitations of the trial were the high percentage of surgical and neurologic cases, exclusion of patients with a variety of common comorbidities, and the inability to blind the physicians to the treatment arm of the subjects. Select patients may benefit from noninvasive ventilation to prevent reintubation, which was not studied. These results are highly relevant to post-extubation patients, with the optimum therapy for low-risk patients now appearing to be NHF.

Bottom line: NHF oxygen reduced reintubation compared to conventional oxygen therapy (nasal cannula or face mask) in extubated patients at low risk of reintubation.

Citation: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354-1361. doi:10.1001/jama.2016.2711.

U.S. hospitals may be getting paid for more of the care they actually provide thanks to the Affordable Care Act, if research from Michigan reflects the situation around the country.

While the study didn't look directly at hospital finances, researchers found that the proportion of uninsured adults discharged from Michigan hospitals fell after public insurance options expanded in 2014.

"What we found is that the overwhelming majority of hospitals experienced a decrease in the proportion of uninsured patients and an increase in Medicaid covered patients," said lead author Dr. Matthew Davis, deputy director of Institute for Healthcare Policy and Innovation at the University of Michigan Health System in Ann Arbor.

Under the Affordable Care Act, also known as Obamacare, some U.S. states - including Michigan - expanded Medicaid, which is the joint federal and state insurance program for the poor.

Previous studies showed many people who gained health insurance through the law were previously uninsured, Davis told Reuters Health.

For the new study, he and his colleagues analyzed data on young adults discharged from 130 Michigan hospitals before and after Medicaid became more broadly available in 2014.

About 6 percent of young adults discharged at those hospitals between April and December before the Medicaid expansion were uninsured, compared to about 2 percent during those months in 2014, according to the findings scheduled for online publication June 21 in JAMA.

The proportion of discharged young adults on Medicaid rose from 23 percent in 2012 and 24 percent in 2013 to 30 percent in 2014.

There was a small decline in the number of people discharged with private or other insurance, they found.

The researchers were surprised at how uniform the impact of Medicaid expansion seemed to be in hospitals across Michigan, Davis said.

"This impact wasn't limited to urban areas or population centers, or safety net hospitals," he said.

According to Davis, past research shows that decreases in the number of uninsured patients are tied to decreases in healthcare that goes unpaid for.

"As we have more and more years of the Affordable Care Act that have provided expanded coverage for millions of Americans, it's going to be important to understand how that coverage translates into positive health," he said.

"Coverage through insurance plans and programs like Medicaid is most (needed) when our health is at its worst and we need to be hospitalized," he said. "Yet, that coverage is also essential in times when our health is better and we need to be focused on preventing the next illness rather than just responding to it."

SOURCE: http://bit.ly/WddS8K JAMA 2016.

U.S. hospitals may be getting paid for more of the care they actually provide thanks to the Affordable Care Act, if research from Michigan reflects the situation around the country.

While the study didn't look directly at hospital finances, researchers found that the proportion of uninsured adults discharged from Michigan hospitals fell after public insurance options expanded in 2014.

"What we found is that the overwhelming majority of hospitals experienced a decrease in the proportion of uninsured patients and an increase in Medicaid covered patients," said lead author Dr. Matthew Davis, deputy director of Institute for Healthcare Policy and Innovation at the University of Michigan Health System in Ann Arbor.

Under the Affordable Care Act, also known as Obamacare, some U.S. states - including Michigan - expanded Medicaid, which is the joint federal and state insurance program for the poor.

Previous studies showed many people who gained health insurance through the law were previously uninsured, Davis told Reuters Health.

For the new study, he and his colleagues analyzed data on young adults discharged from 130 Michigan hospitals before and after Medicaid became more broadly available in 2014.

About 6 percent of young adults discharged at those hospitals between April and December before the Medicaid expansion were uninsured, compared to about 2 percent during those months in 2014, according to the findings scheduled for online publication June 21 in JAMA.

The proportion of discharged young adults on Medicaid rose from 23 percent in 2012 and 24 percent in 2013 to 30 percent in 2014.

There was a small decline in the number of people discharged with private or other insurance, they found.

The researchers were surprised at how uniform the impact of Medicaid expansion seemed to be in hospitals across Michigan, Davis said.

"This impact wasn't limited to urban areas or population centers, or safety net hospitals," he said.

According to Davis, past research shows that decreases in the number of uninsured patients are tied to decreases in healthcare that goes unpaid for.

"As we have more and more years of the Affordable Care Act that have provided expanded coverage for millions of Americans, it's going to be important to understand how that coverage translates into positive health," he said.

"Coverage through insurance plans and programs like Medicaid is most (needed) when our health is at its worst and we need to be hospitalized," he said. "Yet, that coverage is also essential in times when our health is better and we need to be focused on preventing the next illness rather than just responding to it."

SOURCE: http://bit.ly/WddS8K JAMA 2016.

U.S. hospitals may be getting paid for more of the care they actually provide thanks to the Affordable Care Act, if research from Michigan reflects the situation around the country.

While the study didn't look directly at hospital finances, researchers found that the proportion of uninsured adults discharged from Michigan hospitals fell after public insurance options expanded in 2014.

"What we found is that the overwhelming majority of hospitals experienced a decrease in the proportion of uninsured patients and an increase in Medicaid covered patients," said lead author Dr. Matthew Davis, deputy director of Institute for Healthcare Policy and Innovation at the University of Michigan Health System in Ann Arbor.

Under the Affordable Care Act, also known as Obamacare, some U.S. states - including Michigan - expanded Medicaid, which is the joint federal and state insurance program for the poor.

Previous studies showed many people who gained health insurance through the law were previously uninsured, Davis told Reuters Health.

For the new study, he and his colleagues analyzed data on young adults discharged from 130 Michigan hospitals before and after Medicaid became more broadly available in 2014.

About 6 percent of young adults discharged at those hospitals between April and December before the Medicaid expansion were uninsured, compared to about 2 percent during those months in 2014, according to the findings scheduled for online publication June 21 in JAMA.

The proportion of discharged young adults on Medicaid rose from 23 percent in 2012 and 24 percent in 2013 to 30 percent in 2014.

There was a small decline in the number of people discharged with private or other insurance, they found.

The researchers were surprised at how uniform the impact of Medicaid expansion seemed to be in hospitals across Michigan, Davis said.

"This impact wasn't limited to urban areas or population centers, or safety net hospitals," he said.

According to Davis, past research shows that decreases in the number of uninsured patients are tied to decreases in healthcare that goes unpaid for.

"As we have more and more years of the Affordable Care Act that have provided expanded coverage for millions of Americans, it's going to be important to understand how that coverage translates into positive health," he said.

"Coverage through insurance plans and programs like Medicaid is most (needed) when our health is at its worst and we need to be hospitalized," he said. "Yet, that coverage is also essential in times when our health is better and we need to be focused on preventing the next illness rather than just responding to it."

SOURCE: http://bit.ly/WddS8K JAMA 2016.

Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.

“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”

“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”

The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.

“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P

Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”

Reference

1. Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.

Quick Byte

Telehealth Expansion

In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.

Reference

1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.

Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.

“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”

“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”

The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.

“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P

Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”

Reference

1. Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.

Quick Byte

Telehealth Expansion

In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.

Reference

1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.

Hospitalists face ever-increasing pressure to reduce drug expenditures without compromising the quality of care provided to patients, and as a consequence, are creating new ways to approach the issue. A recent study published in the American Journal of Medical Quality assessed the effectiveness of computerized provider order entry alerts as one method. The alerts displayed the cost of a high-cost medication alongside a lower-cost alternative.

“We regularly scrutinize our drug budgets and look for medications that display changing costs/utilization,” says Gregory K. Gipson, PharmD, cardiothoracic surgery and cardiology pharmacist at the University of Washington and lead author of “Optimizing Prescribing Practices of High-Cost Medications with Computerized Alerts in the Inpatient Setting.”

“We were able to identify a few medications that were both high in cost and utilization but had lower-cost alternatives that could be substituted in certain situations,” Dr. Gipson says. “These higher-cost medications also had formulary restrictions for use; however, it was felt that very few people knew about these restrictions or had any idea how much any of these medications cost. In an attempt to reduce unnecessary use of these high-cost medications, we created alerts that informed providers of the cost of both high- and low-cost medications and restrictions for use, and we gave them the ability to convert the order to the lower-cost alternative.”

The study looked specifically at three high-cost medications and their utilization during the year prior to the intervention and compared it to usage in the year after implementation, and it found reduced utilization of high-cost medications.

“Ipratropium hydrofluoroalkane and fluticasone hydrofluoroalkane metered dose inhaler utilization were reduced by 29% and 62%, respectively (P

Overall, they saw this as a success. “This type of interruptive electronic order entry alert containing cost information and therapeutic alternatives is an effective educational tool that reduces medication costs,” Dr. Gipson says. “… This suggests that new computerized alerts can be implemented in thoughtful ways to minimize the interference with hospital workflow and alert fatigue yet still achieve their desired outcome.”

Reference

1. Gipson G, Kelly JL, McKinney CM, White AA. Optimizing prescribing practices of high-cost medications with computerized alerts in the inpatient setting. Am J Med Qual. doi:10.1177/1062860616649660.

Quick Byte

Telehealth Expansion

In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program, according to “Integrating Health Care and Housing to Promote Healthy Aging,” a recent Health Affairs blog. But, the authors suggest, the Centers for Medicare & Medicaid Services and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies that have the potential to improve health outcomes and reduce costs, especially for seniors who could remain at home. “The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth,” according to the post.

Reference

1. Schwartz A, Parekh A. Integrating health care and housing to promote healthy aging. Health Aff. Available at: http://healthaffairs.org/blog/2016/05/23/integrating-health-care-and-housing-to-promote-healthy-aging/. Accessed May 31, 2016.

“I recently discharged a complex patient from the hospital, and I was shocked to see the poor quality of his clinical summary,” says Erin Sarzynski, MD, MS, of Michigan State University’s Department of Family Medicine. This observation drove the research underlying the paper she co-wrote titled “Opportunities to Improve Clinical Summaries for Patients at Hospital Discharge,” published in BMJ Quality & Safety.

The problem, the paper lays out, is that, “presently, it is unclear whether clinical summaries include relevant content or whether healthcare organizations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge.”

As a first step toward improving these documents, Dr. Sarzynski worked with a team to evaluate 100 clinical summaries generated at two Michigan hospitals based on content, organization, and understandability. They became aware of systemic problems.

“Clinical summaries are produced from templates, but physicians’ workflows do not prompt them to preview the document before the nurse prints it to review with the patient,” Dr. Sarzynski says. “Clinical summaries are lengthy yet omit key discharge information. They are poorly organized, written at the 8th- to 12th-grade reading level, and score poorly on assessments of understandability and actionability.

“Medication lists illustrate a key safety issue resulting from poor-quality clinical summaries; for example, we routinely send patients home without parameters for sliding-scale insulin.”

The study highlights opportunities to improve clinical summaries for guiding patients’ post-discharge care.

“We developed an audit tool based on the Meaningful Use view-download-transmit objective and the SHM Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organization); and five readability formulas and the Patient Education Materials Assessment Tool,” the authors write.

“If possible, hospitalists should preview their patients’ clinical summaries before printing—it’s an opportunity to ensure key discharge information is correct and appropriately emphasized,” Dr. Sarzynski says.

Reference

1. Sarzynski E, Hashmi H, Subramanian J, et al. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf. doi:10.1136/bmjqs-2015-005201.

“I recently discharged a complex patient from the hospital, and I was shocked to see the poor quality of his clinical summary,” says Erin Sarzynski, MD, MS, of Michigan State University’s Department of Family Medicine. This observation drove the research underlying the paper she co-wrote titled “Opportunities to Improve Clinical Summaries for Patients at Hospital Discharge,” published in BMJ Quality & Safety.

The problem, the paper lays out, is that, “presently, it is unclear whether clinical summaries include relevant content or whether healthcare organizations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge.”

As a first step toward improving these documents, Dr. Sarzynski worked with a team to evaluate 100 clinical summaries generated at two Michigan hospitals based on content, organization, and understandability. They became aware of systemic problems.

“Clinical summaries are produced from templates, but physicians’ workflows do not prompt them to preview the document before the nurse prints it to review with the patient,” Dr. Sarzynski says. “Clinical summaries are lengthy yet omit key discharge information. They are poorly organized, written at the 8th- to 12th-grade reading level, and score poorly on assessments of understandability and actionability.

“Medication lists illustrate a key safety issue resulting from poor-quality clinical summaries; for example, we routinely send patients home without parameters for sliding-scale insulin.”

The study highlights opportunities to improve clinical summaries for guiding patients’ post-discharge care.

“We developed an audit tool based on the Meaningful Use view-download-transmit objective and the SHM Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organization); and five readability formulas and the Patient Education Materials Assessment Tool,” the authors write.

“If possible, hospitalists should preview their patients’ clinical summaries before printing—it’s an opportunity to ensure key discharge information is correct and appropriately emphasized,” Dr. Sarzynski says.

Reference

1. Sarzynski E, Hashmi H, Subramanian J, et al. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf. doi:10.1136/bmjqs-2015-005201.

“I recently discharged a complex patient from the hospital, and I was shocked to see the poor quality of his clinical summary,” says Erin Sarzynski, MD, MS, of Michigan State University’s Department of Family Medicine. This observation drove the research underlying the paper she co-wrote titled “Opportunities to Improve Clinical Summaries for Patients at Hospital Discharge,” published in BMJ Quality & Safety.

The problem, the paper lays out, is that, “presently, it is unclear whether clinical summaries include relevant content or whether healthcare organizations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge.”

As a first step toward improving these documents, Dr. Sarzynski worked with a team to evaluate 100 clinical summaries generated at two Michigan hospitals based on content, organization, and understandability. They became aware of systemic problems.

“Clinical summaries are produced from templates, but physicians’ workflows do not prompt them to preview the document before the nurse prints it to review with the patient,” Dr. Sarzynski says. “Clinical summaries are lengthy yet omit key discharge information. They are poorly organized, written at the 8th- to 12th-grade reading level, and score poorly on assessments of understandability and actionability.

“Medication lists illustrate a key safety issue resulting from poor-quality clinical summaries; for example, we routinely send patients home without parameters for sliding-scale insulin.”

The study highlights opportunities to improve clinical summaries for guiding patients’ post-discharge care.

“We developed an audit tool based on the Meaningful Use view-download-transmit objective and the SHM Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organization); and five readability formulas and the Patient Education Materials Assessment Tool,” the authors write.

“If possible, hospitalists should preview their patients’ clinical summaries before printing—it’s an opportunity to ensure key discharge information is correct and appropriately emphasized,” Dr. Sarzynski says.

Reference

1. Sarzynski E, Hashmi H, Subramanian J, et al. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf. doi:10.1136/bmjqs-2015-005201.

Americans are adding more whole grains,nuts and seeds to their diets and cutting back on sodas and sugary drinks, a U.S. study suggests.

While these changes point to some improvements in U.S.eating habits over the past decade, many people still consume too much sugar and processed food and not enough whole fruits and vegetables, the study scheduled for online publication June 21 in JAMA found.

"The overall diet is still far from optimal - less than one-third of American adults meet guidelines for most foods," said senior study author Dr. Dariush Mozaffarian, dean of the Tufts Friedman School of Nutrition Science and Policy in Boston.

"The single biggest focus should be on reducing highly processed foods rich in refined grains, starch, added sugars and salt; and increasing minimally processed healthful foods such as fruits, non-starchy vegetables, nuts, seeds, beans, fish and yogurt," Mozaffarian added by email.

Researchers looked at trends in eating habits for almost 34,000 adults aged 20 or older who participated in seven nationally representative surveys from 1999 to 2012.

The study team scored diets based, among other things, on how well people followed recommendations from the American Heart Association (AHA) that are designed to help prevent chronic health problems like cardiovascular disease.

Under these guidelines, a healthy diet includes at least 4.5 cups a day of fruits and vegetables, at least three ounces a day of fiber-rich whole grains and at least seven ounces a week of fish. It also caps sodium intake at 1,500 mg a day, the amount in three quarters of a teaspoon (3.75 g) of salt, and limits sodas and sugary juices at 36 ounces (1 liter) a week.

Overall, the percentage of Americans with poor diets based on these AHA standards dropped from 56 percent to 46 percent during the study period. The proportion of people with ideal diets was low but inched up to 1.5 percent from less than 1 percent.

Racial disparities in eating habits persisted throughout the study period. The proportion of white people with poor diets declined, while remaining little changed among black and Hispanic adults.

More affluent adults saw greater improvements in diet than lower-income people, the study also found.

For some eating patterns - including consumption of total vegetables, whole grains, unprocessed red meat and milk - trends over time were similar regardless of race, ethnicity, income or education levels. Intake of these things was consistently higher for more affluent people and white people and lower for poor people and black and Hispanic adults.

At the same time, salt intake was unchanged for white people but increased for black and Hispanic people during the study period.

Refined grain consumption dropped for white and black adults while increasing for Hispanics.

Limitations of the study include its reliance on survey participants to accurately recall and report what they ate and drank, as well as the potential for diet fads or food trends in popular culture to influence how people described their diets, the authors note.

Even so, the findings suggest that doctors need to do a better job educating patients about how to eat and how food choices influence their health, Dr. Margo Denke, a former researcher at the University of Texas Southwestern Medical Center in Dallas noted in an accompanying editorial.

Physicians also have to recognize that improving diets may be not be just a question of education, but of access and affordability, Denke added by email. While it's possible some people are confused about what to eat, the bigger problem is that they aren't sure what to do when fresh produce isn't at their local store.

"The import of less expensive fruits and vegetables I believe drove improved intake among those who have higher incomes," Denke said. "How can we pass this on to those who are financially struggling?"

SOURCE: http://bit.ly/28LE2ye JAMA 2016.

Americans are adding more whole grains,nuts and seeds to their diets and cutting back on sodas and sugary drinks, a U.S. study suggests.

While these changes point to some improvements in U.S.eating habits over the past decade, many people still consume too much sugar and processed food and not enough whole fruits and vegetables, the study scheduled for online publication June 21 in JAMA found.

"The overall diet is still far from optimal - less than one-third of American adults meet guidelines for most foods," said senior study author Dr. Dariush Mozaffarian, dean of the Tufts Friedman School of Nutrition Science and Policy in Boston.

"The single biggest focus should be on reducing highly processed foods rich in refined grains, starch, added sugars and salt; and increasing minimally processed healthful foods such as fruits, non-starchy vegetables, nuts, seeds, beans, fish and yogurt," Mozaffarian added by email.

Researchers looked at trends in eating habits for almost 34,000 adults aged 20 or older who participated in seven nationally representative surveys from 1999 to 2012.

The study team scored diets based, among other things, on how well people followed recommendations from the American Heart Association (AHA) that are designed to help prevent chronic health problems like cardiovascular disease.

Under these guidelines, a healthy diet includes at least 4.5 cups a day of fruits and vegetables, at least three ounces a day of fiber-rich whole grains and at least seven ounces a week of fish. It also caps sodium intake at 1,500 mg a day, the amount in three quarters of a teaspoon (3.75 g) of salt, and limits sodas and sugary juices at 36 ounces (1 liter) a week.

Overall, the percentage of Americans with poor diets based on these AHA standards dropped from 56 percent to 46 percent during the study period. The proportion of people with ideal diets was low but inched up to 1.5 percent from less than 1 percent.

Racial disparities in eating habits persisted throughout the study period. The proportion of white people with poor diets declined, while remaining little changed among black and Hispanic adults.

More affluent adults saw greater improvements in diet than lower-income people, the study also found.

For some eating patterns - including consumption of total vegetables, whole grains, unprocessed red meat and milk - trends over time were similar regardless of race, ethnicity, income or education levels. Intake of these things was consistently higher for more affluent people and white people and lower for poor people and black and Hispanic adults.

At the same time, salt intake was unchanged for white people but increased for black and Hispanic people during the study period.

Refined grain consumption dropped for white and black adults while increasing for Hispanics.

Limitations of the study include its reliance on survey participants to accurately recall and report what they ate and drank, as well as the potential for diet fads or food trends in popular culture to influence how people described their diets, the authors note.

Even so, the findings suggest that doctors need to do a better job educating patients about how to eat and how food choices influence their health, Dr. Margo Denke, a former researcher at the University of Texas Southwestern Medical Center in Dallas noted in an accompanying editorial.

Physicians also have to recognize that improving diets may be not be just a question of education, but of access and affordability, Denke added by email. While it's possible some people are confused about what to eat, the bigger problem is that they aren't sure what to do when fresh produce isn't at their local store.

"The import of less expensive fruits and vegetables I believe drove improved intake among those who have higher incomes," Denke said. "How can we pass this on to those who are financially struggling?"

SOURCE: http://bit.ly/28LE2ye JAMA 2016.

Americans are adding more whole grains,nuts and seeds to their diets and cutting back on sodas and sugary drinks, a U.S. study suggests.

While these changes point to some improvements in U.S.eating habits over the past decade, many people still consume too much sugar and processed food and not enough whole fruits and vegetables, the study scheduled for online publication June 21 in JAMA found.

"The overall diet is still far from optimal - less than one-third of American adults meet guidelines for most foods," said senior study author Dr. Dariush Mozaffarian, dean of the Tufts Friedman School of Nutrition Science and Policy in Boston.

"The single biggest focus should be on reducing highly processed foods rich in refined grains, starch, added sugars and salt; and increasing minimally processed healthful foods such as fruits, non-starchy vegetables, nuts, seeds, beans, fish and yogurt," Mozaffarian added by email.

Researchers looked at trends in eating habits for almost 34,000 adults aged 20 or older who participated in seven nationally representative surveys from 1999 to 2012.

The study team scored diets based, among other things, on how well people followed recommendations from the American Heart Association (AHA) that are designed to help prevent chronic health problems like cardiovascular disease.

Under these guidelines, a healthy diet includes at least 4.5 cups a day of fruits and vegetables, at least three ounces a day of fiber-rich whole grains and at least seven ounces a week of fish. It also caps sodium intake at 1,500 mg a day, the amount in three quarters of a teaspoon (3.75 g) of salt, and limits sodas and sugary juices at 36 ounces (1 liter) a week.

Overall, the percentage of Americans with poor diets based on these AHA standards dropped from 56 percent to 46 percent during the study period. The proportion of people with ideal diets was low but inched up to 1.5 percent from less than 1 percent.

Racial disparities in eating habits persisted throughout the study period. The proportion of white people with poor diets declined, while remaining little changed among black and Hispanic adults.

More affluent adults saw greater improvements in diet than lower-income people, the study also found.

For some eating patterns - including consumption of total vegetables, whole grains, unprocessed red meat and milk - trends over time were similar regardless of race, ethnicity, income or education levels. Intake of these things was consistently higher for more affluent people and white people and lower for poor people and black and Hispanic adults.

At the same time, salt intake was unchanged for white people but increased for black and Hispanic people during the study period.

Refined grain consumption dropped for white and black adults while increasing for Hispanics.

Limitations of the study include its reliance on survey participants to accurately recall and report what they ate and drank, as well as the potential for diet fads or food trends in popular culture to influence how people described their diets, the authors note.

Even so, the findings suggest that doctors need to do a better job educating patients about how to eat and how food choices influence their health, Dr. Margo Denke, a former researcher at the University of Texas Southwestern Medical Center in Dallas noted in an accompanying editorial.

Physicians also have to recognize that improving diets may be not be just a question of education, but of access and affordability, Denke added by email. While it's possible some people are confused about what to eat, the bigger problem is that they aren't sure what to do when fresh produce isn't at their local store.

"The import of less expensive fruits and vegetables I believe drove improved intake among those who have higher incomes," Denke said. "How can we pass this on to those who are financially struggling?"

SOURCE: http://bit.ly/28LE2ye JAMA 2016.

It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.

When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.

I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.

Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.

Most important, he listened and didn’t judge.

Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.

As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.

But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.

We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.

So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.

As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.

Happy July, everyone! TH

It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.

When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.

I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.

Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.

Most important, he listened and didn’t judge.

Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.

As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.

But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.

We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.

So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.

As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.

Happy July, everyone! TH

It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.

When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.

I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.

Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.

Most important, he listened and didn’t judge.

Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.

As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.

But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.

We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.

So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.

As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.

Happy July, everyone! TH

NEW YORK - In patients with atrial fibrillation (AF) and a wide range of renal function, compared to warfarin, treatment with apixaban reduces the risk of cardiovascular events, according to multinational investigators.

As Dr. Ziad Hijazi told Reuters Health by email, "Renal dysfunction is a complex issue in patients with atrial fibrillation when balancing the risk of stroke versus the risk of bleeding."

"This study," he added, "shows that apixaban, compared with warfarin, was associated with a lower risk of stroke, death, and major bleeding, regardless of changes in renal function over time. These findings may aid clinicians in the treatment decision."

In a June 15 online paper in JAMA Cardiology, Dr. Hijazi, of Uppsala University Hospital, Sweden, and colleagues report that they came to this conclusion after examining data from a clinical trial (ARISTOTLE) on more than 16,800 AF patients randomized to apixaban or warfarin.

Over the course of a year, about a quarter (26%) maintained good renal function. Renal function declined in the others, and 13.6% showed a drop of more than 20%. The decline in renal function was more rapid in patients who were older or had comorbidities.

Overall, the risks of stroke or systemic embolism, major bleeding, and mortality were greater in patients with worsening renal function (hazard ratio, 1.53 for stroke or systemic embolism, 1.56 for major bleeding, and 2.31 for mortality).

However, such patients on apixaban, compared with warfarin, consistently demonstrated a lower relative risk of stroke or systemic embolism (HR 0.80), ischemic or unspecified stroke (HR 0.88), and major bleeding (HR 0.76).

In fact, as well as showing benefit in this group of patients, the researchers conclude, "The superior efficacy and safety of apixaban as compared with warfarin were similar in patients with normal, poor, and worsening renal function."

Commenting on the findings by email, cardiologist Dr. Anil Pandit of Scottsdale, Arizona, told Reuters Health, "The study by Hijazi et al answers very important clinical questions regarding safety and efficacy of apixaban in situations of declining renal function, a common phenomenon in a real world scenario."

An earlier meta-analysis, in which Dr. Pandit was involved, found decreased risk of major bleeding with apixaban in mild to moderate renal impairment when compared with other anticoagulants (warfarin, aspirin, and Lovenox) as a group.

"The main criticism of the findings of our meta-analysis was inapplicability in the real world scenario, where subclinical episodes of acute kidney injury and worsening renal failure, may lead to increased anticoagulant effect and bleeding," Dr. Pandit said. This new study "exactly answers this question in a large patient population, providing sustained evidence that apixaban is safe and effective in mild to moderate renal impairment patients."

"However," Dr. Pandit concluded, "one should keep in mind limitations of the retrospective data." He also pointed out that "the efficacy and safety of apixaban is not established in patients with severe renal failure, ... as this group of patients was not studied in the ARISTOTLE trial."

Bristol Myers Squibb and Pfizer funded the ARISTOTLE trial. Ten coauthors reported disclosures.

SOURCE: http://bit.ly/28LbKlt JAMA Cardiol 2016.

NEW YORK - In patients with atrial fibrillation (AF) and a wide range of renal function, compared to warfarin, treatment with apixaban reduces the risk of cardiovascular events, according to multinational investigators.

As Dr. Ziad Hijazi told Reuters Health by email, "Renal dysfunction is a complex issue in patients with atrial fibrillation when balancing the risk of stroke versus the risk of bleeding."

"This study," he added, "shows that apixaban, compared with warfarin, was associated with a lower risk of stroke, death, and major bleeding, regardless of changes in renal function over time. These findings may aid clinicians in the treatment decision."

In a June 15 online paper in JAMA Cardiology, Dr. Hijazi, of Uppsala University Hospital, Sweden, and colleagues report that they came to this conclusion after examining data from a clinical trial (ARISTOTLE) on more than 16,800 AF patients randomized to apixaban or warfarin.

Over the course of a year, about a quarter (26%) maintained good renal function. Renal function declined in the others, and 13.6% showed a drop of more than 20%. The decline in renal function was more rapid in patients who were older or had comorbidities.

Overall, the risks of stroke or systemic embolism, major bleeding, and mortality were greater in patients with worsening renal function (hazard ratio, 1.53 for stroke or systemic embolism, 1.56 for major bleeding, and 2.31 for mortality).

However, such patients on apixaban, compared with warfarin, consistently demonstrated a lower relative risk of stroke or systemic embolism (HR 0.80), ischemic or unspecified stroke (HR 0.88), and major bleeding (HR 0.76).

In fact, as well as showing benefit in this group of patients, the researchers conclude, "The superior efficacy and safety of apixaban as compared with warfarin were similar in patients with normal, poor, and worsening renal function."

Commenting on the findings by email, cardiologist Dr. Anil Pandit of Scottsdale, Arizona, told Reuters Health, "The study by Hijazi et al answers very important clinical questions regarding safety and efficacy of apixaban in situations of declining renal function, a common phenomenon in a real world scenario."

An earlier meta-analysis, in which Dr. Pandit was involved, found decreased risk of major bleeding with apixaban in mild to moderate renal impairment when compared with other anticoagulants (warfarin, aspirin, and Lovenox) as a group.

"The main criticism of the findings of our meta-analysis was inapplicability in the real world scenario, where subclinical episodes of acute kidney injury and worsening renal failure, may lead to increased anticoagulant effect and bleeding," Dr. Pandit said. This new study "exactly answers this question in a large patient population, providing sustained evidence that apixaban is safe and effective in mild to moderate renal impairment patients."

"However," Dr. Pandit concluded, "one should keep in mind limitations of the retrospective data." He also pointed out that "the efficacy and safety of apixaban is not established in patients with severe renal failure, ... as this group of patients was not studied in the ARISTOTLE trial."

Bristol Myers Squibb and Pfizer funded the ARISTOTLE trial. Ten coauthors reported disclosures.

SOURCE: http://bit.ly/28LbKlt JAMA Cardiol 2016.

NEW YORK - In patients with atrial fibrillation (AF) and a wide range of renal function, compared to warfarin, treatment with apixaban reduces the risk of cardiovascular events, according to multinational investigators.

As Dr. Ziad Hijazi told Reuters Health by email, "Renal dysfunction is a complex issue in patients with atrial fibrillation when balancing the risk of stroke versus the risk of bleeding."

"This study," he added, "shows that apixaban, compared with warfarin, was associated with a lower risk of stroke, death, and major bleeding, regardless of changes in renal function over time. These findings may aid clinicians in the treatment decision."

In a June 15 online paper in JAMA Cardiology, Dr. Hijazi, of Uppsala University Hospital, Sweden, and colleagues report that they came to this conclusion after examining data from a clinical trial (ARISTOTLE) on more than 16,800 AF patients randomized to apixaban or warfarin.

Over the course of a year, about a quarter (26%) maintained good renal function. Renal function declined in the others, and 13.6% showed a drop of more than 20%. The decline in renal function was more rapid in patients who were older or had comorbidities.

Overall, the risks of stroke or systemic embolism, major bleeding, and mortality were greater in patients with worsening renal function (hazard ratio, 1.53 for stroke or systemic embolism, 1.56 for major bleeding, and 2.31 for mortality).

However, such patients on apixaban, compared with warfarin, consistently demonstrated a lower relative risk of stroke or systemic embolism (HR 0.80), ischemic or unspecified stroke (HR 0.88), and major bleeding (HR 0.76).

In fact, as well as showing benefit in this group of patients, the researchers conclude, "The superior efficacy and safety of apixaban as compared with warfarin were similar in patients with normal, poor, and worsening renal function."

Commenting on the findings by email, cardiologist Dr. Anil Pandit of Scottsdale, Arizona, told Reuters Health, "The study by Hijazi et al answers very important clinical questions regarding safety and efficacy of apixaban in situations of declining renal function, a common phenomenon in a real world scenario."

An earlier meta-analysis, in which Dr. Pandit was involved, found decreased risk of major bleeding with apixaban in mild to moderate renal impairment when compared with other anticoagulants (warfarin, aspirin, and Lovenox) as a group.

"The main criticism of the findings of our meta-analysis was inapplicability in the real world scenario, where subclinical episodes of acute kidney injury and worsening renal failure, may lead to increased anticoagulant effect and bleeding," Dr. Pandit said. This new study "exactly answers this question in a large patient population, providing sustained evidence that apixaban is safe and effective in mild to moderate renal impairment patients."

"However," Dr. Pandit concluded, "one should keep in mind limitations of the retrospective data." He also pointed out that "the efficacy and safety of apixaban is not established in patients with severe renal failure, ... as this group of patients was not studied in the ARISTOTLE trial."

Bristol Myers Squibb and Pfizer funded the ARISTOTLE trial. Ten coauthors reported disclosures.

SOURCE: http://bit.ly/28LbKlt JAMA Cardiol 2016.

Clinical question: How do interhospital handoff practices differ among U.S. tertiary care centers, and what challenges and innovations have providers encountered?

Background: Little has been studied regarding interhospital transfers. Many centers differ in the processes they follow, and well-delineated national guidelines are lacking. Adverse events occur in up to 30% of transfers. Standardization of these handoffs has been shown to reduce preventable errors and near misses.

Study design: Survey of convenience sample of institutions.

Setting: Transfer center directors from 32 tertiary care centers in the U.S.

Synopsis: The authors surveyed directors of 32 transfer centers between 2013 and 2015. Hospitals were selected from a nationally ranked list as well as those comparable to the authors’ own institutions. The median number of patients transferred per month was 700.

Only 23% of hospitals surveyed identified significant EHR interoperability. Almost all required three-way recorded discussion between transfer center staff and referring and accepting physicians. Only 29% had available objective clinical information to share. Only 23% recorded a three-way nursing handoff, and only 32% used their EHR to document the transfer process and share clinical information among providers.

Innovations included electronic transfer notes, a standardized system of feedback to referring hospitals, automatic internal review for adverse events and delayed transfers, and use of a scorecard with key measures shared with stakeholders.

Barriers noted included complexity, acuity, and lack of continuity. Increased use of EHRs, checklists, and common processes were identified as best practices.

Limitations of the study included reliance on verbal qualitative data, a single investigator doing most of the discussions, and possible sampling bias.

Bottom line: Interhospital transfer practices at academic tertiary care centers vary widely, and optimizing and aligning practices between sending and receiving hospitals may improve efficiency and patient outcomes.

References: Herrigel DJ, Carroll M, Fanning C, Steinberg MB, Parikh A, Usher M. Interhospital transfer handoff practices among US tertiary care centers: a descriptive survey. J Hosp Med. 2016;11(6):413-417.

Clinical question: How do interhospital handoff practices differ among U.S. tertiary care centers, and what challenges and innovations have providers encountered?

Background: Little has been studied regarding interhospital transfers. Many centers differ in the processes they follow, and well-delineated national guidelines are lacking. Adverse events occur in up to 30% of transfers. Standardization of these handoffs has been shown to reduce preventable errors and near misses.

Study design: Survey of convenience sample of institutions.

Setting: Transfer center directors from 32 tertiary care centers in the U.S.

Synopsis: The authors surveyed directors of 32 transfer centers between 2013 and 2015. Hospitals were selected from a nationally ranked list as well as those comparable to the authors’ own institutions. The median number of patients transferred per month was 700.

Only 23% of hospitals surveyed identified significant EHR interoperability. Almost all required three-way recorded discussion between transfer center staff and referring and accepting physicians. Only 29% had available objective clinical information to share. Only 23% recorded a three-way nursing handoff, and only 32% used their EHR to document the transfer process and share clinical information among providers.

Innovations included electronic transfer notes, a standardized system of feedback to referring hospitals, automatic internal review for adverse events and delayed transfers, and use of a scorecard with key measures shared with stakeholders.

Barriers noted included complexity, acuity, and lack of continuity. Increased use of EHRs, checklists, and common processes were identified as best practices.

Limitations of the study included reliance on verbal qualitative data, a single investigator doing most of the discussions, and possible sampling bias.

Bottom line: Interhospital transfer practices at academic tertiary care centers vary widely, and optimizing and aligning practices between sending and receiving hospitals may improve efficiency and patient outcomes.

References: Herrigel DJ, Carroll M, Fanning C, Steinberg MB, Parikh A, Usher M. Interhospital transfer handoff practices among US tertiary care centers: a descriptive survey. J Hosp Med. 2016;11(6):413-417.

Clinical question: How do interhospital handoff practices differ among U.S. tertiary care centers, and what challenges and innovations have providers encountered?

Background: Little has been studied regarding interhospital transfers. Many centers differ in the processes they follow, and well-delineated national guidelines are lacking. Adverse events occur in up to 30% of transfers. Standardization of these handoffs has been shown to reduce preventable errors and near misses.

Study design: Survey of convenience sample of institutions.

Setting: Transfer center directors from 32 tertiary care centers in the U.S.

Synopsis: The authors surveyed directors of 32 transfer centers between 2013 and 2015. Hospitals were selected from a nationally ranked list as well as those comparable to the authors’ own institutions. The median number of patients transferred per month was 700.

Only 23% of hospitals surveyed identified significant EHR interoperability. Almost all required three-way recorded discussion between transfer center staff and referring and accepting physicians. Only 29% had available objective clinical information to share. Only 23% recorded a three-way nursing handoff, and only 32% used their EHR to document the transfer process and share clinical information among providers.

Innovations included electronic transfer notes, a standardized system of feedback to referring hospitals, automatic internal review for adverse events and delayed transfers, and use of a scorecard with key measures shared with stakeholders.

Barriers noted included complexity, acuity, and lack of continuity. Increased use of EHRs, checklists, and common processes were identified as best practices.

Limitations of the study included reliance on verbal qualitative data, a single investigator doing most of the discussions, and possible sampling bias.

Bottom line: Interhospital transfer practices at academic tertiary care centers vary widely, and optimizing and aligning practices between sending and receiving hospitals may improve efficiency and patient outcomes.

References: Herrigel DJ, Carroll M, Fanning C, Steinberg MB, Parikh A, Usher M. Interhospital transfer handoff practices among US tertiary care centers: a descriptive survey. J Hosp Med. 2016;11(6):413-417.

Clinical question: Are oral steroids as effective as NSAIDs in treating acute gout?

Background: Two small trials have suggested that oral steroids are as effective as NSAIDs in treating acute gout. Wider acceptance of steroids as first-line agents for acute gout may require more robust evidence supporting their safety and efficacy.

Study design: Multicenter, double-blind, randomized equivalence trial.

Setting: Four EDs in Hong Kong.

Synopsis: The study included 416 patients presenting to the ED with clinically suspected acute gout who were randomized to treatment with either oral indomethacin or oral prednisolone for five days. A research investigator assessed response to therapy in the ED at 30, 60, 90, and 120 minutes after administration of the initial dose of medication. Patients then kept pain-assessment diaries for 14 days after discharge from the ED.

Pain scores were assessed using a visual analog scale of 0 mm (no pain) to 100 mm (worst pain the patient had experienced). Clinically significant changes in pain scores were defined as decreases of >13 mm on the visual analog scale.

The number of patients with clinically significant decreases in pain scores did not differ statistically between groups. Both groups had similar reductions in mean pain scores over the course of the study. Patients in the indomethacin group had a statistically significant increase in minor adverse events. No patients in either group had major adverse events.

Bottom line: Oral prednisolone appears to be a safe and effective first-line agent for the treatment of acute gout.

Citation: Rainer TH, Chen CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout. Ann Intern Med. 2016;164(7):464-471.

Short Take

Rate Control as Effective as Rhythm Control in Postoperative Atrial Fibrillation

This study randomized patients with postoperative atrial fibrillation to rhythm control (using amiodarone and/or direct current cardioversion) or rate control and found neither treatment strategy has a clinical benefit over the other.

Citation: Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate control versus rhythm control for atrial fibrillation after cardiac surgery. N Engl J Med. 2016;374(20):1911-1921.

Clinical question: Are oral steroids as effective as NSAIDs in treating acute gout?

Background: Two small trials have suggested that oral steroids are as effective as NSAIDs in treating acute gout. Wider acceptance of steroids as first-line agents for acute gout may require more robust evidence supporting their safety and efficacy.

Study design: Multicenter, double-blind, randomized equivalence trial.

Setting: Four EDs in Hong Kong.

Synopsis: The study included 416 patients presenting to the ED with clinically suspected acute gout who were randomized to treatment with either oral indomethacin or oral prednisolone for five days. A research investigator assessed response to therapy in the ED at 30, 60, 90, and 120 minutes after administration of the initial dose of medication. Patients then kept pain-assessment diaries for 14 days after discharge from the ED.

Pain scores were assessed using a visual analog scale of 0 mm (no pain) to 100 mm (worst pain the patient had experienced). Clinically significant changes in pain scores were defined as decreases of >13 mm on the visual analog scale.

The number of patients with clinically significant decreases in pain scores did not differ statistically between groups. Both groups had similar reductions in mean pain scores over the course of the study. Patients in the indomethacin group had a statistically significant increase in minor adverse events. No patients in either group had major adverse events.

Bottom line: Oral prednisolone appears to be a safe and effective first-line agent for the treatment of acute gout.

Citation: Rainer TH, Chen CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout. Ann Intern Med. 2016;164(7):464-471.

Short Take

Rate Control as Effective as Rhythm Control in Postoperative Atrial Fibrillation

This study randomized patients with postoperative atrial fibrillation to rhythm control (using amiodarone and/or direct current cardioversion) or rate control and found neither treatment strategy has a clinical benefit over the other.

Citation: Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate control versus rhythm control for atrial fibrillation after cardiac surgery. N Engl J Med. 2016;374(20):1911-1921.

Clinical question: Are oral steroids as effective as NSAIDs in treating acute gout?

Background: Two small trials have suggested that oral steroids are as effective as NSAIDs in treating acute gout. Wider acceptance of steroids as first-line agents for acute gout may require more robust evidence supporting their safety and efficacy.

Study design: Multicenter, double-blind, randomized equivalence trial.

Setting: Four EDs in Hong Kong.

Synopsis: The study included 416 patients presenting to the ED with clinically suspected acute gout who were randomized to treatment with either oral indomethacin or oral prednisolone for five days. A research investigator assessed response to therapy in the ED at 30, 60, 90, and 120 minutes after administration of the initial dose of medication. Patients then kept pain-assessment diaries for 14 days after discharge from the ED.

Pain scores were assessed using a visual analog scale of 0 mm (no pain) to 100 mm (worst pain the patient had experienced). Clinically significant changes in pain scores were defined as decreases of >13 mm on the visual analog scale.

The number of patients with clinically significant decreases in pain scores did not differ statistically between groups. Both groups had similar reductions in mean pain scores over the course of the study. Patients in the indomethacin group had a statistically significant increase in minor adverse events. No patients in either group had major adverse events.

Bottom line: Oral prednisolone appears to be a safe and effective first-line agent for the treatment of acute gout.

Citation: Rainer TH, Chen CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout. Ann Intern Med. 2016;164(7):464-471.

Short Take

Rate Control as Effective as Rhythm Control in Postoperative Atrial Fibrillation

This study randomized patients with postoperative atrial fibrillation to rhythm control (using amiodarone and/or direct current cardioversion) or rate control and found neither treatment strategy has a clinical benefit over the other.

Citation: Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate control versus rhythm control for atrial fibrillation after cardiac surgery. N Engl J Med. 2016;374(20):1911-1921.

When too many surgery patients are readmitted, the hospital can be fined by the federal government - but a new study suggests many of those readmissions are not the hospital's fault.

Many readmissions were due to issues like drug abuse or homelessness, the researchers found. Less than one in five patients returned to the hospital due to something doctors could have managed better.

"Very few were due to reasons we could control with better medical care at the index admission," said lead author Dr. Lisa McIntyre, of Harbourview Medical Center in Seattle.

McIntyre and her colleagues noted June 15 in JAMA Surgery that the U.S. government began fining hospitals in 2015 for surgery readmission rates that are higher than expected. Fines were already being imposed since 2012 for readmissions following treatments for various medical conditions.

The researchers studied the medical records of patients who were discharged from their hospital's general surgery department in 2014 or 2015 and readmitted within 30 days.

Out of the 2,100 discharges during that time, there were 173 unplanned readmissions. About 17% of those readmissions were due to injection drug use and about 15% were due to issues like homelessness or difficulty getting to follow-up appointments.

Only about 18% of readmissions - about 2% of all discharges - were due to potentially avoidable problems following surgery.

While the results are only from a single hospital, that hospital is also a safety-net facility for the local area - and McIntyre pointed out that all hospitals have some amount of disadvantaged patients.

"To be able to affect this rate, there are going to need to be new interventions that require money and a more global care package of each individual patient that doesn't stop at discharge," said McIntyre, who is also affiliated with the University of Washington.

Being female, having diabetes, having sepsis upon admission, being in the ICU and being discharged to respite care were all tied to an increased risk of readmission, the researchers found.

The results raise the question of whether readmission rates are valuable measures of surgical quality, write Drs. Alexander Schwed and Christian de Virgilio of the University of California, Los Angeles in an editorial.

Some would argue that readmitting patients is a sound medical decision that is tied to lower risks of death, they write.

"Should such an inexact marker of quality be used to financially penalize hospitals?" they ask. "Health services researchers (need to find) a better marker for surgical quality that is reliably calculable and clinically useful."

SOURCE: http://bit.ly/28Km3aH and http://bit.ly/28Km3Ye JAMA Surgery 2016.

When too many surgery patients are readmitted, the hospital can be fined by the federal government - but a new study suggests many of those readmissions are not the hospital's fault.

Many readmissions were due to issues like drug abuse or homelessness, the researchers found. Less than one in five patients returned to the hospital due to something doctors could have managed better.

"Very few were due to reasons we could control with better medical care at the index admission," said lead author Dr. Lisa McIntyre, of Harbourview Medical Center in Seattle.

McIntyre and her colleagues noted June 15 in JAMA Surgery that the U.S. government began fining hospitals in 2015 for surgery readmission rates that are higher than expected. Fines were already being imposed since 2012 for readmissions following treatments for various medical conditions.

The researchers studied the medical records of patients who were discharged from their hospital's general surgery department in 2014 or 2015 and readmitted within 30 days.

Out of the 2,100 discharges during that time, there were 173 unplanned readmissions. About 17% of those readmissions were due to injection drug use and about 15% were due to issues like homelessness or difficulty getting to follow-up appointments.

Only about 18% of readmissions - about 2% of all discharges - were due to potentially avoidable problems following surgery.

While the results are only from a single hospital, that hospital is also a safety-net facility for the local area - and McIntyre pointed out that all hospitals have some amount of disadvantaged patients.

"To be able to affect this rate, there are going to need to be new interventions that require money and a more global care package of each individual patient that doesn't stop at discharge," said McIntyre, who is also affiliated with the University of Washington.

Being female, having diabetes, having sepsis upon admission, being in the ICU and being discharged to respite care were all tied to an increased risk of readmission, the researchers found.

The results raise the question of whether readmission rates are valuable measures of surgical quality, write Drs. Alexander Schwed and Christian de Virgilio of the University of California, Los Angeles in an editorial.

Some would argue that readmitting patients is a sound medical decision that is tied to lower risks of death, they write.

"Should such an inexact marker of quality be used to financially penalize hospitals?" they ask. "Health services researchers (need to find) a better marker for surgical quality that is reliably calculable and clinically useful."

SOURCE: http://bit.ly/28Km3aH and http://bit.ly/28Km3Ye JAMA Surgery 2016.

When too many surgery patients are readmitted, the hospital can be fined by the federal government - but a new study suggests many of those readmissions are not the hospital's fault.

Many readmissions were due to issues like drug abuse or homelessness, the researchers found. Less than one in five patients returned to the hospital due to something doctors could have managed better.

"Very few were due to reasons we could control with better medical care at the index admission," said lead author Dr. Lisa McIntyre, of Harbourview Medical Center in Seattle.

McIntyre and her colleagues noted June 15 in JAMA Surgery that the U.S. government began fining hospitals in 2015 for surgery readmission rates that are higher than expected. Fines were already being imposed since 2012 for readmissions following treatments for various medical conditions.

The researchers studied the medical records of patients who were discharged from their hospital's general surgery department in 2014 or 2015 and readmitted within 30 days.

Out of the 2,100 discharges during that time, there were 173 unplanned readmissions. About 17% of those readmissions were due to injection drug use and about 15% were due to issues like homelessness or difficulty getting to follow-up appointments.

Only about 18% of readmissions - about 2% of all discharges - were due to potentially avoidable problems following surgery.

While the results are only from a single hospital, that hospital is also a safety-net facility for the local area - and McIntyre pointed out that all hospitals have some amount of disadvantaged patients.

"To be able to affect this rate, there are going to need to be new interventions that require money and a more global care package of each individual patient that doesn't stop at discharge," said McIntyre, who is also affiliated with the University of Washington.

Being female, having diabetes, having sepsis upon admission, being in the ICU and being discharged to respite care were all tied to an increased risk of readmission, the researchers found.

The results raise the question of whether readmission rates are valuable measures of surgical quality, write Drs. Alexander Schwed and Christian de Virgilio of the University of California, Los Angeles in an editorial.

Some would argue that readmitting patients is a sound medical decision that is tied to lower risks of death, they write.

"Should such an inexact marker of quality be used to financially penalize hospitals?" they ask. "Health services researchers (need to find) a better marker for surgical quality that is reliably calculable and clinically useful."

SOURCE: http://bit.ly/28Km3aH and http://bit.ly/28Km3Ye JAMA Surgery 2016.