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Temporary IVC Filter Added to Anticoagulation Does Not Decrease Pulmonary Embolism Recurrence Risk
Clinical question: Does the insertion of a retrievable inferior vena cava filter in addition to anticoagulation prevent the recurrence of pulmonary embolism in high-risk patients?
Bottom line: For patients with pulmonary embolism (PE) who are at high risk of recurrence or who have poor cardiopulmonary reserve, the addition of a retrievable inferior vena cava (IVC) filter plus anticoagulation does not decrease the risk of recurrent PE as compared with anticoagulation alone. Although this study was underpowered to detect a difference if one truly exists, the authors postulate that such a difference would likely be small and thus clinically irrelevant. (LOE = 1b-)
Reference: Mismetti P, Laporte S, Pellerin O, et al, for the PREPIC2 Study Group. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism. JAMA. 2015;313(16):1627–1635.
Study design: Randomized controlled trial (nonblinded)
Funding source: Government
Allocation: Concealed
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
The utility of retrievable IVC filters added to anticoagulation for the prevention of recurrent PE is unknown. This study included adults who were hospitalized for acute PE associated with lower extremity venous thrombosis and had one additional criterion for severity (older than 75 years, active cancer, chronic cardiopulmonary conditions, recent stroke with leg paralysis, iliocaval or bilateral venous thromboses, or evidence of right ventricular dysfunction or myocardial injury).
The patients were randomized, using concealed allocation, to receive a filter plus anticoagulation or anticoagulation alone. Both groups were anticoagulated for at least 6 months and filters were retrieved at 3 months. More patients in the filter group had chronic respiratory failure at baseline but the groups were otherwise well matched. Analysis was by intention to treat.
At 3 months, the rate of recurrent PE did not differ between the 2 groups (3% in filter group vs 1.5% in control group; P = .50; RR with filter 2.00; 95% CI 0.51-7.89). Additionally, there were no differences detected in venous thromboembolism recurrence, major bleeding, or death at either 3 or 6 months. Complications in the filter group included access site hematomas, filter thromboses, and filter retrieval failures. The authors based their analysis on an expected PE recurrence rate of 8% in the control group but the actual rate was much lower. Although this results in an underpowered study, the authors note that the point estimate of the relative risk still favors the control group and if filters did confer a small advantage it would likely not be clinically meaningful.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Does the insertion of a retrievable inferior vena cava filter in addition to anticoagulation prevent the recurrence of pulmonary embolism in high-risk patients?
Bottom line: For patients with pulmonary embolism (PE) who are at high risk of recurrence or who have poor cardiopulmonary reserve, the addition of a retrievable inferior vena cava (IVC) filter plus anticoagulation does not decrease the risk of recurrent PE as compared with anticoagulation alone. Although this study was underpowered to detect a difference if one truly exists, the authors postulate that such a difference would likely be small and thus clinically irrelevant. (LOE = 1b-)
Reference: Mismetti P, Laporte S, Pellerin O, et al, for the PREPIC2 Study Group. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism. JAMA. 2015;313(16):1627–1635.
Study design: Randomized controlled trial (nonblinded)
Funding source: Government
Allocation: Concealed
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
The utility of retrievable IVC filters added to anticoagulation for the prevention of recurrent PE is unknown. This study included adults who were hospitalized for acute PE associated with lower extremity venous thrombosis and had one additional criterion for severity (older than 75 years, active cancer, chronic cardiopulmonary conditions, recent stroke with leg paralysis, iliocaval or bilateral venous thromboses, or evidence of right ventricular dysfunction or myocardial injury).
The patients were randomized, using concealed allocation, to receive a filter plus anticoagulation or anticoagulation alone. Both groups were anticoagulated for at least 6 months and filters were retrieved at 3 months. More patients in the filter group had chronic respiratory failure at baseline but the groups were otherwise well matched. Analysis was by intention to treat.
At 3 months, the rate of recurrent PE did not differ between the 2 groups (3% in filter group vs 1.5% in control group; P = .50; RR with filter 2.00; 95% CI 0.51-7.89). Additionally, there were no differences detected in venous thromboembolism recurrence, major bleeding, or death at either 3 or 6 months. Complications in the filter group included access site hematomas, filter thromboses, and filter retrieval failures. The authors based their analysis on an expected PE recurrence rate of 8% in the control group but the actual rate was much lower. Although this results in an underpowered study, the authors note that the point estimate of the relative risk still favors the control group and if filters did confer a small advantage it would likely not be clinically meaningful.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Does the insertion of a retrievable inferior vena cava filter in addition to anticoagulation prevent the recurrence of pulmonary embolism in high-risk patients?
Bottom line: For patients with pulmonary embolism (PE) who are at high risk of recurrence or who have poor cardiopulmonary reserve, the addition of a retrievable inferior vena cava (IVC) filter plus anticoagulation does not decrease the risk of recurrent PE as compared with anticoagulation alone. Although this study was underpowered to detect a difference if one truly exists, the authors postulate that such a difference would likely be small and thus clinically irrelevant. (LOE = 1b-)
Reference: Mismetti P, Laporte S, Pellerin O, et al, for the PREPIC2 Study Group. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism. JAMA. 2015;313(16):1627–1635.
Study design: Randomized controlled trial (nonblinded)
Funding source: Government
Allocation: Concealed
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
The utility of retrievable IVC filters added to anticoagulation for the prevention of recurrent PE is unknown. This study included adults who were hospitalized for acute PE associated with lower extremity venous thrombosis and had one additional criterion for severity (older than 75 years, active cancer, chronic cardiopulmonary conditions, recent stroke with leg paralysis, iliocaval or bilateral venous thromboses, or evidence of right ventricular dysfunction or myocardial injury).
The patients were randomized, using concealed allocation, to receive a filter plus anticoagulation or anticoagulation alone. Both groups were anticoagulated for at least 6 months and filters were retrieved at 3 months. More patients in the filter group had chronic respiratory failure at baseline but the groups were otherwise well matched. Analysis was by intention to treat.
At 3 months, the rate of recurrent PE did not differ between the 2 groups (3% in filter group vs 1.5% in control group; P = .50; RR with filter 2.00; 95% CI 0.51-7.89). Additionally, there were no differences detected in venous thromboembolism recurrence, major bleeding, or death at either 3 or 6 months. Complications in the filter group included access site hematomas, filter thromboses, and filter retrieval failures. The authors based their analysis on an expected PE recurrence rate of 8% in the control group but the actual rate was much lower. Although this results in an underpowered study, the authors note that the point estimate of the relative risk still favors the control group and if filters did confer a small advantage it would likely not be clinically meaningful.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Healthcare Industry Agents of Change Promote Responsible Spending
1 Caring Wisely Program
http://healthvalue.ucsf.edu/caring-wisely
- Started in 2012 within the division of hospital medicine at the University of California, San Francisco (UCSF), the program sponsored or collaborated on six high-value care projects within its first year. “We don’t shy away from the fact that part of what we do is address cost, but it is about making sure that we’ve got the right mindset and right frame, which is that we’re going to improve quality while decreasing costs and keeping it really patient centered,” says Christopher Moriates, MD, program director and an assistant clinical professor.
- Beyond its successful Nebs No More After 24 project, Caring Wisely helped hospital pharmacists and the UCSF Medication Outcomes Center develop and implement an evidence-based initiative to cut inappropriate stress ulcer prophylaxis in intensive care unit patients. After its first month, the program had cut unnecessary use of the medication from 19% to 6.6%.
2 Choosing Wisely Program
- Launched in 2012 as an initiative of the ABIM Foundation and based on a pilot project by the National Physicians Alliance, Choosing Wisely was designed to encourage more proactive conversations between providers and patients. The goal is to help patients choose care that is both evidence-based and necessary, while minimizing harm and avoiding duplication of tests or procedures.
- Since its debut, the program has gathered nearly 60 specialty society lists of “Five Things Physicians and Patients Should Question,” including two lists compiled by SHM for adult and pediatric hospital medicine. As a complement, Consumer Reports and many of the specialty societies have collaborated on 75 patient-friendly reports that dispense advice about whether a test, treatment, or procedure is really needed.
3 Costs of Care
- Founded in 2009 by Neel Shah, MD, an assistant professor at Harvard Medical School, the nonprofit got its start by collecting stories from patients and physicians about unnecessary or inflated healthcare costs. “It had a manifesto about what the role of physicians ought to be and thinking about healthcare costs, and that message actually really resonated with a lot of people,” Dr. Shah says. “That basic message that we decide what goes on the bill, patients have to pay for it, and yet we don’t know what it’s costing them—that just seemed crazy and we heard from a lot of people, both from patients with whom that message resonated and physicians who were like, ‘Yeah.’”
- In 2010, the organizers hosted their first essay contest and ended up receiving more than 300 entries; several were subsequently included as case reports in a report on healthcare waste by the Institute of Medicine. The nonprofit, supported by the ABIM Foundation and other institutions, has since led to an educational venture called the Teaching Value Project, a textbook titled Understanding Value-Based Care (McGraw-Hill), and a “Costs of Care” iPhone app—all designed to help clinicians make high-value clinical decisions and increase price transparency.
4 The Do No Harm Project
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/
GIM/education/DoNoHarmProject/Pages/Welcome.aspx
- Launched in 2012 at the University of Colorado by Brandon Combs, MD, and Tanner Caverly, MD, MPH, the project is aimed at medical trainees. Starting with the internal medicine program, the physicians asked medical residents to reflect on a patient who had suffered an adverse consequence from medical overuse. “This was reasonable care that was nevertheless unneeded or unwanted by a fully informed patient,” Dr. Combs says. “So this isn’t errors or malpractice; this is the stuff that flies under the radar, the stuff that people might miss.”
- The project uses clinical vignettes written by medical trainees (including those found in the “Teachable Moments” section of JAMA Internal Medicine) to improve the recognition of potential harm from overuse and to spur a culture change. In 2013, the Teaching Value and Choosing Wisely Competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized the project as one of its Innovations award winners; so far, five internal medicine and emergency medicine programs around the country have adopted the model.
5 I-CARE
- The Interactive Cost-Awareness Resident Exercise (I-CARE) was launched in 2011 by Yale hospitalist Robert Fogerty, MD, MPH, and colleagues. The friendly competition among medical students, interns, residents, and attending physicians uses a traditional morning report structure and charge data. At these conferences, the providers compete to come up with the correct diagnosis using the fewest resources possible. In 2013, the Teaching Value and Choosing Wisely competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized I-CARE as one of its Innovations award winners.
- “Physicians tend not to have a lot of business training,” Dr. Fogerty says. “They don’t have a lot of financial training. They don’t have a lot of economics background, and when you tell them that healthcare expense is 18% of GDP [gross domestic product], they don’t really know what that means. When you tell them that that would be in the top 10 of world economies, now they’re starting to get a picture of it. And when you tell them that that CAT scan you just ordered is going to cost your patient $1,200, that’s an eye-opening number that they can understand. So I think the purpose behind I-CARE was to take this seemingly insurmountable problem and to begin to digest it into small enough bits of information that allowed this problem to be accessible to the trainees.”
6 Providers for Responsible Ordering (PRO)
www.providersforresponsibleordering.org
- The organization launched in 2009 with a mission to “promote high-value care and create a culture that minimizes unnecessary or potentially-harmful diagnostic tests and interventions.” By the end of 2014, five chapters had been established and more than 150 providers had signed the PRO pledge that asks signatories, in part, “to provide my patients with all of the care that they need and none that they do not, thereby protecting them from unnecessary diagnostic tests and treatments.”
- “Our model is simple and yet powerful. It’s a grass-roots effort that any interested provider can join, and it builds on a peer-to-peer approach of establishment of chapters that solve local problems and reporting of those solutions back to the national group,” says Anthony Accurso, MD, PRO faculty director at Johns Hopkins Bayview Medical Center in Baltimore.
1 Caring Wisely Program
http://healthvalue.ucsf.edu/caring-wisely
- Started in 2012 within the division of hospital medicine at the University of California, San Francisco (UCSF), the program sponsored or collaborated on six high-value care projects within its first year. “We don’t shy away from the fact that part of what we do is address cost, but it is about making sure that we’ve got the right mindset and right frame, which is that we’re going to improve quality while decreasing costs and keeping it really patient centered,” says Christopher Moriates, MD, program director and an assistant clinical professor.
- Beyond its successful Nebs No More After 24 project, Caring Wisely helped hospital pharmacists and the UCSF Medication Outcomes Center develop and implement an evidence-based initiative to cut inappropriate stress ulcer prophylaxis in intensive care unit patients. After its first month, the program had cut unnecessary use of the medication from 19% to 6.6%.
2 Choosing Wisely Program
- Launched in 2012 as an initiative of the ABIM Foundation and based on a pilot project by the National Physicians Alliance, Choosing Wisely was designed to encourage more proactive conversations between providers and patients. The goal is to help patients choose care that is both evidence-based and necessary, while minimizing harm and avoiding duplication of tests or procedures.
- Since its debut, the program has gathered nearly 60 specialty society lists of “Five Things Physicians and Patients Should Question,” including two lists compiled by SHM for adult and pediatric hospital medicine. As a complement, Consumer Reports and many of the specialty societies have collaborated on 75 patient-friendly reports that dispense advice about whether a test, treatment, or procedure is really needed.
3 Costs of Care
- Founded in 2009 by Neel Shah, MD, an assistant professor at Harvard Medical School, the nonprofit got its start by collecting stories from patients and physicians about unnecessary or inflated healthcare costs. “It had a manifesto about what the role of physicians ought to be and thinking about healthcare costs, and that message actually really resonated with a lot of people,” Dr. Shah says. “That basic message that we decide what goes on the bill, patients have to pay for it, and yet we don’t know what it’s costing them—that just seemed crazy and we heard from a lot of people, both from patients with whom that message resonated and physicians who were like, ‘Yeah.’”
- In 2010, the organizers hosted their first essay contest and ended up receiving more than 300 entries; several were subsequently included as case reports in a report on healthcare waste by the Institute of Medicine. The nonprofit, supported by the ABIM Foundation and other institutions, has since led to an educational venture called the Teaching Value Project, a textbook titled Understanding Value-Based Care (McGraw-Hill), and a “Costs of Care” iPhone app—all designed to help clinicians make high-value clinical decisions and increase price transparency.
4 The Do No Harm Project
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/
GIM/education/DoNoHarmProject/Pages/Welcome.aspx
- Launched in 2012 at the University of Colorado by Brandon Combs, MD, and Tanner Caverly, MD, MPH, the project is aimed at medical trainees. Starting with the internal medicine program, the physicians asked medical residents to reflect on a patient who had suffered an adverse consequence from medical overuse. “This was reasonable care that was nevertheless unneeded or unwanted by a fully informed patient,” Dr. Combs says. “So this isn’t errors or malpractice; this is the stuff that flies under the radar, the stuff that people might miss.”
- The project uses clinical vignettes written by medical trainees (including those found in the “Teachable Moments” section of JAMA Internal Medicine) to improve the recognition of potential harm from overuse and to spur a culture change. In 2013, the Teaching Value and Choosing Wisely Competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized the project as one of its Innovations award winners; so far, five internal medicine and emergency medicine programs around the country have adopted the model.
5 I-CARE
- The Interactive Cost-Awareness Resident Exercise (I-CARE) was launched in 2011 by Yale hospitalist Robert Fogerty, MD, MPH, and colleagues. The friendly competition among medical students, interns, residents, and attending physicians uses a traditional morning report structure and charge data. At these conferences, the providers compete to come up with the correct diagnosis using the fewest resources possible. In 2013, the Teaching Value and Choosing Wisely competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized I-CARE as one of its Innovations award winners.
- “Physicians tend not to have a lot of business training,” Dr. Fogerty says. “They don’t have a lot of financial training. They don’t have a lot of economics background, and when you tell them that healthcare expense is 18% of GDP [gross domestic product], they don’t really know what that means. When you tell them that that would be in the top 10 of world economies, now they’re starting to get a picture of it. And when you tell them that that CAT scan you just ordered is going to cost your patient $1,200, that’s an eye-opening number that they can understand. So I think the purpose behind I-CARE was to take this seemingly insurmountable problem and to begin to digest it into small enough bits of information that allowed this problem to be accessible to the trainees.”
6 Providers for Responsible Ordering (PRO)
www.providersforresponsibleordering.org
- The organization launched in 2009 with a mission to “promote high-value care and create a culture that minimizes unnecessary or potentially-harmful diagnostic tests and interventions.” By the end of 2014, five chapters had been established and more than 150 providers had signed the PRO pledge that asks signatories, in part, “to provide my patients with all of the care that they need and none that they do not, thereby protecting them from unnecessary diagnostic tests and treatments.”
- “Our model is simple and yet powerful. It’s a grass-roots effort that any interested provider can join, and it builds on a peer-to-peer approach of establishment of chapters that solve local problems and reporting of those solutions back to the national group,” says Anthony Accurso, MD, PRO faculty director at Johns Hopkins Bayview Medical Center in Baltimore.
1 Caring Wisely Program
http://healthvalue.ucsf.edu/caring-wisely
- Started in 2012 within the division of hospital medicine at the University of California, San Francisco (UCSF), the program sponsored or collaborated on six high-value care projects within its first year. “We don’t shy away from the fact that part of what we do is address cost, but it is about making sure that we’ve got the right mindset and right frame, which is that we’re going to improve quality while decreasing costs and keeping it really patient centered,” says Christopher Moriates, MD, program director and an assistant clinical professor.
- Beyond its successful Nebs No More After 24 project, Caring Wisely helped hospital pharmacists and the UCSF Medication Outcomes Center develop and implement an evidence-based initiative to cut inappropriate stress ulcer prophylaxis in intensive care unit patients. After its first month, the program had cut unnecessary use of the medication from 19% to 6.6%.
2 Choosing Wisely Program
- Launched in 2012 as an initiative of the ABIM Foundation and based on a pilot project by the National Physicians Alliance, Choosing Wisely was designed to encourage more proactive conversations between providers and patients. The goal is to help patients choose care that is both evidence-based and necessary, while minimizing harm and avoiding duplication of tests or procedures.
- Since its debut, the program has gathered nearly 60 specialty society lists of “Five Things Physicians and Patients Should Question,” including two lists compiled by SHM for adult and pediatric hospital medicine. As a complement, Consumer Reports and many of the specialty societies have collaborated on 75 patient-friendly reports that dispense advice about whether a test, treatment, or procedure is really needed.
3 Costs of Care
- Founded in 2009 by Neel Shah, MD, an assistant professor at Harvard Medical School, the nonprofit got its start by collecting stories from patients and physicians about unnecessary or inflated healthcare costs. “It had a manifesto about what the role of physicians ought to be and thinking about healthcare costs, and that message actually really resonated with a lot of people,” Dr. Shah says. “That basic message that we decide what goes on the bill, patients have to pay for it, and yet we don’t know what it’s costing them—that just seemed crazy and we heard from a lot of people, both from patients with whom that message resonated and physicians who were like, ‘Yeah.’”
- In 2010, the organizers hosted their first essay contest and ended up receiving more than 300 entries; several were subsequently included as case reports in a report on healthcare waste by the Institute of Medicine. The nonprofit, supported by the ABIM Foundation and other institutions, has since led to an educational venture called the Teaching Value Project, a textbook titled Understanding Value-Based Care (McGraw-Hill), and a “Costs of Care” iPhone app—all designed to help clinicians make high-value clinical decisions and increase price transparency.
4 The Do No Harm Project
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/
GIM/education/DoNoHarmProject/Pages/Welcome.aspx
- Launched in 2012 at the University of Colorado by Brandon Combs, MD, and Tanner Caverly, MD, MPH, the project is aimed at medical trainees. Starting with the internal medicine program, the physicians asked medical residents to reflect on a patient who had suffered an adverse consequence from medical overuse. “This was reasonable care that was nevertheless unneeded or unwanted by a fully informed patient,” Dr. Combs says. “So this isn’t errors or malpractice; this is the stuff that flies under the radar, the stuff that people might miss.”
- The project uses clinical vignettes written by medical trainees (including those found in the “Teachable Moments” section of JAMA Internal Medicine) to improve the recognition of potential harm from overuse and to spur a culture change. In 2013, the Teaching Value and Choosing Wisely Competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized the project as one of its Innovations award winners; so far, five internal medicine and emergency medicine programs around the country have adopted the model.
5 I-CARE
- The Interactive Cost-Awareness Resident Exercise (I-CARE) was launched in 2011 by Yale hospitalist Robert Fogerty, MD, MPH, and colleagues. The friendly competition among medical students, interns, residents, and attending physicians uses a traditional morning report structure and charge data. At these conferences, the providers compete to come up with the correct diagnosis using the fewest resources possible. In 2013, the Teaching Value and Choosing Wisely competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized I-CARE as one of its Innovations award winners.
- “Physicians tend not to have a lot of business training,” Dr. Fogerty says. “They don’t have a lot of financial training. They don’t have a lot of economics background, and when you tell them that healthcare expense is 18% of GDP [gross domestic product], they don’t really know what that means. When you tell them that that would be in the top 10 of world economies, now they’re starting to get a picture of it. And when you tell them that that CAT scan you just ordered is going to cost your patient $1,200, that’s an eye-opening number that they can understand. So I think the purpose behind I-CARE was to take this seemingly insurmountable problem and to begin to digest it into small enough bits of information that allowed this problem to be accessible to the trainees.”
6 Providers for Responsible Ordering (PRO)
www.providersforresponsibleordering.org
- The organization launched in 2009 with a mission to “promote high-value care and create a culture that minimizes unnecessary or potentially-harmful diagnostic tests and interventions.” By the end of 2014, five chapters had been established and more than 150 providers had signed the PRO pledge that asks signatories, in part, “to provide my patients with all of the care that they need and none that they do not, thereby protecting them from unnecessary diagnostic tests and treatments.”
- “Our model is simple and yet powerful. It’s a grass-roots effort that any interested provider can join, and it builds on a peer-to-peer approach of establishment of chapters that solve local problems and reporting of those solutions back to the national group,” says Anthony Accurso, MD, PRO faculty director at Johns Hopkins Bayview Medical Center in Baltimore.
Standard Text Messaging for Smartphones Not HIPAA Compliant
Doctors were the first to begin using pagers and, along with drug dealers, appear to be the last to give them up. But we really need to get rid of them.
Sadly, for the foreseeable future, we will need a pager replacement, but, in the longer term, I’m hopeful that we can:
- Reduce the frequency of electronic interruptions—all forms of interruptions—and the adverse effects that reliably accompany them, and
- Ensure that each interruption has value—that is, reduce or eliminate the many low value and non-urgent messages we all get (e.g. the ones informing you of a lab result you’ve already seen).
Death to the Pager
I can’t imagine anyone who will be more pleased than I will if pagers go the way of now rare hospital-wide PA announcements. Some hospitals have eliminated these announcements entirely, and even critical messages like “code blue” announcements are sent directly to each responder via a pager or other personal device.
Around the time the first iPhone was born, hospital signs banning cell phones began coming down. It seems the fear that they would disrupt hospital electronics, such as telemetry and other monitoring devices, has proven largely unfounded (though, along with things like computer keyboards and stethoscopes, pagers and cell phones can serve as dangerous repositories of bacteria).
Now nearly everyone, from staff to patients, keeps a cell phone with them while in the hospital. I think that is the most important step toward getting rid of pagers. Many doctors already are using the standard text messaging apps that come with the phone to communicate with one another efficiently.
“Regular” Texting Won’t Cut It
Unfortunately, the standard text messaging that comes with every smartphone is not HIPAA compliant. Though I certainly don’t know how anyone would do it, it is apparently too easy for another person to intercept the message. So, if you’re texting information related to your clinical work, you need to make sure it doesn’t include anything that could be considered protected health information. It isn’t enough just to leave the patient’s name off the message. If you’re in the habit of regularly texting doctors, nurses, and other healthcare personnel about patient care, you are at high risk of violating HIPAA, even if you try hard to avoid it.
Another big drawback is that there isn’t a good way to turn off work-related texting when you’re off duty, while leaving your texting app open for communication with your friends and family. Hospital staff will sometimes fail to check whether you’re on duty before texting, and that will lead to your personal time being interrupted by work reminders.
I think these shortcomings mean that none of us should rely on the standard text messaging apps that come with our phones.
But in order for a different app or service to be of any value, we will need to ensure that most providers associated with our hospital are on the same messaging system. That is a tall order, but fortunately there are a lot of companies trying to produce an attractive product that makes it as easy as possible to attract a critical mass of users at your institution.
HIPAA-Compliant Texting Vendors
Many healthcare tech companies provide secure messaging, usually at no additional cost, as an add-on to their main products, such as charge capture software (e.g. IngeniousMed), or physician social networking (e.g. Doximity). Something like 30 companies now offer a dedicated HIPAA-compliant texting option, including IM Your Doc, Voalte, Telmediq, PerfectServe, Vocera, and TigerText. There are so many that it is awfully tough to understand all of their strengths and shortcomings in detail, but I’m having fun trying to do just that. And I anticipate there will be significant consolidation in vendors within the next two to three years.
The dedicated HIPAA-compliant texting services range in price from free for basic features to a monthly fee per user that varies depending on the features you choose to enable. Some offer integration with the hospital’s EHR, which can let a message sender who only knows the patient’s name to see which doctor, nurse, or other caregiver is currently responsible for the patient. Some offer integration with a call schedule and answering service, or even replace an answering service.
No pager replacement will be viable if there are sites in the hospital or elsewhere where it is out of contact; a solution that works on both cellular networks and Wi-Fi is essential. Some vendors offer the ability for messages not delivered to or acknowledged by the recipient to escalate to other forms of delivery after a specified period of time.
I would love to see a feature that I don’t think any vendor offers yet. It would be great if all messages the sender hasn’t marked “stat” or “urgent” first went to a queue in the EHR rather than immediately interrupting the recipient. That way a doctor or other caregiver could see messages while already working in the EHR, rather than glancing at each new message as it arrives, something that all too often needlessly interrupts another important task such as talking with a patient.
And, since most work in EHRs is done in front of a larger device with a full keyboard, it would be easier to type a quick reply message than it would be to rely on a smartphone keyboard for return messaging. Protocols could be established such that messages waiting in the EHR without a reply or dismissal after a specified time would then be sent to the recipient’s personal device.
A Texting Ecosystem
In nearly every case, the hospital will select the text messaging vendor, though hospitalists and nurses, who will typically be among the highest-volume users, should participate in the decision. But the real value of the system hinges on ensuring its wide adoption by most, or nearly all, hospital caregivers and affiliated ambulatory providers.
I would enjoy hearing from those who are already using a HIPAA-secure texting and pager replacement service now, as well as those still researching their options. This has the potential to meaningfully change the way hospitalists and others do their work.
Doctors were the first to begin using pagers and, along with drug dealers, appear to be the last to give them up. But we really need to get rid of them.
Sadly, for the foreseeable future, we will need a pager replacement, but, in the longer term, I’m hopeful that we can:
- Reduce the frequency of electronic interruptions—all forms of interruptions—and the adverse effects that reliably accompany them, and
- Ensure that each interruption has value—that is, reduce or eliminate the many low value and non-urgent messages we all get (e.g. the ones informing you of a lab result you’ve already seen).
Death to the Pager
I can’t imagine anyone who will be more pleased than I will if pagers go the way of now rare hospital-wide PA announcements. Some hospitals have eliminated these announcements entirely, and even critical messages like “code blue” announcements are sent directly to each responder via a pager or other personal device.
Around the time the first iPhone was born, hospital signs banning cell phones began coming down. It seems the fear that they would disrupt hospital electronics, such as telemetry and other monitoring devices, has proven largely unfounded (though, along with things like computer keyboards and stethoscopes, pagers and cell phones can serve as dangerous repositories of bacteria).
Now nearly everyone, from staff to patients, keeps a cell phone with them while in the hospital. I think that is the most important step toward getting rid of pagers. Many doctors already are using the standard text messaging apps that come with the phone to communicate with one another efficiently.
“Regular” Texting Won’t Cut It
Unfortunately, the standard text messaging that comes with every smartphone is not HIPAA compliant. Though I certainly don’t know how anyone would do it, it is apparently too easy for another person to intercept the message. So, if you’re texting information related to your clinical work, you need to make sure it doesn’t include anything that could be considered protected health information. It isn’t enough just to leave the patient’s name off the message. If you’re in the habit of regularly texting doctors, nurses, and other healthcare personnel about patient care, you are at high risk of violating HIPAA, even if you try hard to avoid it.
Another big drawback is that there isn’t a good way to turn off work-related texting when you’re off duty, while leaving your texting app open for communication with your friends and family. Hospital staff will sometimes fail to check whether you’re on duty before texting, and that will lead to your personal time being interrupted by work reminders.
I think these shortcomings mean that none of us should rely on the standard text messaging apps that come with our phones.
But in order for a different app or service to be of any value, we will need to ensure that most providers associated with our hospital are on the same messaging system. That is a tall order, but fortunately there are a lot of companies trying to produce an attractive product that makes it as easy as possible to attract a critical mass of users at your institution.
HIPAA-Compliant Texting Vendors
Many healthcare tech companies provide secure messaging, usually at no additional cost, as an add-on to their main products, such as charge capture software (e.g. IngeniousMed), or physician social networking (e.g. Doximity). Something like 30 companies now offer a dedicated HIPAA-compliant texting option, including IM Your Doc, Voalte, Telmediq, PerfectServe, Vocera, and TigerText. There are so many that it is awfully tough to understand all of their strengths and shortcomings in detail, but I’m having fun trying to do just that. And I anticipate there will be significant consolidation in vendors within the next two to three years.
The dedicated HIPAA-compliant texting services range in price from free for basic features to a monthly fee per user that varies depending on the features you choose to enable. Some offer integration with the hospital’s EHR, which can let a message sender who only knows the patient’s name to see which doctor, nurse, or other caregiver is currently responsible for the patient. Some offer integration with a call schedule and answering service, or even replace an answering service.
No pager replacement will be viable if there are sites in the hospital or elsewhere where it is out of contact; a solution that works on both cellular networks and Wi-Fi is essential. Some vendors offer the ability for messages not delivered to or acknowledged by the recipient to escalate to other forms of delivery after a specified period of time.
I would love to see a feature that I don’t think any vendor offers yet. It would be great if all messages the sender hasn’t marked “stat” or “urgent” first went to a queue in the EHR rather than immediately interrupting the recipient. That way a doctor or other caregiver could see messages while already working in the EHR, rather than glancing at each new message as it arrives, something that all too often needlessly interrupts another important task such as talking with a patient.
And, since most work in EHRs is done in front of a larger device with a full keyboard, it would be easier to type a quick reply message than it would be to rely on a smartphone keyboard for return messaging. Protocols could be established such that messages waiting in the EHR without a reply or dismissal after a specified time would then be sent to the recipient’s personal device.
A Texting Ecosystem
In nearly every case, the hospital will select the text messaging vendor, though hospitalists and nurses, who will typically be among the highest-volume users, should participate in the decision. But the real value of the system hinges on ensuring its wide adoption by most, or nearly all, hospital caregivers and affiliated ambulatory providers.
I would enjoy hearing from those who are already using a HIPAA-secure texting and pager replacement service now, as well as those still researching their options. This has the potential to meaningfully change the way hospitalists and others do their work.
Doctors were the first to begin using pagers and, along with drug dealers, appear to be the last to give them up. But we really need to get rid of them.
Sadly, for the foreseeable future, we will need a pager replacement, but, in the longer term, I’m hopeful that we can:
- Reduce the frequency of electronic interruptions—all forms of interruptions—and the adverse effects that reliably accompany them, and
- Ensure that each interruption has value—that is, reduce or eliminate the many low value and non-urgent messages we all get (e.g. the ones informing you of a lab result you’ve already seen).
Death to the Pager
I can’t imagine anyone who will be more pleased than I will if pagers go the way of now rare hospital-wide PA announcements. Some hospitals have eliminated these announcements entirely, and even critical messages like “code blue” announcements are sent directly to each responder via a pager or other personal device.
Around the time the first iPhone was born, hospital signs banning cell phones began coming down. It seems the fear that they would disrupt hospital electronics, such as telemetry and other monitoring devices, has proven largely unfounded (though, along with things like computer keyboards and stethoscopes, pagers and cell phones can serve as dangerous repositories of bacteria).
Now nearly everyone, from staff to patients, keeps a cell phone with them while in the hospital. I think that is the most important step toward getting rid of pagers. Many doctors already are using the standard text messaging apps that come with the phone to communicate with one another efficiently.
“Regular” Texting Won’t Cut It
Unfortunately, the standard text messaging that comes with every smartphone is not HIPAA compliant. Though I certainly don’t know how anyone would do it, it is apparently too easy for another person to intercept the message. So, if you’re texting information related to your clinical work, you need to make sure it doesn’t include anything that could be considered protected health information. It isn’t enough just to leave the patient’s name off the message. If you’re in the habit of regularly texting doctors, nurses, and other healthcare personnel about patient care, you are at high risk of violating HIPAA, even if you try hard to avoid it.
Another big drawback is that there isn’t a good way to turn off work-related texting when you’re off duty, while leaving your texting app open for communication with your friends and family. Hospital staff will sometimes fail to check whether you’re on duty before texting, and that will lead to your personal time being interrupted by work reminders.
I think these shortcomings mean that none of us should rely on the standard text messaging apps that come with our phones.
But in order for a different app or service to be of any value, we will need to ensure that most providers associated with our hospital are on the same messaging system. That is a tall order, but fortunately there are a lot of companies trying to produce an attractive product that makes it as easy as possible to attract a critical mass of users at your institution.
HIPAA-Compliant Texting Vendors
Many healthcare tech companies provide secure messaging, usually at no additional cost, as an add-on to their main products, such as charge capture software (e.g. IngeniousMed), or physician social networking (e.g. Doximity). Something like 30 companies now offer a dedicated HIPAA-compliant texting option, including IM Your Doc, Voalte, Telmediq, PerfectServe, Vocera, and TigerText. There are so many that it is awfully tough to understand all of their strengths and shortcomings in detail, but I’m having fun trying to do just that. And I anticipate there will be significant consolidation in vendors within the next two to three years.
The dedicated HIPAA-compliant texting services range in price from free for basic features to a monthly fee per user that varies depending on the features you choose to enable. Some offer integration with the hospital’s EHR, which can let a message sender who only knows the patient’s name to see which doctor, nurse, or other caregiver is currently responsible for the patient. Some offer integration with a call schedule and answering service, or even replace an answering service.
No pager replacement will be viable if there are sites in the hospital or elsewhere where it is out of contact; a solution that works on both cellular networks and Wi-Fi is essential. Some vendors offer the ability for messages not delivered to or acknowledged by the recipient to escalate to other forms of delivery after a specified period of time.
I would love to see a feature that I don’t think any vendor offers yet. It would be great if all messages the sender hasn’t marked “stat” or “urgent” first went to a queue in the EHR rather than immediately interrupting the recipient. That way a doctor or other caregiver could see messages while already working in the EHR, rather than glancing at each new message as it arrives, something that all too often needlessly interrupts another important task such as talking with a patient.
And, since most work in EHRs is done in front of a larger device with a full keyboard, it would be easier to type a quick reply message than it would be to rely on a smartphone keyboard for return messaging. Protocols could be established such that messages waiting in the EHR without a reply or dismissal after a specified time would then be sent to the recipient’s personal device.
A Texting Ecosystem
In nearly every case, the hospital will select the text messaging vendor, though hospitalists and nurses, who will typically be among the highest-volume users, should participate in the decision. But the real value of the system hinges on ensuring its wide adoption by most, or nearly all, hospital caregivers and affiliated ambulatory providers.
I would enjoy hearing from those who are already using a HIPAA-secure texting and pager replacement service now, as well as those still researching their options. This has the potential to meaningfully change the way hospitalists and others do their work.
Consider ACO Participation As Medicare Weighs Changes to Shared Savings Program
In December 2014, nearly three years since its launch, the Centers for Medicare and Medicaid Services (CMS) issued the first proposed rule changes to the Shared Savings Program. The changes, if approved, would take effect in the 2016 performance year and would focus on a host of alterations impacting participating accountable care organizations (ACOs), including reduced administrative burden, improved function and transparency, and enhanced incentives to participate in risk-based models.
Experts say the changes could address some of the biggest flaws in the program but also may not go far enough to incentivize more healthcare providers to participate—or protect them from the risk of financial loss. The rules are under review following a public comment period.
“Many features about the original rules weaken the incentives to participate in ACOs,” says Michael McWilliams, MD, PhD, associate professor of healthcare policy and medicine at Harvard Medical School and a practicing primary care physician at Brigham and Women’s Hospital in Boston.
The ACO model encourages providers to realize savings under fee-for-service Medicare through better-coordinated care and improvements in metrics related to utilization and quality. Any savings relative to a benchmark year are shared between the ACO and CMS.
This year, 424 ACOs are participating in the program nationwide, and while the number of Pioneer ACOs has fallen in recent years (Pioneer ACOs wager higher savings for participants at the risk of greater financial loss), a new independent report commissioned by CMS shows the program saved more than $300 annually per beneficiary in its first two years, achieving $384 million in savings.1 In a statement, CMS concluded this meets the criteria for expanding the Pioneer program; however, Dr. McWilliams says policy changes may still be needed to encourage participation in ACOs with downside risk.
In January, Dr. McWilliams and colleagues published a study in Health Affairs that demonstrated that existing benchmark rules may actually encourage higher Medicare spending as ACOs try to “fatten up” so they have more improvements to make and, therefore, more chance of success at realizing savings.2
Currently, providers’ performance is stacked against their performance and cost benchmarks established in the year prior to forming an ACO. As improvements are made, it becomes increasingly challenging for ACOs to do better. Dr. McWilliams says ACOs should instead be compared to other ACOs and providers.
It’s a “melting ice cube problem,” says Gregory Burke, MPA, director of innovation strategies for New York-based United Health Fund (UHF), a research and philanthropic organization focused on advancing healthcare.
—Gregory Burke, MPA, director of innovation Strategies, United Health Fund
“You are punishing the good, lean providers that are efficient,” he adds, “and rewarding people who are less efficient, in terms of cost of care and utilization of services.”
Burke and a colleague at UHF, health policy analyst Suzanne Brundage, recently completed qualitative and quantitative reports on ACOs in the state of New York, which currently make up 20% of Medicare fee-for-service beneficiaries.3,4
Through their analysis, which included structured interviews with 17 Pioneer ACO leaders, Burke and Brundage found ACO rules could change in the following ways to make the program sustainable and more attractive to providers:
- Patients should be attributed to PCPs within the ACO;
- Risk adjustment should be made for ACO providers serving a sicker population of patients; and
- Benchmark rules should be altered.
Additionally, Dr. McWilliams says the shared savings rate realized by ACOs should be higher than 50%, which is especially true for hospitals within an ACO, since the goals of the program are to reduce hospital visits, extensive specialist services, and testing services.
“For a hospital system, the bulk of the money comes from inpatient care,” Burke says. “We’re saying: ‘You stomp on your own air hose today, and a year from now I’ll give you 50% oxygen—and you have to share with your buddy.’”
The 2014 State of Hospital Medicine report indicates that 36% of adult hospitalist medicine groups are in hospitals either already involved in or considering involvement in an ACO; however, respondents in that report also reflect no clear role for hospitalists in the ACO model.
This is a point disputed by Val Akopov, MD, vice president and chief of hospital medicine at WellStar Health System, a not-for-profit organization in northwestern Atlanta and a participating ACO. Dr. Akopov highlights ways in which hospitals and hospitalists could take advantage of the model.
“Five measures fall into the domain of care coordination that are directly, unequivocally related to what hospitalists do, and these metrics are part of, in my opinion, what any hospital medicine program should have as a value proposition,” Dr. Akopov says.
At WellStar, for example, hospitalists have become part of the ACO structure by serving as medical directors and attending physicians at skilled nursing facilities (SNFs). They are “solely responsible to attend to patients in SNFs, and we have seen a dramatic improvement in readmission rates and quality metrics in nursing homes, such as incidence of falls, use of antipsychotics, and 30-day unplanned readmissions to acute care hospitals,” Dr. Akopov explains.
Additionally, WellStar hospitalists work with each inpatient to ensure they have primary care follow-up scheduled before discharge, Dr. Akopov says, noting that the model is a good opportunity to explore changes to the way hospitals and providers deliver care.
“There are roughly 38,000 Medicare patients in [our] ACO; it’s much easier to work out the kinks with innovations on a limited patient population and then extrapolate findings on 1.5 million annually, rather than trying to bite too much,” he says.
Despite the challenges, experts are optimistic the ACO model can—and will—work. In their reporting, Burke and Brundage found healthcare leaders participating in ACOs remain optimistic.
“It’s a post-Copernican universe, where the world no longer revolves around the hospital, so balancing the equation is a little different,” Burke says. “But they’re staying in the game, because that’s where the puck is going to be.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Affordable Care Act payment model saves more than $384 million in two years, meets criteria for first-ever expansion. Centers for Medicare & Medicaid Services website. Published May 4, 2015. Accessed May 11, 2015.
- Douven R, McGuire TG, McWilliams JM. Avoiding unintended incentives in ACO payment models. Health Aff. 2015;34(1):143-149.
- Burke, G, Brundage S. Accountable care in New York state: emerging themes and issues. United Hospital Fund. Accessed May 9, 2015.
- Burke, G and Brundage S. New York’s Medicare ACOs: participants and performance. United Hospital Fund. Accessed May 9, 2015.
In December 2014, nearly three years since its launch, the Centers for Medicare and Medicaid Services (CMS) issued the first proposed rule changes to the Shared Savings Program. The changes, if approved, would take effect in the 2016 performance year and would focus on a host of alterations impacting participating accountable care organizations (ACOs), including reduced administrative burden, improved function and transparency, and enhanced incentives to participate in risk-based models.
Experts say the changes could address some of the biggest flaws in the program but also may not go far enough to incentivize more healthcare providers to participate—or protect them from the risk of financial loss. The rules are under review following a public comment period.
“Many features about the original rules weaken the incentives to participate in ACOs,” says Michael McWilliams, MD, PhD, associate professor of healthcare policy and medicine at Harvard Medical School and a practicing primary care physician at Brigham and Women’s Hospital in Boston.
The ACO model encourages providers to realize savings under fee-for-service Medicare through better-coordinated care and improvements in metrics related to utilization and quality. Any savings relative to a benchmark year are shared between the ACO and CMS.
This year, 424 ACOs are participating in the program nationwide, and while the number of Pioneer ACOs has fallen in recent years (Pioneer ACOs wager higher savings for participants at the risk of greater financial loss), a new independent report commissioned by CMS shows the program saved more than $300 annually per beneficiary in its first two years, achieving $384 million in savings.1 In a statement, CMS concluded this meets the criteria for expanding the Pioneer program; however, Dr. McWilliams says policy changes may still be needed to encourage participation in ACOs with downside risk.
In January, Dr. McWilliams and colleagues published a study in Health Affairs that demonstrated that existing benchmark rules may actually encourage higher Medicare spending as ACOs try to “fatten up” so they have more improvements to make and, therefore, more chance of success at realizing savings.2
Currently, providers’ performance is stacked against their performance and cost benchmarks established in the year prior to forming an ACO. As improvements are made, it becomes increasingly challenging for ACOs to do better. Dr. McWilliams says ACOs should instead be compared to other ACOs and providers.
It’s a “melting ice cube problem,” says Gregory Burke, MPA, director of innovation strategies for New York-based United Health Fund (UHF), a research and philanthropic organization focused on advancing healthcare.
—Gregory Burke, MPA, director of innovation Strategies, United Health Fund
“You are punishing the good, lean providers that are efficient,” he adds, “and rewarding people who are less efficient, in terms of cost of care and utilization of services.”
Burke and a colleague at UHF, health policy analyst Suzanne Brundage, recently completed qualitative and quantitative reports on ACOs in the state of New York, which currently make up 20% of Medicare fee-for-service beneficiaries.3,4
Through their analysis, which included structured interviews with 17 Pioneer ACO leaders, Burke and Brundage found ACO rules could change in the following ways to make the program sustainable and more attractive to providers:
- Patients should be attributed to PCPs within the ACO;
- Risk adjustment should be made for ACO providers serving a sicker population of patients; and
- Benchmark rules should be altered.
Additionally, Dr. McWilliams says the shared savings rate realized by ACOs should be higher than 50%, which is especially true for hospitals within an ACO, since the goals of the program are to reduce hospital visits, extensive specialist services, and testing services.
“For a hospital system, the bulk of the money comes from inpatient care,” Burke says. “We’re saying: ‘You stomp on your own air hose today, and a year from now I’ll give you 50% oxygen—and you have to share with your buddy.’”
The 2014 State of Hospital Medicine report indicates that 36% of adult hospitalist medicine groups are in hospitals either already involved in or considering involvement in an ACO; however, respondents in that report also reflect no clear role for hospitalists in the ACO model.
This is a point disputed by Val Akopov, MD, vice president and chief of hospital medicine at WellStar Health System, a not-for-profit organization in northwestern Atlanta and a participating ACO. Dr. Akopov highlights ways in which hospitals and hospitalists could take advantage of the model.
“Five measures fall into the domain of care coordination that are directly, unequivocally related to what hospitalists do, and these metrics are part of, in my opinion, what any hospital medicine program should have as a value proposition,” Dr. Akopov says.
At WellStar, for example, hospitalists have become part of the ACO structure by serving as medical directors and attending physicians at skilled nursing facilities (SNFs). They are “solely responsible to attend to patients in SNFs, and we have seen a dramatic improvement in readmission rates and quality metrics in nursing homes, such as incidence of falls, use of antipsychotics, and 30-day unplanned readmissions to acute care hospitals,” Dr. Akopov explains.
Additionally, WellStar hospitalists work with each inpatient to ensure they have primary care follow-up scheduled before discharge, Dr. Akopov says, noting that the model is a good opportunity to explore changes to the way hospitals and providers deliver care.
“There are roughly 38,000 Medicare patients in [our] ACO; it’s much easier to work out the kinks with innovations on a limited patient population and then extrapolate findings on 1.5 million annually, rather than trying to bite too much,” he says.
Despite the challenges, experts are optimistic the ACO model can—and will—work. In their reporting, Burke and Brundage found healthcare leaders participating in ACOs remain optimistic.
“It’s a post-Copernican universe, where the world no longer revolves around the hospital, so balancing the equation is a little different,” Burke says. “But they’re staying in the game, because that’s where the puck is going to be.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Affordable Care Act payment model saves more than $384 million in two years, meets criteria for first-ever expansion. Centers for Medicare & Medicaid Services website. Published May 4, 2015. Accessed May 11, 2015.
- Douven R, McGuire TG, McWilliams JM. Avoiding unintended incentives in ACO payment models. Health Aff. 2015;34(1):143-149.
- Burke, G, Brundage S. Accountable care in New York state: emerging themes and issues. United Hospital Fund. Accessed May 9, 2015.
- Burke, G and Brundage S. New York’s Medicare ACOs: participants and performance. United Hospital Fund. Accessed May 9, 2015.
In December 2014, nearly three years since its launch, the Centers for Medicare and Medicaid Services (CMS) issued the first proposed rule changes to the Shared Savings Program. The changes, if approved, would take effect in the 2016 performance year and would focus on a host of alterations impacting participating accountable care organizations (ACOs), including reduced administrative burden, improved function and transparency, and enhanced incentives to participate in risk-based models.
Experts say the changes could address some of the biggest flaws in the program but also may not go far enough to incentivize more healthcare providers to participate—or protect them from the risk of financial loss. The rules are under review following a public comment period.
“Many features about the original rules weaken the incentives to participate in ACOs,” says Michael McWilliams, MD, PhD, associate professor of healthcare policy and medicine at Harvard Medical School and a practicing primary care physician at Brigham and Women’s Hospital in Boston.
The ACO model encourages providers to realize savings under fee-for-service Medicare through better-coordinated care and improvements in metrics related to utilization and quality. Any savings relative to a benchmark year are shared between the ACO and CMS.
This year, 424 ACOs are participating in the program nationwide, and while the number of Pioneer ACOs has fallen in recent years (Pioneer ACOs wager higher savings for participants at the risk of greater financial loss), a new independent report commissioned by CMS shows the program saved more than $300 annually per beneficiary in its first two years, achieving $384 million in savings.1 In a statement, CMS concluded this meets the criteria for expanding the Pioneer program; however, Dr. McWilliams says policy changes may still be needed to encourage participation in ACOs with downside risk.
In January, Dr. McWilliams and colleagues published a study in Health Affairs that demonstrated that existing benchmark rules may actually encourage higher Medicare spending as ACOs try to “fatten up” so they have more improvements to make and, therefore, more chance of success at realizing savings.2
Currently, providers’ performance is stacked against their performance and cost benchmarks established in the year prior to forming an ACO. As improvements are made, it becomes increasingly challenging for ACOs to do better. Dr. McWilliams says ACOs should instead be compared to other ACOs and providers.
It’s a “melting ice cube problem,” says Gregory Burke, MPA, director of innovation strategies for New York-based United Health Fund (UHF), a research and philanthropic organization focused on advancing healthcare.
—Gregory Burke, MPA, director of innovation Strategies, United Health Fund
“You are punishing the good, lean providers that are efficient,” he adds, “and rewarding people who are less efficient, in terms of cost of care and utilization of services.”
Burke and a colleague at UHF, health policy analyst Suzanne Brundage, recently completed qualitative and quantitative reports on ACOs in the state of New York, which currently make up 20% of Medicare fee-for-service beneficiaries.3,4
Through their analysis, which included structured interviews with 17 Pioneer ACO leaders, Burke and Brundage found ACO rules could change in the following ways to make the program sustainable and more attractive to providers:
- Patients should be attributed to PCPs within the ACO;
- Risk adjustment should be made for ACO providers serving a sicker population of patients; and
- Benchmark rules should be altered.
Additionally, Dr. McWilliams says the shared savings rate realized by ACOs should be higher than 50%, which is especially true for hospitals within an ACO, since the goals of the program are to reduce hospital visits, extensive specialist services, and testing services.
“For a hospital system, the bulk of the money comes from inpatient care,” Burke says. “We’re saying: ‘You stomp on your own air hose today, and a year from now I’ll give you 50% oxygen—and you have to share with your buddy.’”
The 2014 State of Hospital Medicine report indicates that 36% of adult hospitalist medicine groups are in hospitals either already involved in or considering involvement in an ACO; however, respondents in that report also reflect no clear role for hospitalists in the ACO model.
This is a point disputed by Val Akopov, MD, vice president and chief of hospital medicine at WellStar Health System, a not-for-profit organization in northwestern Atlanta and a participating ACO. Dr. Akopov highlights ways in which hospitals and hospitalists could take advantage of the model.
“Five measures fall into the domain of care coordination that are directly, unequivocally related to what hospitalists do, and these metrics are part of, in my opinion, what any hospital medicine program should have as a value proposition,” Dr. Akopov says.
At WellStar, for example, hospitalists have become part of the ACO structure by serving as medical directors and attending physicians at skilled nursing facilities (SNFs). They are “solely responsible to attend to patients in SNFs, and we have seen a dramatic improvement in readmission rates and quality metrics in nursing homes, such as incidence of falls, use of antipsychotics, and 30-day unplanned readmissions to acute care hospitals,” Dr. Akopov explains.
Additionally, WellStar hospitalists work with each inpatient to ensure they have primary care follow-up scheduled before discharge, Dr. Akopov says, noting that the model is a good opportunity to explore changes to the way hospitals and providers deliver care.
“There are roughly 38,000 Medicare patients in [our] ACO; it’s much easier to work out the kinks with innovations on a limited patient population and then extrapolate findings on 1.5 million annually, rather than trying to bite too much,” he says.
Despite the challenges, experts are optimistic the ACO model can—and will—work. In their reporting, Burke and Brundage found healthcare leaders participating in ACOs remain optimistic.
“It’s a post-Copernican universe, where the world no longer revolves around the hospital, so balancing the equation is a little different,” Burke says. “But they’re staying in the game, because that’s where the puck is going to be.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- Affordable Care Act payment model saves more than $384 million in two years, meets criteria for first-ever expansion. Centers for Medicare & Medicaid Services website. Published May 4, 2015. Accessed May 11, 2015.
- Douven R, McGuire TG, McWilliams JM. Avoiding unintended incentives in ACO payment models. Health Aff. 2015;34(1):143-149.
- Burke, G, Brundage S. Accountable care in New York state: emerging themes and issues. United Hospital Fund. Accessed May 9, 2015.
- Burke, G and Brundage S. New York’s Medicare ACOs: participants and performance. United Hospital Fund. Accessed May 9, 2015.
Hospitals’ Uncompensated Costs Estimated at $27.3 Billion in 2014
The estimated total amount of uncompensated costs incurred by hospitals in 2014 was $27.3 billion, which is $7.4 billion, or 21 percent, less than uncompensated hospital care would have been in 2014 at 2013 levels, before Accountable Care Act Medicaid coverage provisions took effect. Federal data reported by CNBC on March 23 indicate most of the reduction came in the 28 states and the District of Columbia that expanded their Medicare programs under the act to cover nearly all poor people in their states, while those that did not could have seen their revenues decline by an additional $1.4 billion.
The estimated total amount of uncompensated costs incurred by hospitals in 2014 was $27.3 billion, which is $7.4 billion, or 21 percent, less than uncompensated hospital care would have been in 2014 at 2013 levels, before Accountable Care Act Medicaid coverage provisions took effect. Federal data reported by CNBC on March 23 indicate most of the reduction came in the 28 states and the District of Columbia that expanded their Medicare programs under the act to cover nearly all poor people in their states, while those that did not could have seen their revenues decline by an additional $1.4 billion.
The estimated total amount of uncompensated costs incurred by hospitals in 2014 was $27.3 billion, which is $7.4 billion, or 21 percent, less than uncompensated hospital care would have been in 2014 at 2013 levels, before Accountable Care Act Medicaid coverage provisions took effect. Federal data reported by CNBC on March 23 indicate most of the reduction came in the 28 states and the District of Columbia that expanded their Medicare programs under the act to cover nearly all poor people in their states, while those that did not could have seen their revenues decline by an additional $1.4 billion.
Quality Data Dashboards Provide Performance Feedback to Physicians
A best-of-research plenary presentation at HM15 in National Harbor, Md., described a project to link physicians’ schedules to the electronic health record (EHR) in order to provide real-time, individualized performance feedback on key quality improvement and value metrics.
The abstract’s lead author, Victoria Valencia, MPH, a research data and project manager at the University of California San Francisco (UCSF), explains that quality improvement priorities have driven feedback of quality metrics at the department level.
“Where I came in was to try to get the same quality metrics down to the level of the team,” she says. “We take data from our EPIC EHR, clean it up by removing outliers, merge it with our online scheduling program, and provide a robust visual presentation of individualized, real-time performance feedback to the clinical team.”
–Dr. Valencia
One example is counting the total number of phlebotomy “sticks” per day, per patient. Reporting this data helped to reduce the number of “sticks per day” by 20%, to 1.6 from 2.0. A similar approach is used for care transitions and the percentage of discharges with high-quality, after-visit summaries.
“The feedback is timely and actionable and allows the teams to address areas needing improvement,” Valencia says.
How have the doctors responded to this feedback?
“Our division is used to receiving quality feedback as part of an ongoing process that includes working meetings where the metrics are reviewed,” she says, adding that there hasn’t been pushback from the teams over these reports.
A best-of-research plenary presentation at HM15 in National Harbor, Md., described a project to link physicians’ schedules to the electronic health record (EHR) in order to provide real-time, individualized performance feedback on key quality improvement and value metrics.
The abstract’s lead author, Victoria Valencia, MPH, a research data and project manager at the University of California San Francisco (UCSF), explains that quality improvement priorities have driven feedback of quality metrics at the department level.
“Where I came in was to try to get the same quality metrics down to the level of the team,” she says. “We take data from our EPIC EHR, clean it up by removing outliers, merge it with our online scheduling program, and provide a robust visual presentation of individualized, real-time performance feedback to the clinical team.”
–Dr. Valencia
One example is counting the total number of phlebotomy “sticks” per day, per patient. Reporting this data helped to reduce the number of “sticks per day” by 20%, to 1.6 from 2.0. A similar approach is used for care transitions and the percentage of discharges with high-quality, after-visit summaries.
“The feedback is timely and actionable and allows the teams to address areas needing improvement,” Valencia says.
How have the doctors responded to this feedback?
“Our division is used to receiving quality feedback as part of an ongoing process that includes working meetings where the metrics are reviewed,” she says, adding that there hasn’t been pushback from the teams over these reports.
A best-of-research plenary presentation at HM15 in National Harbor, Md., described a project to link physicians’ schedules to the electronic health record (EHR) in order to provide real-time, individualized performance feedback on key quality improvement and value metrics.
The abstract’s lead author, Victoria Valencia, MPH, a research data and project manager at the University of California San Francisco (UCSF), explains that quality improvement priorities have driven feedback of quality metrics at the department level.
“Where I came in was to try to get the same quality metrics down to the level of the team,” she says. “We take data from our EPIC EHR, clean it up by removing outliers, merge it with our online scheduling program, and provide a robust visual presentation of individualized, real-time performance feedback to the clinical team.”
–Dr. Valencia
One example is counting the total number of phlebotomy “sticks” per day, per patient. Reporting this data helped to reduce the number of “sticks per day” by 20%, to 1.6 from 2.0. A similar approach is used for care transitions and the percentage of discharges with high-quality, after-visit summaries.
“The feedback is timely and actionable and allows the teams to address areas needing improvement,” Valencia says.
How have the doctors responded to this feedback?
“Our division is used to receiving quality feedback as part of an ongoing process that includes working meetings where the metrics are reviewed,” she says, adding that there hasn’t been pushback from the teams over these reports.
Why Physicians Override Best Practice Alerts
Research published earlier this year in the Journal of Hospital Medicine finds that rationales offered by physicians for overriding interruptive, computerized best practice alerts (BPAs) regarding whether or not to give blood transfusions vary widely, including specialty service protocolized behaviors, anticipation of surgical or procedural interventions, and imminent hospital transfers.
The electronic health record at Stanford University Medical Center in Palo Alto, Calif., has an automated alert function to check reported hemoglobin level and trigger a pop-up reminder when a doctor orders a transfusion for a patient with a hemoglobin level of 9 or above—outside of the recognized guidelines—prompting the doctor to either abort the transfusion or provide a reason for the override, explains co-author Lisa Shieh, MD, PhD, FHM, medical director of quality in the department of medicine at Stanford.
“Our study was trying to understand why providers still transfuse, even when we provide just-in-time education on transfusion recommendations,” she says. “We can’t say that all of these orders are inappropriate. But, for many reasons, blood has harms and is costly.
“We want to convey an overall understanding about why this issue is important.”
Although a substantial number of transfusions continue outside of the recommended guidelines, Stanford has reduced its numbers significantly.
“I’m a big believer in clinical decision support … if it’s designed well and doesn’t add to alert fatigue,” Dr. Shieh says. “I think this BPA was effective in education and making people stop and think why they were ordering transfusions. Our next step will be to look at the outlier practices and maybe have a conversation with them, doctor to doctor.”
Stanford is looking at sepsis treatment as a next target.
Research published earlier this year in the Journal of Hospital Medicine finds that rationales offered by physicians for overriding interruptive, computerized best practice alerts (BPAs) regarding whether or not to give blood transfusions vary widely, including specialty service protocolized behaviors, anticipation of surgical or procedural interventions, and imminent hospital transfers.
The electronic health record at Stanford University Medical Center in Palo Alto, Calif., has an automated alert function to check reported hemoglobin level and trigger a pop-up reminder when a doctor orders a transfusion for a patient with a hemoglobin level of 9 or above—outside of the recognized guidelines—prompting the doctor to either abort the transfusion or provide a reason for the override, explains co-author Lisa Shieh, MD, PhD, FHM, medical director of quality in the department of medicine at Stanford.
“Our study was trying to understand why providers still transfuse, even when we provide just-in-time education on transfusion recommendations,” she says. “We can’t say that all of these orders are inappropriate. But, for many reasons, blood has harms and is costly.
“We want to convey an overall understanding about why this issue is important.”
Although a substantial number of transfusions continue outside of the recommended guidelines, Stanford has reduced its numbers significantly.
“I’m a big believer in clinical decision support … if it’s designed well and doesn’t add to alert fatigue,” Dr. Shieh says. “I think this BPA was effective in education and making people stop and think why they were ordering transfusions. Our next step will be to look at the outlier practices and maybe have a conversation with them, doctor to doctor.”
Stanford is looking at sepsis treatment as a next target.
Research published earlier this year in the Journal of Hospital Medicine finds that rationales offered by physicians for overriding interruptive, computerized best practice alerts (BPAs) regarding whether or not to give blood transfusions vary widely, including specialty service protocolized behaviors, anticipation of surgical or procedural interventions, and imminent hospital transfers.
The electronic health record at Stanford University Medical Center in Palo Alto, Calif., has an automated alert function to check reported hemoglobin level and trigger a pop-up reminder when a doctor orders a transfusion for a patient with a hemoglobin level of 9 or above—outside of the recognized guidelines—prompting the doctor to either abort the transfusion or provide a reason for the override, explains co-author Lisa Shieh, MD, PhD, FHM, medical director of quality in the department of medicine at Stanford.
“Our study was trying to understand why providers still transfuse, even when we provide just-in-time education on transfusion recommendations,” she says. “We can’t say that all of these orders are inappropriate. But, for many reasons, blood has harms and is costly.
“We want to convey an overall understanding about why this issue is important.”
Although a substantial number of transfusions continue outside of the recommended guidelines, Stanford has reduced its numbers significantly.
“I’m a big believer in clinical decision support … if it’s designed well and doesn’t add to alert fatigue,” Dr. Shieh says. “I think this BPA was effective in education and making people stop and think why they were ordering transfusions. Our next step will be to look at the outlier practices and maybe have a conversation with them, doctor to doctor.”
Stanford is looking at sepsis treatment as a next target.
Hospitals with Hotel-Like Amenities Don’t Improve Satisfaction Scores
Hospital design may not contribute to patients’ satisfaction with the care given by their hospital professionals, according to new research from Johns Hopkins Hospital in Baltimore, published in the Journal of Hospital Medicine. Newly built hospitals often emphasize patient-centered features like reduced noise, natural light, visitor-friendly facilities, well-designed rooms, and hotel-like amenities, note the authors, led by Zishan Siddiqui, MD, attending physician and assistant professor of medicine at Johns Hopkins.
When Hopkins moved a number of its hospital units to the sleek new Sheikh Zayed Tower in 2012, researchers used a pre-post design experiment to compare patient satisfaction in the newer, more pleasing surroundings via Press Ganey and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores. Patients responded positively to the new environment, with significant improvement in facility-related satisfaction, but were able to distinguish that satisfaction from their ratings of their doctors and nurses, which were not impacted by the new environment.
“It is more likely that provider-level interventions will have a greater impact on provider level and overall satisfaction,” the authors conclude. “Hospital administrators should not use outdated facilities as an excuse for suboptimal provider satisfaction scores.”
Hospital design may not contribute to patients’ satisfaction with the care given by their hospital professionals, according to new research from Johns Hopkins Hospital in Baltimore, published in the Journal of Hospital Medicine. Newly built hospitals often emphasize patient-centered features like reduced noise, natural light, visitor-friendly facilities, well-designed rooms, and hotel-like amenities, note the authors, led by Zishan Siddiqui, MD, attending physician and assistant professor of medicine at Johns Hopkins.
When Hopkins moved a number of its hospital units to the sleek new Sheikh Zayed Tower in 2012, researchers used a pre-post design experiment to compare patient satisfaction in the newer, more pleasing surroundings via Press Ganey and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores. Patients responded positively to the new environment, with significant improvement in facility-related satisfaction, but were able to distinguish that satisfaction from their ratings of their doctors and nurses, which were not impacted by the new environment.
“It is more likely that provider-level interventions will have a greater impact on provider level and overall satisfaction,” the authors conclude. “Hospital administrators should not use outdated facilities as an excuse for suboptimal provider satisfaction scores.”
Hospital design may not contribute to patients’ satisfaction with the care given by their hospital professionals, according to new research from Johns Hopkins Hospital in Baltimore, published in the Journal of Hospital Medicine. Newly built hospitals often emphasize patient-centered features like reduced noise, natural light, visitor-friendly facilities, well-designed rooms, and hotel-like amenities, note the authors, led by Zishan Siddiqui, MD, attending physician and assistant professor of medicine at Johns Hopkins.
When Hopkins moved a number of its hospital units to the sleek new Sheikh Zayed Tower in 2012, researchers used a pre-post design experiment to compare patient satisfaction in the newer, more pleasing surroundings via Press Ganey and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores. Patients responded positively to the new environment, with significant improvement in facility-related satisfaction, but were able to distinguish that satisfaction from their ratings of their doctors and nurses, which were not impacted by the new environment.
“It is more likely that provider-level interventions will have a greater impact on provider level and overall satisfaction,” the authors conclude. “Hospital administrators should not use outdated facilities as an excuse for suboptimal provider satisfaction scores.”
Hospitalists Should Make Commitment to Improve Healthcare Safety
Peter Pronovost, MD, PhD, FCCM, knows how to deliver a great talk. It is no wonder he is highly sought after and was asked to speak at the plenary for SHM’s annual meeting. Dr. Pronovost, also known as the “Checklist Doctor,” knows how to combine just the right amount of sadness, inspiration, and humor to make his audience feel motivated and compelled to DO something. And, in fact, he implores you—DO something.
Most of us feel excited and inspired during the annual meeting. But those feelings serve little purpose unless we translate them into actions that will make the medical industry a better place for clinicians to work and for patients to receive care. As Dr. Pronovost said, “We are the only hope that the healthcare system has of improving quality and safety.”
He was inspired years ago by the watershed event that will forever be imprinted upon Johns Hopkins Hospital in Baltimore, the preventable death of 18-month-old Josie King on Feb. 22, 2001. Years after the event, her mother, Sorrel King, a passionate patient safety advocate, wanted to know if hospitals are any safer than they were the day that Josie died. She wanted to know what patient safety experts at Hopkins had done to ensure there would not be another Josie King story.
Patients and their families consistently voice similar desires after they have suffered preventable harm. They want to know what happened, why it happened, what it means for them, and what will be done to prevent it from happening again.1 The latter question is one I am frequently asked by patients and their families at my hospital. “What are you going to do to make sure this does not happen again?”
I would venture to guess most hospitalists have been responsible for some type of preventable patient harm during their careers. We work in complex, high-volume, unpredictable, and continuously changing environments. Many of the patients and families in our care are new to us and are with us for only short periods of time. Those of us who have been responsible for preventable patient harm know that it is an unforgettable moment in time that can weigh upon your conscious. And, of course, we all want to do something to make sure it does not happen again.
That is exactly what patients and their families expect of all of us—to DO something—and they should.
But this can be an overwhelming responsibility, especially when the root causes of harm are difficult either to identify or to fix—such as a miscommunication, a diagnostic error, or an inadequate handoff.
Which gets me back to Dr. Pronovost giving a great talk. His appeal to our audience of about 3,000 hospitalists was to DO something. To make the healthcare system improve quality and safety for future patients. To not wait until we or our colleagues are involved in a preventable harm event. To do something, anything, now, that contributes to safer care, today and every day going forward.
He ended his talk with “I will….” Dr. Pronovost (and I would venture to guess patients and their families) wants each of us to fill in the blank with a statement of personal accountability for action. Unfortunately, many of us still believe that we are personally unable to make complex systems safer for patients. Many of us still believe that patients and the systems they traverse are too complex, unpredictable, unreliable, or noncompliant.
The truth is, patients and systems are indeed complex, unpredictable, unreliable, and noncompliant. The further truth is, the only way to make care safer is for each of us to start with a collective shared mental model that we can make it better—and for each of us to commit to personal accountability for action.
My “I Will”
So, while I really enjoyed Dr. Pronovost’s talk, what I enjoyed even more was reading the section in last month’s edition of The Hospitalist in which about a half dozen hospitalists interviewed after the plenary accepted the challenge of filling in the blank “I will….” A few excerpts:
- “I will let them know that everything is possible…”
- “I will improve healthcare…”
- “[I will] make sure the patient is heard…”
By a simple proclamation of personal accountability, a mere thousand hospitalists attending an annual meeting can collectively and progressively change the safety of healthcare in thousands of hospitals around the country. It starts with thinking we can do it and publicly committing to the journey. Although we are still a relatively new specialty, we have permeated almost every hospital in the country, and we have outpaced the growth of any specialty in the history of modern medicine. We are perfectly poised to be the safety change agents for every hospital system. As Margaret Meade famously said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has….”
So don’t delay. Whether or not you had the good fortune of being inspired at the SHM annual meeting, each of us owes it to our patients to commit to improving the safety of healthcare and paving the future of hospital care. Get out your pen, craft a commitment now, follow through with it, and make hospitals safer tomorrow than they were yesterday.
I will…
Reference
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
Peter Pronovost, MD, PhD, FCCM, knows how to deliver a great talk. It is no wonder he is highly sought after and was asked to speak at the plenary for SHM’s annual meeting. Dr. Pronovost, also known as the “Checklist Doctor,” knows how to combine just the right amount of sadness, inspiration, and humor to make his audience feel motivated and compelled to DO something. And, in fact, he implores you—DO something.
Most of us feel excited and inspired during the annual meeting. But those feelings serve little purpose unless we translate them into actions that will make the medical industry a better place for clinicians to work and for patients to receive care. As Dr. Pronovost said, “We are the only hope that the healthcare system has of improving quality and safety.”
He was inspired years ago by the watershed event that will forever be imprinted upon Johns Hopkins Hospital in Baltimore, the preventable death of 18-month-old Josie King on Feb. 22, 2001. Years after the event, her mother, Sorrel King, a passionate patient safety advocate, wanted to know if hospitals are any safer than they were the day that Josie died. She wanted to know what patient safety experts at Hopkins had done to ensure there would not be another Josie King story.
Patients and their families consistently voice similar desires after they have suffered preventable harm. They want to know what happened, why it happened, what it means for them, and what will be done to prevent it from happening again.1 The latter question is one I am frequently asked by patients and their families at my hospital. “What are you going to do to make sure this does not happen again?”
I would venture to guess most hospitalists have been responsible for some type of preventable patient harm during their careers. We work in complex, high-volume, unpredictable, and continuously changing environments. Many of the patients and families in our care are new to us and are with us for only short periods of time. Those of us who have been responsible for preventable patient harm know that it is an unforgettable moment in time that can weigh upon your conscious. And, of course, we all want to do something to make sure it does not happen again.
That is exactly what patients and their families expect of all of us—to DO something—and they should.
But this can be an overwhelming responsibility, especially when the root causes of harm are difficult either to identify or to fix—such as a miscommunication, a diagnostic error, or an inadequate handoff.
Which gets me back to Dr. Pronovost giving a great talk. His appeal to our audience of about 3,000 hospitalists was to DO something. To make the healthcare system improve quality and safety for future patients. To not wait until we or our colleagues are involved in a preventable harm event. To do something, anything, now, that contributes to safer care, today and every day going forward.
He ended his talk with “I will….” Dr. Pronovost (and I would venture to guess patients and their families) wants each of us to fill in the blank with a statement of personal accountability for action. Unfortunately, many of us still believe that we are personally unable to make complex systems safer for patients. Many of us still believe that patients and the systems they traverse are too complex, unpredictable, unreliable, or noncompliant.
The truth is, patients and systems are indeed complex, unpredictable, unreliable, and noncompliant. The further truth is, the only way to make care safer is for each of us to start with a collective shared mental model that we can make it better—and for each of us to commit to personal accountability for action.
My “I Will”
So, while I really enjoyed Dr. Pronovost’s talk, what I enjoyed even more was reading the section in last month’s edition of The Hospitalist in which about a half dozen hospitalists interviewed after the plenary accepted the challenge of filling in the blank “I will….” A few excerpts:
- “I will let them know that everything is possible…”
- “I will improve healthcare…”
- “[I will] make sure the patient is heard…”
By a simple proclamation of personal accountability, a mere thousand hospitalists attending an annual meeting can collectively and progressively change the safety of healthcare in thousands of hospitals around the country. It starts with thinking we can do it and publicly committing to the journey. Although we are still a relatively new specialty, we have permeated almost every hospital in the country, and we have outpaced the growth of any specialty in the history of modern medicine. We are perfectly poised to be the safety change agents for every hospital system. As Margaret Meade famously said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has….”
So don’t delay. Whether or not you had the good fortune of being inspired at the SHM annual meeting, each of us owes it to our patients to commit to improving the safety of healthcare and paving the future of hospital care. Get out your pen, craft a commitment now, follow through with it, and make hospitals safer tomorrow than they were yesterday.
I will…
Reference
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
Peter Pronovost, MD, PhD, FCCM, knows how to deliver a great talk. It is no wonder he is highly sought after and was asked to speak at the plenary for SHM’s annual meeting. Dr. Pronovost, also known as the “Checklist Doctor,” knows how to combine just the right amount of sadness, inspiration, and humor to make his audience feel motivated and compelled to DO something. And, in fact, he implores you—DO something.
Most of us feel excited and inspired during the annual meeting. But those feelings serve little purpose unless we translate them into actions that will make the medical industry a better place for clinicians to work and for patients to receive care. As Dr. Pronovost said, “We are the only hope that the healthcare system has of improving quality and safety.”
He was inspired years ago by the watershed event that will forever be imprinted upon Johns Hopkins Hospital in Baltimore, the preventable death of 18-month-old Josie King on Feb. 22, 2001. Years after the event, her mother, Sorrel King, a passionate patient safety advocate, wanted to know if hospitals are any safer than they were the day that Josie died. She wanted to know what patient safety experts at Hopkins had done to ensure there would not be another Josie King story.
Patients and their families consistently voice similar desires after they have suffered preventable harm. They want to know what happened, why it happened, what it means for them, and what will be done to prevent it from happening again.1 The latter question is one I am frequently asked by patients and their families at my hospital. “What are you going to do to make sure this does not happen again?”
I would venture to guess most hospitalists have been responsible for some type of preventable patient harm during their careers. We work in complex, high-volume, unpredictable, and continuously changing environments. Many of the patients and families in our care are new to us and are with us for only short periods of time. Those of us who have been responsible for preventable patient harm know that it is an unforgettable moment in time that can weigh upon your conscious. And, of course, we all want to do something to make sure it does not happen again.
That is exactly what patients and their families expect of all of us—to DO something—and they should.
But this can be an overwhelming responsibility, especially when the root causes of harm are difficult either to identify or to fix—such as a miscommunication, a diagnostic error, or an inadequate handoff.
Which gets me back to Dr. Pronovost giving a great talk. His appeal to our audience of about 3,000 hospitalists was to DO something. To make the healthcare system improve quality and safety for future patients. To not wait until we or our colleagues are involved in a preventable harm event. To do something, anything, now, that contributes to safer care, today and every day going forward.
He ended his talk with “I will….” Dr. Pronovost (and I would venture to guess patients and their families) wants each of us to fill in the blank with a statement of personal accountability for action. Unfortunately, many of us still believe that we are personally unable to make complex systems safer for patients. Many of us still believe that patients and the systems they traverse are too complex, unpredictable, unreliable, or noncompliant.
The truth is, patients and systems are indeed complex, unpredictable, unreliable, and noncompliant. The further truth is, the only way to make care safer is for each of us to start with a collective shared mental model that we can make it better—and for each of us to commit to personal accountability for action.
My “I Will”
So, while I really enjoyed Dr. Pronovost’s talk, what I enjoyed even more was reading the section in last month’s edition of The Hospitalist in which about a half dozen hospitalists interviewed after the plenary accepted the challenge of filling in the blank “I will….” A few excerpts:
- “I will let them know that everything is possible…”
- “I will improve healthcare…”
- “[I will] make sure the patient is heard…”
By a simple proclamation of personal accountability, a mere thousand hospitalists attending an annual meeting can collectively and progressively change the safety of healthcare in thousands of hospitals around the country. It starts with thinking we can do it and publicly committing to the journey. Although we are still a relatively new specialty, we have permeated almost every hospital in the country, and we have outpaced the growth of any specialty in the history of modern medicine. We are perfectly poised to be the safety change agents for every hospital system. As Margaret Meade famously said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has….”
So don’t delay. Whether or not you had the good fortune of being inspired at the SHM annual meeting, each of us owes it to our patients to commit to improving the safety of healthcare and paving the future of hospital care. Get out your pen, craft a commitment now, follow through with it, and make hospitals safer tomorrow than they were yesterday.
I will…
Reference
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
How Should a Patient with Pulmonary Hypertension Be Evaluated, Managed?
Case
A 62-year-old female with no significant past medical history presents with three weeks of progressive dyspnea on exertion and bilateral lower extremity edema. Family members report that the patient often snores and “gasps for air” during sleep. B-type natriuretic peptide is elevated at 2,261 pg/ml. Due to concern for congestive heart failure, transthoracic echocardiography (TTE) is performed and shows normal left ventricular systolic function, mild left ventricular diastolic dysfunction, severely elevated right ventricular systolic pressure of 74 mm Hg, and right ventricular dilatation and hypokinesis.
How should this patient with newfound pulmonary hypertension (PH) be evaluated and managed?
Background
PH is a progressive disease that presents with nonspecific signs and symptoms and can be fatal if untreated. Ernst von Romberg first identified the disease in 1891, and efforts have been made through the last century to understand its etiology and mechanisms.1
PH is defined as an elevated mean pulmonary arterial pressure (mPAP) of ≥25 mmHg at rest; a mPAP of ≤20 mmHg is considered normal, and a mPAP of 21-24 mmHg is borderline.2 This elevation of the mPAP can be due to a primary elevation of pressures in the pulmonary arterial system alone (pulmonary arterial hypertension) or secondary to elevation in pressures in the pulmonary venous and pulmonary capillary systems (pulmonary venous hypertension).
PH classification has endured many modifications through the years with better understanding of its pathophysiology. Currently, the World Health Organization (WHO) classification system includes five groups based on etiology (see Table 1):3,4
- Group 1: Pulmonary arterial hypertension (PAH);
- Group 2: PH due to left heart disease;
- Group 3: PH due to chronic lung disease and hypoxemia;
- Group 4: Chronic thromboembolic PH (CTEPH); and
- Group 5: PH due to unclear multifactorial mechanisms.
The pathophysiology differs among the groups, and much of what is known has come from studies performed in patients with idiopathic PAH. It is a proliferative vasculopathy characterized by vasoconstriction, cell proliferation, fibrosis, and thrombosis. Both genetic predisposition and modifiers that include drugs and toxins, human immunodeficiency virus (HIV), congenital heart disease with left-to-right shunting, and potassium channel dysfunction play a role in the pathogenesis.3,5,6 Although many processes underlying the pathophysiology of PH groups 2, 3, 4, and 5 are not fully understood, vascular remodeling and increased vascular resistance are common to all of them.
PH affects both genders and all age groups and races. Due to its broad classification and multiple etiologies, it is difficult to assess PH prevalence in the general population. There are wide ranges among different populations, with PH prevalence in sickle cell disease ranging from 20% to 40%, in systemic sclerosis from 10% to 15%, and in portal hypertension from 2% to 16%.7,8,9 PH in COPD is usually mild to moderate, with preserved cardiac output, although a minority of patients develop severe PH.10-12 PH is present in approximately 20% of patients with moderate to severe sleep apnea.13 The prevalence of PH in left heart disease is unknown due to variability in populations assessed and methods used in various studies; estimates have ranged from 25-100%.14
Evaluation
Initial evaluation: A thorough history and physical examination can help determine PH etiology, identify associated conditions, and determine the severity of disease. Dyspnea on exertion is the most common presenting complaint; weakness, fatigue, and angina may be present.15 Lower extremity edema and ascites are indicative of more advanced disease.
A patient’s symptoms may suggest the presence of undiagnosed conditions that are associated with PH, and past medical history should evaluate for previous diagnoses of these conditions (see Table 1).
Family history may reveal relatives with PH, given the genetic predisposition to development of Group 1 PH. Physical exam findings include a prominent pulmonic valve closure during the second heart sound, a palpable left parasternal heave, and a tricuspid regurgitation murmur.
Electrocardiogram (ECG) and chest X-ray (CXR) are not sufficiently sensitive or specific to diagnose PH but may provide initial supporting evidence that prompts further testing. Signs of right ventricular hypertrophy and right atrial enlargement may be present on ECG. The CXR may show pruning (prominent hilar vasculature with reduced vasculature peripherally) and right ventricular hypertrophy, as evidenced by shrinking of the retrosternal window on lateral CXR. An unremarkable ECG or normal CXR does not rule out PH.
Echocardiography: TTE allows estimation of pulmonary artery systolic pressure (PASP) via measurement of tricuspid regurgitation jet velocity and estimation of right atrial pressure. Although results of TTE do correlate with measurements from right heart catheterization (RHC), underestimation and overestimation commonly occur. PASP thresholds for diagnosing or ruling out PH cannot thus be defined easily. An elevated PASP less than 36 mmHg, tricuspid regurgitation velocity <2.8 m/s, and no additional echocardiographic variables suggestive of PH may indicate that PH is unlikely, based on arbitrary criteria from one clinical practice guideline.16
The guideline suggested that tricuspid regurgitation velocity >3.4 m/s or estimated PASP >50 mmHg indicated that PH was likely. Other echocardiographic variables that may suggest the presence of PH include right ventricular enlargement or intraventricular septal flattening. Finally, TTE should also be used to assess for possible causes of PH, such as left heart disease or cardiac shunts.
Further evaluation: Following identification of PH via TTE, further testing can confirm the diagnosis, determine the etiology of the PH, and allow appropriate treatment (see Table 2). Much of this evaluation may occur after hospital discharge and, in cases of unexplained PH, referral to a pulmonologist for further evaluation and management is appropriate. Depending on patient stability, test availability, and patient ability to follow up, some testing may be reasonable during the inpatient stay.
Patients should undergo a stepwise series of testing that initially may be guided by clinical suspicion for underlying conditions.15-19 Polysomnography can identify sleep-disordered breathing, and pulmonary function tests and high-resolution chest CT can assess for chronic pulmonary diseases. Patients with groups 2 and 3 PH, whose PH can be explained by left heart disease or lung disease, do not necessarily require RHC or extensive evaluation for other etiologies of PH.2,17 These patients may be monitored while their underlying conditions are managed.
Patients with worsening clinical course or PH that is “out of proportion” to their lung disease or heart disease, however, do require further evaluation, including RHC. “Out of proportion” has not been consistently defined but generally refers to severe PH observed in patients with mild left heart or lung disease.18 More precise terminology and criteria to define patients with out of proportion PH have been proposed.14
Ventilation-perfusion scanning is required in all cases of PH of unknown etiology to evaluate for CTEPH (Group 4 PH). CT angiography, while appropriate to use in testing for acute pulmonary embolism, is not sufficiently sensitive to evaluate for CTEPH. Tests for liver function, HIV, and connective tissue disease may identify conditions associated with Group 1 PH. Ultimately, RHC is required to confirm the diagnosis of PH, given the shortcomings of TTE. A vasodilator study during RHC allows identification of candidates for advanced therapies, such as patients with Group 1 PH.
Management
The prognosis and treatment of PH varies by WHO Group. The hospitalist will often undertake initial management of symptomatic patients (see Table 3). Intravenous loop diuretics will successfully treat peripheral edema and hepatic congestion in all PH patients.20 Due to the possibility of decreased cardiac output or worsened hypotension in some PH groups, patients should be monitored closely during initial diuresis.
All patients with PH should be assessed for hypoxia during rest, ambulation, and sleep during their hospitalization. Supplemental oxygen therapy should be initiated in all patients with evidence of persistent hypoxia (arterial oxygen blood pressure <60 mmHg).20 Vaccination against pneumococcus and influenza should also be performed during the initial hospitalization. Pregnant patients diagnosed with PH require urgent maternal-fetal medicine consultation.
Further management should be guided by the underlying etiology of the PH:17,18
- Group 1 PH. These patients should be evaluated by a pulmonology consultant, if one is available, as they require intense outpatient follow-up with a pulmonologist. Specialized treatment regimens include calcium channel blockers, phosphodiesterase inhibitors, prostanoids, endothelin receptor antagonists, or newly approved guanylate cyclase stimulants. In previously diagnosed patients, these medications should be continued during a patient’s admission unless the medication is clearly causing the patient harm (such as worsening hypotension) or preventing improvement. Many of these patients are placed on chronic anticoagulation with warfarin, with a goal international normalized ratio (INR) of 1.5 to 2.5.
- Group 2 PH. Patients with left heart or valvular dysfunction and PH have a worse prognosis than similar patients without PH. Management of these patients should focus on treating the underlying etiology. Use of prostanoids may be harmful in this patient population.18
- Group 3 PH. Patients whose PH is fully explained by pulmonary disease should be started on continuous oxygen therapy to treat persistent hypoxemia, and their underlying disorder should be treated, with pulmonologist consultation and referral if necessary.
- Group 4 PH. Patients with newly diagnosed CTEPH should be initiated on warfarin with a goal INR of 2.0 to 3.0. They should undergo evaluation by a pulmonologist for thromboendarterectomy and possibly advanced medical therapies.
- Group 5 PH. Patients with sarcoidosis as the cause of their PH may benefit from prostanoid or endothelin receptor antagonist therapy and should undergo evaluation by a pulmonologist.21,22
Patients with sickle cell anemia, metabolic disorders, and other causes should undergo further subspecialist evaluation prior to initiating therapy to treat their PH.
Back to the Case
The patient underwent diuresis with intravenous furosemide over several days, with gradual improvement in her lower extremity edema and dyspnea. She was placed on oxygen therapy for persistent hypoxemia. As her highly elevated pulmonary artery pressure appeared to be “out of proportion” to her mild left ventricular diastolic dysfunction, further evaluation was pursued. Ventilation-perfusion scanning was performed and showed no mismatch of perfusion and ventilation, effectively ruling out CTEPH. Liver function, HIV, and connective tissue disease testing yielded unremarkable results.
The patient was euvolemic after one week of diuresis and was discharged home with plans for PH specialist follow-up, polysomnography to evaluate for sleep-disordered breathing, and likely RHC. The etiology of her PH was not clear at discharge.
Bottom Line
Evaluation of PH is a step-wise process that starts with history and physical exam and may require extensive evaluation, including right heart catheterization to confirm the diagnosis and define the etiology. A primary goal of evaluation is to define the appropriate therapy for a given patient, which may include advanced therapies in some cases.
Dr. Griffith is a quality improvement fellow and instructor of medicine in the Hospital Medicine Division at the University of Colorado Denver. Drs. McFarland and Smolkin are hospitalists and instructors of medicine at the University of Colorado Denver.
References
- von Romberg E. Über sklerose der lungenarterie. Dtsch Arch Klin Med. 1891;48:197-206.
- Hoeper MM, Bogaard HJ, Condliffe R, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D42-D50.
- Simonneau G, Gatzoulis MA, Adatia I, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D34-D41.
- Rich S, Rubin L, Abenhail L, et al. Executive summary from the World Symposium on primary pulmonary hypertension. Evian, France: The World Health Organization; 1998.
- Newman JH, Wheeler L, Lane KB, et al. Mutation in the gene for bone morphogenetic protein receptor II as a cause of primary pulmonary hypertension in a large kindred. New Engl J Med. 2001;345(5):319-24.'
- Petitpretz P, Brenot F, Azarian R, et al. Pulmonary hypertension in patients with human immunodeficiency virus infection. Comparison with primary pulmonary hypertension. Circulation. 1994;89(6):2722-2727.
- Gladwin MT, Vichinsky E. Pulmonary complications of sickle cell disease. New Engl J Med. 2008;359(21):2254-2265.
- Wigley FM, Lima JA, Mayes M, McLain D, Chapin JL, Ward-Able C. The prevalence of undiagnosed pulmonary arterial hypertension in subjects with connective tissue disease at the secondary health care level of community-based rheumatologists (the UNCOVER study). Arthritis Rheum. 2005;52(7):2125-2132.
- Ramsay MA, Simpson BR, Nguyen AT, Ramsay KJ, East C, Klintmalm GB. Severe pulmonary hypertension in liver transplant candidates. Liver Transpl Surg. 1997;3(5):494-500.
- Kessler R, Faller M, Weitzenblum E, et al. “Natural history” of pulmonary hypertension in a series of 131 patients with chronic obstructive lung disease. Am J Respir Crit Care Med. 2001;164(2):219-24.
- Chaouat A, Bugnet AS, Kadaoui N, et al. Severe pulmonary hypertension and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(2):189-94.
- Thabut G, Dauriat G, Stern JB, et al. Pulmonary hemodynamics in advanced COPD candidates for lung volume reduction surgery or lung transplantation. Chest. 2005;127(5):1531-1536.
- Yamakawa H, Shiomi T, Sasanabe R, et al. Pulmonary hypertension in patients with severe obstructive sleep apnea. Psychiatry Clin Neurosci. 2002;56(3):311-312.
- Vachiery JL, Adir Y, Barberà JA, et al. Pulmonary hypertension due to left heart diseases. J Am Coll Cardiol. 2013;62(25 Suppl):D100-D108.
- McGoon M, Gutterman D, Steen V, et al. Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest. 2004;126(1 Suppl):14S-34S.
- Grünig E, Barner A, Bell M, et al. Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with Updated Commentary of the Cologne Consensus Conference 2011. Int J Cardiol. 2011;154 Suppl 1:S3-12.
- Galiè N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J. 2009;30(20):2493-2537.
- McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association. Circulation. 2009;119(16):2250-2294.
- Brown K, Gutierrez AJ, Mohammed TL, et al. ACR Appropriateness Criteria(R) pulmonary hypertension. J Thorac Imaging. 2013;28(4):W57-60.
- Galiè N, Corris PA, Frost A, et al. Updated treatment algorithm of pulmonary arterial hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D60-72.
- Fisher KA, Serlin DM, Wilson KC, Walter RE, Berman JS, Farber HW. Sarcoidosis-associated pulmonary hypertension: outcome with long-term epoprostenol treatment. Chest. 2006;130(5):1481-1488.
- Steiner MK, Preston IR, Klinger JR, et al. Conversion to bosentan from prostacyclin infusion therapy in pulmonary arterial hypertension: a pilot study. Chest. 2006;130(5):1471-1480.
Case
A 62-year-old female with no significant past medical history presents with three weeks of progressive dyspnea on exertion and bilateral lower extremity edema. Family members report that the patient often snores and “gasps for air” during sleep. B-type natriuretic peptide is elevated at 2,261 pg/ml. Due to concern for congestive heart failure, transthoracic echocardiography (TTE) is performed and shows normal left ventricular systolic function, mild left ventricular diastolic dysfunction, severely elevated right ventricular systolic pressure of 74 mm Hg, and right ventricular dilatation and hypokinesis.
How should this patient with newfound pulmonary hypertension (PH) be evaluated and managed?
Background
PH is a progressive disease that presents with nonspecific signs and symptoms and can be fatal if untreated. Ernst von Romberg first identified the disease in 1891, and efforts have been made through the last century to understand its etiology and mechanisms.1
PH is defined as an elevated mean pulmonary arterial pressure (mPAP) of ≥25 mmHg at rest; a mPAP of ≤20 mmHg is considered normal, and a mPAP of 21-24 mmHg is borderline.2 This elevation of the mPAP can be due to a primary elevation of pressures in the pulmonary arterial system alone (pulmonary arterial hypertension) or secondary to elevation in pressures in the pulmonary venous and pulmonary capillary systems (pulmonary venous hypertension).
PH classification has endured many modifications through the years with better understanding of its pathophysiology. Currently, the World Health Organization (WHO) classification system includes five groups based on etiology (see Table 1):3,4
- Group 1: Pulmonary arterial hypertension (PAH);
- Group 2: PH due to left heart disease;
- Group 3: PH due to chronic lung disease and hypoxemia;
- Group 4: Chronic thromboembolic PH (CTEPH); and
- Group 5: PH due to unclear multifactorial mechanisms.
The pathophysiology differs among the groups, and much of what is known has come from studies performed in patients with idiopathic PAH. It is a proliferative vasculopathy characterized by vasoconstriction, cell proliferation, fibrosis, and thrombosis. Both genetic predisposition and modifiers that include drugs and toxins, human immunodeficiency virus (HIV), congenital heart disease with left-to-right shunting, and potassium channel dysfunction play a role in the pathogenesis.3,5,6 Although many processes underlying the pathophysiology of PH groups 2, 3, 4, and 5 are not fully understood, vascular remodeling and increased vascular resistance are common to all of them.
PH affects both genders and all age groups and races. Due to its broad classification and multiple etiologies, it is difficult to assess PH prevalence in the general population. There are wide ranges among different populations, with PH prevalence in sickle cell disease ranging from 20% to 40%, in systemic sclerosis from 10% to 15%, and in portal hypertension from 2% to 16%.7,8,9 PH in COPD is usually mild to moderate, with preserved cardiac output, although a minority of patients develop severe PH.10-12 PH is present in approximately 20% of patients with moderate to severe sleep apnea.13 The prevalence of PH in left heart disease is unknown due to variability in populations assessed and methods used in various studies; estimates have ranged from 25-100%.14
Evaluation
Initial evaluation: A thorough history and physical examination can help determine PH etiology, identify associated conditions, and determine the severity of disease. Dyspnea on exertion is the most common presenting complaint; weakness, fatigue, and angina may be present.15 Lower extremity edema and ascites are indicative of more advanced disease.
A patient’s symptoms may suggest the presence of undiagnosed conditions that are associated with PH, and past medical history should evaluate for previous diagnoses of these conditions (see Table 1).
Family history may reveal relatives with PH, given the genetic predisposition to development of Group 1 PH. Physical exam findings include a prominent pulmonic valve closure during the second heart sound, a palpable left parasternal heave, and a tricuspid regurgitation murmur.
Electrocardiogram (ECG) and chest X-ray (CXR) are not sufficiently sensitive or specific to diagnose PH but may provide initial supporting evidence that prompts further testing. Signs of right ventricular hypertrophy and right atrial enlargement may be present on ECG. The CXR may show pruning (prominent hilar vasculature with reduced vasculature peripherally) and right ventricular hypertrophy, as evidenced by shrinking of the retrosternal window on lateral CXR. An unremarkable ECG or normal CXR does not rule out PH.
Echocardiography: TTE allows estimation of pulmonary artery systolic pressure (PASP) via measurement of tricuspid regurgitation jet velocity and estimation of right atrial pressure. Although results of TTE do correlate with measurements from right heart catheterization (RHC), underestimation and overestimation commonly occur. PASP thresholds for diagnosing or ruling out PH cannot thus be defined easily. An elevated PASP less than 36 mmHg, tricuspid regurgitation velocity <2.8 m/s, and no additional echocardiographic variables suggestive of PH may indicate that PH is unlikely, based on arbitrary criteria from one clinical practice guideline.16
The guideline suggested that tricuspid regurgitation velocity >3.4 m/s or estimated PASP >50 mmHg indicated that PH was likely. Other echocardiographic variables that may suggest the presence of PH include right ventricular enlargement or intraventricular septal flattening. Finally, TTE should also be used to assess for possible causes of PH, such as left heart disease or cardiac shunts.
Further evaluation: Following identification of PH via TTE, further testing can confirm the diagnosis, determine the etiology of the PH, and allow appropriate treatment (see Table 2). Much of this evaluation may occur after hospital discharge and, in cases of unexplained PH, referral to a pulmonologist for further evaluation and management is appropriate. Depending on patient stability, test availability, and patient ability to follow up, some testing may be reasonable during the inpatient stay.
Patients should undergo a stepwise series of testing that initially may be guided by clinical suspicion for underlying conditions.15-19 Polysomnography can identify sleep-disordered breathing, and pulmonary function tests and high-resolution chest CT can assess for chronic pulmonary diseases. Patients with groups 2 and 3 PH, whose PH can be explained by left heart disease or lung disease, do not necessarily require RHC or extensive evaluation for other etiologies of PH.2,17 These patients may be monitored while their underlying conditions are managed.
Patients with worsening clinical course or PH that is “out of proportion” to their lung disease or heart disease, however, do require further evaluation, including RHC. “Out of proportion” has not been consistently defined but generally refers to severe PH observed in patients with mild left heart or lung disease.18 More precise terminology and criteria to define patients with out of proportion PH have been proposed.14
Ventilation-perfusion scanning is required in all cases of PH of unknown etiology to evaluate for CTEPH (Group 4 PH). CT angiography, while appropriate to use in testing for acute pulmonary embolism, is not sufficiently sensitive to evaluate for CTEPH. Tests for liver function, HIV, and connective tissue disease may identify conditions associated with Group 1 PH. Ultimately, RHC is required to confirm the diagnosis of PH, given the shortcomings of TTE. A vasodilator study during RHC allows identification of candidates for advanced therapies, such as patients with Group 1 PH.
Management
The prognosis and treatment of PH varies by WHO Group. The hospitalist will often undertake initial management of symptomatic patients (see Table 3). Intravenous loop diuretics will successfully treat peripheral edema and hepatic congestion in all PH patients.20 Due to the possibility of decreased cardiac output or worsened hypotension in some PH groups, patients should be monitored closely during initial diuresis.
All patients with PH should be assessed for hypoxia during rest, ambulation, and sleep during their hospitalization. Supplemental oxygen therapy should be initiated in all patients with evidence of persistent hypoxia (arterial oxygen blood pressure <60 mmHg).20 Vaccination against pneumococcus and influenza should also be performed during the initial hospitalization. Pregnant patients diagnosed with PH require urgent maternal-fetal medicine consultation.
Further management should be guided by the underlying etiology of the PH:17,18
- Group 1 PH. These patients should be evaluated by a pulmonology consultant, if one is available, as they require intense outpatient follow-up with a pulmonologist. Specialized treatment regimens include calcium channel blockers, phosphodiesterase inhibitors, prostanoids, endothelin receptor antagonists, or newly approved guanylate cyclase stimulants. In previously diagnosed patients, these medications should be continued during a patient’s admission unless the medication is clearly causing the patient harm (such as worsening hypotension) or preventing improvement. Many of these patients are placed on chronic anticoagulation with warfarin, with a goal international normalized ratio (INR) of 1.5 to 2.5.
- Group 2 PH. Patients with left heart or valvular dysfunction and PH have a worse prognosis than similar patients without PH. Management of these patients should focus on treating the underlying etiology. Use of prostanoids may be harmful in this patient population.18
- Group 3 PH. Patients whose PH is fully explained by pulmonary disease should be started on continuous oxygen therapy to treat persistent hypoxemia, and their underlying disorder should be treated, with pulmonologist consultation and referral if necessary.
- Group 4 PH. Patients with newly diagnosed CTEPH should be initiated on warfarin with a goal INR of 2.0 to 3.0. They should undergo evaluation by a pulmonologist for thromboendarterectomy and possibly advanced medical therapies.
- Group 5 PH. Patients with sarcoidosis as the cause of their PH may benefit from prostanoid or endothelin receptor antagonist therapy and should undergo evaluation by a pulmonologist.21,22
Patients with sickle cell anemia, metabolic disorders, and other causes should undergo further subspecialist evaluation prior to initiating therapy to treat their PH.
Back to the Case
The patient underwent diuresis with intravenous furosemide over several days, with gradual improvement in her lower extremity edema and dyspnea. She was placed on oxygen therapy for persistent hypoxemia. As her highly elevated pulmonary artery pressure appeared to be “out of proportion” to her mild left ventricular diastolic dysfunction, further evaluation was pursued. Ventilation-perfusion scanning was performed and showed no mismatch of perfusion and ventilation, effectively ruling out CTEPH. Liver function, HIV, and connective tissue disease testing yielded unremarkable results.
The patient was euvolemic after one week of diuresis and was discharged home with plans for PH specialist follow-up, polysomnography to evaluate for sleep-disordered breathing, and likely RHC. The etiology of her PH was not clear at discharge.
Bottom Line
Evaluation of PH is a step-wise process that starts with history and physical exam and may require extensive evaluation, including right heart catheterization to confirm the diagnosis and define the etiology. A primary goal of evaluation is to define the appropriate therapy for a given patient, which may include advanced therapies in some cases.
Dr. Griffith is a quality improvement fellow and instructor of medicine in the Hospital Medicine Division at the University of Colorado Denver. Drs. McFarland and Smolkin are hospitalists and instructors of medicine at the University of Colorado Denver.
References
- von Romberg E. Über sklerose der lungenarterie. Dtsch Arch Klin Med. 1891;48:197-206.
- Hoeper MM, Bogaard HJ, Condliffe R, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D42-D50.
- Simonneau G, Gatzoulis MA, Adatia I, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D34-D41.
- Rich S, Rubin L, Abenhail L, et al. Executive summary from the World Symposium on primary pulmonary hypertension. Evian, France: The World Health Organization; 1998.
- Newman JH, Wheeler L, Lane KB, et al. Mutation in the gene for bone morphogenetic protein receptor II as a cause of primary pulmonary hypertension in a large kindred. New Engl J Med. 2001;345(5):319-24.'
- Petitpretz P, Brenot F, Azarian R, et al. Pulmonary hypertension in patients with human immunodeficiency virus infection. Comparison with primary pulmonary hypertension. Circulation. 1994;89(6):2722-2727.
- Gladwin MT, Vichinsky E. Pulmonary complications of sickle cell disease. New Engl J Med. 2008;359(21):2254-2265.
- Wigley FM, Lima JA, Mayes M, McLain D, Chapin JL, Ward-Able C. The prevalence of undiagnosed pulmonary arterial hypertension in subjects with connective tissue disease at the secondary health care level of community-based rheumatologists (the UNCOVER study). Arthritis Rheum. 2005;52(7):2125-2132.
- Ramsay MA, Simpson BR, Nguyen AT, Ramsay KJ, East C, Klintmalm GB. Severe pulmonary hypertension in liver transplant candidates. Liver Transpl Surg. 1997;3(5):494-500.
- Kessler R, Faller M, Weitzenblum E, et al. “Natural history” of pulmonary hypertension in a series of 131 patients with chronic obstructive lung disease. Am J Respir Crit Care Med. 2001;164(2):219-24.
- Chaouat A, Bugnet AS, Kadaoui N, et al. Severe pulmonary hypertension and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(2):189-94.
- Thabut G, Dauriat G, Stern JB, et al. Pulmonary hemodynamics in advanced COPD candidates for lung volume reduction surgery or lung transplantation. Chest. 2005;127(5):1531-1536.
- Yamakawa H, Shiomi T, Sasanabe R, et al. Pulmonary hypertension in patients with severe obstructive sleep apnea. Psychiatry Clin Neurosci. 2002;56(3):311-312.
- Vachiery JL, Adir Y, Barberà JA, et al. Pulmonary hypertension due to left heart diseases. J Am Coll Cardiol. 2013;62(25 Suppl):D100-D108.
- McGoon M, Gutterman D, Steen V, et al. Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest. 2004;126(1 Suppl):14S-34S.
- Grünig E, Barner A, Bell M, et al. Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with Updated Commentary of the Cologne Consensus Conference 2011. Int J Cardiol. 2011;154 Suppl 1:S3-12.
- Galiè N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J. 2009;30(20):2493-2537.
- McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association. Circulation. 2009;119(16):2250-2294.
- Brown K, Gutierrez AJ, Mohammed TL, et al. ACR Appropriateness Criteria(R) pulmonary hypertension. J Thorac Imaging. 2013;28(4):W57-60.
- Galiè N, Corris PA, Frost A, et al. Updated treatment algorithm of pulmonary arterial hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D60-72.
- Fisher KA, Serlin DM, Wilson KC, Walter RE, Berman JS, Farber HW. Sarcoidosis-associated pulmonary hypertension: outcome with long-term epoprostenol treatment. Chest. 2006;130(5):1481-1488.
- Steiner MK, Preston IR, Klinger JR, et al. Conversion to bosentan from prostacyclin infusion therapy in pulmonary arterial hypertension: a pilot study. Chest. 2006;130(5):1471-1480.
Case
A 62-year-old female with no significant past medical history presents with three weeks of progressive dyspnea on exertion and bilateral lower extremity edema. Family members report that the patient often snores and “gasps for air” during sleep. B-type natriuretic peptide is elevated at 2,261 pg/ml. Due to concern for congestive heart failure, transthoracic echocardiography (TTE) is performed and shows normal left ventricular systolic function, mild left ventricular diastolic dysfunction, severely elevated right ventricular systolic pressure of 74 mm Hg, and right ventricular dilatation and hypokinesis.
How should this patient with newfound pulmonary hypertension (PH) be evaluated and managed?
Background
PH is a progressive disease that presents with nonspecific signs and symptoms and can be fatal if untreated. Ernst von Romberg first identified the disease in 1891, and efforts have been made through the last century to understand its etiology and mechanisms.1
PH is defined as an elevated mean pulmonary arterial pressure (mPAP) of ≥25 mmHg at rest; a mPAP of ≤20 mmHg is considered normal, and a mPAP of 21-24 mmHg is borderline.2 This elevation of the mPAP can be due to a primary elevation of pressures in the pulmonary arterial system alone (pulmonary arterial hypertension) or secondary to elevation in pressures in the pulmonary venous and pulmonary capillary systems (pulmonary venous hypertension).
PH classification has endured many modifications through the years with better understanding of its pathophysiology. Currently, the World Health Organization (WHO) classification system includes five groups based on etiology (see Table 1):3,4
- Group 1: Pulmonary arterial hypertension (PAH);
- Group 2: PH due to left heart disease;
- Group 3: PH due to chronic lung disease and hypoxemia;
- Group 4: Chronic thromboembolic PH (CTEPH); and
- Group 5: PH due to unclear multifactorial mechanisms.
The pathophysiology differs among the groups, and much of what is known has come from studies performed in patients with idiopathic PAH. It is a proliferative vasculopathy characterized by vasoconstriction, cell proliferation, fibrosis, and thrombosis. Both genetic predisposition and modifiers that include drugs and toxins, human immunodeficiency virus (HIV), congenital heart disease with left-to-right shunting, and potassium channel dysfunction play a role in the pathogenesis.3,5,6 Although many processes underlying the pathophysiology of PH groups 2, 3, 4, and 5 are not fully understood, vascular remodeling and increased vascular resistance are common to all of them.
PH affects both genders and all age groups and races. Due to its broad classification and multiple etiologies, it is difficult to assess PH prevalence in the general population. There are wide ranges among different populations, with PH prevalence in sickle cell disease ranging from 20% to 40%, in systemic sclerosis from 10% to 15%, and in portal hypertension from 2% to 16%.7,8,9 PH in COPD is usually mild to moderate, with preserved cardiac output, although a minority of patients develop severe PH.10-12 PH is present in approximately 20% of patients with moderate to severe sleep apnea.13 The prevalence of PH in left heart disease is unknown due to variability in populations assessed and methods used in various studies; estimates have ranged from 25-100%.14
Evaluation
Initial evaluation: A thorough history and physical examination can help determine PH etiology, identify associated conditions, and determine the severity of disease. Dyspnea on exertion is the most common presenting complaint; weakness, fatigue, and angina may be present.15 Lower extremity edema and ascites are indicative of more advanced disease.
A patient’s symptoms may suggest the presence of undiagnosed conditions that are associated with PH, and past medical history should evaluate for previous diagnoses of these conditions (see Table 1).
Family history may reveal relatives with PH, given the genetic predisposition to development of Group 1 PH. Physical exam findings include a prominent pulmonic valve closure during the second heart sound, a palpable left parasternal heave, and a tricuspid regurgitation murmur.
Electrocardiogram (ECG) and chest X-ray (CXR) are not sufficiently sensitive or specific to diagnose PH but may provide initial supporting evidence that prompts further testing. Signs of right ventricular hypertrophy and right atrial enlargement may be present on ECG. The CXR may show pruning (prominent hilar vasculature with reduced vasculature peripherally) and right ventricular hypertrophy, as evidenced by shrinking of the retrosternal window on lateral CXR. An unremarkable ECG or normal CXR does not rule out PH.
Echocardiography: TTE allows estimation of pulmonary artery systolic pressure (PASP) via measurement of tricuspid regurgitation jet velocity and estimation of right atrial pressure. Although results of TTE do correlate with measurements from right heart catheterization (RHC), underestimation and overestimation commonly occur. PASP thresholds for diagnosing or ruling out PH cannot thus be defined easily. An elevated PASP less than 36 mmHg, tricuspid regurgitation velocity <2.8 m/s, and no additional echocardiographic variables suggestive of PH may indicate that PH is unlikely, based on arbitrary criteria from one clinical practice guideline.16
The guideline suggested that tricuspid regurgitation velocity >3.4 m/s or estimated PASP >50 mmHg indicated that PH was likely. Other echocardiographic variables that may suggest the presence of PH include right ventricular enlargement or intraventricular septal flattening. Finally, TTE should also be used to assess for possible causes of PH, such as left heart disease or cardiac shunts.
Further evaluation: Following identification of PH via TTE, further testing can confirm the diagnosis, determine the etiology of the PH, and allow appropriate treatment (see Table 2). Much of this evaluation may occur after hospital discharge and, in cases of unexplained PH, referral to a pulmonologist for further evaluation and management is appropriate. Depending on patient stability, test availability, and patient ability to follow up, some testing may be reasonable during the inpatient stay.
Patients should undergo a stepwise series of testing that initially may be guided by clinical suspicion for underlying conditions.15-19 Polysomnography can identify sleep-disordered breathing, and pulmonary function tests and high-resolution chest CT can assess for chronic pulmonary diseases. Patients with groups 2 and 3 PH, whose PH can be explained by left heart disease or lung disease, do not necessarily require RHC or extensive evaluation for other etiologies of PH.2,17 These patients may be monitored while their underlying conditions are managed.
Patients with worsening clinical course or PH that is “out of proportion” to their lung disease or heart disease, however, do require further evaluation, including RHC. “Out of proportion” has not been consistently defined but generally refers to severe PH observed in patients with mild left heart or lung disease.18 More precise terminology and criteria to define patients with out of proportion PH have been proposed.14
Ventilation-perfusion scanning is required in all cases of PH of unknown etiology to evaluate for CTEPH (Group 4 PH). CT angiography, while appropriate to use in testing for acute pulmonary embolism, is not sufficiently sensitive to evaluate for CTEPH. Tests for liver function, HIV, and connective tissue disease may identify conditions associated with Group 1 PH. Ultimately, RHC is required to confirm the diagnosis of PH, given the shortcomings of TTE. A vasodilator study during RHC allows identification of candidates for advanced therapies, such as patients with Group 1 PH.
Management
The prognosis and treatment of PH varies by WHO Group. The hospitalist will often undertake initial management of symptomatic patients (see Table 3). Intravenous loop diuretics will successfully treat peripheral edema and hepatic congestion in all PH patients.20 Due to the possibility of decreased cardiac output or worsened hypotension in some PH groups, patients should be monitored closely during initial diuresis.
All patients with PH should be assessed for hypoxia during rest, ambulation, and sleep during their hospitalization. Supplemental oxygen therapy should be initiated in all patients with evidence of persistent hypoxia (arterial oxygen blood pressure <60 mmHg).20 Vaccination against pneumococcus and influenza should also be performed during the initial hospitalization. Pregnant patients diagnosed with PH require urgent maternal-fetal medicine consultation.
Further management should be guided by the underlying etiology of the PH:17,18
- Group 1 PH. These patients should be evaluated by a pulmonology consultant, if one is available, as they require intense outpatient follow-up with a pulmonologist. Specialized treatment regimens include calcium channel blockers, phosphodiesterase inhibitors, prostanoids, endothelin receptor antagonists, or newly approved guanylate cyclase stimulants. In previously diagnosed patients, these medications should be continued during a patient’s admission unless the medication is clearly causing the patient harm (such as worsening hypotension) or preventing improvement. Many of these patients are placed on chronic anticoagulation with warfarin, with a goal international normalized ratio (INR) of 1.5 to 2.5.
- Group 2 PH. Patients with left heart or valvular dysfunction and PH have a worse prognosis than similar patients without PH. Management of these patients should focus on treating the underlying etiology. Use of prostanoids may be harmful in this patient population.18
- Group 3 PH. Patients whose PH is fully explained by pulmonary disease should be started on continuous oxygen therapy to treat persistent hypoxemia, and their underlying disorder should be treated, with pulmonologist consultation and referral if necessary.
- Group 4 PH. Patients with newly diagnosed CTEPH should be initiated on warfarin with a goal INR of 2.0 to 3.0. They should undergo evaluation by a pulmonologist for thromboendarterectomy and possibly advanced medical therapies.
- Group 5 PH. Patients with sarcoidosis as the cause of their PH may benefit from prostanoid or endothelin receptor antagonist therapy and should undergo evaluation by a pulmonologist.21,22
Patients with sickle cell anemia, metabolic disorders, and other causes should undergo further subspecialist evaluation prior to initiating therapy to treat their PH.
Back to the Case
The patient underwent diuresis with intravenous furosemide over several days, with gradual improvement in her lower extremity edema and dyspnea. She was placed on oxygen therapy for persistent hypoxemia. As her highly elevated pulmonary artery pressure appeared to be “out of proportion” to her mild left ventricular diastolic dysfunction, further evaluation was pursued. Ventilation-perfusion scanning was performed and showed no mismatch of perfusion and ventilation, effectively ruling out CTEPH. Liver function, HIV, and connective tissue disease testing yielded unremarkable results.
The patient was euvolemic after one week of diuresis and was discharged home with plans for PH specialist follow-up, polysomnography to evaluate for sleep-disordered breathing, and likely RHC. The etiology of her PH was not clear at discharge.
Bottom Line
Evaluation of PH is a step-wise process that starts with history and physical exam and may require extensive evaluation, including right heart catheterization to confirm the diagnosis and define the etiology. A primary goal of evaluation is to define the appropriate therapy for a given patient, which may include advanced therapies in some cases.
Dr. Griffith is a quality improvement fellow and instructor of medicine in the Hospital Medicine Division at the University of Colorado Denver. Drs. McFarland and Smolkin are hospitalists and instructors of medicine at the University of Colorado Denver.
References
- von Romberg E. Über sklerose der lungenarterie. Dtsch Arch Klin Med. 1891;48:197-206.
- Hoeper MM, Bogaard HJ, Condliffe R, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D42-D50.
- Simonneau G, Gatzoulis MA, Adatia I, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D34-D41.
- Rich S, Rubin L, Abenhail L, et al. Executive summary from the World Symposium on primary pulmonary hypertension. Evian, France: The World Health Organization; 1998.
- Newman JH, Wheeler L, Lane KB, et al. Mutation in the gene for bone morphogenetic protein receptor II as a cause of primary pulmonary hypertension in a large kindred. New Engl J Med. 2001;345(5):319-24.'
- Petitpretz P, Brenot F, Azarian R, et al. Pulmonary hypertension in patients with human immunodeficiency virus infection. Comparison with primary pulmonary hypertension. Circulation. 1994;89(6):2722-2727.
- Gladwin MT, Vichinsky E. Pulmonary complications of sickle cell disease. New Engl J Med. 2008;359(21):2254-2265.
- Wigley FM, Lima JA, Mayes M, McLain D, Chapin JL, Ward-Able C. The prevalence of undiagnosed pulmonary arterial hypertension in subjects with connective tissue disease at the secondary health care level of community-based rheumatologists (the UNCOVER study). Arthritis Rheum. 2005;52(7):2125-2132.
- Ramsay MA, Simpson BR, Nguyen AT, Ramsay KJ, East C, Klintmalm GB. Severe pulmonary hypertension in liver transplant candidates. Liver Transpl Surg. 1997;3(5):494-500.
- Kessler R, Faller M, Weitzenblum E, et al. “Natural history” of pulmonary hypertension in a series of 131 patients with chronic obstructive lung disease. Am J Respir Crit Care Med. 2001;164(2):219-24.
- Chaouat A, Bugnet AS, Kadaoui N, et al. Severe pulmonary hypertension and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(2):189-94.
- Thabut G, Dauriat G, Stern JB, et al. Pulmonary hemodynamics in advanced COPD candidates for lung volume reduction surgery or lung transplantation. Chest. 2005;127(5):1531-1536.
- Yamakawa H, Shiomi T, Sasanabe R, et al. Pulmonary hypertension in patients with severe obstructive sleep apnea. Psychiatry Clin Neurosci. 2002;56(3):311-312.
- Vachiery JL, Adir Y, Barberà JA, et al. Pulmonary hypertension due to left heart diseases. J Am Coll Cardiol. 2013;62(25 Suppl):D100-D108.
- McGoon M, Gutterman D, Steen V, et al. Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest. 2004;126(1 Suppl):14S-34S.
- Grünig E, Barner A, Bell M, et al. Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with Updated Commentary of the Cologne Consensus Conference 2011. Int J Cardiol. 2011;154 Suppl 1:S3-12.
- Galiè N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J. 2009;30(20):2493-2537.
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