User login
Avoid Trimethoprim-Sulfamethoxazole for Severe MRSA Infections
Clinical question: Is trimethoprim-sulfamethoxazole equivalent to vancomycin for the treatment of severe infections caused by methicillin-resistant Staphyloccus aureus?
Bottom line: Trimethoprim-sulfamethoxazole (TMP-SMX) did not achieve noninferiority as compared with vancomycin for the treatment of severe methicillin-resistant Staphyloccus aureus (MRSA) infections in hospitalized patients, and it may lead to increased mortality in the subset of patients with bacteremia. (LOE = 1b)
Reference: Paul M, Bishara J, Yahav D, et al. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin-resistant Staphylococcus aureus. BMJ 2015;350:h2219.
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (any location)
Synopsis
Although TMP-SMX can be used to treat uncomplicated skin and soft-tissue infections caused by MRSA, it is not currently recommended for more serious MRSA infections such as bacteremia or pneumonia. In this study, investigators tested whether TMP-SMX is noninferior to vancomycin for the treatment of hospitalized patients with severe MRSA infections. Patients included in the study (N = 252) had microbiologically documented MRSA infections, including complicated skin and soft-tissue infections, bone or joint infections, pneumonia, or primary bacteremia. Patients with MRSA isolates resistant to TMP-SMX or vancomycin were excluded.
Using concealed allocation, the investigators randomized the patients to receive either high-dose TMP-SMX (320 mg trimethoprim/1600 mg sulfamethoxazole intravenously twice daily) or vancomycin (1 mg intravenously twice daily) for at least 7 days. In the TMP-SMX group, treatment could be transitioned to an oral regimen of an equivalent dose at the clinician's discretion. The 2 groups had similar baseline characteristics with a mean age of 66 years and similar comorbidities, though the vancomycin group had a higher percentage of patients with bacteremia than the TMP-SMX group (30% vs 43%; P = .042). The primary outcome was treatment failure at 7 days, defined as a composite of death, persistent fever or hypotension, stable or worsening Sequential Organ Failure Assessment score, or persistent bacteremia. There was no statistically significant difference detected between the 2 groups for this outcome (38% treatment failure with TMP-SMX vs 27% with vancomycin; absolute difference 10.4%, 95% CI -1.2% to 21.5%).
However, since the 95% confidence interval for the absolute difference fell outside the predefined lower limit of noninferiority of 15%, the authors concluded that TMP-SMX failed to achieve noninferiority as compared with vancomycin. Additionally, in the subgroup of patients with bacteremia, patients were more likely to die in the TMP-SMX group as compared with the vancomycin group, although this difference again was not statistically significant (34% with TMP-SMX vs 18% with vancomycin; relative risk 1.90, 0.92-3.93).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Is trimethoprim-sulfamethoxazole equivalent to vancomycin for the treatment of severe infections caused by methicillin-resistant Staphyloccus aureus?
Bottom line: Trimethoprim-sulfamethoxazole (TMP-SMX) did not achieve noninferiority as compared with vancomycin for the treatment of severe methicillin-resistant Staphyloccus aureus (MRSA) infections in hospitalized patients, and it may lead to increased mortality in the subset of patients with bacteremia. (LOE = 1b)
Reference: Paul M, Bishara J, Yahav D, et al. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin-resistant Staphylococcus aureus. BMJ 2015;350:h2219.
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (any location)
Synopsis
Although TMP-SMX can be used to treat uncomplicated skin and soft-tissue infections caused by MRSA, it is not currently recommended for more serious MRSA infections such as bacteremia or pneumonia. In this study, investigators tested whether TMP-SMX is noninferior to vancomycin for the treatment of hospitalized patients with severe MRSA infections. Patients included in the study (N = 252) had microbiologically documented MRSA infections, including complicated skin and soft-tissue infections, bone or joint infections, pneumonia, or primary bacteremia. Patients with MRSA isolates resistant to TMP-SMX or vancomycin were excluded.
Using concealed allocation, the investigators randomized the patients to receive either high-dose TMP-SMX (320 mg trimethoprim/1600 mg sulfamethoxazole intravenously twice daily) or vancomycin (1 mg intravenously twice daily) for at least 7 days. In the TMP-SMX group, treatment could be transitioned to an oral regimen of an equivalent dose at the clinician's discretion. The 2 groups had similar baseline characteristics with a mean age of 66 years and similar comorbidities, though the vancomycin group had a higher percentage of patients with bacteremia than the TMP-SMX group (30% vs 43%; P = .042). The primary outcome was treatment failure at 7 days, defined as a composite of death, persistent fever or hypotension, stable or worsening Sequential Organ Failure Assessment score, or persistent bacteremia. There was no statistically significant difference detected between the 2 groups for this outcome (38% treatment failure with TMP-SMX vs 27% with vancomycin; absolute difference 10.4%, 95% CI -1.2% to 21.5%).
However, since the 95% confidence interval for the absolute difference fell outside the predefined lower limit of noninferiority of 15%, the authors concluded that TMP-SMX failed to achieve noninferiority as compared with vancomycin. Additionally, in the subgroup of patients with bacteremia, patients were more likely to die in the TMP-SMX group as compared with the vancomycin group, although this difference again was not statistically significant (34% with TMP-SMX vs 18% with vancomycin; relative risk 1.90, 0.92-3.93).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Is trimethoprim-sulfamethoxazole equivalent to vancomycin for the treatment of severe infections caused by methicillin-resistant Staphyloccus aureus?
Bottom line: Trimethoprim-sulfamethoxazole (TMP-SMX) did not achieve noninferiority as compared with vancomycin for the treatment of severe methicillin-resistant Staphyloccus aureus (MRSA) infections in hospitalized patients, and it may lead to increased mortality in the subset of patients with bacteremia. (LOE = 1b)
Reference: Paul M, Bishara J, Yahav D, et al. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin-resistant Staphylococcus aureus. BMJ 2015;350:h2219.
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (any location)
Synopsis
Although TMP-SMX can be used to treat uncomplicated skin and soft-tissue infections caused by MRSA, it is not currently recommended for more serious MRSA infections such as bacteremia or pneumonia. In this study, investigators tested whether TMP-SMX is noninferior to vancomycin for the treatment of hospitalized patients with severe MRSA infections. Patients included in the study (N = 252) had microbiologically documented MRSA infections, including complicated skin and soft-tissue infections, bone or joint infections, pneumonia, or primary bacteremia. Patients with MRSA isolates resistant to TMP-SMX or vancomycin were excluded.
Using concealed allocation, the investigators randomized the patients to receive either high-dose TMP-SMX (320 mg trimethoprim/1600 mg sulfamethoxazole intravenously twice daily) or vancomycin (1 mg intravenously twice daily) for at least 7 days. In the TMP-SMX group, treatment could be transitioned to an oral regimen of an equivalent dose at the clinician's discretion. The 2 groups had similar baseline characteristics with a mean age of 66 years and similar comorbidities, though the vancomycin group had a higher percentage of patients with bacteremia than the TMP-SMX group (30% vs 43%; P = .042). The primary outcome was treatment failure at 7 days, defined as a composite of death, persistent fever or hypotension, stable or worsening Sequential Organ Failure Assessment score, or persistent bacteremia. There was no statistically significant difference detected between the 2 groups for this outcome (38% treatment failure with TMP-SMX vs 27% with vancomycin; absolute difference 10.4%, 95% CI -1.2% to 21.5%).
However, since the 95% confidence interval for the absolute difference fell outside the predefined lower limit of noninferiority of 15%, the authors concluded that TMP-SMX failed to achieve noninferiority as compared with vancomycin. Additionally, in the subgroup of patients with bacteremia, patients were more likely to die in the TMP-SMX group as compared with the vancomycin group, although this difference again was not statistically significant (34% with TMP-SMX vs 18% with vancomycin; relative risk 1.90, 0.92-3.93).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Listen Now: Teaching Value-Based Care: A Med-Ed Perspective
LISTEN NOW: Hospitalist, Edwin Lopez, PA-C, on Post-Acute Care in the U.S. Health System
Edwin Lopez, PA-C, of St. Elizabeth Hospital in Enumclaw, Wash., offers his views on post-acute care in the U.S. health system, and how his work as a hospitalist has expanded to the nursing home across the street.
Edwin Lopez, PA-C, of St. Elizabeth Hospital in Enumclaw, Wash., offers his views on post-acute care in the U.S. health system, and how his work as a hospitalist has expanded to the nursing home across the street.
Edwin Lopez, PA-C, of St. Elizabeth Hospital in Enumclaw, Wash., offers his views on post-acute care in the U.S. health system, and how his work as a hospitalist has expanded to the nursing home across the street.
Society of Hospital Medicine Events, Online Tools, Programs for Hospitalists
Career Advancers: SHM Events, Online Tools, and Programs
Hospitalists can advance their careers and the hospital medicine movement at the same time, with in-person events, online tools, and other programs designed specifically for people providing care to hospitalized patients.
When hospitalists meet face to face, good things happen. Solutions are shared. Challenges are addressed. But most importantly, SHM’s meetings are sources of energy and inspiration for the thousands of hospitalists who attend them every year.
July 23-26, San Antonio
There’s still time to register for the fast-growing national event organized specifically for pediatric hospitalists. This year, the meeting will focus on mentoring, networking, and partnerships to improve children’s health locally and globally.
Meeting attendees should plan on downloading the PHM 2015 app to get session materials, download presentations, and find their way at the conference.
October 19-22, Austin
Have you taken on more leadership responsibilities at your hospital?
Or are you ready to demonstrate that you’re ready to take them on?
SHM’s Leadership Academy has trained thousands of hospitalists to lead groups more effectively and to understand the financial realities of running a hospital
medicine practice. www.hospitalmedicine.org/leadership
March 6-9, 2016, San Diego
Every year, thousands of hospitalists gather for educational sessions, professional networking, and time to catch up with friends in the hospital medicine movement. Now is the time to schedule time off and register! www.hospitalmedicine2016.org
Meet-Ups for Medical Students and Residents
Chicago and Los Angeles
Are you in the Chicago or Los Angeles area? Do you know medical students and residents exploring their career options? Make sure they know about SHM’s
Future of Hospital Medicine events later this year. Each event features hospitalist leaders talking about their careers and—of course—there will be food. The first event was held in May at University of Chicago. Upcoming events will be at Rush University in Chicago on September 24 and David Geffen School of Medicine at UCLA on October 22. Visit the website below for details, and share with your colleagues! www.futureofhospitalmedicine.org/events
If you can’t make it to in-person events, SHM brings some of the very best of the hospital medicine movement to your smartphone, tablet, and computer.
New at the Learning Portal: “Perioperative Cardiac Risk Assessment” and “Patient Safety Tools”
Free CME is available to all SHM members at www.shmlearningportal.org, and new modules are added all the time. Recently, SHM has added two new modules:
- Perioperative Cardiac Risk Assessment. Perioperative cardiac complications are the most widely feared medical issues for the anesthesiologist, surgeon, and medical consultant as they approach a patient with the option of surgery. To assess for pre-operative cardiac risk, hospitalists should follow a step-wise algorithm. This new module reviews the risk assessment process and enables the hospitalist to order appropriate pre-operative testing.
- Patient Safety Tools: Root Cause Analysis and Failure Mode and Effects Analysis 2015. This updated online learning module begins with a lesson and contains a 10-question post-test with accompanying answers, rationales, and references. When the participant selects an answer, immediate feedback is given explaining the correct answer.
Quality Improvement Webinars
SHM is hosting nine webinars between now and September. Hospitalists can attend the webinars in real time or download them from the SHM website at www.hospitalmedicine.org/qiwebinar.
Project BOOST webinar series:
- Project BOOST Teach-Back;
- Project BOOST Presents “Partnering with Skilled Nursing Facilities”; and
- Project BOOST Presents “Approaches to Readmission Risk Stratification.”
Glycemic control webinar series:
- Perioperative Management of Hyperglycemia;
- Hypoglycemia Management and Prevention; and
- Subcutaneous Insulin Order Sets in the Inpatient Setting: Design and Implementation.
General QI webinars:
- Quality Improvement for Hospital Medicine Groups: Self-Assessment and Self-Improvement Using the SHM Key Characteristics;
- Coaching a Quality Improvement Team: Basics for Being Sure Any QI Team and Project Are on the Right Track; and
- Elevating Provider Experience to Improve Patient Experience.
Evaluate Your Performance with the ACS Performance Improvement CME Program
The ACS PI-CME is a self-directed, web-based activity designed to help you evaluate your practice. Registration is FREE. Upon completion of the activity, participants will receive 20 CME Credits.
For details, visit www.hospitalmedicine.org/acs and click “REGISTER.”
Brand New Podcast: “Before the White Coat”
To download and subscribe to “Before the White Coat,” visit www.beforethewhitecoat.org.
Career Advancers: SHM Events, Online Tools, and Programs
Hospitalists can advance their careers and the hospital medicine movement at the same time, with in-person events, online tools, and other programs designed specifically for people providing care to hospitalized patients.
When hospitalists meet face to face, good things happen. Solutions are shared. Challenges are addressed. But most importantly, SHM’s meetings are sources of energy and inspiration for the thousands of hospitalists who attend them every year.
July 23-26, San Antonio
There’s still time to register for the fast-growing national event organized specifically for pediatric hospitalists. This year, the meeting will focus on mentoring, networking, and partnerships to improve children’s health locally and globally.
Meeting attendees should plan on downloading the PHM 2015 app to get session materials, download presentations, and find their way at the conference.
October 19-22, Austin
Have you taken on more leadership responsibilities at your hospital?
Or are you ready to demonstrate that you’re ready to take them on?
SHM’s Leadership Academy has trained thousands of hospitalists to lead groups more effectively and to understand the financial realities of running a hospital
medicine practice. www.hospitalmedicine.org/leadership
March 6-9, 2016, San Diego
Every year, thousands of hospitalists gather for educational sessions, professional networking, and time to catch up with friends in the hospital medicine movement. Now is the time to schedule time off and register! www.hospitalmedicine2016.org
Meet-Ups for Medical Students and Residents
Chicago and Los Angeles
Are you in the Chicago or Los Angeles area? Do you know medical students and residents exploring their career options? Make sure they know about SHM’s
Future of Hospital Medicine events later this year. Each event features hospitalist leaders talking about their careers and—of course—there will be food. The first event was held in May at University of Chicago. Upcoming events will be at Rush University in Chicago on September 24 and David Geffen School of Medicine at UCLA on October 22. Visit the website below for details, and share with your colleagues! www.futureofhospitalmedicine.org/events
If you can’t make it to in-person events, SHM brings some of the very best of the hospital medicine movement to your smartphone, tablet, and computer.
New at the Learning Portal: “Perioperative Cardiac Risk Assessment” and “Patient Safety Tools”
Free CME is available to all SHM members at www.shmlearningportal.org, and new modules are added all the time. Recently, SHM has added two new modules:
- Perioperative Cardiac Risk Assessment. Perioperative cardiac complications are the most widely feared medical issues for the anesthesiologist, surgeon, and medical consultant as they approach a patient with the option of surgery. To assess for pre-operative cardiac risk, hospitalists should follow a step-wise algorithm. This new module reviews the risk assessment process and enables the hospitalist to order appropriate pre-operative testing.
- Patient Safety Tools: Root Cause Analysis and Failure Mode and Effects Analysis 2015. This updated online learning module begins with a lesson and contains a 10-question post-test with accompanying answers, rationales, and references. When the participant selects an answer, immediate feedback is given explaining the correct answer.
Quality Improvement Webinars
SHM is hosting nine webinars between now and September. Hospitalists can attend the webinars in real time or download them from the SHM website at www.hospitalmedicine.org/qiwebinar.
Project BOOST webinar series:
- Project BOOST Teach-Back;
- Project BOOST Presents “Partnering with Skilled Nursing Facilities”; and
- Project BOOST Presents “Approaches to Readmission Risk Stratification.”
Glycemic control webinar series:
- Perioperative Management of Hyperglycemia;
- Hypoglycemia Management and Prevention; and
- Subcutaneous Insulin Order Sets in the Inpatient Setting: Design and Implementation.
General QI webinars:
- Quality Improvement for Hospital Medicine Groups: Self-Assessment and Self-Improvement Using the SHM Key Characteristics;
- Coaching a Quality Improvement Team: Basics for Being Sure Any QI Team and Project Are on the Right Track; and
- Elevating Provider Experience to Improve Patient Experience.
Evaluate Your Performance with the ACS Performance Improvement CME Program
The ACS PI-CME is a self-directed, web-based activity designed to help you evaluate your practice. Registration is FREE. Upon completion of the activity, participants will receive 20 CME Credits.
For details, visit www.hospitalmedicine.org/acs and click “REGISTER.”
Brand New Podcast: “Before the White Coat”
To download and subscribe to “Before the White Coat,” visit www.beforethewhitecoat.org.
Career Advancers: SHM Events, Online Tools, and Programs
Hospitalists can advance their careers and the hospital medicine movement at the same time, with in-person events, online tools, and other programs designed specifically for people providing care to hospitalized patients.
When hospitalists meet face to face, good things happen. Solutions are shared. Challenges are addressed. But most importantly, SHM’s meetings are sources of energy and inspiration for the thousands of hospitalists who attend them every year.
July 23-26, San Antonio
There’s still time to register for the fast-growing national event organized specifically for pediatric hospitalists. This year, the meeting will focus on mentoring, networking, and partnerships to improve children’s health locally and globally.
Meeting attendees should plan on downloading the PHM 2015 app to get session materials, download presentations, and find their way at the conference.
October 19-22, Austin
Have you taken on more leadership responsibilities at your hospital?
Or are you ready to demonstrate that you’re ready to take them on?
SHM’s Leadership Academy has trained thousands of hospitalists to lead groups more effectively and to understand the financial realities of running a hospital
medicine practice. www.hospitalmedicine.org/leadership
March 6-9, 2016, San Diego
Every year, thousands of hospitalists gather for educational sessions, professional networking, and time to catch up with friends in the hospital medicine movement. Now is the time to schedule time off and register! www.hospitalmedicine2016.org
Meet-Ups for Medical Students and Residents
Chicago and Los Angeles
Are you in the Chicago or Los Angeles area? Do you know medical students and residents exploring their career options? Make sure they know about SHM’s
Future of Hospital Medicine events later this year. Each event features hospitalist leaders talking about their careers and—of course—there will be food. The first event was held in May at University of Chicago. Upcoming events will be at Rush University in Chicago on September 24 and David Geffen School of Medicine at UCLA on October 22. Visit the website below for details, and share with your colleagues! www.futureofhospitalmedicine.org/events
If you can’t make it to in-person events, SHM brings some of the very best of the hospital medicine movement to your smartphone, tablet, and computer.
New at the Learning Portal: “Perioperative Cardiac Risk Assessment” and “Patient Safety Tools”
Free CME is available to all SHM members at www.shmlearningportal.org, and new modules are added all the time. Recently, SHM has added two new modules:
- Perioperative Cardiac Risk Assessment. Perioperative cardiac complications are the most widely feared medical issues for the anesthesiologist, surgeon, and medical consultant as they approach a patient with the option of surgery. To assess for pre-operative cardiac risk, hospitalists should follow a step-wise algorithm. This new module reviews the risk assessment process and enables the hospitalist to order appropriate pre-operative testing.
- Patient Safety Tools: Root Cause Analysis and Failure Mode and Effects Analysis 2015. This updated online learning module begins with a lesson and contains a 10-question post-test with accompanying answers, rationales, and references. When the participant selects an answer, immediate feedback is given explaining the correct answer.
Quality Improvement Webinars
SHM is hosting nine webinars between now and September. Hospitalists can attend the webinars in real time or download them from the SHM website at www.hospitalmedicine.org/qiwebinar.
Project BOOST webinar series:
- Project BOOST Teach-Back;
- Project BOOST Presents “Partnering with Skilled Nursing Facilities”; and
- Project BOOST Presents “Approaches to Readmission Risk Stratification.”
Glycemic control webinar series:
- Perioperative Management of Hyperglycemia;
- Hypoglycemia Management and Prevention; and
- Subcutaneous Insulin Order Sets in the Inpatient Setting: Design and Implementation.
General QI webinars:
- Quality Improvement for Hospital Medicine Groups: Self-Assessment and Self-Improvement Using the SHM Key Characteristics;
- Coaching a Quality Improvement Team: Basics for Being Sure Any QI Team and Project Are on the Right Track; and
- Elevating Provider Experience to Improve Patient Experience.
Evaluate Your Performance with the ACS Performance Improvement CME Program
The ACS PI-CME is a self-directed, web-based activity designed to help you evaluate your practice. Registration is FREE. Upon completion of the activity, participants will receive 20 CME Credits.
For details, visit www.hospitalmedicine.org/acs and click “REGISTER.”
Brand New Podcast: “Before the White Coat”
To download and subscribe to “Before the White Coat,” visit www.beforethewhitecoat.org.
Society of Hospital Medicine Membership Ambassador Program Benefits Hospitalists
Now, through SHM’s Membership Ambassador Program, SHM members can earn 2016-2017 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members. And for every new member recruited, hospitalists will receive one entry into a grand prize drawing to receive complimentary registration to Hospital Medicine 2016 in San Diego.
Demonstrating leadership by becoming a Fellow or Senior Fellow in Hospital Medicine is another great way to move it forward—and propel your career at the same time. July and August are excellent months to begin the FHM or SFHM application process.
Click for more details and great SHM merchandise.
Now, through SHM’s Membership Ambassador Program, SHM members can earn 2016-2017 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members. And for every new member recruited, hospitalists will receive one entry into a grand prize drawing to receive complimentary registration to Hospital Medicine 2016 in San Diego.
Demonstrating leadership by becoming a Fellow or Senior Fellow in Hospital Medicine is another great way to move it forward—and propel your career at the same time. July and August are excellent months to begin the FHM or SFHM application process.
Click for more details and great SHM merchandise.
Now, through SHM’s Membership Ambassador Program, SHM members can earn 2016-2017 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members. And for every new member recruited, hospitalists will receive one entry into a grand prize drawing to receive complimentary registration to Hospital Medicine 2016 in San Diego.
Demonstrating leadership by becoming a Fellow or Senior Fellow in Hospital Medicine is another great way to move it forward—and propel your career at the same time. July and August are excellent months to begin the FHM or SFHM application process.
Click for more details and great SHM merchandise.
Proton Pump Inhibitors Commonly Prescribed, Not Always Necessary
Robert Coben, MD, academic coordinator for the Gastrointestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia, says that when patients get admitted with chest pain for reasons other than a heart-related problem, he is frequently called on to do an endoscopy right away.
But that’s usually not the best starting point, he says.
“I would say the best test would be to just place the patient on a high-dose proton pump inhibitor once or twice a day first, to see if those symptoms resolve,” he says. “Many times we’re called in to do an upper endoscopy. … And many times that’s not really indicated unless they’re
having other alarm symptoms such as dysphagia, odynophagia, and weight loss.”
Marcelo Vela, MD, gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, adds that it’s okay to start a patient with non-cardiac chest pain on PPIs when they have concomitant, typical symptoms of gastroesophageal reflux disease (GERD)—heartburn and acid regurgitation. But in patients without such symptoms, further testing is needed to confirm GERD, he says (Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328, Table 1).
This evaluation is usually done in the outpatient setting, he says.
Dr. Vela suggests more care might be needed in the prescribing of PPIs. He says he frequently sees patients who have been hospitalized and put on a PPI without a clear reason.
“They get admitted for various reasons—DVT [deep vein thrombosis], pneumonia, whatever, and then in the hospital, they get started on a proton pump inhibitor for unclear reasons. And then they leave and they stay on it,” Dr. Vela says.
When he asks why, patients just say, “On my last hospitalization, they put me on it,” he says.
“I think you should only leave the hospital on a PPI with a very clear indication—either you found an ulcer or the patient clearly has GERD” or some other reason, he says. “They’re fairly benign medications, but if there’s no indication for it, there’s no benefit.”
Robert Coben, MD, academic coordinator for the Gastrointestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia, says that when patients get admitted with chest pain for reasons other than a heart-related problem, he is frequently called on to do an endoscopy right away.
But that’s usually not the best starting point, he says.
“I would say the best test would be to just place the patient on a high-dose proton pump inhibitor once or twice a day first, to see if those symptoms resolve,” he says. “Many times we’re called in to do an upper endoscopy. … And many times that’s not really indicated unless they’re
having other alarm symptoms such as dysphagia, odynophagia, and weight loss.”
Marcelo Vela, MD, gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, adds that it’s okay to start a patient with non-cardiac chest pain on PPIs when they have concomitant, typical symptoms of gastroesophageal reflux disease (GERD)—heartburn and acid regurgitation. But in patients without such symptoms, further testing is needed to confirm GERD, he says (Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328, Table 1).
This evaluation is usually done in the outpatient setting, he says.
Dr. Vela suggests more care might be needed in the prescribing of PPIs. He says he frequently sees patients who have been hospitalized and put on a PPI without a clear reason.
“They get admitted for various reasons—DVT [deep vein thrombosis], pneumonia, whatever, and then in the hospital, they get started on a proton pump inhibitor for unclear reasons. And then they leave and they stay on it,” Dr. Vela says.
When he asks why, patients just say, “On my last hospitalization, they put me on it,” he says.
“I think you should only leave the hospital on a PPI with a very clear indication—either you found an ulcer or the patient clearly has GERD” or some other reason, he says. “They’re fairly benign medications, but if there’s no indication for it, there’s no benefit.”
Robert Coben, MD, academic coordinator for the Gastrointestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia, says that when patients get admitted with chest pain for reasons other than a heart-related problem, he is frequently called on to do an endoscopy right away.
But that’s usually not the best starting point, he says.
“I would say the best test would be to just place the patient on a high-dose proton pump inhibitor once or twice a day first, to see if those symptoms resolve,” he says. “Many times we’re called in to do an upper endoscopy. … And many times that’s not really indicated unless they’re
having other alarm symptoms such as dysphagia, odynophagia, and weight loss.”
Marcelo Vela, MD, gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, adds that it’s okay to start a patient with non-cardiac chest pain on PPIs when they have concomitant, typical symptoms of gastroesophageal reflux disease (GERD)—heartburn and acid regurgitation. But in patients without such symptoms, further testing is needed to confirm GERD, he says (Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328, Table 1).
This evaluation is usually done in the outpatient setting, he says.
Dr. Vela suggests more care might be needed in the prescribing of PPIs. He says he frequently sees patients who have been hospitalized and put on a PPI without a clear reason.
“They get admitted for various reasons—DVT [deep vein thrombosis], pneumonia, whatever, and then in the hospital, they get started on a proton pump inhibitor for unclear reasons. And then they leave and they stay on it,” Dr. Vela says.
When he asks why, patients just say, “On my last hospitalization, they put me on it,” he says.
“I think you should only leave the hospital on a PPI with a very clear indication—either you found an ulcer or the patient clearly has GERD” or some other reason, he says. “They’re fairly benign medications, but if there’s no indication for it, there’s no benefit.”
ProMISe Trial Adds Skepticism to Early Goal-Directed Therapy for Sepsis
Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?
Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.
Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.
Setting: Fifty-six National Health Service EDs in the United Kingdom.
Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.
Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.
Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.
Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.
Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?
Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.
Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.
Setting: Fifty-six National Health Service EDs in the United Kingdom.
Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.
Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.
Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.
Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.
Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?
Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.
Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.
Setting: Fifty-six National Health Service EDs in the United Kingdom.
Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.
Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.
Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.
Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.
Effectiveness of Multicomponent Nonpharmacological Delirium Interventions
Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?
Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.
Study design: Systemic literature review and meta-analysis.
Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.
Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.
Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.
Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?
Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.
Study design: Systemic literature review and meta-analysis.
Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.
Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.
Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.
Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?
Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.
Study design: Systemic literature review and meta-analysis.
Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.
Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.
Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.
How to Quantify “Safe” Level of Hyponatremia to Treat at Small Hospitals
I am a hospitalist at a small rural hospital, and I’ve read both the hyponatremia and SIADH articles published in The Hospitalist. Our lab does not do any urine testing beyond a UA [urinalysis] in house, so the urine osmol and urine Na+ tests are send-outs, which take several days to come back. I’m having difficulty with diagnosing the reason for and treating hyponatremia. I find it complicated, and when the urine tests are not readily available, it’s difficult to use the algorithm. Do you know of any basic tips that could help? If our hospital does not have the right urine tests readily available, should I be sending these patients to the larger hospital from the ED if sodium is <125, instead of admitting them?
—Carleigh Wilson, DO
Dr. Hospitalist responds:
I too can recall moonlighting in a small rural hospital in southern Georgia 25 years ago; I remember having to improvise when taking care of patients with hyponatremia. Fortunately, even though we have developed more sophisticated equipment to help in the diagnosis (e.g. electrodes that are not hampered by excess triglycerides or proteins), my basic approach to evaluating these patients hasn’t changed much.
I still begin with an assessment of the patients’ serum osmolarity, which is usually low in most hospitalized patients. If it is elevated, then, of course, hyperglycemia is the most common cause, but we also must consider alcohol or, way less common these days, mannitol. Hypoosmolar hyponatremia most often occurs when the kidneys are overwhelmed by the intake of water and cannot excrete it as free water. Even though it can occur when there is pathologic consumption of large amounts of water (psychogenic polydipsia) or excess consumption of beer, it most often occurs when the kidney fails to fully dilute the urine, which would be evidenced by urine osmolality >100mmol/l.
A good history and physical will help categorize the patients with poorly diluted urine; in the absence of measured urine osmolality, however, urine specific gravity (USG) can be used with some caveats. Studies have shown that USG done by refractometry and reagent strip (both very inexpensive) have a correlation of 0.75-0.80 with urine osmolality. Although there are many variables affecting both (pH, ketones, glucose, urobilinogen, bilirubin, and protein for the reagent strips), I would use the refractometer, which only seems to be affected by bilirubin, ketones, and hemoglobin. So, at a pH of 7, with all the variables considered and a USG of 1.010, predicted osmolality is approximately 300 mosm/kg/H20. Also, while osmolarity and specific gravity change in parallel, the two measurements diverge when there are large particles in solution (e.g. glucose or proteins), so be careful … Dr Kokko would be so proud of me!
The next step is to determine the patients’ volume status. Because I’m old school, I still believe this can be done at the bedside. On most occasions, it is only when I’m trying to decide whether the primary sodium loss in hypovolemic patients is due to a renal or extra-renal cause that the urine sodium is helpful. In truly hypovolemic and asymptomatic patients, I usually start with normal saline (NS) to correct the volume status and follow the serum sodium closely to avoid correcting too rapidly. Urine sodium is not particularly helpful in caring for euvolemic and hypervolemic hyponatremic patients.
Due to multiple variables (e.g. acute vs. chronic, co-morbidities, nursing and lab support, quick and safe transfer to higher level of care), it is difficult to quantify a “safe” level of hyponatremia to treat at a small rural hospital. Considering the clinical variables and presence of symptoms, I probably would not be comfortable with a serum sodium less than 123 meq/L. However, you have to understand and appreciate your limitations and develop your own level of comfort.
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].
I am a hospitalist at a small rural hospital, and I’ve read both the hyponatremia and SIADH articles published in The Hospitalist. Our lab does not do any urine testing beyond a UA [urinalysis] in house, so the urine osmol and urine Na+ tests are send-outs, which take several days to come back. I’m having difficulty with diagnosing the reason for and treating hyponatremia. I find it complicated, and when the urine tests are not readily available, it’s difficult to use the algorithm. Do you know of any basic tips that could help? If our hospital does not have the right urine tests readily available, should I be sending these patients to the larger hospital from the ED if sodium is <125, instead of admitting them?
—Carleigh Wilson, DO
Dr. Hospitalist responds:
I too can recall moonlighting in a small rural hospital in southern Georgia 25 years ago; I remember having to improvise when taking care of patients with hyponatremia. Fortunately, even though we have developed more sophisticated equipment to help in the diagnosis (e.g. electrodes that are not hampered by excess triglycerides or proteins), my basic approach to evaluating these patients hasn’t changed much.
I still begin with an assessment of the patients’ serum osmolarity, which is usually low in most hospitalized patients. If it is elevated, then, of course, hyperglycemia is the most common cause, but we also must consider alcohol or, way less common these days, mannitol. Hypoosmolar hyponatremia most often occurs when the kidneys are overwhelmed by the intake of water and cannot excrete it as free water. Even though it can occur when there is pathologic consumption of large amounts of water (psychogenic polydipsia) or excess consumption of beer, it most often occurs when the kidney fails to fully dilute the urine, which would be evidenced by urine osmolality >100mmol/l.
A good history and physical will help categorize the patients with poorly diluted urine; in the absence of measured urine osmolality, however, urine specific gravity (USG) can be used with some caveats. Studies have shown that USG done by refractometry and reagent strip (both very inexpensive) have a correlation of 0.75-0.80 with urine osmolality. Although there are many variables affecting both (pH, ketones, glucose, urobilinogen, bilirubin, and protein for the reagent strips), I would use the refractometer, which only seems to be affected by bilirubin, ketones, and hemoglobin. So, at a pH of 7, with all the variables considered and a USG of 1.010, predicted osmolality is approximately 300 mosm/kg/H20. Also, while osmolarity and specific gravity change in parallel, the two measurements diverge when there are large particles in solution (e.g. glucose or proteins), so be careful … Dr Kokko would be so proud of me!
The next step is to determine the patients’ volume status. Because I’m old school, I still believe this can be done at the bedside. On most occasions, it is only when I’m trying to decide whether the primary sodium loss in hypovolemic patients is due to a renal or extra-renal cause that the urine sodium is helpful. In truly hypovolemic and asymptomatic patients, I usually start with normal saline (NS) to correct the volume status and follow the serum sodium closely to avoid correcting too rapidly. Urine sodium is not particularly helpful in caring for euvolemic and hypervolemic hyponatremic patients.
Due to multiple variables (e.g. acute vs. chronic, co-morbidities, nursing and lab support, quick and safe transfer to higher level of care), it is difficult to quantify a “safe” level of hyponatremia to treat at a small rural hospital. Considering the clinical variables and presence of symptoms, I probably would not be comfortable with a serum sodium less than 123 meq/L. However, you have to understand and appreciate your limitations and develop your own level of comfort.
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].
I am a hospitalist at a small rural hospital, and I’ve read both the hyponatremia and SIADH articles published in The Hospitalist. Our lab does not do any urine testing beyond a UA [urinalysis] in house, so the urine osmol and urine Na+ tests are send-outs, which take several days to come back. I’m having difficulty with diagnosing the reason for and treating hyponatremia. I find it complicated, and when the urine tests are not readily available, it’s difficult to use the algorithm. Do you know of any basic tips that could help? If our hospital does not have the right urine tests readily available, should I be sending these patients to the larger hospital from the ED if sodium is <125, instead of admitting them?
—Carleigh Wilson, DO
Dr. Hospitalist responds:
I too can recall moonlighting in a small rural hospital in southern Georgia 25 years ago; I remember having to improvise when taking care of patients with hyponatremia. Fortunately, even though we have developed more sophisticated equipment to help in the diagnosis (e.g. electrodes that are not hampered by excess triglycerides or proteins), my basic approach to evaluating these patients hasn’t changed much.
I still begin with an assessment of the patients’ serum osmolarity, which is usually low in most hospitalized patients. If it is elevated, then, of course, hyperglycemia is the most common cause, but we also must consider alcohol or, way less common these days, mannitol. Hypoosmolar hyponatremia most often occurs when the kidneys are overwhelmed by the intake of water and cannot excrete it as free water. Even though it can occur when there is pathologic consumption of large amounts of water (psychogenic polydipsia) or excess consumption of beer, it most often occurs when the kidney fails to fully dilute the urine, which would be evidenced by urine osmolality >100mmol/l.
A good history and physical will help categorize the patients with poorly diluted urine; in the absence of measured urine osmolality, however, urine specific gravity (USG) can be used with some caveats. Studies have shown that USG done by refractometry and reagent strip (both very inexpensive) have a correlation of 0.75-0.80 with urine osmolality. Although there are many variables affecting both (pH, ketones, glucose, urobilinogen, bilirubin, and protein for the reagent strips), I would use the refractometer, which only seems to be affected by bilirubin, ketones, and hemoglobin. So, at a pH of 7, with all the variables considered and a USG of 1.010, predicted osmolality is approximately 300 mosm/kg/H20. Also, while osmolarity and specific gravity change in parallel, the two measurements diverge when there are large particles in solution (e.g. glucose or proteins), so be careful … Dr Kokko would be so proud of me!
The next step is to determine the patients’ volume status. Because I’m old school, I still believe this can be done at the bedside. On most occasions, it is only when I’m trying to decide whether the primary sodium loss in hypovolemic patients is due to a renal or extra-renal cause that the urine sodium is helpful. In truly hypovolemic and asymptomatic patients, I usually start with normal saline (NS) to correct the volume status and follow the serum sodium closely to avoid correcting too rapidly. Urine sodium is not particularly helpful in caring for euvolemic and hypervolemic hyponatremic patients.
Due to multiple variables (e.g. acute vs. chronic, co-morbidities, nursing and lab support, quick and safe transfer to higher level of care), it is difficult to quantify a “safe” level of hyponatremia to treat at a small rural hospital. Considering the clinical variables and presence of symptoms, I probably would not be comfortable with a serum sodium less than 123 meq/L. However, you have to understand and appreciate your limitations and develop your own level of comfort.
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].
Hospitalists Should Embrace Advances, Transparency in Health Record Technology
We are definitely in the era of data access and transparency. These days you can find information on anything and everything within a matter of seconds. You can become a subject matter expert on any topic within a matter of hours: music, cooking, foreign language, weather, travel. The possibilities are endless. That is, unless you want information on yourself—specifically, medical information.
Despite all of our advances in technology in the information era, many patients still find it extremely difficult and frustrating to gain full and transparent access to their medical records. Electronic health records (EHRs) have made it easier than ever for practitioners to find information about their patients, including pharmacy and access queries to determine what medications they are (or are not) taking, and where they have recently accessed care. But EHRs have not been widely utilized as a tool to grant extensive, real-time access to patients.
But change is afoot. Both providers and patients are now realizing the value of offering patients more open access to their medical records. Many organizations with EHRs have created patient portals, where patients can access limited portions of their medical records such as medications and allergies, can request items such as prescription refills or appointments, and can ask their providers about their care. Some medical centers are participating in OpenNotes initiatives, which give patients direct access to provider notes within the medical record.
Although these patient portals are a great first step in transparency and engagement, the information granted to patients is limited in content and timeliness. Generally, such items as test results must first be “released” by a provider before they can be viewed by the patient; some organizations have set restrictions, determining that some tests cannot be released at all (i.e., abnormal pathology or HIV test results). The rationale for such restrictions is to prevent patients from finding out sensitive information from a web page; many assume that the patient would be much better off finding out such information from a provider than a computer, and that well may be true, if the information is available in a timely fashion and is shared by a provider who can relay the information better than a computer.
Barriers Aplenty
The medical industry still has a long way to go to realize full medical record transparency for patients. One legitimate barrier is that medical records were never intended for patient view or use. Most do not read like a story; they read more like a ledger, full of medical jargon and text boxes in illogical order. This is primarily due to the fact that EHRs were designed for regulatory and billing purposes, not to eloquently—or even adequately—summarize what the patient is (or was) experiencing.
Another major barrier is that the information in the medical record is often difficult to find, and the record itself is difficult to maneuver. Experienced and trained providers, even those who have dutifully completed medical training, often find it challenging to locate exactly what they are looking for. The burden would be on the patient to learn, understand, and navigate the medical record, and few would likely undertake such a challenge.
There also are legitimate cultural barriers among providers, who will resist giving patients carte blanche access to the EHR; many providers cite concerns that if they honestly summarize sensitive information in the medical record (i.e., social habits or medication compliance issues), patients may be angered, with resultant loss of trust, retaliation, or legal action.
Clear the Hurdles, and Next Steps
There is a great story about how well medical record transparency can work, summarized in a New York Times article a few months ago.1 The story tells of 26-year-old Steven Keating, who had a “slight abnormality” on a brain CT that was done in 2007 as part of a study he had volunteered for.2 Although reassured by a “normal” follow-up scan in 2010, Keating was inquisitive, wanting to understand everything about his condition, and read voraciously about what his initial brain scan could mean. He knew the initial abnormality was near his olfactory nerve, so in 2014, when he started intermittently smelling vinegar, he suspected it might be related to the abnormality noted in his initial scan.
He sought immediate care and follow-up imaging, which showed a very large mass. Within weeks, this large astrocytoma was successfully removed; surgery was followed by chemotherapy and radiation.
Over the course of Keating’s care, he amassed more than 70 gigabytes of medical information about himself, including 10 hours of video footage from his initial surgery. Throughout the course of his illness, he remained eager to obtain all facets of his medical information, including such videos and scans, and considered these pieces of information critical to his healing process. He found that, in general, when he asked doctors to share information, he was usually granted access to what he wanted and needed, but the onus was always on him to ask. At one point he asked, “How come there isn’t a ‘share’ button at the hospital?”
Steven now has an entire website dedicated to his personal healthcare story, coupled with a passionate plea to enhance open access to medical records.2 He writes: “I have become passionate about open-sourcing the data and how we can learn through sharing. … Patients can collect their own data and they should be able to share it, amongst patients, communities, and to benefit science if desired. Healthcare should be a two-way road, patients alongside doctors and researchers as a team. The future will be driven by networked healthcare, support communities, and, I believe, patient curiosity.”
Steven was able to cobble together his medical record better than most others could, as he definitely has some advantages over many other patients; he is young, articulate, bright, and highly educated. It would be much more difficult for an older, less well educated, or disenfranchised patient to accomplish this level of understanding of and engagement in the current system. “The person with the least access to data in the system is the patient,” he writes on his website. “You can get it, but the burden is always on the patient. And it is scattered across many different silos of patient data.”
Providers and patients alike should insist on more transparency, coupled with better and more streamlined communication. As patients become more agile at maneuvering through the web portals and more engaged in their care, patients and providers gain innumerable advantages. Patients could help to find any and all medical record information that is incorrect or inconsistent, working to ensure the accuracy of the content—and get rid of “chart lore.” They could fill in missing content and update information between visits, such as changes to their social history or demographics. This is all very good timing, given the recent shift to pay for performance and population health; as financial incentives are veering away from fee for service, it is becoming more profitable to help patients stay well than to keep them sick.
As hospitalists, we should look forward to these advances in technology to enhance access to information for ourselves and for our patients. We should seek out mechanisms within our organization to enhance the speed at which open access for patients is granted, to improve patient engagement throughout the spectrum of their care.
References
- Lohr S. The healing power of your own medical records. March 31, 2015. The New York Times website.. Accessed June 1, 2015.
- Keating S. Steven Keating homepage. Accessed June 1, 2015.
We are definitely in the era of data access and transparency. These days you can find information on anything and everything within a matter of seconds. You can become a subject matter expert on any topic within a matter of hours: music, cooking, foreign language, weather, travel. The possibilities are endless. That is, unless you want information on yourself—specifically, medical information.
Despite all of our advances in technology in the information era, many patients still find it extremely difficult and frustrating to gain full and transparent access to their medical records. Electronic health records (EHRs) have made it easier than ever for practitioners to find information about their patients, including pharmacy and access queries to determine what medications they are (or are not) taking, and where they have recently accessed care. But EHRs have not been widely utilized as a tool to grant extensive, real-time access to patients.
But change is afoot. Both providers and patients are now realizing the value of offering patients more open access to their medical records. Many organizations with EHRs have created patient portals, where patients can access limited portions of their medical records such as medications and allergies, can request items such as prescription refills or appointments, and can ask their providers about their care. Some medical centers are participating in OpenNotes initiatives, which give patients direct access to provider notes within the medical record.
Although these patient portals are a great first step in transparency and engagement, the information granted to patients is limited in content and timeliness. Generally, such items as test results must first be “released” by a provider before they can be viewed by the patient; some organizations have set restrictions, determining that some tests cannot be released at all (i.e., abnormal pathology or HIV test results). The rationale for such restrictions is to prevent patients from finding out sensitive information from a web page; many assume that the patient would be much better off finding out such information from a provider than a computer, and that well may be true, if the information is available in a timely fashion and is shared by a provider who can relay the information better than a computer.
Barriers Aplenty
The medical industry still has a long way to go to realize full medical record transparency for patients. One legitimate barrier is that medical records were never intended for patient view or use. Most do not read like a story; they read more like a ledger, full of medical jargon and text boxes in illogical order. This is primarily due to the fact that EHRs were designed for regulatory and billing purposes, not to eloquently—or even adequately—summarize what the patient is (or was) experiencing.
Another major barrier is that the information in the medical record is often difficult to find, and the record itself is difficult to maneuver. Experienced and trained providers, even those who have dutifully completed medical training, often find it challenging to locate exactly what they are looking for. The burden would be on the patient to learn, understand, and navigate the medical record, and few would likely undertake such a challenge.
There also are legitimate cultural barriers among providers, who will resist giving patients carte blanche access to the EHR; many providers cite concerns that if they honestly summarize sensitive information in the medical record (i.e., social habits or medication compliance issues), patients may be angered, with resultant loss of trust, retaliation, or legal action.
Clear the Hurdles, and Next Steps
There is a great story about how well medical record transparency can work, summarized in a New York Times article a few months ago.1 The story tells of 26-year-old Steven Keating, who had a “slight abnormality” on a brain CT that was done in 2007 as part of a study he had volunteered for.2 Although reassured by a “normal” follow-up scan in 2010, Keating was inquisitive, wanting to understand everything about his condition, and read voraciously about what his initial brain scan could mean. He knew the initial abnormality was near his olfactory nerve, so in 2014, when he started intermittently smelling vinegar, he suspected it might be related to the abnormality noted in his initial scan.
He sought immediate care and follow-up imaging, which showed a very large mass. Within weeks, this large astrocytoma was successfully removed; surgery was followed by chemotherapy and radiation.
Over the course of Keating’s care, he amassed more than 70 gigabytes of medical information about himself, including 10 hours of video footage from his initial surgery. Throughout the course of his illness, he remained eager to obtain all facets of his medical information, including such videos and scans, and considered these pieces of information critical to his healing process. He found that, in general, when he asked doctors to share information, he was usually granted access to what he wanted and needed, but the onus was always on him to ask. At one point he asked, “How come there isn’t a ‘share’ button at the hospital?”
Steven now has an entire website dedicated to his personal healthcare story, coupled with a passionate plea to enhance open access to medical records.2 He writes: “I have become passionate about open-sourcing the data and how we can learn through sharing. … Patients can collect their own data and they should be able to share it, amongst patients, communities, and to benefit science if desired. Healthcare should be a two-way road, patients alongside doctors and researchers as a team. The future will be driven by networked healthcare, support communities, and, I believe, patient curiosity.”
Steven was able to cobble together his medical record better than most others could, as he definitely has some advantages over many other patients; he is young, articulate, bright, and highly educated. It would be much more difficult for an older, less well educated, or disenfranchised patient to accomplish this level of understanding of and engagement in the current system. “The person with the least access to data in the system is the patient,” he writes on his website. “You can get it, but the burden is always on the patient. And it is scattered across many different silos of patient data.”
Providers and patients alike should insist on more transparency, coupled with better and more streamlined communication. As patients become more agile at maneuvering through the web portals and more engaged in their care, patients and providers gain innumerable advantages. Patients could help to find any and all medical record information that is incorrect or inconsistent, working to ensure the accuracy of the content—and get rid of “chart lore.” They could fill in missing content and update information between visits, such as changes to their social history or demographics. This is all very good timing, given the recent shift to pay for performance and population health; as financial incentives are veering away from fee for service, it is becoming more profitable to help patients stay well than to keep them sick.
As hospitalists, we should look forward to these advances in technology to enhance access to information for ourselves and for our patients. We should seek out mechanisms within our organization to enhance the speed at which open access for patients is granted, to improve patient engagement throughout the spectrum of their care.
References
- Lohr S. The healing power of your own medical records. March 31, 2015. The New York Times website.. Accessed June 1, 2015.
- Keating S. Steven Keating homepage. Accessed June 1, 2015.
We are definitely in the era of data access and transparency. These days you can find information on anything and everything within a matter of seconds. You can become a subject matter expert on any topic within a matter of hours: music, cooking, foreign language, weather, travel. The possibilities are endless. That is, unless you want information on yourself—specifically, medical information.
Despite all of our advances in technology in the information era, many patients still find it extremely difficult and frustrating to gain full and transparent access to their medical records. Electronic health records (EHRs) have made it easier than ever for practitioners to find information about their patients, including pharmacy and access queries to determine what medications they are (or are not) taking, and where they have recently accessed care. But EHRs have not been widely utilized as a tool to grant extensive, real-time access to patients.
But change is afoot. Both providers and patients are now realizing the value of offering patients more open access to their medical records. Many organizations with EHRs have created patient portals, where patients can access limited portions of their medical records such as medications and allergies, can request items such as prescription refills or appointments, and can ask their providers about their care. Some medical centers are participating in OpenNotes initiatives, which give patients direct access to provider notes within the medical record.
Although these patient portals are a great first step in transparency and engagement, the information granted to patients is limited in content and timeliness. Generally, such items as test results must first be “released” by a provider before they can be viewed by the patient; some organizations have set restrictions, determining that some tests cannot be released at all (i.e., abnormal pathology or HIV test results). The rationale for such restrictions is to prevent patients from finding out sensitive information from a web page; many assume that the patient would be much better off finding out such information from a provider than a computer, and that well may be true, if the information is available in a timely fashion and is shared by a provider who can relay the information better than a computer.
Barriers Aplenty
The medical industry still has a long way to go to realize full medical record transparency for patients. One legitimate barrier is that medical records were never intended for patient view or use. Most do not read like a story; they read more like a ledger, full of medical jargon and text boxes in illogical order. This is primarily due to the fact that EHRs were designed for regulatory and billing purposes, not to eloquently—or even adequately—summarize what the patient is (or was) experiencing.
Another major barrier is that the information in the medical record is often difficult to find, and the record itself is difficult to maneuver. Experienced and trained providers, even those who have dutifully completed medical training, often find it challenging to locate exactly what they are looking for. The burden would be on the patient to learn, understand, and navigate the medical record, and few would likely undertake such a challenge.
There also are legitimate cultural barriers among providers, who will resist giving patients carte blanche access to the EHR; many providers cite concerns that if they honestly summarize sensitive information in the medical record (i.e., social habits or medication compliance issues), patients may be angered, with resultant loss of trust, retaliation, or legal action.
Clear the Hurdles, and Next Steps
There is a great story about how well medical record transparency can work, summarized in a New York Times article a few months ago.1 The story tells of 26-year-old Steven Keating, who had a “slight abnormality” on a brain CT that was done in 2007 as part of a study he had volunteered for.2 Although reassured by a “normal” follow-up scan in 2010, Keating was inquisitive, wanting to understand everything about his condition, and read voraciously about what his initial brain scan could mean. He knew the initial abnormality was near his olfactory nerve, so in 2014, when he started intermittently smelling vinegar, he suspected it might be related to the abnormality noted in his initial scan.
He sought immediate care and follow-up imaging, which showed a very large mass. Within weeks, this large astrocytoma was successfully removed; surgery was followed by chemotherapy and radiation.
Over the course of Keating’s care, he amassed more than 70 gigabytes of medical information about himself, including 10 hours of video footage from his initial surgery. Throughout the course of his illness, he remained eager to obtain all facets of his medical information, including such videos and scans, and considered these pieces of information critical to his healing process. He found that, in general, when he asked doctors to share information, he was usually granted access to what he wanted and needed, but the onus was always on him to ask. At one point he asked, “How come there isn’t a ‘share’ button at the hospital?”
Steven now has an entire website dedicated to his personal healthcare story, coupled with a passionate plea to enhance open access to medical records.2 He writes: “I have become passionate about open-sourcing the data and how we can learn through sharing. … Patients can collect their own data and they should be able to share it, amongst patients, communities, and to benefit science if desired. Healthcare should be a two-way road, patients alongside doctors and researchers as a team. The future will be driven by networked healthcare, support communities, and, I believe, patient curiosity.”
Steven was able to cobble together his medical record better than most others could, as he definitely has some advantages over many other patients; he is young, articulate, bright, and highly educated. It would be much more difficult for an older, less well educated, or disenfranchised patient to accomplish this level of understanding of and engagement in the current system. “The person with the least access to data in the system is the patient,” he writes on his website. “You can get it, but the burden is always on the patient. And it is scattered across many different silos of patient data.”
Providers and patients alike should insist on more transparency, coupled with better and more streamlined communication. As patients become more agile at maneuvering through the web portals and more engaged in their care, patients and providers gain innumerable advantages. Patients could help to find any and all medical record information that is incorrect or inconsistent, working to ensure the accuracy of the content—and get rid of “chart lore.” They could fill in missing content and update information between visits, such as changes to their social history or demographics. This is all very good timing, given the recent shift to pay for performance and population health; as financial incentives are veering away from fee for service, it is becoming more profitable to help patients stay well than to keep them sick.
As hospitalists, we should look forward to these advances in technology to enhance access to information for ourselves and for our patients. We should seek out mechanisms within our organization to enhance the speed at which open access for patients is granted, to improve patient engagement throughout the spectrum of their care.
References
- Lohr S. The healing power of your own medical records. March 31, 2015. The New York Times website.. Accessed June 1, 2015.
- Keating S. Steven Keating homepage. Accessed June 1, 2015.