All Content

Clinical question

Does a lower transfusion threshold for critically ill patients with septic shock affect outcomes?

Bottom line

Using a lower threshold for transfusion for patients with septic shock in the intensive care unit (ICU) decreases the number of transfusions received without affecting mortality.

Reference

Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014;371(15):1381-1391.

Study design

Randomized controlled trial (nonblinded); (LOE: 1b)

Setting

Inpatient (ICU only)

Synopsis

Using partial blinding and concealed allocation, these investigators randomized ICU patients with septic shock and a hemoglobin level of less than 9 g/dL to receive red blood cell transfusions at either a higher threshold (< 9 g/dL) or a lower threshold (< 7 g/dL). The intervention continued for the entire ICU stay, to a maximum of 90 days. The 2 groups were similar at baseline with an average age of 67 years and a median Sepsis-Related Organ Failure Assessment (SOFA) score of 10 out of 24. Analysis was by intention to treat. Not suprisingly, patients in the higher threshold group received twice as many transfusions as those in the lower threshold group (3088 transfusions vs 1545; P < .001). Notably, one third of the patients in the lower-threshold group required no transfusions at all compared with only 1% in the higher-threshold group (P < .001). For the primary outcome of death at 90 days, there was no significant difference detected between the 2 groups. The per-protocol analysis, which excluded patients with major protocol violations, also showed the same result. Secondary outcomes, including the use of life support and the number of ischemic events in the ICU (eg, acute myocardial or cerebral ischemia), were also similar in the 2 groups.

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

Clinical question

Does a lower transfusion threshold for critically ill patients with septic shock affect outcomes?

Bottom line

Using a lower threshold for transfusion for patients with septic shock in the intensive care unit (ICU) decreases the number of transfusions received without affecting mortality.

Reference

Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014;371(15):1381-1391.

Study design

Randomized controlled trial (nonblinded); (LOE: 1b)

Setting

Inpatient (ICU only)

Synopsis

Using partial blinding and concealed allocation, these investigators randomized ICU patients with septic shock and a hemoglobin level of less than 9 g/dL to receive red blood cell transfusions at either a higher threshold (< 9 g/dL) or a lower threshold (< 7 g/dL). The intervention continued for the entire ICU stay, to a maximum of 90 days. The 2 groups were similar at baseline with an average age of 67 years and a median Sepsis-Related Organ Failure Assessment (SOFA) score of 10 out of 24. Analysis was by intention to treat. Not suprisingly, patients in the higher threshold group received twice as many transfusions as those in the lower threshold group (3088 transfusions vs 1545; P < .001). Notably, one third of the patients in the lower-threshold group required no transfusions at all compared with only 1% in the higher-threshold group (P < .001). For the primary outcome of death at 90 days, there was no significant difference detected between the 2 groups. The per-protocol analysis, which excluded patients with major protocol violations, also showed the same result. Secondary outcomes, including the use of life support and the number of ischemic events in the ICU (eg, acute myocardial or cerebral ischemia), were also similar in the 2 groups.

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

Clinical question

Does a lower transfusion threshold for critically ill patients with septic shock affect outcomes?

Bottom line

Using a lower threshold for transfusion for patients with septic shock in the intensive care unit (ICU) decreases the number of transfusions received without affecting mortality.

Reference

Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014;371(15):1381-1391.

Study design

Randomized controlled trial (nonblinded); (LOE: 1b)

Setting

Inpatient (ICU only)

Synopsis

Using partial blinding and concealed allocation, these investigators randomized ICU patients with septic shock and a hemoglobin level of less than 9 g/dL to receive red blood cell transfusions at either a higher threshold (< 9 g/dL) or a lower threshold (< 7 g/dL). The intervention continued for the entire ICU stay, to a maximum of 90 days. The 2 groups were similar at baseline with an average age of 67 years and a median Sepsis-Related Organ Failure Assessment (SOFA) score of 10 out of 24. Analysis was by intention to treat. Not suprisingly, patients in the higher threshold group received twice as many transfusions as those in the lower threshold group (3088 transfusions vs 1545; P < .001). Notably, one third of the patients in the lower-threshold group required no transfusions at all compared with only 1% in the higher-threshold group (P < .001). For the primary outcome of death at 90 days, there was no significant difference detected between the 2 groups. The per-protocol analysis, which excluded patients with major protocol violations, also showed the same result. Secondary outcomes, including the use of life support and the number of ischemic events in the ICU (eg, acute myocardial or cerebral ischemia), were also similar in the 2 groups.

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

Bob Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco, talks about Accountable Care Organizations, trends in managed care, his new book, and why hospitalists need to think, at times, like Machiavelli.

Bob Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco, talks about Accountable Care Organizations, trends in managed care, his new book, and why hospitalists need to think, at times, like Machiavelli.

Bob Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco, talks about Accountable Care Organizations, trends in managed care, his new book, and why hospitalists need to think, at times, like Machiavelli.

69%: the percentage of hospitals that had perfect compliance with the Leapfrog Group employer coalition’s safe practices for hand hygiene in its 2013 annual quality survey of 1,437 U.S. hospitals.

The CDC estimates 2 million patients annually acquire hospital-acquired infections (HAIs), often spread by contaminated hands of healthcare workers.

Urban hospitals performed better than rural hospitals in compliance with Leapfrog’s standard.

69%: the percentage of hospitals that had perfect compliance with the Leapfrog Group employer coalition’s safe practices for hand hygiene in its 2013 annual quality survey of 1,437 U.S. hospitals.

The CDC estimates 2 million patients annually acquire hospital-acquired infections (HAIs), often spread by contaminated hands of healthcare workers.

Urban hospitals performed better than rural hospitals in compliance with Leapfrog’s standard.

69%: the percentage of hospitals that had perfect compliance with the Leapfrog Group employer coalition’s safe practices for hand hygiene in its 2013 annual quality survey of 1,437 U.S. hospitals.

The CDC estimates 2 million patients annually acquire hospital-acquired infections (HAIs), often spread by contaminated hands of healthcare workers.

Urban hospitals performed better than rural hospitals in compliance with Leapfrog’s standard.

$167 billion: Amount of federal Medicaid reimbursement payments that hospitals will forego between 2013 and 2022 in states that have opted not to expand their state programs under the 2010 Affordable Care Act.

For every $1 a state spends on expanding Medicaid, $13.41 in federal funding flows into the state, according to a new report from the Urban Institute and Robert Wood Johnson Foundation.

$167 billion: Amount of federal Medicaid reimbursement payments that hospitals will forego between 2013 and 2022 in states that have opted not to expand their state programs under the 2010 Affordable Care Act.

For every $1 a state spends on expanding Medicaid, $13.41 in federal funding flows into the state, according to a new report from the Urban Institute and Robert Wood Johnson Foundation.

$167 billion: Amount of federal Medicaid reimbursement payments that hospitals will forego between 2013 and 2022 in states that have opted not to expand their state programs under the 2010 Affordable Care Act.

For every $1 a state spends on expanding Medicaid, $13.41 in federal funding flows into the state, according to a new report from the Urban Institute and Robert Wood Johnson Foundation.

UpToDate, a leading clinical decision support resource for physicians, in July added palliative care as the newest of its 22 medical specialties. The palliative care section covers a variety of topics focused on improving symptoms and providing best quality of life for patients with serious illnesses. The new service resulted from two years of extensive collaboration by a team of 100 leading palliative care specialists from around the world, led by Harvard Medical School palliative care physicians J. Andrew Billings, MD, and Susan D. Block, MD, reviewing and grading the body of research and scientific literature on palliative care.

UpToDate, a leading clinical decision support resource for physicians, in July added palliative care as the newest of its 22 medical specialties. The palliative care section covers a variety of topics focused on improving symptoms and providing best quality of life for patients with serious illnesses. The new service resulted from two years of extensive collaboration by a team of 100 leading palliative care specialists from around the world, led by Harvard Medical School palliative care physicians J. Andrew Billings, MD, and Susan D. Block, MD, reviewing and grading the body of research and scientific literature on palliative care.

UpToDate, a leading clinical decision support resource for physicians, in July added palliative care as the newest of its 22 medical specialties. The palliative care section covers a variety of topics focused on improving symptoms and providing best quality of life for patients with serious illnesses. The new service resulted from two years of extensive collaboration by a team of 100 leading palliative care specialists from around the world, led by Harvard Medical School palliative care physicians J. Andrew Billings, MD, and Susan D. Block, MD, reviewing and grading the body of research and scientific literature on palliative care.

Hospitals and Health Networks in July presented its 16^th annual list of Most Wired Hospitals and Health Systems. Rigorous criteria were used to identify 375 hospitals that use technology to link up disparate care providers and patients. "Most Wired" hospitals are more likely to share critical information electronically with specialists, to use bar codes for matching medications to patients at the bedside, to use IT to reduce the likelihood of medical errors, to better manage care transitions, and to adopt and meaningfully use certified electronic health records.

Meanwhile, Eric Wicklund, editor of mHealth News, called for nominations of the best wireless hospitals, which are moving toward a wireless landscape for mobile health technology and engaging an ever more connected consumer population.

“I’ve already got a few on my own list,” he writes, asking his readers to submit examples of programs and projects that are doing it right and using mobile health to make a difference.

MHADegree.org, a resource for students and professionals in health administration, named the top 50 most social media-friendly hospitals for 2013, led by Mayo Clinic in Rochester, Minn., and Cleveland Clinic in Cleveland, Ohio.

Hospitals and Health Networks in July presented its 16^th annual list of Most Wired Hospitals and Health Systems. Rigorous criteria were used to identify 375 hospitals that use technology to link up disparate care providers and patients. "Most Wired" hospitals are more likely to share critical information electronically with specialists, to use bar codes for matching medications to patients at the bedside, to use IT to reduce the likelihood of medical errors, to better manage care transitions, and to adopt and meaningfully use certified electronic health records.

Meanwhile, Eric Wicklund, editor of mHealth News, called for nominations of the best wireless hospitals, which are moving toward a wireless landscape for mobile health technology and engaging an ever more connected consumer population.

“I’ve already got a few on my own list,” he writes, asking his readers to submit examples of programs and projects that are doing it right and using mobile health to make a difference.

MHADegree.org, a resource for students and professionals in health administration, named the top 50 most social media-friendly hospitals for 2013, led by Mayo Clinic in Rochester, Minn., and Cleveland Clinic in Cleveland, Ohio.

Hospitals and Health Networks in July presented its 16^th annual list of Most Wired Hospitals and Health Systems. Rigorous criteria were used to identify 375 hospitals that use technology to link up disparate care providers and patients. "Most Wired" hospitals are more likely to share critical information electronically with specialists, to use bar codes for matching medications to patients at the bedside, to use IT to reduce the likelihood of medical errors, to better manage care transitions, and to adopt and meaningfully use certified electronic health records.

Meanwhile, Eric Wicklund, editor of mHealth News, called for nominations of the best wireless hospitals, which are moving toward a wireless landscape for mobile health technology and engaging an ever more connected consumer population.

“I’ve already got a few on my own list,” he writes, asking his readers to submit examples of programs and projects that are doing it right and using mobile health to make a difference.

MHADegree.org, a resource for students and professionals in health administration, named the top 50 most social media-friendly hospitals for 2013, led by Mayo Clinic in Rochester, Minn., and Cleveland Clinic in Cleveland, Ohio.

Steven Z. Pantilat, MD, SFHM, medical director of the University of California San Francisco School of Medicine palliative care service, explains palliative care is not end-of-life care, and the role hospitalists should play in palliative cases.

 

 

Steven Z. Pantilat, MD, SFHM, medical director of the University of California San Francisco School of Medicine palliative care service, explains palliative care is not end-of-life care, and the role hospitalists should play in palliative cases.

 

 

Steven Z. Pantilat, MD, SFHM, medical director of the University of California San Francisco School of Medicine palliative care service, explains palliative care is not end-of-life care, and the role hospitalists should play in palliative cases.

 

 

Josiah Halm, MD, and Sahitya Gadiraju, DO, assistant professors of general internal medicine at M.D. Anderson Cancer Center in Houston, discuss the breadth of care provided to cancer patients, a risk assessment being developed there on readmission risk, and factors in care that go beyond the medical.

Josiah Halm, MD, and Sahitya Gadiraju, DO, assistant professors of general internal medicine at M.D. Anderson Cancer Center in Houston, discuss the breadth of care provided to cancer patients, a risk assessment being developed there on readmission risk, and factors in care that go beyond the medical.

Josiah Halm, MD, and Sahitya Gadiraju, DO, assistant professors of general internal medicine at M.D. Anderson Cancer Center in Houston, discuss the breadth of care provided to cancer patients, a risk assessment being developed there on readmission risk, and factors in care that go beyond the medical.

Government penalties meant to reduce COPD readmissions will unfairly impact hospitals that care for vulnerable patients, according to a report from the University of Michigan.

Beginning in January 2015, the Centers for Medicare & Medicaid Services will add COPD to its list of medical conditions for which it penalizes hospitals for excessive readmissions and fines them up to 3% of their total Medicare reimbursement for COPD readmissions.

Researchers Michael W. Sjoding, MD, and Colin R. Cooke, MD, MSc, MS, both of the University of Michigan Institute for Healthcare Policy and Innovation in Ann Arbor, evaluated three years of data on 3,018 hospitals and found that COPD readmission rates ranged from 17% to 28% across all hospitals. Hospitals designated as major teaching hospitals, those with a high percentage of patients with low socioeconomic status, and those with a high volume of COPD patients were associated with higher COPD readmission rates (P<0.001 for all).

The findings were published last month in the American Journal of Respiratory and Critical Care Medicine.

"It has been shown that there is a correlation between patients' social structures and support at home and COPD readmissions," Dr. Sjoding says. "Economic resources and education level can also drive readmissions, situations that are beyond hospital control."

Policies that measure hospital quality, Dr. Sjoding says, are important to ensure that patients have access to quality care across the country. However, when creating policies aimed at reducing readmission rates, CMS should level the playing field, he says. For example, academic hospitals caring for complex patients should be compared against their peers.

"It's important that physicians speak up to make sure that policies do the right thing," he says.

Visit our website for more information about managing patients with COPD.

Government penalties meant to reduce COPD readmissions will unfairly impact hospitals that care for vulnerable patients, according to a report from the University of Michigan.

Beginning in January 2015, the Centers for Medicare & Medicaid Services will add COPD to its list of medical conditions for which it penalizes hospitals for excessive readmissions and fines them up to 3% of their total Medicare reimbursement for COPD readmissions.

Researchers Michael W. Sjoding, MD, and Colin R. Cooke, MD, MSc, MS, both of the University of Michigan Institute for Healthcare Policy and Innovation in Ann Arbor, evaluated three years of data on 3,018 hospitals and found that COPD readmission rates ranged from 17% to 28% across all hospitals. Hospitals designated as major teaching hospitals, those with a high percentage of patients with low socioeconomic status, and those with a high volume of COPD patients were associated with higher COPD readmission rates (P<0.001 for all).

The findings were published last month in the American Journal of Respiratory and Critical Care Medicine.

"It has been shown that there is a correlation between patients' social structures and support at home and COPD readmissions," Dr. Sjoding says. "Economic resources and education level can also drive readmissions, situations that are beyond hospital control."

Policies that measure hospital quality, Dr. Sjoding says, are important to ensure that patients have access to quality care across the country. However, when creating policies aimed at reducing readmission rates, CMS should level the playing field, he says. For example, academic hospitals caring for complex patients should be compared against their peers.

"It's important that physicians speak up to make sure that policies do the right thing," he says.

Visit our website for more information about managing patients with COPD.

Government penalties meant to reduce COPD readmissions will unfairly impact hospitals that care for vulnerable patients, according to a report from the University of Michigan.

Beginning in January 2015, the Centers for Medicare & Medicaid Services will add COPD to its list of medical conditions for which it penalizes hospitals for excessive readmissions and fines them up to 3% of their total Medicare reimbursement for COPD readmissions.

Researchers Michael W. Sjoding, MD, and Colin R. Cooke, MD, MSc, MS, both of the University of Michigan Institute for Healthcare Policy and Innovation in Ann Arbor, evaluated three years of data on 3,018 hospitals and found that COPD readmission rates ranged from 17% to 28% across all hospitals. Hospitals designated as major teaching hospitals, those with a high percentage of patients with low socioeconomic status, and those with a high volume of COPD patients were associated with higher COPD readmission rates (P<0.001 for all).

The findings were published last month in the American Journal of Respiratory and Critical Care Medicine.

"It has been shown that there is a correlation between patients' social structures and support at home and COPD readmissions," Dr. Sjoding says. "Economic resources and education level can also drive readmissions, situations that are beyond hospital control."

Policies that measure hospital quality, Dr. Sjoding says, are important to ensure that patients have access to quality care across the country. However, when creating policies aimed at reducing readmission rates, CMS should level the playing field, he says. For example, academic hospitals caring for complex patients should be compared against their peers.

"It's important that physicians speak up to make sure that policies do the right thing," he says.

Visit our website for more information about managing patients with COPD.

A group of hospitalists in Oregon have formed what is believed to be the first hospitalist union in the country—but it may not be the last.

Hospitalists at PeaceHealth Sacred Heart Medical Center locations in Springfield and Eugene, Ore., voted to form the union, dubbed Pacific Northwest Hospital Medicine Association, to have more say in patient care and working conditions there. Talk of unionizing started after hospitalists objected to a recommendation by a PeaceHealth consultant that their group's employment model be outsourced and run by a national management firm rather than remain hospital-owned.

"We really didn't have much of a say other than all quitting, which we didn't want to do because we like where we work," says hospitalist and union spokesperson David Schwartz, MD. "We started talking about unionizing."

The union is under the umbrella of the American Federation of Teachers, and likely is the first of its kind in the nation. The group started with 38 members, but 12 physicians who did not want to be managed under a national firm have left.

Now, the union is trying to persuade PeaceHealth to keep the group's management in-house. If not, the union will look to negotiate a contract with a national management firm chosen by its hospital administration.

A union of hospital physicians is uncommon. Healthcare workers often unionize but not individual specialists. Dr. Schwartz says he is curious to see whether other hospitalists who feel they want more of a say in their practice management will follow suit.

"The fact that we unionized seemed to galvanize a lot of the staff at the hospital," he says. "This might be a wave of the future. … Now people have a choice, which is interesting to watch."

Visit our website for more information on managing hospitalist groups.

A group of hospitalists in Oregon have formed what is believed to be the first hospitalist union in the country—but it may not be the last.

Hospitalists at PeaceHealth Sacred Heart Medical Center locations in Springfield and Eugene, Ore., voted to form the union, dubbed Pacific Northwest Hospital Medicine Association, to have more say in patient care and working conditions there. Talk of unionizing started after hospitalists objected to a recommendation by a PeaceHealth consultant that their group's employment model be outsourced and run by a national management firm rather than remain hospital-owned.

"We really didn't have much of a say other than all quitting, which we didn't want to do because we like where we work," says hospitalist and union spokesperson David Schwartz, MD. "We started talking about unionizing."

The union is under the umbrella of the American Federation of Teachers, and likely is the first of its kind in the nation. The group started with 38 members, but 12 physicians who did not want to be managed under a national firm have left.

Now, the union is trying to persuade PeaceHealth to keep the group's management in-house. If not, the union will look to negotiate a contract with a national management firm chosen by its hospital administration.

A union of hospital physicians is uncommon. Healthcare workers often unionize but not individual specialists. Dr. Schwartz says he is curious to see whether other hospitalists who feel they want more of a say in their practice management will follow suit.

"The fact that we unionized seemed to galvanize a lot of the staff at the hospital," he says. "This might be a wave of the future. … Now people have a choice, which is interesting to watch."

Visit our website for more information on managing hospitalist groups.

A group of hospitalists in Oregon have formed what is believed to be the first hospitalist union in the country—but it may not be the last.

Hospitalists at PeaceHealth Sacred Heart Medical Center locations in Springfield and Eugene, Ore., voted to form the union, dubbed Pacific Northwest Hospital Medicine Association, to have more say in patient care and working conditions there. Talk of unionizing started after hospitalists objected to a recommendation by a PeaceHealth consultant that their group's employment model be outsourced and run by a national management firm rather than remain hospital-owned.

"We really didn't have much of a say other than all quitting, which we didn't want to do because we like where we work," says hospitalist and union spokesperson David Schwartz, MD. "We started talking about unionizing."

The union is under the umbrella of the American Federation of Teachers, and likely is the first of its kind in the nation. The group started with 38 members, but 12 physicians who did not want to be managed under a national firm have left.

Now, the union is trying to persuade PeaceHealth to keep the group's management in-house. If not, the union will look to negotiate a contract with a national management firm chosen by its hospital administration.

A union of hospital physicians is uncommon. Healthcare workers often unionize but not individual specialists. Dr. Schwartz says he is curious to see whether other hospitalists who feel they want more of a say in their practice management will follow suit.

"The fact that we unionized seemed to galvanize a lot of the staff at the hospital," he says. "This might be a wave of the future. … Now people have a choice, which is interesting to watch."

Visit our website for more information on managing hospitalist groups.