All Content

[WpProQuiz 9]

---

[WpProQuiz_toplist 9]

[WpProQuiz 9]

---

[WpProQuiz_toplist 9]

[WpProQuiz 9]

---

[WpProQuiz_toplist 9]

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.

Clinical question: Will a multifaceted quality improvement initiative targeted at hospitalists reduce inpatient laboratory costs?

Background: Routine inpatient laboratory testing is a well-recognized area of healthcare waste and was highlighted by the American Board of Internal Medicine Choosing Wisely campaign as a practice that should be questioned. Multifaceted quality improvement interventions, especially those that incorporate interventions beyond education, are more successful at achieving sustainable change.

Study design: Retrospective, controlled, interrupted time series study.

Setting: University of Utah, academic general internal medicine hospitalist service.

Synopsis: The intervention group, a teaching hospitalist service, received targeted education, cost feedback comparing individual provider performance, and divisional financial incentives. Additionally, a standardized rounding checklist was implemented and completed by rotating medical students. The control group included all non-hospitalist services. Approximately 20% of the 31,896 encounters measured in pre-intervention and post-intervention periods took place in the intervention group. Lab cost per day was reduced from $138 to $123 in the intervention group (P<0.001), while cost per day was non-significantly increased in the control group from $130 to $132 (P=0.37). Limitations of this study include the fact that the University of Utah already prioritizes high-value care and utilizes a local tool to provide individual cost and ordering feedback to providers as well as the financial incentives. Additionally, the use of medical students to implement the rounding checklist may not be feasible in many practice settings.

Bottom line: An approach of targeted education, direct provider feedback, consistent use of a rounding checklist, and financial incentives may decrease lab utilization.

Citation: Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs [published online ahead of print February 4, 2016]. J Hosp Med. doi:10.1002/jhm.2552.

Short Take

aVL ST-Depression Differentiates Inferior Stemi from Pericarditis

This retrospective analysis showed that any aVL ST-depression helps to distinguish inferior myocardial infarctions from pericarditis.

Citation: Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149-154.

Clinical question: Will a multifaceted quality improvement initiative targeted at hospitalists reduce inpatient laboratory costs?

Background: Routine inpatient laboratory testing is a well-recognized area of healthcare waste and was highlighted by the American Board of Internal Medicine Choosing Wisely campaign as a practice that should be questioned. Multifaceted quality improvement interventions, especially those that incorporate interventions beyond education, are more successful at achieving sustainable change.

Study design: Retrospective, controlled, interrupted time series study.

Setting: University of Utah, academic general internal medicine hospitalist service.

Synopsis: The intervention group, a teaching hospitalist service, received targeted education, cost feedback comparing individual provider performance, and divisional financial incentives. Additionally, a standardized rounding checklist was implemented and completed by rotating medical students. The control group included all non-hospitalist services. Approximately 20% of the 31,896 encounters measured in pre-intervention and post-intervention periods took place in the intervention group. Lab cost per day was reduced from $138 to $123 in the intervention group (P<0.001), while cost per day was non-significantly increased in the control group from $130 to $132 (P=0.37). Limitations of this study include the fact that the University of Utah already prioritizes high-value care and utilizes a local tool to provide individual cost and ordering feedback to providers as well as the financial incentives. Additionally, the use of medical students to implement the rounding checklist may not be feasible in many practice settings.

Bottom line: An approach of targeted education, direct provider feedback, consistent use of a rounding checklist, and financial incentives may decrease lab utilization.

Citation: Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs [published online ahead of print February 4, 2016]. J Hosp Med. doi:10.1002/jhm.2552.

Short Take

aVL ST-Depression Differentiates Inferior Stemi from Pericarditis

This retrospective analysis showed that any aVL ST-depression helps to distinguish inferior myocardial infarctions from pericarditis.

Citation: Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149-154.

Clinical question: Will a multifaceted quality improvement initiative targeted at hospitalists reduce inpatient laboratory costs?

Background: Routine inpatient laboratory testing is a well-recognized area of healthcare waste and was highlighted by the American Board of Internal Medicine Choosing Wisely campaign as a practice that should be questioned. Multifaceted quality improvement interventions, especially those that incorporate interventions beyond education, are more successful at achieving sustainable change.

Study design: Retrospective, controlled, interrupted time series study.

Setting: University of Utah, academic general internal medicine hospitalist service.

Synopsis: The intervention group, a teaching hospitalist service, received targeted education, cost feedback comparing individual provider performance, and divisional financial incentives. Additionally, a standardized rounding checklist was implemented and completed by rotating medical students. The control group included all non-hospitalist services. Approximately 20% of the 31,896 encounters measured in pre-intervention and post-intervention periods took place in the intervention group. Lab cost per day was reduced from $138 to $123 in the intervention group (P<0.001), while cost per day was non-significantly increased in the control group from $130 to $132 (P=0.37). Limitations of this study include the fact that the University of Utah already prioritizes high-value care and utilizes a local tool to provide individual cost and ordering feedback to providers as well as the financial incentives. Additionally, the use of medical students to implement the rounding checklist may not be feasible in many practice settings.

Bottom line: An approach of targeted education, direct provider feedback, consistent use of a rounding checklist, and financial incentives may decrease lab utilization.

Citation: Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs [published online ahead of print February 4, 2016]. J Hosp Med. doi:10.1002/jhm.2552.

Short Take

aVL ST-Depression Differentiates Inferior Stemi from Pericarditis

This retrospective analysis showed that any aVL ST-depression helps to distinguish inferior myocardial infarctions from pericarditis.

Citation: Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149-154.

Clinical question: Does discharge planning improve length of stay and reduce readmission rates compared to usual care?

Background: Discharge planning is accomplished to varying degrees for patients admitted to an acute-care hospital. Goals include improving the quality of care transitions as well as cost containment.

Study design: Meta-analysis.

Setting: Thirty studies that examined the effects of discharge planning.

Synopsis: In 12 studies focusing on older patients, discharge planning resulted in a reduction in hospital length of stay by 0.73 days (95% CI, -1.33 to -0.12). Readmission rates for this population were reduced, with approximately three fewer readmissions per 100 patients (relative risk, 0.87; 95% CI, 0.79–0.97). These results were not consistent for other populations, including surgical patients and patients admitted following a fall. No conclusions could be drawn on other outcomes, including patient and provider satisfaction, location of eventual discharge, and mortality. The effect of discharge planning on cost of care was uncertain based on the five trials reporting varied outcomes. Limitations include the varied descriptions of what constituted discharge planning and the lack of reporting on the role of communication in the process. Given the Centers for Medicare & Medicaid Services’ requirements for discharge planning, it is difficult to estimate the effect this study has on clinical practice.

Further study is needed to determine which aspects of discharge planning lead to desired clinical outcomes and the effects on overall cost of care.

Bottom line: Discharge planning in older patients with medical admissions appears to marginally reduce length of stay and readmission rates without a clear effect on cost of care.

Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;1:CD000313. doi:10.1002/14651858.CD000313.pub5.

Clinical question: Does discharge planning improve length of stay and reduce readmission rates compared to usual care?

Background: Discharge planning is accomplished to varying degrees for patients admitted to an acute-care hospital. Goals include improving the quality of care transitions as well as cost containment.

Study design: Meta-analysis.

Setting: Thirty studies that examined the effects of discharge planning.

Synopsis: In 12 studies focusing on older patients, discharge planning resulted in a reduction in hospital length of stay by 0.73 days (95% CI, -1.33 to -0.12). Readmission rates for this population were reduced, with approximately three fewer readmissions per 100 patients (relative risk, 0.87; 95% CI, 0.79–0.97). These results were not consistent for other populations, including surgical patients and patients admitted following a fall. No conclusions could be drawn on other outcomes, including patient and provider satisfaction, location of eventual discharge, and mortality. The effect of discharge planning on cost of care was uncertain based on the five trials reporting varied outcomes. Limitations include the varied descriptions of what constituted discharge planning and the lack of reporting on the role of communication in the process. Given the Centers for Medicare & Medicaid Services’ requirements for discharge planning, it is difficult to estimate the effect this study has on clinical practice.

Further study is needed to determine which aspects of discharge planning lead to desired clinical outcomes and the effects on overall cost of care.

Bottom line: Discharge planning in older patients with medical admissions appears to marginally reduce length of stay and readmission rates without a clear effect on cost of care.

Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;1:CD000313. doi:10.1002/14651858.CD000313.pub5.

Clinical question: Does discharge planning improve length of stay and reduce readmission rates compared to usual care?

Background: Discharge planning is accomplished to varying degrees for patients admitted to an acute-care hospital. Goals include improving the quality of care transitions as well as cost containment.

Study design: Meta-analysis.

Setting: Thirty studies that examined the effects of discharge planning.

Synopsis: In 12 studies focusing on older patients, discharge planning resulted in a reduction in hospital length of stay by 0.73 days (95% CI, -1.33 to -0.12). Readmission rates for this population were reduced, with approximately three fewer readmissions per 100 patients (relative risk, 0.87; 95% CI, 0.79–0.97). These results were not consistent for other populations, including surgical patients and patients admitted following a fall. No conclusions could be drawn on other outcomes, including patient and provider satisfaction, location of eventual discharge, and mortality. The effect of discharge planning on cost of care was uncertain based on the five trials reporting varied outcomes. Limitations include the varied descriptions of what constituted discharge planning and the lack of reporting on the role of communication in the process. Given the Centers for Medicare & Medicaid Services’ requirements for discharge planning, it is difficult to estimate the effect this study has on clinical practice.

Further study is needed to determine which aspects of discharge planning lead to desired clinical outcomes and the effects on overall cost of care.

Bottom line: Discharge planning in older patients with medical admissions appears to marginally reduce length of stay and readmission rates without a clear effect on cost of care.

Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;1:CD000313. doi:10.1002/14651858.CD000313.pub5.

SHM’s implementation toolkits provide hospitalists with the resources they need to lead quality improvement projects on a variety of clinical topics, including a new toolkit on venous thromboembolism (VTE) released in May. The new toolkit features a literature review, an implementation guide, and additional reference materials, such as discharge instructions and checklists. Be on the lookout for information about an upcoming webinar series on the treatment of patients with VTE with free CME.

Don’t miss other online toolkits and implementation guides from SHM, covering:

• COPD
• Acute coronary syndrome
• Pain management
• Glycemic control

Check out all available toolkits at www.hospitalmedicine.org/qi.

---

Brett Radler is SHM’s communications coordinator.

SHM’s implementation toolkits provide hospitalists with the resources they need to lead quality improvement projects on a variety of clinical topics, including a new toolkit on venous thromboembolism (VTE) released in May. The new toolkit features a literature review, an implementation guide, and additional reference materials, such as discharge instructions and checklists. Be on the lookout for information about an upcoming webinar series on the treatment of patients with VTE with free CME.

Don’t miss other online toolkits and implementation guides from SHM, covering:

• COPD
• Acute coronary syndrome
• Pain management
• Glycemic control

Check out all available toolkits at www.hospitalmedicine.org/qi.

---

Brett Radler is SHM’s communications coordinator.

SHM’s implementation toolkits provide hospitalists with the resources they need to lead quality improvement projects on a variety of clinical topics, including a new toolkit on venous thromboembolism (VTE) released in May. The new toolkit features a literature review, an implementation guide, and additional reference materials, such as discharge instructions and checklists. Be on the lookout for information about an upcoming webinar series on the treatment of patients with VTE with free CME.

Don’t miss other online toolkits and implementation guides from SHM, covering:

• COPD
• Acute coronary syndrome
• Pain management
• Glycemic control

Check out all available toolkits at www.hospitalmedicine.org/qi.

---

Brett Radler is SHM’s communications coordinator.

The Society of Hospital Medicine and the Journal of Hospital Medicine (JHM) are excited to announce the fourth installment in our #JHMChat Twitter chat series, which brings the latest hospital medicine research from JHM to Twitter and the bedside. We invite you to join us on Twitter on Monday, July 11, at 9 p.m. EDT.

During the chat, we invite you to join the conversation with Robert Mahoney, MD, associate professor of medicine at the Washington University School of Medicine, and Vinny Arora, MD, #JHMChat moderator and JHM deputy editor, to discuss the recent JHM publication “As-Needed Intravenous Antihypertensive Therapy and Blood Pressure Control.”

Participating in a #JHMChat allows you to have a dialogue with experts in the field conducting research with implications for your daily practice, network with fellow hospital medicine professionals, and lend your expertise to help others improve patient care. As you get ready for the chat, follow us and our Twitter partners:

• @JHospMedicine (Journal of Hospital Medicine)
• @SHMLive (Society of Hospital Medicine)
• @mahoneyr (Dr. Mahoney)
• @FutureDocs (Dr. Arora)
• @CostsofCare and @ABIMFoundation (#JHMChat partners)

On chat day, don’t forget to include #JHMChat in each of your tweets related to the chat to make sure all participants see them and are able to respond. To learn more, read the featured paper, and check out transcripts from our first three chats, visit www.hospitalmedicine.org/jhmchat.

See you on Twitter!

---

Brett Radler is SHM’s communications coordinator.

The Society of Hospital Medicine and the Journal of Hospital Medicine (JHM) are excited to announce the fourth installment in our #JHMChat Twitter chat series, which brings the latest hospital medicine research from JHM to Twitter and the bedside. We invite you to join us on Twitter on Monday, July 11, at 9 p.m. EDT.

During the chat, we invite you to join the conversation with Robert Mahoney, MD, associate professor of medicine at the Washington University School of Medicine, and Vinny Arora, MD, #JHMChat moderator and JHM deputy editor, to discuss the recent JHM publication “As-Needed Intravenous Antihypertensive Therapy and Blood Pressure Control.”

Participating in a #JHMChat allows you to have a dialogue with experts in the field conducting research with implications for your daily practice, network with fellow hospital medicine professionals, and lend your expertise to help others improve patient care. As you get ready for the chat, follow us and our Twitter partners:

• @JHospMedicine (Journal of Hospital Medicine)
• @SHMLive (Society of Hospital Medicine)
• @mahoneyr (Dr. Mahoney)
• @FutureDocs (Dr. Arora)
• @CostsofCare and @ABIMFoundation (#JHMChat partners)

On chat day, don’t forget to include #JHMChat in each of your tweets related to the chat to make sure all participants see them and are able to respond. To learn more, read the featured paper, and check out transcripts from our first three chats, visit www.hospitalmedicine.org/jhmchat.

See you on Twitter!

---

Brett Radler is SHM’s communications coordinator.

The Society of Hospital Medicine and the Journal of Hospital Medicine (JHM) are excited to announce the fourth installment in our #JHMChat Twitter chat series, which brings the latest hospital medicine research from JHM to Twitter and the bedside. We invite you to join us on Twitter on Monday, July 11, at 9 p.m. EDT.

During the chat, we invite you to join the conversation with Robert Mahoney, MD, associate professor of medicine at the Washington University School of Medicine, and Vinny Arora, MD, #JHMChat moderator and JHM deputy editor, to discuss the recent JHM publication “As-Needed Intravenous Antihypertensive Therapy and Blood Pressure Control.”

Participating in a #JHMChat allows you to have a dialogue with experts in the field conducting research with implications for your daily practice, network with fellow hospital medicine professionals, and lend your expertise to help others improve patient care. As you get ready for the chat, follow us and our Twitter partners:

• @JHospMedicine (Journal of Hospital Medicine)
• @SHMLive (Society of Hospital Medicine)
• @mahoneyr (Dr. Mahoney)
• @FutureDocs (Dr. Arora)
• @CostsofCare and @ABIMFoundation (#JHMChat partners)

On chat day, don’t forget to include #JHMChat in each of your tweets related to the chat to make sure all participants see them and are able to respond. To learn more, read the featured paper, and check out transcripts from our first three chats, visit www.hospitalmedicine.org/jhmchat.

See you on Twitter!

---

Brett Radler is SHM’s communications coordinator.

Clinical question: Does coronary artery bypass grafting added to medical therapy decrease mortality in patients with coronary artery disease and systolic heart failure?

Bottom line: Coronary artery bypass grafting (CABG) plus medical therapy decreases mortality as compared with medical therapy alone in patients with ischemic cardiomyopathy. You would need to treat 14 patients with CABG to prevent one death. (LOE = 1b)

Reference: Velazquez EJ, Lee KL, Jones RH, et al, for the STICHES Investigators. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med 2016;374(16):1511-1520.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Synopsis: Using concealed allocation, these investigators randomized patients with heart failure with ejection fraction of 35% or less and coronary artery disease amenable to CABG to receive either guideline-directed medical therapy plus CABG (n = 610) or guideline-directed medical therapy alone (n = 602). The 2 groups were similar at baseline and the majority was categorized as New York Heart Failure Association class II. Overall, 91% of the CABG group underwent the procedure within the first year following randomization. Notably, 20% of the medical therapy group also underwent CABG during the long-term follow-up period (11% crossed over to CABG within the first year). The medial duration for follow-up was 9.8 years and analysis was by intention to treat. CABG plus medical therapy resulted in fewer deaths over 10 years as compared with medical therapy alone (59% vs 66%; hazard ratio [HR] = 0.84; 95% CI 0.73 - 0.97; P = .02). The CABG group also had fewer deaths specifically from cardiovascular causes (40% vs 49%; P = .006). A per-protocol analysis showed an even greater benefit with CABG (HR = 0.77; 0.67 - 0.90; P = .001) suggesting that the crossovers in this trial may have diluted the observed effect of CABG.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does coronary artery bypass grafting added to medical therapy decrease mortality in patients with coronary artery disease and systolic heart failure?

Bottom line: Coronary artery bypass grafting (CABG) plus medical therapy decreases mortality as compared with medical therapy alone in patients with ischemic cardiomyopathy. You would need to treat 14 patients with CABG to prevent one death. (LOE = 1b)

Reference: Velazquez EJ, Lee KL, Jones RH, et al, for the STICHES Investigators. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med 2016;374(16):1511-1520.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Synopsis: Using concealed allocation, these investigators randomized patients with heart failure with ejection fraction of 35% or less and coronary artery disease amenable to CABG to receive either guideline-directed medical therapy plus CABG (n = 610) or guideline-directed medical therapy alone (n = 602). The 2 groups were similar at baseline and the majority was categorized as New York Heart Failure Association class II. Overall, 91% of the CABG group underwent the procedure within the first year following randomization. Notably, 20% of the medical therapy group also underwent CABG during the long-term follow-up period (11% crossed over to CABG within the first year). The medial duration for follow-up was 9.8 years and analysis was by intention to treat. CABG plus medical therapy resulted in fewer deaths over 10 years as compared with medical therapy alone (59% vs 66%; hazard ratio [HR] = 0.84; 95% CI 0.73 - 0.97; P = .02). The CABG group also had fewer deaths specifically from cardiovascular causes (40% vs 49%; P = .006). A per-protocol analysis showed an even greater benefit with CABG (HR = 0.77; 0.67 - 0.90; P = .001) suggesting that the crossovers in this trial may have diluted the observed effect of CABG.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does coronary artery bypass grafting added to medical therapy decrease mortality in patients with coronary artery disease and systolic heart failure?

Bottom line: Coronary artery bypass grafting (CABG) plus medical therapy decreases mortality as compared with medical therapy alone in patients with ischemic cardiomyopathy. You would need to treat 14 patients with CABG to prevent one death. (LOE = 1b)

Reference: Velazquez EJ, Lee KL, Jones RH, et al, for the STICHES Investigators. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med 2016;374(16):1511-1520.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Synopsis: Using concealed allocation, these investigators randomized patients with heart failure with ejection fraction of 35% or less and coronary artery disease amenable to CABG to receive either guideline-directed medical therapy plus CABG (n = 610) or guideline-directed medical therapy alone (n = 602). The 2 groups were similar at baseline and the majority was categorized as New York Heart Failure Association class II. Overall, 91% of the CABG group underwent the procedure within the first year following randomization. Notably, 20% of the medical therapy group also underwent CABG during the long-term follow-up period (11% crossed over to CABG within the first year). The medial duration for follow-up was 9.8 years and analysis was by intention to treat. CABG plus medical therapy resulted in fewer deaths over 10 years as compared with medical therapy alone (59% vs 66%; hazard ratio [HR] = 0.84; 95% CI 0.73 - 0.97; P = .02). The CABG group also had fewer deaths specifically from cardiovascular causes (40% vs 49%; P = .006). A per-protocol analysis showed an even greater benefit with CABG (HR = 0.77; 0.67 - 0.90; P = .001) suggesting that the crossovers in this trial may have diluted the observed effect of CABG.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does the use of stent retrievers in conjunction with tissue plasminogen activator improve outcomes in patients with acute ischemic stroke?

Bottom line: The use of stent retriever devices in addition to tissue plasminogen activator (tPA) in patients with anterior circulation acute ischemic stroke results in more patients with functional independence at 90 days. Based on data from the studies included in this review, the American Heart Association/American Stroke Association guidelines now strongly recommend the use of stent retrievers with class 1a level of evidence. (LOE = 1a)

Reference: Touma L, Filion KB, Sterling LH, Atallah R, Windle SB, Eisenberg MJ. Stent retrievers for the treatment of acute ischemic stroke. JAMA Neurol 2016;73(3):275-281.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Unknown/not stated

Allocation: Uncertain

Setting: Inpatient (any location) with outpatient follow-up

Synopsis: Intra-arterial therapy using stent retriever devices for thrombectomy added to standard therapy with tPA is a promising treatment for acute ischemic stroke. Four recent randomized controlled trials examining the effectiveness of stent retrievers have been terminated early because of the strong benefit seen with this therapy.

In this study, investigators searched MEDLINE, EMBASE, and the Cochrane Library, as well as trial registries and references of included studies, to find randomized controlled trials that compared stent retrievers plus tPA with tPA alone. Two authors independently extracted data from the 5 included studies (N = 1287) and assessed study quality using the Cochrane Collaboration Risk of Bias Tool.

All studies included patients with imaging-confirmed anterior circulation strokes and used the modified Rankin Scale (mRS) to assess for improvement in functional status at 90 days. Four of the 5 studies only included patients with excellent pre-stroke functional independence. Additionally, 4 of the 5 studies restricted stent retriever therapy to patients who presented within 6 hours of onset of stroke symptoms. The studies had a low risk of bias overall.

The pooled 90-day outcomes showed that patients who received stent retriever therapy plus tPA were more likely to achieve greater functional independence, defined as an mRS score of 0 to 2, than patients who received tPA alone (relative risk 1.72; 95% CI 1.38 - 1.99). You would need to treat 6 patients with stent retriever therapy to have one patient achieve functional independence. There were no significant differences detected in mortality or in the rates of intracranial bleeds or parenchymal hematomas.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does the use of stent retrievers in conjunction with tissue plasminogen activator improve outcomes in patients with acute ischemic stroke?

Bottom line: The use of stent retriever devices in addition to tissue plasminogen activator (tPA) in patients with anterior circulation acute ischemic stroke results in more patients with functional independence at 90 days. Based on data from the studies included in this review, the American Heart Association/American Stroke Association guidelines now strongly recommend the use of stent retrievers with class 1a level of evidence. (LOE = 1a)

Reference: Touma L, Filion KB, Sterling LH, Atallah R, Windle SB, Eisenberg MJ. Stent retrievers for the treatment of acute ischemic stroke. JAMA Neurol 2016;73(3):275-281.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Unknown/not stated

Allocation: Uncertain

Setting: Inpatient (any location) with outpatient follow-up

Synopsis: Intra-arterial therapy using stent retriever devices for thrombectomy added to standard therapy with tPA is a promising treatment for acute ischemic stroke. Four recent randomized controlled trials examining the effectiveness of stent retrievers have been terminated early because of the strong benefit seen with this therapy.

In this study, investigators searched MEDLINE, EMBASE, and the Cochrane Library, as well as trial registries and references of included studies, to find randomized controlled trials that compared stent retrievers plus tPA with tPA alone. Two authors independently extracted data from the 5 included studies (N = 1287) and assessed study quality using the Cochrane Collaboration Risk of Bias Tool.

All studies included patients with imaging-confirmed anterior circulation strokes and used the modified Rankin Scale (mRS) to assess for improvement in functional status at 90 days. Four of the 5 studies only included patients with excellent pre-stroke functional independence. Additionally, 4 of the 5 studies restricted stent retriever therapy to patients who presented within 6 hours of onset of stroke symptoms. The studies had a low risk of bias overall.

The pooled 90-day outcomes showed that patients who received stent retriever therapy plus tPA were more likely to achieve greater functional independence, defined as an mRS score of 0 to 2, than patients who received tPA alone (relative risk 1.72; 95% CI 1.38 - 1.99). You would need to treat 6 patients with stent retriever therapy to have one patient achieve functional independence. There were no significant differences detected in mortality or in the rates of intracranial bleeds or parenchymal hematomas.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Does the use of stent retrievers in conjunction with tissue plasminogen activator improve outcomes in patients with acute ischemic stroke?

Bottom line: The use of stent retriever devices in addition to tissue plasminogen activator (tPA) in patients with anterior circulation acute ischemic stroke results in more patients with functional independence at 90 days. Based on data from the studies included in this review, the American Heart Association/American Stroke Association guidelines now strongly recommend the use of stent retrievers with class 1a level of evidence. (LOE = 1a)

Reference: Touma L, Filion KB, Sterling LH, Atallah R, Windle SB, Eisenberg MJ. Stent retrievers for the treatment of acute ischemic stroke. JAMA Neurol 2016;73(3):275-281.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Unknown/not stated

Allocation: Uncertain

Setting: Inpatient (any location) with outpatient follow-up

Synopsis: Intra-arterial therapy using stent retriever devices for thrombectomy added to standard therapy with tPA is a promising treatment for acute ischemic stroke. Four recent randomized controlled trials examining the effectiveness of stent retrievers have been terminated early because of the strong benefit seen with this therapy.

In this study, investigators searched MEDLINE, EMBASE, and the Cochrane Library, as well as trial registries and references of included studies, to find randomized controlled trials that compared stent retrievers plus tPA with tPA alone. Two authors independently extracted data from the 5 included studies (N = 1287) and assessed study quality using the Cochrane Collaboration Risk of Bias Tool.

All studies included patients with imaging-confirmed anterior circulation strokes and used the modified Rankin Scale (mRS) to assess for improvement in functional status at 90 days. Four of the 5 studies only included patients with excellent pre-stroke functional independence. Additionally, 4 of the 5 studies restricted stent retriever therapy to patients who presented within 6 hours of onset of stroke symptoms. The studies had a low risk of bias overall.

The pooled 90-day outcomes showed that patients who received stent retriever therapy plus tPA were more likely to achieve greater functional independence, defined as an mRS score of 0 to 2, than patients who received tPA alone (relative risk 1.72; 95% CI 1.38 - 1.99). You would need to treat 6 patients with stent retriever therapy to have one patient achieve functional independence. There were no significant differences detected in mortality or in the rates of intracranial bleeds or parenchymal hematomas.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Can a nurse-driven early ambulation program aimed at all hospitalized adults increase patient mobility and decrease length of stay?

Background: Many adults experience decline of functional abilities during their hospitalization. Interventions to increase early mobilization of patients in the ICU have been associated with decreased length of stay, decreased costs, and improved patient satisfaction. Previous studies of interventions in non-ICU patients have used specialized staff or have targeted select patient populations.

Study design: Before-after cohort study.

Setting: Patients admitted to two general medical units at a single large academic hospital.

Synopsis: The authors implemented a 12-month multidisciplinary quality improvement project in 3,352 patients, with the goal of mobilizing patients three times per day. Additional goals included consistently documenting daily mobility, setting daily goals to increase activity, and standardizing the description of mobility across disciplines. Ambulation, documentation, and goal setting were assigned to regular nursing staff and targeted at each of the patients admitted to these units during the study period. Highest level of mobility was documented using a locally derived simple eight-point ordinal scale. Daily documentation rate of mobility averaged 85% over the 12 months of the project. Comparing the four-month study period at the beginning of the project implementation to the four-month period after implementation, more patients ambulated (70% versus 43%), patients with improved mobility scores increased from 32% to 45%, and length of stay declined by 0.40 days. All of these differences were statistically significant. There was no increase in falls with injury.

Bottom line: A nurse-driven early mobility program aimed at all patients admitted to general medical services may improve mobility and decrease length of stay.

Citation: Hoyer EH, Friedman M, Lavezza A, et al. Promoting mobility and reducing length of stay in hospitalized general medicine patients: a quality-improvement project [published online ahead of print February 5, 2016]. J Hosp Med. doi:10.1002/jhm.2546.

Short Take

Prednisolone is Equivalent to NSAIDs in the Treatment of Acute Gout

In a multicenter, double-blind, randomized equivalence trial of 416 patients presenting to the emergency department with symptoms of acute gout, treatment with prednisolone was equivalent to indomethacin for pain treatment without any difference in adverse events.

Citation: Rainer TH, Cheng CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout: a pragmatic, multicenter, double-blind, randomized trial. Ann Intern Med. 2016;164(7):464-471. doi:10.7326/M14-2070.

Clinical question: Can a nurse-driven early ambulation program aimed at all hospitalized adults increase patient mobility and decrease length of stay?

Background: Many adults experience decline of functional abilities during their hospitalization. Interventions to increase early mobilization of patients in the ICU have been associated with decreased length of stay, decreased costs, and improved patient satisfaction. Previous studies of interventions in non-ICU patients have used specialized staff or have targeted select patient populations.

Study design: Before-after cohort study.

Setting: Patients admitted to two general medical units at a single large academic hospital.

Synopsis: The authors implemented a 12-month multidisciplinary quality improvement project in 3,352 patients, with the goal of mobilizing patients three times per day. Additional goals included consistently documenting daily mobility, setting daily goals to increase activity, and standardizing the description of mobility across disciplines. Ambulation, documentation, and goal setting were assigned to regular nursing staff and targeted at each of the patients admitted to these units during the study period. Highest level of mobility was documented using a locally derived simple eight-point ordinal scale. Daily documentation rate of mobility averaged 85% over the 12 months of the project. Comparing the four-month study period at the beginning of the project implementation to the four-month period after implementation, more patients ambulated (70% versus 43%), patients with improved mobility scores increased from 32% to 45%, and length of stay declined by 0.40 days. All of these differences were statistically significant. There was no increase in falls with injury.

Bottom line: A nurse-driven early mobility program aimed at all patients admitted to general medical services may improve mobility and decrease length of stay.

Citation: Hoyer EH, Friedman M, Lavezza A, et al. Promoting mobility and reducing length of stay in hospitalized general medicine patients: a quality-improvement project [published online ahead of print February 5, 2016]. J Hosp Med. doi:10.1002/jhm.2546.

Short Take

Prednisolone is Equivalent to NSAIDs in the Treatment of Acute Gout

In a multicenter, double-blind, randomized equivalence trial of 416 patients presenting to the emergency department with symptoms of acute gout, treatment with prednisolone was equivalent to indomethacin for pain treatment without any difference in adverse events.

Citation: Rainer TH, Cheng CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout: a pragmatic, multicenter, double-blind, randomized trial. Ann Intern Med. 2016;164(7):464-471. doi:10.7326/M14-2070.

Clinical question: Can a nurse-driven early ambulation program aimed at all hospitalized adults increase patient mobility and decrease length of stay?

Background: Many adults experience decline of functional abilities during their hospitalization. Interventions to increase early mobilization of patients in the ICU have been associated with decreased length of stay, decreased costs, and improved patient satisfaction. Previous studies of interventions in non-ICU patients have used specialized staff or have targeted select patient populations.

Study design: Before-after cohort study.

Setting: Patients admitted to two general medical units at a single large academic hospital.

Synopsis: The authors implemented a 12-month multidisciplinary quality improvement project in 3,352 patients, with the goal of mobilizing patients three times per day. Additional goals included consistently documenting daily mobility, setting daily goals to increase activity, and standardizing the description of mobility across disciplines. Ambulation, documentation, and goal setting were assigned to regular nursing staff and targeted at each of the patients admitted to these units during the study period. Highest level of mobility was documented using a locally derived simple eight-point ordinal scale. Daily documentation rate of mobility averaged 85% over the 12 months of the project. Comparing the four-month study period at the beginning of the project implementation to the four-month period after implementation, more patients ambulated (70% versus 43%), patients with improved mobility scores increased from 32% to 45%, and length of stay declined by 0.40 days. All of these differences were statistically significant. There was no increase in falls with injury.

Bottom line: A nurse-driven early mobility program aimed at all patients admitted to general medical services may improve mobility and decrease length of stay.

Citation: Hoyer EH, Friedman M, Lavezza A, et al. Promoting mobility and reducing length of stay in hospitalized general medicine patients: a quality-improvement project [published online ahead of print February 5, 2016]. J Hosp Med. doi:10.1002/jhm.2546.

Short Take

Prednisolone is Equivalent to NSAIDs in the Treatment of Acute Gout

In a multicenter, double-blind, randomized equivalence trial of 416 patients presenting to the emergency department with symptoms of acute gout, treatment with prednisolone was equivalent to indomethacin for pain treatment without any difference in adverse events.

Citation: Rainer TH, Cheng CH, Janssens HJEM, et al. Oral prednisolone in the treatment of acute gout: a pragmatic, multicenter, double-blind, randomized trial. Ann Intern Med. 2016;164(7):464-471. doi:10.7326/M14-2070.