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(Reuters Health) - Some cancer patients may turn down care that could ease their pain and improve their quality of life because they think this type of "palliative" treatment amounts

to giving up and simply waiting to die, a small Canadian study suggests.

Even though the World Health Organization recommends early palliative care for patients living with any serious illness, negative attitudes among patients and family caregivers often lead them to reject this option, researchers note in the Canadian Medical Association Journal.

"Patients and caregivers in our study saw palliative care as being equated with death, loss of hope, dependency, and going into places you never get out of again," said lead study author Dr. Camilla Zimmermann, head of the division of palliative care at the University Health Network in Toronto.

"This is in stark contrast with the actual definition of palliative care, which is interdisciplinary care that provides quality of life for patients with any serious illness and their families, and that is provided throughout the course of the illness rather than only at the end of life," Zimmermann added by email.

Zimmermann and colleagues interviewed 48 cancer patients and 23 of their family caregivers in cases when life expectancy was six to 24 months.

The researchers randomly assigned 26 patients to receive palliative care in addition to standard cancer care, while another 22 patients had only standard care.

Twenty-two patients in the palliative care group and 20 in the control group were receiving chemotherapy.

Over four months, patients in the palliative care group had at least monthly palliative care clinic visits, while those in the standard care group didn't receive any formal interventions. Caregivers could attend clinic visits for the palliative care participants, but they weren't required to do so.

Patients were typically in their early to mid 60s. Most were married and had at least some education beyond high school.

Most family caregivers were spouses, but a few were children or other relatives.

Initial perceptions of palliative care were similar in both groups - patients generally thought this was done only for the dying. While patients in both groups thought of palliative care

as providing comfort, they also associated it with giving up on treatment.

Once some patients received palliative care, however, their thinking shifted. Some patients now saw this as a way to live life to the fullest despite the terminal diagnosis, while others

suggested that doctors might have better luck renaming this as something other than "palliative care."

Calling palliative care providers "pain specialists" because they treat discomfort and focus on quality of life would make this sound more appealing and less frightening, some patients

said after getting this type of care.

But in the control group, without any experience with palliative care during the study, patients didn't see the point of renaming it because they thought it would still carry the stigma of giving up and waiting to die.

"Palliative care should not be framed as a last resort option," said Dr. Anthony Caprio, a geriatrician and hospice and palliative medicine physician at Carolinas HealthCare System in

North Carolina.

"These `nothing left to do' conversations often frame palliative care as a way to help people die comfortably, rather than an approach to care that allows them to live with the highest quality of life for as long as possible," said Caprio, who wrote an editorial that was published with the study.

Using different language in discussions with patients can make a big difference, Caprio added.

"I often describe palliative care as an extra layer of support," Caprio said. "Who wouldn't want more support, especially during a difficult illness?"

 

 

 

 

 

 

(Reuters Health) - Some cancer patients may turn down care that could ease their pain and improve their quality of life because they think this type of "palliative" treatment amounts

to giving up and simply waiting to die, a small Canadian study suggests.

Even though the World Health Organization recommends early palliative care for patients living with any serious illness, negative attitudes among patients and family caregivers often lead them to reject this option, researchers note in the Canadian Medical Association Journal.

"Patients and caregivers in our study saw palliative care as being equated with death, loss of hope, dependency, and going into places you never get out of again," said lead study author Dr. Camilla Zimmermann, head of the division of palliative care at the University Health Network in Toronto.

"This is in stark contrast with the actual definition of palliative care, which is interdisciplinary care that provides quality of life for patients with any serious illness and their families, and that is provided throughout the course of the illness rather than only at the end of life," Zimmermann added by email.

Zimmermann and colleagues interviewed 48 cancer patients and 23 of their family caregivers in cases when life expectancy was six to 24 months.

The researchers randomly assigned 26 patients to receive palliative care in addition to standard cancer care, while another 22 patients had only standard care.

Twenty-two patients in the palliative care group and 20 in the control group were receiving chemotherapy.

Over four months, patients in the palliative care group had at least monthly palliative care clinic visits, while those in the standard care group didn't receive any formal interventions. Caregivers could attend clinic visits for the palliative care participants, but they weren't required to do so.

Patients were typically in their early to mid 60s. Most were married and had at least some education beyond high school.

Most family caregivers were spouses, but a few were children or other relatives.

Initial perceptions of palliative care were similar in both groups - patients generally thought this was done only for the dying. While patients in both groups thought of palliative care

as providing comfort, they also associated it with giving up on treatment.

Once some patients received palliative care, however, their thinking shifted. Some patients now saw this as a way to live life to the fullest despite the terminal diagnosis, while others

suggested that doctors might have better luck renaming this as something other than "palliative care."

Calling palliative care providers "pain specialists" because they treat discomfort and focus on quality of life would make this sound more appealing and less frightening, some patients

said after getting this type of care.

But in the control group, without any experience with palliative care during the study, patients didn't see the point of renaming it because they thought it would still carry the stigma of giving up and waiting to die.

"Palliative care should not be framed as a last resort option," said Dr. Anthony Caprio, a geriatrician and hospice and palliative medicine physician at Carolinas HealthCare System in

North Carolina.

"These `nothing left to do' conversations often frame palliative care as a way to help people die comfortably, rather than an approach to care that allows them to live with the highest quality of life for as long as possible," said Caprio, who wrote an editorial that was published with the study.

Using different language in discussions with patients can make a big difference, Caprio added.

"I often describe palliative care as an extra layer of support," Caprio said. "Who wouldn't want more support, especially during a difficult illness?"

 

 

 

 

 

 

(Reuters Health) - Some cancer patients may turn down care that could ease their pain and improve their quality of life because they think this type of "palliative" treatment amounts

to giving up and simply waiting to die, a small Canadian study suggests.

Even though the World Health Organization recommends early palliative care for patients living with any serious illness, negative attitudes among patients and family caregivers often lead them to reject this option, researchers note in the Canadian Medical Association Journal.

"Patients and caregivers in our study saw palliative care as being equated with death, loss of hope, dependency, and going into places you never get out of again," said lead study author Dr. Camilla Zimmermann, head of the division of palliative care at the University Health Network in Toronto.

"This is in stark contrast with the actual definition of palliative care, which is interdisciplinary care that provides quality of life for patients with any serious illness and their families, and that is provided throughout the course of the illness rather than only at the end of life," Zimmermann added by email.

Zimmermann and colleagues interviewed 48 cancer patients and 23 of their family caregivers in cases when life expectancy was six to 24 months.

The researchers randomly assigned 26 patients to receive palliative care in addition to standard cancer care, while another 22 patients had only standard care.

Twenty-two patients in the palliative care group and 20 in the control group were receiving chemotherapy.

Over four months, patients in the palliative care group had at least monthly palliative care clinic visits, while those in the standard care group didn't receive any formal interventions. Caregivers could attend clinic visits for the palliative care participants, but they weren't required to do so.

Patients were typically in their early to mid 60s. Most were married and had at least some education beyond high school.

Most family caregivers were spouses, but a few were children or other relatives.

Initial perceptions of palliative care were similar in both groups - patients generally thought this was done only for the dying. While patients in both groups thought of palliative care

as providing comfort, they also associated it with giving up on treatment.

Once some patients received palliative care, however, their thinking shifted. Some patients now saw this as a way to live life to the fullest despite the terminal diagnosis, while others

suggested that doctors might have better luck renaming this as something other than "palliative care."

Calling palliative care providers "pain specialists" because they treat discomfort and focus on quality of life would make this sound more appealing and less frightening, some patients

said after getting this type of care.

But in the control group, without any experience with palliative care during the study, patients didn't see the point of renaming it because they thought it would still carry the stigma of giving up and waiting to die.

"Palliative care should not be framed as a last resort option," said Dr. Anthony Caprio, a geriatrician and hospice and palliative medicine physician at Carolinas HealthCare System in

North Carolina.

"These `nothing left to do' conversations often frame palliative care as a way to help people die comfortably, rather than an approach to care that allows them to live with the highest quality of life for as long as possible," said Caprio, who wrote an editorial that was published with the study.

Using different language in discussions with patients can make a big difference, Caprio added.

"I often describe palliative care as an extra layer of support," Caprio said. "Who wouldn't want more support, especially during a difficult illness?"

 

 

 

 

 

 

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each column will focus on how the contributor applies one of the “Key Communication” areas in practice.

View a chart outlining key communication tactics

What I Say and Do

I counsel and deliver the diagnosis or give recommendations through a dialogue, instead of a monologue, using active listening.

Why I Do It

The monologue, or lecture, is among the least effective ways to instill behavior change. Research studies have demonstrated that, after a monologue, only around 20% to 60% of medical information is remembered by the end of a visit. Out of what is remembered, less than 50% is accurate. Furthermore, 47% of Americans have health literacy levels below the intermediate range, defined as the ability to determine when to take a medication with food from reading the label.

Lecturing the patient without first understanding what the patient knows and finds important, and understanding the barriers to plan implementation, runs the risk of decreased comprehension, a lack of understanding, or a lack of personal relevance—all leading to decreased adherence. Doing the opposite, by involving the patient in decision making, inspires change that comes from within in the context of the patient’s own needs. This approach is more enduring, emphasizes self-accountability, and ultimately leads to better outcomes.

How I Do It

I open up a dialogue using the Cleveland Clinic’s ARIA approach as adapted from the REDE model of healthcare communication.1

• First, assess: What does the patient know about diagnosis and treatment? How much and what type of education does the patient desire/need? What are the patient’s treatment preferences and health literacy?
• Second, reflect on what the patient just said. Validate meaning and emotion.
• Third, inform the patient within the context of the patient’s perspectives and preferences. Speak slowly and provide small chunks of information at a time. Use understandable language and visual aids. (This will increase recall by 60%.)
• Finally, assess the patient’s understanding and emotional reaction to information provided.
• Repeat the cycle to introduce other chunks of information.

---

Dr. Velez is director of faculty development in the Center for Excellence in Healthcare Communication at the Cleveland Clinic.

Reference

1. Windover A, Boissy A, Rice T, Gilligan T, Velez V, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Exp. 2014;1(1):8-13.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each column will focus on how the contributor applies one of the “Key Communication” areas in practice.

View a chart outlining key communication tactics

What I Say and Do

I counsel and deliver the diagnosis or give recommendations through a dialogue, instead of a monologue, using active listening.

Why I Do It

The monologue, or lecture, is among the least effective ways to instill behavior change. Research studies have demonstrated that, after a monologue, only around 20% to 60% of medical information is remembered by the end of a visit. Out of what is remembered, less than 50% is accurate. Furthermore, 47% of Americans have health literacy levels below the intermediate range, defined as the ability to determine when to take a medication with food from reading the label.

Lecturing the patient without first understanding what the patient knows and finds important, and understanding the barriers to plan implementation, runs the risk of decreased comprehension, a lack of understanding, or a lack of personal relevance—all leading to decreased adherence. Doing the opposite, by involving the patient in decision making, inspires change that comes from within in the context of the patient’s own needs. This approach is more enduring, emphasizes self-accountability, and ultimately leads to better outcomes.

How I Do It

I open up a dialogue using the Cleveland Clinic’s ARIA approach as adapted from the REDE model of healthcare communication.1

• First, assess: What does the patient know about diagnosis and treatment? How much and what type of education does the patient desire/need? What are the patient’s treatment preferences and health literacy?
• Second, reflect on what the patient just said. Validate meaning and emotion.
• Third, inform the patient within the context of the patient’s perspectives and preferences. Speak slowly and provide small chunks of information at a time. Use understandable language and visual aids. (This will increase recall by 60%.)
• Finally, assess the patient’s understanding and emotional reaction to information provided.
• Repeat the cycle to introduce other chunks of information.

---

Dr. Velez is director of faculty development in the Center for Excellence in Healthcare Communication at the Cleveland Clinic.

Reference

1. Windover A, Boissy A, Rice T, Gilligan T, Velez V, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Exp. 2014;1(1):8-13.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each column will focus on how the contributor applies one of the “Key Communication” areas in practice.

View a chart outlining key communication tactics

What I Say and Do

I counsel and deliver the diagnosis or give recommendations through a dialogue, instead of a monologue, using active listening.

Why I Do It

The monologue, or lecture, is among the least effective ways to instill behavior change. Research studies have demonstrated that, after a monologue, only around 20% to 60% of medical information is remembered by the end of a visit. Out of what is remembered, less than 50% is accurate. Furthermore, 47% of Americans have health literacy levels below the intermediate range, defined as the ability to determine when to take a medication with food from reading the label.

Lecturing the patient without first understanding what the patient knows and finds important, and understanding the barriers to plan implementation, runs the risk of decreased comprehension, a lack of understanding, or a lack of personal relevance—all leading to decreased adherence. Doing the opposite, by involving the patient in decision making, inspires change that comes from within in the context of the patient’s own needs. This approach is more enduring, emphasizes self-accountability, and ultimately leads to better outcomes.

How I Do It

I open up a dialogue using the Cleveland Clinic’s ARIA approach as adapted from the REDE model of healthcare communication.1

• First, assess: What does the patient know about diagnosis and treatment? How much and what type of education does the patient desire/need? What are the patient’s treatment preferences and health literacy?
• Second, reflect on what the patient just said. Validate meaning and emotion.
• Third, inform the patient within the context of the patient’s perspectives and preferences. Speak slowly and provide small chunks of information at a time. Use understandable language and visual aids. (This will increase recall by 60%.)
• Finally, assess the patient’s understanding and emotional reaction to information provided.
• Repeat the cycle to introduce other chunks of information.

---

Dr. Velez is director of faculty development in the Center for Excellence in Healthcare Communication at the Cleveland Clinic.

Reference

1. Windover A, Boissy A, Rice T, Gilligan T, Velez V, Merlino J. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Exp. 2014;1(1):8-13.

Clinical question: What is the harm associated with long-term beta-blocker therapy in patients with uncomplicated hypertension undergoing non-cardiac surgery?

Background: Given the recent concerns over the validity of prior studies, there is uncertainty about which patients benefit most from perioperative beta-blockade. Current guidelines suggest continuing beta-blockers in the perioperative period. More data are needed to delineate which patients maximally benefit from perioperative beta-blockade.

Study design: Association study.

Setting: Danish nationwide cohort of patients.

Synopsis: Study investigators included 55,320 uncomplicated hypertension (no cardiovascular, renal, or liver disease) patients >19 years of age on ≥2 antihypertensive drugs undergoing non-cardiac surgery. In the 14,664 patients who received beta-blockers, the rates of 30-day major adverse cardiovascular events (MACE; cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction) and 30-day all-cause mortality were 1.32% and 1.93%, respectively. However, in the 40,676 patients who did not receive beta-blockers, 30-day MACEs and 30-day all-cause mortality rates were 0.84% and 1.32%, respectively (P<0.001). When looking at the individual MACEs, cardiovascular death was the only statistically significant event with higher incidence (0.9% versus 0.45%, P<0.001).

Combination therapy with beta-blocker and RAS inhibitor, calcium channel blockers, or thiazide was associated with statistically significant higher risks of MACEs and all-cause mortality when compared to the combination of RAS inhibitor plus thiazide. Men >70 years of age or undergoing urgent surgery had the highest risk of harm. This study was not a randomized control trial, so caution must be used when attributing causality to beta-blockers, MACEs, and all-cause mortality.

Bottom line: Antihypertensive regimens containing beta-blockers may increase risk of perioperative MACEs and all-cause mortality in patients with uncomplicated hypertension.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. β-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: What is the harm associated with long-term beta-blocker therapy in patients with uncomplicated hypertension undergoing non-cardiac surgery?

Background: Given the recent concerns over the validity of prior studies, there is uncertainty about which patients benefit most from perioperative beta-blockade. Current guidelines suggest continuing beta-blockers in the perioperative period. More data are needed to delineate which patients maximally benefit from perioperative beta-blockade.

Study design: Association study.

Setting: Danish nationwide cohort of patients.

Synopsis: Study investigators included 55,320 uncomplicated hypertension (no cardiovascular, renal, or liver disease) patients >19 years of age on ≥2 antihypertensive drugs undergoing non-cardiac surgery. In the 14,664 patients who received beta-blockers, the rates of 30-day major adverse cardiovascular events (MACE; cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction) and 30-day all-cause mortality were 1.32% and 1.93%, respectively. However, in the 40,676 patients who did not receive beta-blockers, 30-day MACEs and 30-day all-cause mortality rates were 0.84% and 1.32%, respectively (P<0.001). When looking at the individual MACEs, cardiovascular death was the only statistically significant event with higher incidence (0.9% versus 0.45%, P<0.001).

Combination therapy with beta-blocker and RAS inhibitor, calcium channel blockers, or thiazide was associated with statistically significant higher risks of MACEs and all-cause mortality when compared to the combination of RAS inhibitor plus thiazide. Men >70 years of age or undergoing urgent surgery had the highest risk of harm. This study was not a randomized control trial, so caution must be used when attributing causality to beta-blockers, MACEs, and all-cause mortality.

Bottom line: Antihypertensive regimens containing beta-blockers may increase risk of perioperative MACEs and all-cause mortality in patients with uncomplicated hypertension.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. β-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: What is the harm associated with long-term beta-blocker therapy in patients with uncomplicated hypertension undergoing non-cardiac surgery?

Background: Given the recent concerns over the validity of prior studies, there is uncertainty about which patients benefit most from perioperative beta-blockade. Current guidelines suggest continuing beta-blockers in the perioperative period. More data are needed to delineate which patients maximally benefit from perioperative beta-blockade.

Study design: Association study.

Setting: Danish nationwide cohort of patients.

Synopsis: Study investigators included 55,320 uncomplicated hypertension (no cardiovascular, renal, or liver disease) patients >19 years of age on ≥2 antihypertensive drugs undergoing non-cardiac surgery. In the 14,664 patients who received beta-blockers, the rates of 30-day major adverse cardiovascular events (MACE; cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction) and 30-day all-cause mortality were 1.32% and 1.93%, respectively. However, in the 40,676 patients who did not receive beta-blockers, 30-day MACEs and 30-day all-cause mortality rates were 0.84% and 1.32%, respectively (P<0.001). When looking at the individual MACEs, cardiovascular death was the only statistically significant event with higher incidence (0.9% versus 0.45%, P<0.001).

Combination therapy with beta-blocker and RAS inhibitor, calcium channel blockers, or thiazide was associated with statistically significant higher risks of MACEs and all-cause mortality when compared to the combination of RAS inhibitor plus thiazide. Men >70 years of age or undergoing urgent surgery had the highest risk of harm. This study was not a randomized control trial, so caution must be used when attributing causality to beta-blockers, MACEs, and all-cause mortality.

Bottom line: Antihypertensive regimens containing beta-blockers may increase risk of perioperative MACEs and all-cause mortality in patients with uncomplicated hypertension.

Citation: Jorgensen ME, Hlatky MA, Kober L, et al. β-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.

Clinical question: What is the prevalence of depression or depressive symptoms in resident physicians?

Background: Depression in resident physicians can lead to poor-quality medical care, increased errors, and long-term morbidity. Prevalence of depression or depressive symptoms has varied in prior studies, and more data are needed to better understand the true prevalence.

Study design: Systematic review and meta-analysis.

Setting: Surgical and nonsurgical residency programs in North America, Asia, Europe, South America, and Africa

Synopsis: Thirty-one cross-sectional studies (9,447 individuals) and 23 longitudinal studies (8,113 individuals) from January 1963 to September 2015 were included in this analysis, with the majority using self-reporting to identify residents with depression or depressive symptoms. Overall prevalence of depression or depressive symptoms was 28.8%, with a range of 20.9% to 43.2%, depending on the screening tool (95% CI, 25.3%–32.5%; P<0.001). There was an increased prevalence in depression or depressive symptoms as the calendar year progressed (slope=0.5% per calendar year increase; 95% CI, 0.03%–0.09%), with no difference in prevalence rates between surgical versus nonsurgical residents, U.S. versus elsewhere, cross-sectional versus longitudinal, or interns versus upper-level residents.

Because studies were heterogeneous with respect to the screening tools and resident population, the prevalence of depression or depressive symptoms cannot be precisely determined.

Bottom line: Prevalence of depression or depressive symptoms ranged from 20.9% to 43.2%, with pooled prevalence of 28.8%, and increased with time.

Citation: Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and met-analysis. JAMA. 2015;314(22):2373-2383.

Clinical question: What is the prevalence of depression or depressive symptoms in resident physicians?

Background: Depression in resident physicians can lead to poor-quality medical care, increased errors, and long-term morbidity. Prevalence of depression or depressive symptoms has varied in prior studies, and more data are needed to better understand the true prevalence.

Study design: Systematic review and meta-analysis.

Setting: Surgical and nonsurgical residency programs in North America, Asia, Europe, South America, and Africa

Synopsis: Thirty-one cross-sectional studies (9,447 individuals) and 23 longitudinal studies (8,113 individuals) from January 1963 to September 2015 were included in this analysis, with the majority using self-reporting to identify residents with depression or depressive symptoms. Overall prevalence of depression or depressive symptoms was 28.8%, with a range of 20.9% to 43.2%, depending on the screening tool (95% CI, 25.3%–32.5%; P<0.001). There was an increased prevalence in depression or depressive symptoms as the calendar year progressed (slope=0.5% per calendar year increase; 95% CI, 0.03%–0.09%), with no difference in prevalence rates between surgical versus nonsurgical residents, U.S. versus elsewhere, cross-sectional versus longitudinal, or interns versus upper-level residents.

Because studies were heterogeneous with respect to the screening tools and resident population, the prevalence of depression or depressive symptoms cannot be precisely determined.

Bottom line: Prevalence of depression or depressive symptoms ranged from 20.9% to 43.2%, with pooled prevalence of 28.8%, and increased with time.

Citation: Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and met-analysis. JAMA. 2015;314(22):2373-2383.

Clinical question: What is the prevalence of depression or depressive symptoms in resident physicians?

Background: Depression in resident physicians can lead to poor-quality medical care, increased errors, and long-term morbidity. Prevalence of depression or depressive symptoms has varied in prior studies, and more data are needed to better understand the true prevalence.

Study design: Systematic review and meta-analysis.

Setting: Surgical and nonsurgical residency programs in North America, Asia, Europe, South America, and Africa

Synopsis: Thirty-one cross-sectional studies (9,447 individuals) and 23 longitudinal studies (8,113 individuals) from January 1963 to September 2015 were included in this analysis, with the majority using self-reporting to identify residents with depression or depressive symptoms. Overall prevalence of depression or depressive symptoms was 28.8%, with a range of 20.9% to 43.2%, depending on the screening tool (95% CI, 25.3%–32.5%; P<0.001). There was an increased prevalence in depression or depressive symptoms as the calendar year progressed (slope=0.5% per calendar year increase; 95% CI, 0.03%–0.09%), with no difference in prevalence rates between surgical versus nonsurgical residents, U.S. versus elsewhere, cross-sectional versus longitudinal, or interns versus upper-level residents.

Because studies were heterogeneous with respect to the screening tools and resident population, the prevalence of depression or depressive symptoms cannot be precisely determined.

Bottom line: Prevalence of depression or depressive symptoms ranged from 20.9% to 43.2%, with pooled prevalence of 28.8%, and increased with time.

Citation: Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and met-analysis. JAMA. 2015;314(22):2373-2383.

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p&lt;0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p&lt;0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p&lt;0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

 

 

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p&lt;0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p&lt;0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p&lt;0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

 

 

NEW YORK (Reuters Health) - A breakfast rich in whey protein may help people with type 2 diabetes manage their illness better, new research from Israel suggests.

"Whey protein, a byproduct of cheese manufacturing, lowers postprandial glycemia more than other protein sources," said lead author Dr. Daniela Jakubowicz from Wolfson Medical Center at Tel Aviv University."

We found that in type 2 diabetes, increasing protein content at breakfast has a greater impact on weight loss, glycated hemoglobin (HbA1C), satiety and postprandial glycemia when the protein source is whey protein, compared with other protein sources, such as eggs, tuna and soy," she told Reuters Health by email.

Dr. Jakubowicz and her group presented their findings April 1 at ENDO 2016, the annual meeting of the Endocrine Society, in Boston.

They randomly assigned 48 overweight and obese patients with type 2 diabetes to one of three isocaloric diets. Over 12 weeks, everyone ate a large breakfast, a medium-sized lunch and a small dinner, but the amount and source of each group's breakfast proteins differed.

At breakfast, the 17 participants in the whey group ate 36 g of protein as part of a whey protein shake consisting of 40% carbohydrate, 40% protein and 20% fat. The 16 participants in the high-protein group ate 36 g of protein in the form of eggs, tuna and cheese (40% carbs; 40% protein; 20% fat). The 15 in the high-carbohydrate group ate 13 g of protein in ready-to-eat cereals (65% carbs; 15% protein; 20% fat).

All three diets included a 660 kcal breakfast, a 567 cal lunch and a 276 cal dinner, with the same composition at lunch and dinner.

After 12 weeks, the participants in the whey protein group lost the most weight (7.6 kg vs. 6.1 kg for participants in the high-protein group and 3.5 kg for those in the high-carbohydrate group (p&lt;0.0001).

Participants on the whey protein diet were less hungry during the day and had lower glucose spikes after meals compared with those on the other two diets.

The drop in HbA1C was 11.5% in the whey group, 7.7% in the protein group and 4.6% in the carbohydrate group (p&lt;0.0001). Compared with the carbohydrate group, the percentage drop in HbA1c was greater by 41% in the protein group and by 64% in the whey group (p&lt;0.0001).

"Whey protein was consumed only at breakfast; however, the improvement of glucose, insulin and glucagon-like peptide 1 (GLP-1) was also observed after lunch and dinner. The mechanism of this persistent beneficial effect of whey protein needs further research," Dr. Jakubowicz said.

Co-author Dr. Julio Wainstein, also at Wolfson Medical Center, added by email, "Usually, patients with type 2 diabetes are treated with a combination of several antidiabetic drugs to achieve adequate glucose regulation and decrease HbA1c. Whey protein should be considered an important adjuvant in the management of type 2 diabetes."

"Furthermore," Dr. Wainstein added, "it is possible that by adding whey protein to the diet, glucose regulation might be achieved with less medication, which is a valuable advantage in type 2 diabetes treatment."

The study had no commercial funding, and the authors declared no conflicts of interest.

 

 

I believe there is no better field than hospital medicine to find your career path, and there’s no better organization than SHM to support you as you follow that path. My path is probably similar to most, a little unplanned and a little unexpected, but I am sure each member has their story. Hospital medicine made an early impact on me during an internship where I was exposed to physician role models with terrific leadership skills. They were blazing trails by challenging long-held beliefs about the care of hospitalized patients.

The term “hospitalist” had not yet quite penetrated national consciousness, but Dr. Bob Wachter and Dr. Lee Goldman had already started implementing the model at the University of California, San Francisco, where I was privileged to be an intern during an exciting time. There, I learned directly from some of the individuals who would quickly become pioneers in hospital medicine, influencing a generation of physicians by putting definition and structure around the concept of a hospitalist.

During residency, I saw these hospitalists demonstrate key leadership attributes that distinguished from other physicians. They had an appreciation for the team, a collaborative approach, and an ability to understand the complexity of coordinating acute care. They led from the front, not from behind the lines. So it was no wonder that so many of my colleagues gravitated toward this new field.

After residency, my first job was at a community hospital in Marin, Calif., where a new hospitalist program had started just a year or two earlier. The same collaborative skills that created better patient care with nurses, pharmacists, and the medical staff were positively reinforced and recognized. I got married and had my first child, and my path took a turn east to the Cleveland Clinic. Now back in the academic world and after two more children, that path for me turned in highly unexpected ways—as a department chair, then as medical director for data and analytics, then briefly overseeing population health, and now as head of a hospital in the Cleveland Clinic system.

Stories like mine are not at all extraordinary. At HM16 in San Diego, I heard stories of hospitalists ascendant in their organizations, being given incredible responsibilities and a long rope. The day-to-day work we have done as hospitalists has been our training for all these roles. This daily practice demands a level of growth, development, and exposure that no other specialty requires. There is no better environment to learn about leadership, teaching, and complex systems than perhaps the most complex system of all—the hospital. In this environment, we have innumerable opportunities to find, pick, and create our own paths to improve our healthcare system at every level from the bedside to the top of the Centers for Medicare & Medicaid Services (CMS).

Hospital medicine puts so many components and challenges of healthcare in our daily practice: complex team problem-solving; relationships up, down, and across a hierarchy; IT; education; process improvement; ethics; medical staff politics. The successful hospitalist, by definition, has to be able to learn and attain mastery across a broad set of knowledge and skills. We have become naturals in a world of "matrixes management" because it is how we live our lives every day. This is why when our medical staffs and administration come looking for a project leader, a new department chair, a head of patient experience, a leader, or an educator, they come looking for us.

As SHM’s new president, I commit to SHM being the organization that is dedicated to helping you. It’s impossible to see around every corner, but starting in the coming year, I think SHM and hospitalists have to move forward in four key directions:

 

1. Expand and engage SHM’s membership. Although we just reached our 15,000th member, there are 52,000 hospitalists, plus even more when you include advanced practice colleagues, whom we would like to become SHM members under our “big tent.” We want to draw in those hospitalists, show them how, whether it’s through our educational offerings, learning portal, or active involvement in projects and committees, we can engage them at every stage of their career—and ask them what else we can do to help them find their path and be prepared for it.
2. We must continue pushing our members and projects to be focused on patient- and family-centered care. Every project that takes the extra steps of incorporating the thoughts and feelings of our patients and families will get a better result. I would like to see hospitalists everywhere take a strong position to remember that our patients and their families are our partners in their care; We need to lead on the patient experience and patient-centered care front. Two years ago, we launched the Patient Experience Committee to do just that, and it is an important research topic on the minds of the Journal of Hospital Medicine editors. After all, we are all people needing people.
3. We have to move assertively to understand our role in an era of risk. While in many senses we have been managing risk either directly or indirectly for decades, the payment models of care (episodes, bundles, MIPS, ACOs) are evolving quickly, and we must stake out our place in this new risk-sharing world and identify our partners. Hospitalists need to have a clear message about how what we do mitigates risk and adds value. In the coming year, SHM will start to do that.
4. In the coming years, we will need to clarify our position regarding specialty recognition, including our training programs. We already have many key components that we identify with as a specialty. While this is also something contentious and political, when we look at the divergence between what we have to do to be clinically effective (e.g., palliative medicine, ICU care, QI, leadership, etc.) and what our training programs provide for us, that gap appears to be increasing. SHM has stepped up with curriculum to fill these gaps and will continue to do so. However, we must question how best to train physicians for these roles and if the current model is sustainable and suitable.

I am privileged and honored to serve as your new president, and I ask each of you to look at yourselves and the opportunities that your practice provides you with to grow—personally and professionally—and make our system and specialty better. Look to SHM to help you, support you, and provide resources for you to walk your path. TH

---

Dr. Harte is a practicing hospitalist, president of the Society of Hospital Medicine, and president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland.

I believe there is no better field than hospital medicine to find your career path, and there’s no better organization than SHM to support you as you follow that path. My path is probably similar to most, a little unplanned and a little unexpected, but I am sure each member has their story. Hospital medicine made an early impact on me during an internship where I was exposed to physician role models with terrific leadership skills. They were blazing trails by challenging long-held beliefs about the care of hospitalized patients.

The term “hospitalist” had not yet quite penetrated national consciousness, but Dr. Bob Wachter and Dr. Lee Goldman had already started implementing the model at the University of California, San Francisco, where I was privileged to be an intern during an exciting time. There, I learned directly from some of the individuals who would quickly become pioneers in hospital medicine, influencing a generation of physicians by putting definition and structure around the concept of a hospitalist.

During residency, I saw these hospitalists demonstrate key leadership attributes that distinguished from other physicians. They had an appreciation for the team, a collaborative approach, and an ability to understand the complexity of coordinating acute care. They led from the front, not from behind the lines. So it was no wonder that so many of my colleagues gravitated toward this new field.

After residency, my first job was at a community hospital in Marin, Calif., where a new hospitalist program had started just a year or two earlier. The same collaborative skills that created better patient care with nurses, pharmacists, and the medical staff were positively reinforced and recognized. I got married and had my first child, and my path took a turn east to the Cleveland Clinic. Now back in the academic world and after two more children, that path for me turned in highly unexpected ways—as a department chair, then as medical director for data and analytics, then briefly overseeing population health, and now as head of a hospital in the Cleveland Clinic system.

Stories like mine are not at all extraordinary. At HM16 in San Diego, I heard stories of hospitalists ascendant in their organizations, being given incredible responsibilities and a long rope. The day-to-day work we have done as hospitalists has been our training for all these roles. This daily practice demands a level of growth, development, and exposure that no other specialty requires. There is no better environment to learn about leadership, teaching, and complex systems than perhaps the most complex system of all—the hospital. In this environment, we have innumerable opportunities to find, pick, and create our own paths to improve our healthcare system at every level from the bedside to the top of the Centers for Medicare & Medicaid Services (CMS).

Hospital medicine puts so many components and challenges of healthcare in our daily practice: complex team problem-solving; relationships up, down, and across a hierarchy; IT; education; process improvement; ethics; medical staff politics. The successful hospitalist, by definition, has to be able to learn and attain mastery across a broad set of knowledge and skills. We have become naturals in a world of "matrixes management" because it is how we live our lives every day. This is why when our medical staffs and administration come looking for a project leader, a new department chair, a head of patient experience, a leader, or an educator, they come looking for us.

As SHM’s new president, I commit to SHM being the organization that is dedicated to helping you. It’s impossible to see around every corner, but starting in the coming year, I think SHM and hospitalists have to move forward in four key directions:

 

1. Expand and engage SHM’s membership. Although we just reached our 15,000th member, there are 52,000 hospitalists, plus even more when you include advanced practice colleagues, whom we would like to become SHM members under our “big tent.” We want to draw in those hospitalists, show them how, whether it’s through our educational offerings, learning portal, or active involvement in projects and committees, we can engage them at every stage of their career—and ask them what else we can do to help them find their path and be prepared for it.
2. We must continue pushing our members and projects to be focused on patient- and family-centered care. Every project that takes the extra steps of incorporating the thoughts and feelings of our patients and families will get a better result. I would like to see hospitalists everywhere take a strong position to remember that our patients and their families are our partners in their care; We need to lead on the patient experience and patient-centered care front. Two years ago, we launched the Patient Experience Committee to do just that, and it is an important research topic on the minds of the Journal of Hospital Medicine editors. After all, we are all people needing people.
3. We have to move assertively to understand our role in an era of risk. While in many senses we have been managing risk either directly or indirectly for decades, the payment models of care (episodes, bundles, MIPS, ACOs) are evolving quickly, and we must stake out our place in this new risk-sharing world and identify our partners. Hospitalists need to have a clear message about how what we do mitigates risk and adds value. In the coming year, SHM will start to do that.
4. In the coming years, we will need to clarify our position regarding specialty recognition, including our training programs. We already have many key components that we identify with as a specialty. While this is also something contentious and political, when we look at the divergence between what we have to do to be clinically effective (e.g., palliative medicine, ICU care, QI, leadership, etc.) and what our training programs provide for us, that gap appears to be increasing. SHM has stepped up with curriculum to fill these gaps and will continue to do so. However, we must question how best to train physicians for these roles and if the current model is sustainable and suitable.

I am privileged and honored to serve as your new president, and I ask each of you to look at yourselves and the opportunities that your practice provides you with to grow—personally and professionally—and make our system and specialty better. Look to SHM to help you, support you, and provide resources for you to walk your path. TH

---

Dr. Harte is a practicing hospitalist, president of the Society of Hospital Medicine, and president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland.

I believe there is no better field than hospital medicine to find your career path, and there’s no better organization than SHM to support you as you follow that path. My path is probably similar to most, a little unplanned and a little unexpected, but I am sure each member has their story. Hospital medicine made an early impact on me during an internship where I was exposed to physician role models with terrific leadership skills. They were blazing trails by challenging long-held beliefs about the care of hospitalized patients.

The term “hospitalist” had not yet quite penetrated national consciousness, but Dr. Bob Wachter and Dr. Lee Goldman had already started implementing the model at the University of California, San Francisco, where I was privileged to be an intern during an exciting time. There, I learned directly from some of the individuals who would quickly become pioneers in hospital medicine, influencing a generation of physicians by putting definition and structure around the concept of a hospitalist.

During residency, I saw these hospitalists demonstrate key leadership attributes that distinguished from other physicians. They had an appreciation for the team, a collaborative approach, and an ability to understand the complexity of coordinating acute care. They led from the front, not from behind the lines. So it was no wonder that so many of my colleagues gravitated toward this new field.

After residency, my first job was at a community hospital in Marin, Calif., where a new hospitalist program had started just a year or two earlier. The same collaborative skills that created better patient care with nurses, pharmacists, and the medical staff were positively reinforced and recognized. I got married and had my first child, and my path took a turn east to the Cleveland Clinic. Now back in the academic world and after two more children, that path for me turned in highly unexpected ways—as a department chair, then as medical director for data and analytics, then briefly overseeing population health, and now as head of a hospital in the Cleveland Clinic system.

Stories like mine are not at all extraordinary. At HM16 in San Diego, I heard stories of hospitalists ascendant in their organizations, being given incredible responsibilities and a long rope. The day-to-day work we have done as hospitalists has been our training for all these roles. This daily practice demands a level of growth, development, and exposure that no other specialty requires. There is no better environment to learn about leadership, teaching, and complex systems than perhaps the most complex system of all—the hospital. In this environment, we have innumerable opportunities to find, pick, and create our own paths to improve our healthcare system at every level from the bedside to the top of the Centers for Medicare & Medicaid Services (CMS).

Hospital medicine puts so many components and challenges of healthcare in our daily practice: complex team problem-solving; relationships up, down, and across a hierarchy; IT; education; process improvement; ethics; medical staff politics. The successful hospitalist, by definition, has to be able to learn and attain mastery across a broad set of knowledge and skills. We have become naturals in a world of "matrixes management" because it is how we live our lives every day. This is why when our medical staffs and administration come looking for a project leader, a new department chair, a head of patient experience, a leader, or an educator, they come looking for us.

As SHM’s new president, I commit to SHM being the organization that is dedicated to helping you. It’s impossible to see around every corner, but starting in the coming year, I think SHM and hospitalists have to move forward in four key directions:

 

1. Expand and engage SHM’s membership. Although we just reached our 15,000th member, there are 52,000 hospitalists, plus even more when you include advanced practice colleagues, whom we would like to become SHM members under our “big tent.” We want to draw in those hospitalists, show them how, whether it’s through our educational offerings, learning portal, or active involvement in projects and committees, we can engage them at every stage of their career—and ask them what else we can do to help them find their path and be prepared for it.
2. We must continue pushing our members and projects to be focused on patient- and family-centered care. Every project that takes the extra steps of incorporating the thoughts and feelings of our patients and families will get a better result. I would like to see hospitalists everywhere take a strong position to remember that our patients and their families are our partners in their care; We need to lead on the patient experience and patient-centered care front. Two years ago, we launched the Patient Experience Committee to do just that, and it is an important research topic on the minds of the Journal of Hospital Medicine editors. After all, we are all people needing people.
3. We have to move assertively to understand our role in an era of risk. While in many senses we have been managing risk either directly or indirectly for decades, the payment models of care (episodes, bundles, MIPS, ACOs) are evolving quickly, and we must stake out our place in this new risk-sharing world and identify our partners. Hospitalists need to have a clear message about how what we do mitigates risk and adds value. In the coming year, SHM will start to do that.
4. In the coming years, we will need to clarify our position regarding specialty recognition, including our training programs. We already have many key components that we identify with as a specialty. While this is also something contentious and political, when we look at the divergence between what we have to do to be clinically effective (e.g., palliative medicine, ICU care, QI, leadership, etc.) and what our training programs provide for us, that gap appears to be increasing. SHM has stepped up with curriculum to fill these gaps and will continue to do so. However, we must question how best to train physicians for these roles and if the current model is sustainable and suitable.

I am privileged and honored to serve as your new president, and I ask each of you to look at yourselves and the opportunities that your practice provides you with to grow—personally and professionally—and make our system and specialty better. Look to SHM to help you, support you, and provide resources for you to walk your path. TH

---

Dr. Harte is a practicing hospitalist, president of the Society of Hospital Medicine, and president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland.

The healthcare industry is not yet at zero when it comes to healthcare-associated infections—and that’s a problem. Hand hygiene compliance remains a major cause.

The Joint Commission addresses that problem with the Hand Hygiene Targeted Solutions Tool (TST), an online application that guides the user through collecting and analyzing data, with suggested solutions based on the root causes revealed. “It’s based on robust process improvement, what we refer to as RPI, that brings in Lean, Six Sigma, and change management,” says Erin DuPree, MD, chief medical officer and vice president, The Joint Commission Center for Transforming Healthcare.

The tool was tested in a pilot program summarized in an article in the January 2016 issue of The Joint Commission Journal on Quality and Safety, “Hand Hygiene Tool Linked to Decrease in Health Care-Associated Infections at Memorial Hermann Health System,” by M. Michael Shabot, MD, of Memorial Hermann Health System, Mark R. Chassin, MD, MPP, MPH, of The Joint Commission, and their co-authors. In more than 31,600 observations, the organization’s average hand hygiene compliance improved from 58.1% to 95.6%. Rates of central line–associated bloodstream infections and ventilator-associated pneumonia in adult ICUs decreased by 49% and 45%, respectively.

Dr. DuPree encourages hospitalists to champion hand hygiene at their own organizations. “The more physicians lead and participate, the higher performing the organization is.”

The healthcare industry is not yet at zero when it comes to healthcare-associated infections—and that’s a problem. Hand hygiene compliance remains a major cause.

The Joint Commission addresses that problem with the Hand Hygiene Targeted Solutions Tool (TST), an online application that guides the user through collecting and analyzing data, with suggested solutions based on the root causes revealed. “It’s based on robust process improvement, what we refer to as RPI, that brings in Lean, Six Sigma, and change management,” says Erin DuPree, MD, chief medical officer and vice president, The Joint Commission Center for Transforming Healthcare.

The tool was tested in a pilot program summarized in an article in the January 2016 issue of The Joint Commission Journal on Quality and Safety, “Hand Hygiene Tool Linked to Decrease in Health Care-Associated Infections at Memorial Hermann Health System,” by M. Michael Shabot, MD, of Memorial Hermann Health System, Mark R. Chassin, MD, MPP, MPH, of The Joint Commission, and their co-authors. In more than 31,600 observations, the organization’s average hand hygiene compliance improved from 58.1% to 95.6%. Rates of central line–associated bloodstream infections and ventilator-associated pneumonia in adult ICUs decreased by 49% and 45%, respectively.

Dr. DuPree encourages hospitalists to champion hand hygiene at their own organizations. “The more physicians lead and participate, the higher performing the organization is.”

The healthcare industry is not yet at zero when it comes to healthcare-associated infections—and that’s a problem. Hand hygiene compliance remains a major cause.

The Joint Commission addresses that problem with the Hand Hygiene Targeted Solutions Tool (TST), an online application that guides the user through collecting and analyzing data, with suggested solutions based on the root causes revealed. “It’s based on robust process improvement, what we refer to as RPI, that brings in Lean, Six Sigma, and change management,” says Erin DuPree, MD, chief medical officer and vice president, The Joint Commission Center for Transforming Healthcare.

The tool was tested in a pilot program summarized in an article in the January 2016 issue of The Joint Commission Journal on Quality and Safety, “Hand Hygiene Tool Linked to Decrease in Health Care-Associated Infections at Memorial Hermann Health System,” by M. Michael Shabot, MD, of Memorial Hermann Health System, Mark R. Chassin, MD, MPP, MPH, of The Joint Commission, and their co-authors. In more than 31,600 observations, the organization’s average hand hygiene compliance improved from 58.1% to 95.6%. Rates of central line–associated bloodstream infections and ventilator-associated pneumonia in adult ICUs decreased by 49% and 45%, respectively.

Dr. DuPree encourages hospitalists to champion hand hygiene at their own organizations. “The more physicians lead and participate, the higher performing the organization is.”

Are we overlooking factors that could help bring about necessary changes to the healthcare industry? Elliott S. Fisher, MD, MPH, of the Dartmouth Institute for Health Policy and Clinical Practice, thinks so.

“We are missing an important opportunity to learn from what is going on in health systems every day that could tell us how to make healthcare better and cheaper,” says Dr. Fisher, lead author of a January 2016 JAMA “Viewpoint” called “Implementation Science: A Potential Catalyst for Delivery System Reform.” “That’s the argument for the the field of implementation science.”

Implementation science studies ways to promote the integration of research findings and evidence into the healthcare system. Dr. Fisher says that integration is influenced by multiple factors: the characteristic of the innovation itself, the organizational setting, and the policy or community environment within which that organization is working. Context matters.

“We tend to think about adopting innovations like a new blood pressure medication or a new device,” Dr. Fisher says. “Those decisions rest almost entirely on the shoulders of physicians, so adoption requires thinking about the attributes of biomedical innovations and how physicians think.”

With care delivery innovations—for example, how to provide optimal care for people with heart failure across home, hospital, and nursing home—those are often developed with clinical input but by people who are fundamentally managers.

“It’s a more complex set of actors,” he says, “so you have to think about those decision makers if you’re going to get the best evidence-based practice into their setting.”

A third category of innovation focuses on individual behavior change, where the decision makers are the clinician and the patient and family. “You’ve got to persuade the patient the innovation is worth doing, so different factors may influence the successful adoptions of those interventions,” Dr. Fisher says.

Reference

1. Fisher ES, Shortell SM, Savitz LA. Implementation science: a potential catalyst for delivery system reform. JAMA. 2016;315(4):339-340. doi:10.1001/jama.2015.17949.

Are we overlooking factors that could help bring about necessary changes to the healthcare industry? Elliott S. Fisher, MD, MPH, of the Dartmouth Institute for Health Policy and Clinical Practice, thinks so.

“We are missing an important opportunity to learn from what is going on in health systems every day that could tell us how to make healthcare better and cheaper,” says Dr. Fisher, lead author of a January 2016 JAMA “Viewpoint” called “Implementation Science: A Potential Catalyst for Delivery System Reform.” “That’s the argument for the the field of implementation science.”

Implementation science studies ways to promote the integration of research findings and evidence into the healthcare system. Dr. Fisher says that integration is influenced by multiple factors: the characteristic of the innovation itself, the organizational setting, and the policy or community environment within which that organization is working. Context matters.

“We tend to think about adopting innovations like a new blood pressure medication or a new device,” Dr. Fisher says. “Those decisions rest almost entirely on the shoulders of physicians, so adoption requires thinking about the attributes of biomedical innovations and how physicians think.”

With care delivery innovations—for example, how to provide optimal care for people with heart failure across home, hospital, and nursing home—those are often developed with clinical input but by people who are fundamentally managers.

“It’s a more complex set of actors,” he says, “so you have to think about those decision makers if you’re going to get the best evidence-based practice into their setting.”

A third category of innovation focuses on individual behavior change, where the decision makers are the clinician and the patient and family. “You’ve got to persuade the patient the innovation is worth doing, so different factors may influence the successful adoptions of those interventions,” Dr. Fisher says.

Reference

1. Fisher ES, Shortell SM, Savitz LA. Implementation science: a potential catalyst for delivery system reform. JAMA. 2016;315(4):339-340. doi:10.1001/jama.2015.17949.

Are we overlooking factors that could help bring about necessary changes to the healthcare industry? Elliott S. Fisher, MD, MPH, of the Dartmouth Institute for Health Policy and Clinical Practice, thinks so.

“We are missing an important opportunity to learn from what is going on in health systems every day that could tell us how to make healthcare better and cheaper,” says Dr. Fisher, lead author of a January 2016 JAMA “Viewpoint” called “Implementation Science: A Potential Catalyst for Delivery System Reform.” “That’s the argument for the the field of implementation science.”

Implementation science studies ways to promote the integration of research findings and evidence into the healthcare system. Dr. Fisher says that integration is influenced by multiple factors: the characteristic of the innovation itself, the organizational setting, and the policy or community environment within which that organization is working. Context matters.

“We tend to think about adopting innovations like a new blood pressure medication or a new device,” Dr. Fisher says. “Those decisions rest almost entirely on the shoulders of physicians, so adoption requires thinking about the attributes of biomedical innovations and how physicians think.”

With care delivery innovations—for example, how to provide optimal care for people with heart failure across home, hospital, and nursing home—those are often developed with clinical input but by people who are fundamentally managers.

“It’s a more complex set of actors,” he says, “so you have to think about those decision makers if you’re going to get the best evidence-based practice into their setting.”

A third category of innovation focuses on individual behavior change, where the decision makers are the clinician and the patient and family. “You’ve got to persuade the patient the innovation is worth doing, so different factors may influence the successful adoptions of those interventions,” Dr. Fisher says.

Reference

1. Fisher ES, Shortell SM, Savitz LA. Implementation science: a potential catalyst for delivery system reform. JAMA. 2016;315(4):339-340. doi:10.1001/jama.2015.17949.

Clinical question: How frequent is contamination of skin and clothing during personal protective equipment (PPE) removal, and can it be prevented?

Background: PPE reduces transmission of pathogens to healthcare personnel and patients. However, improper removal can lead to contamination of the skin and clothing. Little information exists describing the frequency and sites of contamination after the removal of gloves or gowns.

Study design: Point prevalence study and quasi-experimental intervention.

Setting: Four northeast Ohio hospitals (university, community, county, and VA); intervention performed at VA hospital.

Synopsis: This study began with 435 glove and gown removal simulations performed at four northeast Ohio hospitals. Skin or clothing contamination occurred in 200 (46%) simulations, with similar frequencies across the four hospitals (42.5%–50.3%). Contamination occurred more frequently in the glove removal versus gown removal (52.9% versus 37.8%, P=0.002). Most common causes of contamination were gloves not covering the wrists, removing the gown over the head, donning gloves before the gown, and touching contaminated gloves.

The intervention, performed at the VA hospital, consisted of educational sessions, videos, demonstrations, and practice donning and doffing PPE, which resulted in reduced skin and clothing contamination (60% before versus 18.9% after, P<0.001) that was sustained at one and three months.

Given that the intervention was quasi-experimental and not randomized, it is difficult to attribute

causality to the intervention, and results must be interpreted with caution.

Bottom line: During the removal of gloves and gowns, skin and clothing contamination is frequent, and a simple educational intervention with visual feedback may reduce rates of contamination.

Citation: Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med. 2015;175(12):1904-1910.

Clinical question: How frequent is contamination of skin and clothing during personal protective equipment (PPE) removal, and can it be prevented?

Background: PPE reduces transmission of pathogens to healthcare personnel and patients. However, improper removal can lead to contamination of the skin and clothing. Little information exists describing the frequency and sites of contamination after the removal of gloves or gowns.

Study design: Point prevalence study and quasi-experimental intervention.

Setting: Four northeast Ohio hospitals (university, community, county, and VA); intervention performed at VA hospital.

Synopsis: This study began with 435 glove and gown removal simulations performed at four northeast Ohio hospitals. Skin or clothing contamination occurred in 200 (46%) simulations, with similar frequencies across the four hospitals (42.5%–50.3%). Contamination occurred more frequently in the glove removal versus gown removal (52.9% versus 37.8%, P=0.002). Most common causes of contamination were gloves not covering the wrists, removing the gown over the head, donning gloves before the gown, and touching contaminated gloves.

The intervention, performed at the VA hospital, consisted of educational sessions, videos, demonstrations, and practice donning and doffing PPE, which resulted in reduced skin and clothing contamination (60% before versus 18.9% after, P<0.001) that was sustained at one and three months.

Given that the intervention was quasi-experimental and not randomized, it is difficult to attribute

causality to the intervention, and results must be interpreted with caution.

Bottom line: During the removal of gloves and gowns, skin and clothing contamination is frequent, and a simple educational intervention with visual feedback may reduce rates of contamination.

Citation: Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med. 2015;175(12):1904-1910.

Clinical question: How frequent is contamination of skin and clothing during personal protective equipment (PPE) removal, and can it be prevented?

Background: PPE reduces transmission of pathogens to healthcare personnel and patients. However, improper removal can lead to contamination of the skin and clothing. Little information exists describing the frequency and sites of contamination after the removal of gloves or gowns.

Study design: Point prevalence study and quasi-experimental intervention.

Setting: Four northeast Ohio hospitals (university, community, county, and VA); intervention performed at VA hospital.

Synopsis: This study began with 435 glove and gown removal simulations performed at four northeast Ohio hospitals. Skin or clothing contamination occurred in 200 (46%) simulations, with similar frequencies across the four hospitals (42.5%–50.3%). Contamination occurred more frequently in the glove removal versus gown removal (52.9% versus 37.8%, P=0.002). Most common causes of contamination were gloves not covering the wrists, removing the gown over the head, donning gloves before the gown, and touching contaminated gloves.

The intervention, performed at the VA hospital, consisted of educational sessions, videos, demonstrations, and practice donning and doffing PPE, which resulted in reduced skin and clothing contamination (60% before versus 18.9% after, P<0.001) that was sustained at one and three months.

Given that the intervention was quasi-experimental and not randomized, it is difficult to attribute

causality to the intervention, and results must be interpreted with caution.

Bottom line: During the removal of gloves and gowns, skin and clothing contamination is frequent, and a simple educational intervention with visual feedback may reduce rates of contamination.

Citation: Tomas ME, Kundrapu S, Thota P, et al. Contamination of health care personnel during removal of personal protective equipment. JAMA Intern Med. 2015;175(12):1904-1910.

Clinical question: Can procalcitonin testing be used to determine whether antibiotics should be started and stopped?

Background: Procalcitonin naturally occurs in the body but increases with bacterial infection, with normal levels

Study design: Systematic review.

Setting: ICUs and EDs in Europe, China, and Brazil.

Synopsis: A systematic review of eight RCTs in the ICU showed that, in adults, procalcitonin testing decreased antibiotic duration (weighted mean difference [WMD] -3.2 days; 95% CI, -5.44 to -0.95), decreased hospital length of stay (WMD -3.85 days; 95% CI, -6.78 to -0.92), and trended toward decreased ICU length of stay (WMD -2.03 days; 95% CI, -4.19 to 0.13).

Further review of eight different trials looking at procalcitonin testing in the ED showed that, in adults with suspected bacterial infection, procalcitonin testing reduced proportion of adults receiving antibiotics (relative risk 0.77; 95% CI, 0.68–0.87) and a trend toward reduction in hospital stays. No strong conclusions could be made about the effect on duration of antibiotic therapy. Procalcitonin testing was demonstrated to be cost-effective in the study population, saving £3,268 in adults with sepsis in the ICU.

Most studies were of unclear quality and unclear risk of bias secondary to insufficient reporting; therefore, results must be interpreted with caution.

Bottom line: Procalcitonin testing may be a cost-saving measure for adults with sepsis in the ICU and adults with possible bacterial infections in the ED.

Citation: Westwood M, Raemaekers B, Whiting P, et al. Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2015;19(96):1-236.

Short Take

Adjuvant Flu Vaccine Approved for Prevention of Seasonal Influenza

The FDA approved Fluad, an adjuvanted trivalent vaccine, for the prevention of seasonal influenza in patients >65 years of age based on studies showing comparable safety and immunogenicity to Agriflu, a FDA-approved unadjuvanted trivalent vaccine.

Citation: FDA approves first seasonal influenza vaccine containing an adjuvant [news release]. Washington, DC: FDA; November 24, 2015

Clinical question: Can procalcitonin testing be used to determine whether antibiotics should be started and stopped?

Background: Procalcitonin naturally occurs in the body but increases with bacterial infection, with normal levels

Study design: Systematic review.

Setting: ICUs and EDs in Europe, China, and Brazil.

Synopsis: A systematic review of eight RCTs in the ICU showed that, in adults, procalcitonin testing decreased antibiotic duration (weighted mean difference [WMD] -3.2 days; 95% CI, -5.44 to -0.95), decreased hospital length of stay (WMD -3.85 days; 95% CI, -6.78 to -0.92), and trended toward decreased ICU length of stay (WMD -2.03 days; 95% CI, -4.19 to 0.13).

Further review of eight different trials looking at procalcitonin testing in the ED showed that, in adults with suspected bacterial infection, procalcitonin testing reduced proportion of adults receiving antibiotics (relative risk 0.77; 95% CI, 0.68–0.87) and a trend toward reduction in hospital stays. No strong conclusions could be made about the effect on duration of antibiotic therapy. Procalcitonin testing was demonstrated to be cost-effective in the study population, saving £3,268 in adults with sepsis in the ICU.

Most studies were of unclear quality and unclear risk of bias secondary to insufficient reporting; therefore, results must be interpreted with caution.

Bottom line: Procalcitonin testing may be a cost-saving measure for adults with sepsis in the ICU and adults with possible bacterial infections in the ED.

Citation: Westwood M, Raemaekers B, Whiting P, et al. Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2015;19(96):1-236.

Short Take

Adjuvant Flu Vaccine Approved for Prevention of Seasonal Influenza

The FDA approved Fluad, an adjuvanted trivalent vaccine, for the prevention of seasonal influenza in patients >65 years of age based on studies showing comparable safety and immunogenicity to Agriflu, a FDA-approved unadjuvanted trivalent vaccine.

Citation: FDA approves first seasonal influenza vaccine containing an adjuvant [news release]. Washington, DC: FDA; November 24, 2015

Clinical question: Can procalcitonin testing be used to determine whether antibiotics should be started and stopped?

Background: Procalcitonin naturally occurs in the body but increases with bacterial infection, with normal levels

Study design: Systematic review.

Setting: ICUs and EDs in Europe, China, and Brazil.

Synopsis: A systematic review of eight RCTs in the ICU showed that, in adults, procalcitonin testing decreased antibiotic duration (weighted mean difference [WMD] -3.2 days; 95% CI, -5.44 to -0.95), decreased hospital length of stay (WMD -3.85 days; 95% CI, -6.78 to -0.92), and trended toward decreased ICU length of stay (WMD -2.03 days; 95% CI, -4.19 to 0.13).

Further review of eight different trials looking at procalcitonin testing in the ED showed that, in adults with suspected bacterial infection, procalcitonin testing reduced proportion of adults receiving antibiotics (relative risk 0.77; 95% CI, 0.68–0.87) and a trend toward reduction in hospital stays. No strong conclusions could be made about the effect on duration of antibiotic therapy. Procalcitonin testing was demonstrated to be cost-effective in the study population, saving £3,268 in adults with sepsis in the ICU.

Most studies were of unclear quality and unclear risk of bias secondary to insufficient reporting; therefore, results must be interpreted with caution.

Bottom line: Procalcitonin testing may be a cost-saving measure for adults with sepsis in the ICU and adults with possible bacterial infections in the ED.

Citation: Westwood M, Raemaekers B, Whiting P, et al. Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2015;19(96):1-236.

Short Take

Adjuvant Flu Vaccine Approved for Prevention of Seasonal Influenza

The FDA approved Fluad, an adjuvanted trivalent vaccine, for the prevention of seasonal influenza in patients >65 years of age based on studies showing comparable safety and immunogenicity to Agriflu, a FDA-approved unadjuvanted trivalent vaccine.

Citation: FDA approves first seasonal influenza vaccine containing an adjuvant [news release]. Washington, DC: FDA; November 24, 2015