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Presenters: Sarah White MD, Mark Corden, MD, and Parminder Suchdev, MD, MPH

Summary:

This PHM15 workshop kicked off the Global Health pathway. The speakers explained that they had become interested in nutrition through the international experiences they had in the past with malnourished children around the world.

The learning objectives included reviewing:

• Criteria for admission of malnourished children to feeding centers or inpatient care for severe acute malnutrition (SAM);
• Micronutrient deficiencies in SAM;
• Specific things to look for when treating SAM using rehydration and refeeding protocols;
• Definitions and classification of malnutrition states; and
• The burden disease malnutrition represents in global children’s health, as well as its association with increased mortality.

The presenters used case studies to give specific examples of how malnutrition complicates children’s health. Mid-upper arm circumference (MUAC) was reviewed as a proxy measure to quickly identify children at risk for malnutrition as well as the need for length and weight to fully describe the nutritional/growth state of a child. “Appetite test” was introduced as a way to assess if children have capability to try to increase feeding at home (if access to food is assured) or if they are experiencing a malnutrition state that would benefit from inpatient management. Comorbidities, such as edema, shock, and infections, were considered as reasons to admit the patient for malnutrition rated illness. WHO guidelines for use of specific refeeding formulas [PDF] and therapeutic ready-to-use food (RUTF) to manage stabilization versus transition phases were also reviewed.

In caring for acutely malnourished children, providers also need to be prepared to manage refeeding syndrome. It can be confused with sepsis due to both conditions presenting with acute decompensation of the patient, so it is important to keep in mind. Dehydrated malnourished children have very specialized needs, are sodium sensitive and are at risk of heart failure and pulmonary edema with typical rehydration methods. ReSoMal rehydration solution was described as an oral rehydration solution and lactated ringers IV for use in the management of a dehydrated, malnourished child.

Other topics covered in the workshop included the implications of the presence of edema in a malnourished patient, the use of antibiotics in improving mortality, and need for replenishing micronutrient stores. Overall, the workshop had an effective use of cases to show specific complications that a health care provider may encounter when treating children with SAM. TH

Dr. Hodge is a pediatric hospitalist at Kosair Children’s Hospital in Louisville, Ky., an assistant professor in the department of pediatrics, and director of distinction in global health track at the University of Louisville School of Medicine.

Presenters: Sarah White MD, Mark Corden, MD, and Parminder Suchdev, MD, MPH

Summary:

This PHM15 workshop kicked off the Global Health pathway. The speakers explained that they had become interested in nutrition through the international experiences they had in the past with malnourished children around the world.

The learning objectives included reviewing:

• Criteria for admission of malnourished children to feeding centers or inpatient care for severe acute malnutrition (SAM);
• Micronutrient deficiencies in SAM;
• Specific things to look for when treating SAM using rehydration and refeeding protocols;
• Definitions and classification of malnutrition states; and
• The burden disease malnutrition represents in global children’s health, as well as its association with increased mortality.

The presenters used case studies to give specific examples of how malnutrition complicates children’s health. Mid-upper arm circumference (MUAC) was reviewed as a proxy measure to quickly identify children at risk for malnutrition as well as the need for length and weight to fully describe the nutritional/growth state of a child. “Appetite test” was introduced as a way to assess if children have capability to try to increase feeding at home (if access to food is assured) or if they are experiencing a malnutrition state that would benefit from inpatient management. Comorbidities, such as edema, shock, and infections, were considered as reasons to admit the patient for malnutrition rated illness. WHO guidelines for use of specific refeeding formulas [PDF] and therapeutic ready-to-use food (RUTF) to manage stabilization versus transition phases were also reviewed.

In caring for acutely malnourished children, providers also need to be prepared to manage refeeding syndrome. It can be confused with sepsis due to both conditions presenting with acute decompensation of the patient, so it is important to keep in mind. Dehydrated malnourished children have very specialized needs, are sodium sensitive and are at risk of heart failure and pulmonary edema with typical rehydration methods. ReSoMal rehydration solution was described as an oral rehydration solution and lactated ringers IV for use in the management of a dehydrated, malnourished child.

Other topics covered in the workshop included the implications of the presence of edema in a malnourished patient, the use of antibiotics in improving mortality, and need for replenishing micronutrient stores. Overall, the workshop had an effective use of cases to show specific complications that a health care provider may encounter when treating children with SAM. TH

Dr. Hodge is a pediatric hospitalist at Kosair Children’s Hospital in Louisville, Ky., an assistant professor in the department of pediatrics, and director of distinction in global health track at the University of Louisville School of Medicine.

Presenters: Sarah White MD, Mark Corden, MD, and Parminder Suchdev, MD, MPH

Summary:

This PHM15 workshop kicked off the Global Health pathway. The speakers explained that they had become interested in nutrition through the international experiences they had in the past with malnourished children around the world.

The learning objectives included reviewing:

• Criteria for admission of malnourished children to feeding centers or inpatient care for severe acute malnutrition (SAM);
• Micronutrient deficiencies in SAM;
• Specific things to look for when treating SAM using rehydration and refeeding protocols;
• Definitions and classification of malnutrition states; and
• The burden disease malnutrition represents in global children’s health, as well as its association with increased mortality.

The presenters used case studies to give specific examples of how malnutrition complicates children’s health. Mid-upper arm circumference (MUAC) was reviewed as a proxy measure to quickly identify children at risk for malnutrition as well as the need for length and weight to fully describe the nutritional/growth state of a child. “Appetite test” was introduced as a way to assess if children have capability to try to increase feeding at home (if access to food is assured) or if they are experiencing a malnutrition state that would benefit from inpatient management. Comorbidities, such as edema, shock, and infections, were considered as reasons to admit the patient for malnutrition rated illness. WHO guidelines for use of specific refeeding formulas [PDF] and therapeutic ready-to-use food (RUTF) to manage stabilization versus transition phases were also reviewed.

In caring for acutely malnourished children, providers also need to be prepared to manage refeeding syndrome. It can be confused with sepsis due to both conditions presenting with acute decompensation of the patient, so it is important to keep in mind. Dehydrated malnourished children have very specialized needs, are sodium sensitive and are at risk of heart failure and pulmonary edema with typical rehydration methods. ReSoMal rehydration solution was described as an oral rehydration solution and lactated ringers IV for use in the management of a dehydrated, malnourished child.

Other topics covered in the workshop included the implications of the presence of edema in a malnourished patient, the use of antibiotics in improving mortality, and need for replenishing micronutrient stores. Overall, the workshop had an effective use of cases to show specific complications that a health care provider may encounter when treating children with SAM. TH

Dr. Hodge is a pediatric hospitalist at Kosair Children’s Hospital in Louisville, Ky., an assistant professor in the department of pediatrics, and director of distinction in global health track at the University of Louisville School of Medicine.

Young adult cancer survivors will continue to have high hospitalization rates over time, a Canadian study shows.

In five-year cancer survivors diagnosed between ages 20 and 44, hospitalization rates were elevated for at least 20 years, compared to rates in age- and sex-matched controls, according to Dr. Nancy N. Baxter at St. Michael's Hospital in Toronto and colleagues.

For all malignancies except melanoma and testicular cancer, the adjusted relative rate (ARR) of hospitalizations was significantly higher among survivors than controls.

"Late effects and complications of cancer treatments are experienced by many survivors for the rest of their lives," Dr. Baxter told Reuters Health via e-mail. The patients in this population-based study were treated from 1992-1999. "Therapies have changed, she said. "In some cases there may be fewer late effects, but in others, they may be worse."

The study cohort included 20,275 survivors of young adult cancers who were recurrence-free for at least five years, and 101,344 controls. The authors observed survivors for a median of 9.93 years (range 0-16 years), according to their report online July 13 in the Journal of Clinical Oncology. During this period, 34.3% had at least one hospitalization,

vs. 27.3% for controls. The rate per 100 person-years was similar between male and female survivors.

Overall, the ARR of hospitalization in survivors compared with controls was 1.51. At all-time periods, survivors were more likely to be hospitalized than controls. The rate of hospitalization (per 100-person years) among survivors was 0.22 during years 5 to 8, 9 to11, and 12 to14. It decreased significantly during years 15 to 17 and 18 to 20, falling to 0.17 and 0.15, respectively (P<0.0001). Among controls, the hospitalization rate was relatively constant during all time periods, ranging from 0.13 at 5 to 8 years to 0.12 at years 18 to 20.

The ARR of hospitalizations in survivors compared with controls was also relatively constant during for the first three3 time periods: 1.67, 1.55, and 1.57 at years 5 to 8, 9 to

11, and 12 to 14, respectively. It decreased to 1.36 at 15 to 17 years and 1.22 at years 18 to 20. Those who survived gastrointestinal, urologic, colorectal, or brain cancers, or leukemia or lymphoma, had an ARR of hospitalization at least twice that of controls.

"We only looked at hospital admissions, not visits to the family doctor or medical conditions and disabilities that didn't require inpatient care," Dr. Baxter said, explaining that this likely underestimated the long-term impact of intense treatments that include surgery, chemotherapy, radiation, and hormonal therapy.

"Understanding the late effects of cancer treatment will help us design better treatments, counsel patients, and improve symptom management."

Young adult cancer survivors will continue to have high hospitalization rates over time, a Canadian study shows.

In five-year cancer survivors diagnosed between ages 20 and 44, hospitalization rates were elevated for at least 20 years, compared to rates in age- and sex-matched controls, according to Dr. Nancy N. Baxter at St. Michael's Hospital in Toronto and colleagues.

For all malignancies except melanoma and testicular cancer, the adjusted relative rate (ARR) of hospitalizations was significantly higher among survivors than controls.

"Late effects and complications of cancer treatments are experienced by many survivors for the rest of their lives," Dr. Baxter told Reuters Health via e-mail. The patients in this population-based study were treated from 1992-1999. "Therapies have changed, she said. "In some cases there may be fewer late effects, but in others, they may be worse."

The study cohort included 20,275 survivors of young adult cancers who were recurrence-free for at least five years, and 101,344 controls. The authors observed survivors for a median of 9.93 years (range 0-16 years), according to their report online July 13 in the Journal of Clinical Oncology. During this period, 34.3% had at least one hospitalization,

vs. 27.3% for controls. The rate per 100 person-years was similar between male and female survivors.

Overall, the ARR of hospitalization in survivors compared with controls was 1.51. At all-time periods, survivors were more likely to be hospitalized than controls. The rate of hospitalization (per 100-person years) among survivors was 0.22 during years 5 to 8, 9 to11, and 12 to14. It decreased significantly during years 15 to 17 and 18 to 20, falling to 0.17 and 0.15, respectively (P<0.0001). Among controls, the hospitalization rate was relatively constant during all time periods, ranging from 0.13 at 5 to 8 years to 0.12 at years 18 to 20.

The ARR of hospitalizations in survivors compared with controls was also relatively constant during for the first three3 time periods: 1.67, 1.55, and 1.57 at years 5 to 8, 9 to

11, and 12 to 14, respectively. It decreased to 1.36 at 15 to 17 years and 1.22 at years 18 to 20. Those who survived gastrointestinal, urologic, colorectal, or brain cancers, or leukemia or lymphoma, had an ARR of hospitalization at least twice that of controls.

"We only looked at hospital admissions, not visits to the family doctor or medical conditions and disabilities that didn't require inpatient care," Dr. Baxter said, explaining that this likely underestimated the long-term impact of intense treatments that include surgery, chemotherapy, radiation, and hormonal therapy.

"Understanding the late effects of cancer treatment will help us design better treatments, counsel patients, and improve symptom management."

Young adult cancer survivors will continue to have high hospitalization rates over time, a Canadian study shows.

In five-year cancer survivors diagnosed between ages 20 and 44, hospitalization rates were elevated for at least 20 years, compared to rates in age- and sex-matched controls, according to Dr. Nancy N. Baxter at St. Michael's Hospital in Toronto and colleagues.

For all malignancies except melanoma and testicular cancer, the adjusted relative rate (ARR) of hospitalizations was significantly higher among survivors than controls.

"Late effects and complications of cancer treatments are experienced by many survivors for the rest of their lives," Dr. Baxter told Reuters Health via e-mail. The patients in this population-based study were treated from 1992-1999. "Therapies have changed, she said. "In some cases there may be fewer late effects, but in others, they may be worse."

The study cohort included 20,275 survivors of young adult cancers who were recurrence-free for at least five years, and 101,344 controls. The authors observed survivors for a median of 9.93 years (range 0-16 years), according to their report online July 13 in the Journal of Clinical Oncology. During this period, 34.3% had at least one hospitalization,

vs. 27.3% for controls. The rate per 100 person-years was similar between male and female survivors.

Overall, the ARR of hospitalization in survivors compared with controls was 1.51. At all-time periods, survivors were more likely to be hospitalized than controls. The rate of hospitalization (per 100-person years) among survivors was 0.22 during years 5 to 8, 9 to11, and 12 to14. It decreased significantly during years 15 to 17 and 18 to 20, falling to 0.17 and 0.15, respectively (P<0.0001). Among controls, the hospitalization rate was relatively constant during all time periods, ranging from 0.13 at 5 to 8 years to 0.12 at years 18 to 20.

The ARR of hospitalizations in survivors compared with controls was also relatively constant during for the first three3 time periods: 1.67, 1.55, and 1.57 at years 5 to 8, 9 to

11, and 12 to 14, respectively. It decreased to 1.36 at 15 to 17 years and 1.22 at years 18 to 20. Those who survived gastrointestinal, urologic, colorectal, or brain cancers, or leukemia or lymphoma, had an ARR of hospitalization at least twice that of controls.

"We only looked at hospital admissions, not visits to the family doctor or medical conditions and disabilities that didn't require inpatient care," Dr. Baxter said, explaining that this likely underestimated the long-term impact of intense treatments that include surgery, chemotherapy, radiation, and hormonal therapy.

"Understanding the late effects of cancer treatment will help us design better treatments, counsel patients, and improve symptom management."

Session: Let’s Measure Our Own Performance: Propose and Evaluate Pediatric Hospital Medicine Quality Indicators

Summary: During this workshop, a staff of multiple, nationally-recognized quality leaders led a group to review, help develop, and help validate quality measures. The workshop was facilitated via the use of interactive survey tools, didactic sessions, and small groups.

Presenters discussed why quality measures are important and relevant. These included:

1. Improved quality of care,
2. Demonstration of value,
3. Third-party pay for performance indicators,
4. Determining our own indicators (versus being chosen for us), and
5. Performance incentives.

As part of the introduction to the workshop, the various quality measure validation methods were reviewed. These consisted of methods such as UCLA/RAND and Delphi Panel, as a means to determine validation and feasibility.

Validation was discussed in terms of what is being measured is the true outcome that was hoped to be achieved. The feasibility component used to make sure that the data used for quality measures, or process to be implemented for improvement, can easily be acquired to determine adherence, and that data is free of error. Facilitators reviewed various examples of validity and feasibility of quality measures with direct examples and discussions with attendees.

During the first breakout session, the groups were separated into teams focused on 1. care transitions, 2. safety, and 3. clinical care. The groups were asked to determine three quality indicators per individual, discuss the top five indicators voted on by the group, and than to review and discuss as a group the validity and feasibility of the measures using a scoring tool of 1-3: Not Valid/Feasible, 4-6: Equivocal, 7-9: Valid/Feasible. At the end, a delegated group speaker was asked to discuss either the pros/cons of one of their measures in regards to validity and feasibility to the total audience. Facilitators assisted on clarifying the reasons of why validity and feasibility metrics were appropriate.

During the final parts of workshop, positive and negatives of quality metrics determination methodology were discussed. The attendees reflected on the process of how quality measures are determined along with how these may be used within their settings.

Key Takeaways

Clearly determining the validity and feasibility of quality metrics for pediatrics has become an important topic. It not only has significant ramifications to the value we provide to our patients, but also the financial sustainability of programs and institutions, especially with the current changes in payment models. The workshop gave a clear and concise way of how to come up with quality metrics and the facilitators greatly added to the understanding of how we can “raise the floor” and “raise the ceiling” of pediatric care. TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Session: Let’s Measure Our Own Performance: Propose and Evaluate Pediatric Hospital Medicine Quality Indicators

Summary: During this workshop, a staff of multiple, nationally-recognized quality leaders led a group to review, help develop, and help validate quality measures. The workshop was facilitated via the use of interactive survey tools, didactic sessions, and small groups.

Presenters discussed why quality measures are important and relevant. These included:

1. Improved quality of care,
2. Demonstration of value,
3. Third-party pay for performance indicators,
4. Determining our own indicators (versus being chosen for us), and
5. Performance incentives.

As part of the introduction to the workshop, the various quality measure validation methods were reviewed. These consisted of methods such as UCLA/RAND and Delphi Panel, as a means to determine validation and feasibility.

Validation was discussed in terms of what is being measured is the true outcome that was hoped to be achieved. The feasibility component used to make sure that the data used for quality measures, or process to be implemented for improvement, can easily be acquired to determine adherence, and that data is free of error. Facilitators reviewed various examples of validity and feasibility of quality measures with direct examples and discussions with attendees.

During the first breakout session, the groups were separated into teams focused on 1. care transitions, 2. safety, and 3. clinical care. The groups were asked to determine three quality indicators per individual, discuss the top five indicators voted on by the group, and than to review and discuss as a group the validity and feasibility of the measures using a scoring tool of 1-3: Not Valid/Feasible, 4-6: Equivocal, 7-9: Valid/Feasible. At the end, a delegated group speaker was asked to discuss either the pros/cons of one of their measures in regards to validity and feasibility to the total audience. Facilitators assisted on clarifying the reasons of why validity and feasibility metrics were appropriate.

During the final parts of workshop, positive and negatives of quality metrics determination methodology were discussed. The attendees reflected on the process of how quality measures are determined along with how these may be used within their settings.

Key Takeaways

Clearly determining the validity and feasibility of quality metrics for pediatrics has become an important topic. It not only has significant ramifications to the value we provide to our patients, but also the financial sustainability of programs and institutions, especially with the current changes in payment models. The workshop gave a clear and concise way of how to come up with quality metrics and the facilitators greatly added to the understanding of how we can “raise the floor” and “raise the ceiling” of pediatric care. TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Session: Let’s Measure Our Own Performance: Propose and Evaluate Pediatric Hospital Medicine Quality Indicators

Summary: During this workshop, a staff of multiple, nationally-recognized quality leaders led a group to review, help develop, and help validate quality measures. The workshop was facilitated via the use of interactive survey tools, didactic sessions, and small groups.

Presenters discussed why quality measures are important and relevant. These included:

1. Improved quality of care,
2. Demonstration of value,
3. Third-party pay for performance indicators,
4. Determining our own indicators (versus being chosen for us), and
5. Performance incentives.

As part of the introduction to the workshop, the various quality measure validation methods were reviewed. These consisted of methods such as UCLA/RAND and Delphi Panel, as a means to determine validation and feasibility.

Validation was discussed in terms of what is being measured is the true outcome that was hoped to be achieved. The feasibility component used to make sure that the data used for quality measures, or process to be implemented for improvement, can easily be acquired to determine adherence, and that data is free of error. Facilitators reviewed various examples of validity and feasibility of quality measures with direct examples and discussions with attendees.

During the first breakout session, the groups were separated into teams focused on 1. care transitions, 2. safety, and 3. clinical care. The groups were asked to determine three quality indicators per individual, discuss the top five indicators voted on by the group, and than to review and discuss as a group the validity and feasibility of the measures using a scoring tool of 1-3: Not Valid/Feasible, 4-6: Equivocal, 7-9: Valid/Feasible. At the end, a delegated group speaker was asked to discuss either the pros/cons of one of their measures in regards to validity and feasibility to the total audience. Facilitators assisted on clarifying the reasons of why validity and feasibility metrics were appropriate.

During the final parts of workshop, positive and negatives of quality metrics determination methodology were discussed. The attendees reflected on the process of how quality measures are determined along with how these may be used within their settings.

Key Takeaways

Clearly determining the validity and feasibility of quality metrics for pediatrics has become an important topic. It not only has significant ramifications to the value we provide to our patients, but also the financial sustainability of programs and institutions, especially with the current changes in payment models. The workshop gave a clear and concise way of how to come up with quality metrics and the facilitators greatly added to the understanding of how we can “raise the floor” and “raise the ceiling” of pediatric care. TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Clinical question: Does high-flow oxygen therapy result in a decreased rate of intubation for patients with nonhypercapnic acute hypoxemic respiratory failure?

Bottom line: In this underpowered study, the use of high-flow oxygen therapy did not significantly reduce the rate of intubation as compared with standard oxygen therapy or noninvasive positive pressure ventilation in patients with nonhypercapnic acute hypoxemic respiratory failure. However, patients in the high-flow oxygen group had decreased 90-day mortality, as well as an increased number of ventilator-free days. Patients in the high-flow oxygen group also reported less respiratory discomfort and dyspnea than patients in the other 2 groups. (LOE = 1b-)

Reference: Frat J, Thille AW, Mercat A, et al, for the FLORALI Study Group and the REVA Network. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372(23):2185-2196.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (ICU only)

Synopsis: High-flow oxygen therapy uses oxygen delivered via nasal cannula at high flow rates to provide low-level positive pressure and reduce effective deadspace in the airways. Its effectiveness in the treatment of acute hypoxemic respiratory failure has not been established. In this study, investigators compared high-flow oxygen therapy with noninvasive positive pressure ventilation as well as with standard oxygen therapy in patients with nonhypercapnic acute hypoxemic respiratory failure.

Using concealed allocation, patients were randomized into 1 of 3 groups: (1) standard oxygen therapy using a nonrebreather face mask at a flow rate of 10 liters per minute or more; (2) high-flow oxygen therapy provided through a heated humidifier at a rate of 50 liters per minute for at least 2 days; or (3) noninvasive positive pressure ventilation for 8 hours per day for at least 2 days. With all 3 strategies, the goal was to maintain an oxygen saturation level of 92% or more. The 3 groups were similar at baseline with the majority of patients having community-acquired pneumonia as a cause of their acute respiratory failure. Analysis was by intention to treat.

For the primary outcome, the high-flow oxygen therapy group had a lower rate of intubation at 28 days than the other 2 groups, but this difference was not statistically significant (38% in high-flow group, 47% in standard group, 50% in noninvasive ventilation group; P = .18). Of note, the intubation rate in the standard oxygen therapy group was lower than the expected 60%, thus the study was underpowered to detect a difference if it truly exists. The high-flow therapy resulted in reduced 90-day mortality as compared with both standard therapy (hazard ratio [HR] = 2.01, 95% CI 1.01-3.99; P = .046) and noninvasive ventilation (HR = 2.50, 1.31-4.78; P = .006).

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

Clinical question: Does high-flow oxygen therapy result in a decreased rate of intubation for patients with nonhypercapnic acute hypoxemic respiratory failure?

Bottom line: In this underpowered study, the use of high-flow oxygen therapy did not significantly reduce the rate of intubation as compared with standard oxygen therapy or noninvasive positive pressure ventilation in patients with nonhypercapnic acute hypoxemic respiratory failure. However, patients in the high-flow oxygen group had decreased 90-day mortality, as well as an increased number of ventilator-free days. Patients in the high-flow oxygen group also reported less respiratory discomfort and dyspnea than patients in the other 2 groups. (LOE = 1b-)

Reference: Frat J, Thille AW, Mercat A, et al, for the FLORALI Study Group and the REVA Network. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372(23):2185-2196.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (ICU only)

Synopsis: High-flow oxygen therapy uses oxygen delivered via nasal cannula at high flow rates to provide low-level positive pressure and reduce effective deadspace in the airways. Its effectiveness in the treatment of acute hypoxemic respiratory failure has not been established. In this study, investigators compared high-flow oxygen therapy with noninvasive positive pressure ventilation as well as with standard oxygen therapy in patients with nonhypercapnic acute hypoxemic respiratory failure.

Using concealed allocation, patients were randomized into 1 of 3 groups: (1) standard oxygen therapy using a nonrebreather face mask at a flow rate of 10 liters per minute or more; (2) high-flow oxygen therapy provided through a heated humidifier at a rate of 50 liters per minute for at least 2 days; or (3) noninvasive positive pressure ventilation for 8 hours per day for at least 2 days. With all 3 strategies, the goal was to maintain an oxygen saturation level of 92% or more. The 3 groups were similar at baseline with the majority of patients having community-acquired pneumonia as a cause of their acute respiratory failure. Analysis was by intention to treat.

For the primary outcome, the high-flow oxygen therapy group had a lower rate of intubation at 28 days than the other 2 groups, but this difference was not statistically significant (38% in high-flow group, 47% in standard group, 50% in noninvasive ventilation group; P = .18). Of note, the intubation rate in the standard oxygen therapy group was lower than the expected 60%, thus the study was underpowered to detect a difference if it truly exists. The high-flow therapy resulted in reduced 90-day mortality as compared with both standard therapy (hazard ratio [HR] = 2.01, 95% CI 1.01-3.99; P = .046) and noninvasive ventilation (HR = 2.50, 1.31-4.78; P = .006).

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

Clinical question: Does high-flow oxygen therapy result in a decreased rate of intubation for patients with nonhypercapnic acute hypoxemic respiratory failure?

Bottom line: In this underpowered study, the use of high-flow oxygen therapy did not significantly reduce the rate of intubation as compared with standard oxygen therapy or noninvasive positive pressure ventilation in patients with nonhypercapnic acute hypoxemic respiratory failure. However, patients in the high-flow oxygen group had decreased 90-day mortality, as well as an increased number of ventilator-free days. Patients in the high-flow oxygen group also reported less respiratory discomfort and dyspnea than patients in the other 2 groups. (LOE = 1b-)

Reference: Frat J, Thille AW, Mercat A, et al, for the FLORALI Study Group and the REVA Network. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372(23):2185-2196.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (ICU only)

Synopsis: High-flow oxygen therapy uses oxygen delivered via nasal cannula at high flow rates to provide low-level positive pressure and reduce effective deadspace in the airways. Its effectiveness in the treatment of acute hypoxemic respiratory failure has not been established. In this study, investigators compared high-flow oxygen therapy with noninvasive positive pressure ventilation as well as with standard oxygen therapy in patients with nonhypercapnic acute hypoxemic respiratory failure.

Using concealed allocation, patients were randomized into 1 of 3 groups: (1) standard oxygen therapy using a nonrebreather face mask at a flow rate of 10 liters per minute or more; (2) high-flow oxygen therapy provided through a heated humidifier at a rate of 50 liters per minute for at least 2 days; or (3) noninvasive positive pressure ventilation for 8 hours per day for at least 2 days. With all 3 strategies, the goal was to maintain an oxygen saturation level of 92% or more. The 3 groups were similar at baseline with the majority of patients having community-acquired pneumonia as a cause of their acute respiratory failure. Analysis was by intention to treat.

For the primary outcome, the high-flow oxygen therapy group had a lower rate of intubation at 28 days than the other 2 groups, but this difference was not statistically significant (38% in high-flow group, 47% in standard group, 50% in noninvasive ventilation group; P = .18). Of note, the intubation rate in the standard oxygen therapy group was lower than the expected 60%, thus the study was underpowered to detect a difference if it truly exists. The high-flow therapy resulted in reduced 90-day mortality as compared with both standard therapy (hazard ratio [HR] = 2.01, 95% CI 1.01-3.99; P = .046) and noninvasive ventilation (HR = 2.50, 1.31-4.78; P = .006).

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

Clinical question: Does the use of a patient navigator to guide hospitalized patients through the health care system reduce 30-day readmission rates?

Bottom line: The use of a community health worker acting as a patient navigator (PN), both during hospitalization and after discharge, to assist patients with coordination of care, follow-up appointments, provider communication, and medication compliance decreases the 30-day readmission rate in older high-risk patients, but increased admissions in younger patients, suggesting that the younger population may require different strategies to decrease their use of hospital-based care. (LOE = 1b-)

Reference: Balaban RB, Galbraith AA, Burns ME, Vialle-Valentin CE, Larochelle MR, Ross-Degnan D. A patient navigator intervention to reduce hospital readmissions among high-risk safety-net patients: a randomized controlled trial. J Gen Intern Med 2015;30(7):907-915.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

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

Synopsis: This US study took place within a safety-net hospital system in Massachusetts that has a large underserved patient population. The authors enrolled more than 1500 hospitalized patients with at least 1 of 5 risk factors for readmission (older than 60 years, previous hospitalization within the last 6 months, length of stay of 3 days or more, or admission diagnoses of heart failure or chronic obstructive pulmonary disease). Patients in the intervention group were assigned to a hospital-based community health worker, or PN, while patients in the control group received usual care. The PN's primary responsibility was helping the patient navigate through the health care system, including assessing postdischarge needs, assisting with communication with inpatient providers and primary care physicians, confirming and rescheduling follow-up appointments, addressing barriers to taking medications, and assisting with transportation and insurance issues. These services were provided through a hospital visit and at least 3 weekly postdischarge phone calls. Patients in both groups were racially diverse and the majority carried public insurance. The patients older than 60 years were more medically complex, but younger patients had more psychiatric disorders and substance use disorders, as well as higher rates of previous hospitalizations and longer lengths of stay.

Overall, the 30-day readmission rate did not differ significantly between the control and intervention groups, but the study was underpowered given the limits to enrollment during the prespecified period. In an adjusted analysis of the 2 age subgroups, however, readmissions decreased by 4% in older intervention patients and they increased by 12% in younger intervention patients (both differences statistically significant).

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

Clinical question: Does the use of a patient navigator to guide hospitalized patients through the health care system reduce 30-day readmission rates?

Bottom line: The use of a community health worker acting as a patient navigator (PN), both during hospitalization and after discharge, to assist patients with coordination of care, follow-up appointments, provider communication, and medication compliance decreases the 30-day readmission rate in older high-risk patients, but increased admissions in younger patients, suggesting that the younger population may require different strategies to decrease their use of hospital-based care. (LOE = 1b-)

Reference: Balaban RB, Galbraith AA, Burns ME, Vialle-Valentin CE, Larochelle MR, Ross-Degnan D. A patient navigator intervention to reduce hospital readmissions among high-risk safety-net patients: a randomized controlled trial. J Gen Intern Med 2015;30(7):907-915.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

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

Synopsis: This US study took place within a safety-net hospital system in Massachusetts that has a large underserved patient population. The authors enrolled more than 1500 hospitalized patients with at least 1 of 5 risk factors for readmission (older than 60 years, previous hospitalization within the last 6 months, length of stay of 3 days or more, or admission diagnoses of heart failure or chronic obstructive pulmonary disease). Patients in the intervention group were assigned to a hospital-based community health worker, or PN, while patients in the control group received usual care. The PN's primary responsibility was helping the patient navigate through the health care system, including assessing postdischarge needs, assisting with communication with inpatient providers and primary care physicians, confirming and rescheduling follow-up appointments, addressing barriers to taking medications, and assisting with transportation and insurance issues. These services were provided through a hospital visit and at least 3 weekly postdischarge phone calls. Patients in both groups were racially diverse and the majority carried public insurance. The patients older than 60 years were more medically complex, but younger patients had more psychiatric disorders and substance use disorders, as well as higher rates of previous hospitalizations and longer lengths of stay.

Overall, the 30-day readmission rate did not differ significantly between the control and intervention groups, but the study was underpowered given the limits to enrollment during the prespecified period. In an adjusted analysis of the 2 age subgroups, however, readmissions decreased by 4% in older intervention patients and they increased by 12% in younger intervention patients (both differences statistically significant).

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

Clinical question: Does the use of a patient navigator to guide hospitalized patients through the health care system reduce 30-day readmission rates?

Bottom line: The use of a community health worker acting as a patient navigator (PN), both during hospitalization and after discharge, to assist patients with coordination of care, follow-up appointments, provider communication, and medication compliance decreases the 30-day readmission rate in older high-risk patients, but increased admissions in younger patients, suggesting that the younger population may require different strategies to decrease their use of hospital-based care. (LOE = 1b-)

Reference: Balaban RB, Galbraith AA, Burns ME, Vialle-Valentin CE, Larochelle MR, Ross-Degnan D. A patient navigator intervention to reduce hospital readmissions among high-risk safety-net patients: a randomized controlled trial. J Gen Intern Med 2015;30(7):907-915.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

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

Synopsis: This US study took place within a safety-net hospital system in Massachusetts that has a large underserved patient population. The authors enrolled more than 1500 hospitalized patients with at least 1 of 5 risk factors for readmission (older than 60 years, previous hospitalization within the last 6 months, length of stay of 3 days or more, or admission diagnoses of heart failure or chronic obstructive pulmonary disease). Patients in the intervention group were assigned to a hospital-based community health worker, or PN, while patients in the control group received usual care. The PN's primary responsibility was helping the patient navigate through the health care system, including assessing postdischarge needs, assisting with communication with inpatient providers and primary care physicians, confirming and rescheduling follow-up appointments, addressing barriers to taking medications, and assisting with transportation and insurance issues. These services were provided through a hospital visit and at least 3 weekly postdischarge phone calls. Patients in both groups were racially diverse and the majority carried public insurance. The patients older than 60 years were more medically complex, but younger patients had more psychiatric disorders and substance use disorders, as well as higher rates of previous hospitalizations and longer lengths of stay.

Overall, the 30-day readmission rate did not differ significantly between the control and intervention groups, but the study was underpowered given the limits to enrollment during the prespecified period. In an adjusted analysis of the 2 age subgroups, however, readmissions decreased by 4% in older intervention patients and they increased by 12% in younger intervention patients (both differences statistically significant).

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

Clinical question: Does fecal microbiotia transplantation (FMT) effectively treat patients with recurrent Clostridium difficile infection (CDI)?

Background: Patients with initial CDI have increased rates of recurrence (15%–30%), with variable success noted in treatment of recurrent disease. Increased interest in the use of FMT as a treatment strategy for CDI has led to various studies evaluating its efficacy.

Study design: Systematic review.

Setting: Multiple settings from studies obtained from MEDLINE, Cochrane Library, and ClinicalTrials.gov.

Synopsis: Literature search and review yielded a total of 35 included articles for analysis, mostly case-series studies (28), with only two randomized controlled trials (RCTs). Primary outcome was defined as symptom resolution, with a secondary outcome of recurrence. Although studies included assessed FMT as treatment for initial, recurrent, and refractory CDI, the majority of the evidence was focused on recurrent CDI. Among the studies analyzed, FMT was found to have a substantial effect on primary outcome of symptom resolution (85% of cases) among all pooled studies for recurrent CDI.

Although this review provided evidence suggestive of the efficacy of FMT in recurrent CDI, the paucity of RCT data was well documented and noted as a limitation in providing high-quality recommendations on FMT as a treatment option. Further high-quality research is recommended, and hospitalists caring for patients with recurrent CDI should be wary of treatment with FMT based on these data alone.

Bottom line: Studies evaluating FMT as a treatment option for recurrent CDI demonstrate significant benefit in symptom resolution, but further high-quality research is needed.

Citation: Drekonja D, Reich J, Gezahegn S, et al. Fecal microbiota transplantation for Clostridium difficile infection: a systematic review of the evidence. Ann Intern Med. 2015;162:630-638. doi:10.7326/M14-2693.

Visit our website for more hospitalist-focused literature reviews.

Clinical question: Does fecal microbiotia transplantation (FMT) effectively treat patients with recurrent Clostridium difficile infection (CDI)?

Background: Patients with initial CDI have increased rates of recurrence (15%–30%), with variable success noted in treatment of recurrent disease. Increased interest in the use of FMT as a treatment strategy for CDI has led to various studies evaluating its efficacy.

Study design: Systematic review.

Setting: Multiple settings from studies obtained from MEDLINE, Cochrane Library, and ClinicalTrials.gov.

Synopsis: Literature search and review yielded a total of 35 included articles for analysis, mostly case-series studies (28), with only two randomized controlled trials (RCTs). Primary outcome was defined as symptom resolution, with a secondary outcome of recurrence. Although studies included assessed FMT as treatment for initial, recurrent, and refractory CDI, the majority of the evidence was focused on recurrent CDI. Among the studies analyzed, FMT was found to have a substantial effect on primary outcome of symptom resolution (85% of cases) among all pooled studies for recurrent CDI.

Although this review provided evidence suggestive of the efficacy of FMT in recurrent CDI, the paucity of RCT data was well documented and noted as a limitation in providing high-quality recommendations on FMT as a treatment option. Further high-quality research is recommended, and hospitalists caring for patients with recurrent CDI should be wary of treatment with FMT based on these data alone.

Bottom line: Studies evaluating FMT as a treatment option for recurrent CDI demonstrate significant benefit in symptom resolution, but further high-quality research is needed.

Citation: Drekonja D, Reich J, Gezahegn S, et al. Fecal microbiota transplantation for Clostridium difficile infection: a systematic review of the evidence. Ann Intern Med. 2015;162:630-638. doi:10.7326/M14-2693.

Visit our website for more hospitalist-focused literature reviews.

Clinical question: Does fecal microbiotia transplantation (FMT) effectively treat patients with recurrent Clostridium difficile infection (CDI)?

Background: Patients with initial CDI have increased rates of recurrence (15%–30%), with variable success noted in treatment of recurrent disease. Increased interest in the use of FMT as a treatment strategy for CDI has led to various studies evaluating its efficacy.

Study design: Systematic review.

Setting: Multiple settings from studies obtained from MEDLINE, Cochrane Library, and ClinicalTrials.gov.

Synopsis: Literature search and review yielded a total of 35 included articles for analysis, mostly case-series studies (28), with only two randomized controlled trials (RCTs). Primary outcome was defined as symptom resolution, with a secondary outcome of recurrence. Although studies included assessed FMT as treatment for initial, recurrent, and refractory CDI, the majority of the evidence was focused on recurrent CDI. Among the studies analyzed, FMT was found to have a substantial effect on primary outcome of symptom resolution (85% of cases) among all pooled studies for recurrent CDI.

Although this review provided evidence suggestive of the efficacy of FMT in recurrent CDI, the paucity of RCT data was well documented and noted as a limitation in providing high-quality recommendations on FMT as a treatment option. Further high-quality research is recommended, and hospitalists caring for patients with recurrent CDI should be wary of treatment with FMT based on these data alone.

Bottom line: Studies evaluating FMT as a treatment option for recurrent CDI demonstrate significant benefit in symptom resolution, but further high-quality research is needed.

Citation: Drekonja D, Reich J, Gezahegn S, et al. Fecal microbiota transplantation for Clostridium difficile infection: a systematic review of the evidence. Ann Intern Med. 2015;162:630-638. doi:10.7326/M14-2693.

Visit our website for more hospitalist-focused literature reviews.

The number of inpatient hospital-acquired complications (HACs) typically spikes in July, but hospitalists can be instrumental in reducing this annual uptick, according to the lead author of a study on the "July effect" in hospital admissions.

Researcher Timothy Wen, MPH, a medical student at the Keck School of Medicine of University of Southern California in Los Angeles, examined patient discharge data collected nationally from 2008 to 2011 and found that July admissions had a 6% increase in the likelihood of HAC occurrence compared with admissions during all other months.

Wen, whose research findings were published in the Journal of Hospital Medicine, links the increase with the arrival of new residents, medical students, and hospital faculty in July. He says the annual staff changes can challenge the efficiency of hospital systems and processes.

Fortunately, hospitalists can help to reduce complications during and beyond this time of transition, Wen says.

“Because of their role,” Wen says, “hospitalists have a unique opportunity to not only utilize their institutional knowledge of the system and their patients but also to train residents in navigating the system with improved communication skills and working with ancillary staff. We believe that an initial step in resolving the outcomes associated with the 'July effect' is to have improved communication between ancillary, trainee, and attending staff. Furthermore, we believe that burden of surveillance during this transition period may require additional support from more senior ancillary and attending staff as the new trainees and faculty become more acquainted with the processes of a new hospital and service.”

HACs are a chronic issue for inpatients, contributing to longer lengths of stay and higher hospital costs. Wen says his study is among the first to “address the disparities in HACs between these time periods” and suggests more research on the impact of HACs is needed.

"HACs represent not only egregious complications of high cost and burden to hospitals and patients, but they are also a surrogate marker of adverse events that are preventable through systemic changes," he says. "We need future studies to continue to identify this disparity and its impacts, as well as research into novel initiatives and training protocols to work on reducing these HACs."

Visit our website for more information on reducing HACs.

The number of inpatient hospital-acquired complications (HACs) typically spikes in July, but hospitalists can be instrumental in reducing this annual uptick, according to the lead author of a study on the "July effect" in hospital admissions.

Researcher Timothy Wen, MPH, a medical student at the Keck School of Medicine of University of Southern California in Los Angeles, examined patient discharge data collected nationally from 2008 to 2011 and found that July admissions had a 6% increase in the likelihood of HAC occurrence compared with admissions during all other months.

Wen, whose research findings were published in the Journal of Hospital Medicine, links the increase with the arrival of new residents, medical students, and hospital faculty in July. He says the annual staff changes can challenge the efficiency of hospital systems and processes.

Fortunately, hospitalists can help to reduce complications during and beyond this time of transition, Wen says.

“Because of their role,” Wen says, “hospitalists have a unique opportunity to not only utilize their institutional knowledge of the system and their patients but also to train residents in navigating the system with improved communication skills and working with ancillary staff. We believe that an initial step in resolving the outcomes associated with the 'July effect' is to have improved communication between ancillary, trainee, and attending staff. Furthermore, we believe that burden of surveillance during this transition period may require additional support from more senior ancillary and attending staff as the new trainees and faculty become more acquainted with the processes of a new hospital and service.”

HACs are a chronic issue for inpatients, contributing to longer lengths of stay and higher hospital costs. Wen says his study is among the first to “address the disparities in HACs between these time periods” and suggests more research on the impact of HACs is needed.

"HACs represent not only egregious complications of high cost and burden to hospitals and patients, but they are also a surrogate marker of adverse events that are preventable through systemic changes," he says. "We need future studies to continue to identify this disparity and its impacts, as well as research into novel initiatives and training protocols to work on reducing these HACs."

Visit our website for more information on reducing HACs.

The number of inpatient hospital-acquired complications (HACs) typically spikes in July, but hospitalists can be instrumental in reducing this annual uptick, according to the lead author of a study on the "July effect" in hospital admissions.

Researcher Timothy Wen, MPH, a medical student at the Keck School of Medicine of University of Southern California in Los Angeles, examined patient discharge data collected nationally from 2008 to 2011 and found that July admissions had a 6% increase in the likelihood of HAC occurrence compared with admissions during all other months.

Wen, whose research findings were published in the Journal of Hospital Medicine, links the increase with the arrival of new residents, medical students, and hospital faculty in July. He says the annual staff changes can challenge the efficiency of hospital systems and processes.

Fortunately, hospitalists can help to reduce complications during and beyond this time of transition, Wen says.

“Because of their role,” Wen says, “hospitalists have a unique opportunity to not only utilize their institutional knowledge of the system and their patients but also to train residents in navigating the system with improved communication skills and working with ancillary staff. We believe that an initial step in resolving the outcomes associated with the 'July effect' is to have improved communication between ancillary, trainee, and attending staff. Furthermore, we believe that burden of surveillance during this transition period may require additional support from more senior ancillary and attending staff as the new trainees and faculty become more acquainted with the processes of a new hospital and service.”

HACs are a chronic issue for inpatients, contributing to longer lengths of stay and higher hospital costs. Wen says his study is among the first to “address the disparities in HACs between these time periods” and suggests more research on the impact of HACs is needed.

"HACs represent not only egregious complications of high cost and burden to hospitals and patients, but they are also a surrogate marker of adverse events that are preventable through systemic changes," he says. "We need future studies to continue to identify this disparity and its impacts, as well as research into novel initiatives and training protocols to work on reducing these HACs."

Visit our website for more information on reducing HACs.

Clinical question: Are there long-term benefits to more intensive glycemic control in patients with type 2 diabetes mellitus?

Bottom line: After approximately 10 years of follow-up, this study found 1 fewer cardiovascular event per 116 person-years among a group of patients (97% men) randomized to receive tight glycemic control, but found no reduction in mortality. This result must be balanced against the results from other trials, which saw a mixed bag of benefits and harms with long-term follow-up. It is important to note that even the intensive glycemic control group had a mean hemoglobin A1c of 6.9%, not 6% or 6.5% as some guidelines advocate.

Reference: Hayward RA, Reaven PD, Wiitala WL, et al, for the VADT Investigators. Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2015;372(23):2197-2206.

Study design: Cohort (prospective); (LOE: 2b)

Setting: Outpatient (any)

Synopsis: The Veteran's Affairs Diabetes Trial (VADT) originally randomized 1791 veterans with type 2 diabetes mellitus to receive intensive or usual glycemic control, and achieved mean hemoglobin A1C levels of 6.9% and 8.4%, respectively, after a median of 5.6 years. The original trial found a nonsignificant trend toward fewer cardiovascular events in the intensive therapy group, but no change in mortality. Two other large, similar trials reported similar findings, although one found increased mortality in the intensive glycemic control group. Follow-up studies for these 2 other trials have had mixed results, one finding increased mortality and no change in events, with the other finding fewer events but no change in mortality.

The current study linked patients in the original VADT to national disease registries (92% of participants) and also to regular record reviews and surveys (77% agreed to participte). The median follow-up was 9.8 years for cardiovascular events and 11.8 years for assessment of total mortality. They found a small but statistically significant reduction in the primary combined outcome of myocardial infarction , stroke, new or worsening heart failure, cardiovascular death, or amputation (44.1 vs 52.7 per 1000 person-years; P = .04). There was no significant difference between groups in the likelihood of cardiovascular death or all-cause mortality. The greatest contribution to the reduction in cardiovascular events was fewer nonfatal myocardial infarctions.

Mark H. Ebell, MD, MS, is an associate professor at the University of Georgia in Athens, editor-in-chief of Essential Evidence, and deputy editor of the American Family Physician journal. 

Clinical question: Are there long-term benefits to more intensive glycemic control in patients with type 2 diabetes mellitus?

Bottom line: After approximately 10 years of follow-up, this study found 1 fewer cardiovascular event per 116 person-years among a group of patients (97% men) randomized to receive tight glycemic control, but found no reduction in mortality. This result must be balanced against the results from other trials, which saw a mixed bag of benefits and harms with long-term follow-up. It is important to note that even the intensive glycemic control group had a mean hemoglobin A1c of 6.9%, not 6% or 6.5% as some guidelines advocate.

Reference: Hayward RA, Reaven PD, Wiitala WL, et al, for the VADT Investigators. Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2015;372(23):2197-2206.

Study design: Cohort (prospective); (LOE: 2b)

Setting: Outpatient (any)

Synopsis: The Veteran's Affairs Diabetes Trial (VADT) originally randomized 1791 veterans with type 2 diabetes mellitus to receive intensive or usual glycemic control, and achieved mean hemoglobin A1C levels of 6.9% and 8.4%, respectively, after a median of 5.6 years. The original trial found a nonsignificant trend toward fewer cardiovascular events in the intensive therapy group, but no change in mortality. Two other large, similar trials reported similar findings, although one found increased mortality in the intensive glycemic control group. Follow-up studies for these 2 other trials have had mixed results, one finding increased mortality and no change in events, with the other finding fewer events but no change in mortality.

The current study linked patients in the original VADT to national disease registries (92% of participants) and also to regular record reviews and surveys (77% agreed to participte). The median follow-up was 9.8 years for cardiovascular events and 11.8 years for assessment of total mortality. They found a small but statistically significant reduction in the primary combined outcome of myocardial infarction , stroke, new or worsening heart failure, cardiovascular death, or amputation (44.1 vs 52.7 per 1000 person-years; P = .04). There was no significant difference between groups in the likelihood of cardiovascular death or all-cause mortality. The greatest contribution to the reduction in cardiovascular events was fewer nonfatal myocardial infarctions.

Mark H. Ebell, MD, MS, is an associate professor at the University of Georgia in Athens, editor-in-chief of Essential Evidence, and deputy editor of the American Family Physician journal. 

Clinical question: Are there long-term benefits to more intensive glycemic control in patients with type 2 diabetes mellitus?

Bottom line: After approximately 10 years of follow-up, this study found 1 fewer cardiovascular event per 116 person-years among a group of patients (97% men) randomized to receive tight glycemic control, but found no reduction in mortality. This result must be balanced against the results from other trials, which saw a mixed bag of benefits and harms with long-term follow-up. It is important to note that even the intensive glycemic control group had a mean hemoglobin A1c of 6.9%, not 6% or 6.5% as some guidelines advocate.

Reference: Hayward RA, Reaven PD, Wiitala WL, et al, for the VADT Investigators. Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2015;372(23):2197-2206.

Study design: Cohort (prospective); (LOE: 2b)

Setting: Outpatient (any)

Synopsis: The Veteran's Affairs Diabetes Trial (VADT) originally randomized 1791 veterans with type 2 diabetes mellitus to receive intensive or usual glycemic control, and achieved mean hemoglobin A1C levels of 6.9% and 8.4%, respectively, after a median of 5.6 years. The original trial found a nonsignificant trend toward fewer cardiovascular events in the intensive therapy group, but no change in mortality. Two other large, similar trials reported similar findings, although one found increased mortality in the intensive glycemic control group. Follow-up studies for these 2 other trials have had mixed results, one finding increased mortality and no change in events, with the other finding fewer events but no change in mortality.

The current study linked patients in the original VADT to national disease registries (92% of participants) and also to regular record reviews and surveys (77% agreed to participte). The median follow-up was 9.8 years for cardiovascular events and 11.8 years for assessment of total mortality. They found a small but statistically significant reduction in the primary combined outcome of myocardial infarction , stroke, new or worsening heart failure, cardiovascular death, or amputation (44.1 vs 52.7 per 1000 person-years; P = .04). There was no significant difference between groups in the likelihood of cardiovascular death or all-cause mortality. The greatest contribution to the reduction in cardiovascular events was fewer nonfatal myocardial infarctions.

Mark H. Ebell, MD, MS, is an associate professor at the University of Georgia in Athens, editor-in-chief of Essential Evidence, and deputy editor of the American Family Physician journal. 

On July 1, 2015, the Centers for Medicare and Medicaid Services (CMS) announced proposed changes to its controversial two-midnight rule. The changes afford physicians more flexibility to determine patient hospitalization status and place primary patient status auditing authority with Quality Improvement Organizations (QIO), rather than the unpopular Recovery Auditor Contractors (RACs).

The original policy was implemented in October 2013 to reduce the number of long observation stays impacting Medicare beneficiaries, which are not payable under Part A and impact coverage for some types of follow-up care. Under the policy, stays under two midnights are considered outpatient while longer stays are considered inpatient. Physicians must decide at time of admission how to designate a patient and provide adequate documentation for the decision. The changes give physicians the authority to designate shorter stays for inpatients based on medical necessity.

According to CMS actuary data published in the 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed payment rule, the two-midnight rule is working. Since fiscal year 2013, observation stays longer than two days are down 11%. It also says a related 0.2% reduction in payment for inpatient services is justified based on an increase in the number of inpatient admissions.

The agency has sought public comment on three separate occasions since the policy began but says no suitable alternatives to the rule—other than full repeal—have been offered. While the American Hospital Association has said the changes are a good first step, it and others contend the rule still leaves too much uncertainty.

“There’s so little objectivity, it makes it hard to understand how this is going to be implemented,” says Dr. Lauren Doctoroff, MD, a hospitalist and medical director for utilization management at Beth Israel Deaconess Medical Center in Boston.

While the two-midnight rule has helped Dr. Doctoroff's hospital better determine which stays should be considered inpatient and which observation, when it comes to review of short inpatient stays, CMS has not made clear how much influence RACs will continue to play or how QIOs will be different, she says. The RACs have been unpopular because they share in savings recovered on behalf of CMS even when their aggressive audit decisions are overturned, which studies show happens with frequency. Nor do the changes indicate what constitutes adequate documentation.

“There are so many gray areas,” says Dr. Doctoroff, particularly when physicians treat patients with complex social needs, who may not have a stable situation for discharge. “There are some potential benefits, but it’s unclear how it will work and what role the QIOs take relative to RAs, whether it will be more of the same with a different name. It’s not clear if it’s going to be better.”

Visit our website for more information on CMS' two-midnight rule.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

On July 1, 2015, the Centers for Medicare and Medicaid Services (CMS) announced proposed changes to its controversial two-midnight rule. The changes afford physicians more flexibility to determine patient hospitalization status and place primary patient status auditing authority with Quality Improvement Organizations (QIO), rather than the unpopular Recovery Auditor Contractors (RACs).

The original policy was implemented in October 2013 to reduce the number of long observation stays impacting Medicare beneficiaries, which are not payable under Part A and impact coverage for some types of follow-up care. Under the policy, stays under two midnights are considered outpatient while longer stays are considered inpatient. Physicians must decide at time of admission how to designate a patient and provide adequate documentation for the decision. The changes give physicians the authority to designate shorter stays for inpatients based on medical necessity.

According to CMS actuary data published in the 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed payment rule, the two-midnight rule is working. Since fiscal year 2013, observation stays longer than two days are down 11%. It also says a related 0.2% reduction in payment for inpatient services is justified based on an increase in the number of inpatient admissions.

The agency has sought public comment on three separate occasions since the policy began but says no suitable alternatives to the rule—other than full repeal—have been offered. While the American Hospital Association has said the changes are a good first step, it and others contend the rule still leaves too much uncertainty.

“There’s so little objectivity, it makes it hard to understand how this is going to be implemented,” says Dr. Lauren Doctoroff, MD, a hospitalist and medical director for utilization management at Beth Israel Deaconess Medical Center in Boston.

While the two-midnight rule has helped Dr. Doctoroff's hospital better determine which stays should be considered inpatient and which observation, when it comes to review of short inpatient stays, CMS has not made clear how much influence RACs will continue to play or how QIOs will be different, she says. The RACs have been unpopular because they share in savings recovered on behalf of CMS even when their aggressive audit decisions are overturned, which studies show happens with frequency. Nor do the changes indicate what constitutes adequate documentation.

“There are so many gray areas,” says Dr. Doctoroff, particularly when physicians treat patients with complex social needs, who may not have a stable situation for discharge. “There are some potential benefits, but it’s unclear how it will work and what role the QIOs take relative to RAs, whether it will be more of the same with a different name. It’s not clear if it’s going to be better.”

Visit our website for more information on CMS' two-midnight rule.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

On July 1, 2015, the Centers for Medicare and Medicaid Services (CMS) announced proposed changes to its controversial two-midnight rule. The changes afford physicians more flexibility to determine patient hospitalization status and place primary patient status auditing authority with Quality Improvement Organizations (QIO), rather than the unpopular Recovery Auditor Contractors (RACs).

The original policy was implemented in October 2013 to reduce the number of long observation stays impacting Medicare beneficiaries, which are not payable under Part A and impact coverage for some types of follow-up care. Under the policy, stays under two midnights are considered outpatient while longer stays are considered inpatient. Physicians must decide at time of admission how to designate a patient and provide adequate documentation for the decision. The changes give physicians the authority to designate shorter stays for inpatients based on medical necessity.

According to CMS actuary data published in the 2016 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed payment rule, the two-midnight rule is working. Since fiscal year 2013, observation stays longer than two days are down 11%. It also says a related 0.2% reduction in payment for inpatient services is justified based on an increase in the number of inpatient admissions.

The agency has sought public comment on three separate occasions since the policy began but says no suitable alternatives to the rule—other than full repeal—have been offered. While the American Hospital Association has said the changes are a good first step, it and others contend the rule still leaves too much uncertainty.

“There’s so little objectivity, it makes it hard to understand how this is going to be implemented,” says Dr. Lauren Doctoroff, MD, a hospitalist and medical director for utilization management at Beth Israel Deaconess Medical Center in Boston.

While the two-midnight rule has helped Dr. Doctoroff's hospital better determine which stays should be considered inpatient and which observation, when it comes to review of short inpatient stays, CMS has not made clear how much influence RACs will continue to play or how QIOs will be different, she says. The RACs have been unpopular because they share in savings recovered on behalf of CMS even when their aggressive audit decisions are overturned, which studies show happens with frequency. Nor do the changes indicate what constitutes adequate documentation.

“There are so many gray areas,” says Dr. Doctoroff, particularly when physicians treat patients with complex social needs, who may not have a stable situation for discharge. “There are some potential benefits, but it’s unclear how it will work and what role the QIOs take relative to RAs, whether it will be more of the same with a different name. It’s not clear if it’s going to be better.”

Visit our website for more information on CMS' two-midnight rule.

Kelly April Tyrrell is a freelance writer in Madison, Wis.