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Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

72%

Total growth in hospital capacity needed by the year 2050, according to an analysis in the Journal of Hospital Medicine.⁷ The estimate is based on a predicted 67% increase in the annual number of hospitalizations—assuming that other factors such as age-specific hospitalization rates and lengths of stay do not change—and derived from U.S. Census Bureau projections that by 2050 the U.S. population will increase by 41%. Total U.S. hospital capacity has steadily decreased for the past three decades.

Larry Beresford is a freelance writer in Alameda, Calif.

72%

Total growth in hospital capacity needed by the year 2050, according to an analysis in the Journal of Hospital Medicine.⁷ The estimate is based on a predicted 67% increase in the annual number of hospitalizations—assuming that other factors such as age-specific hospitalization rates and lengths of stay do not change—and derived from U.S. Census Bureau projections that by 2050 the U.S. population will increase by 41%. Total U.S. hospital capacity has steadily decreased for the past three decades.

Larry Beresford is a freelance writer in Alameda, Calif.

72%

Total growth in hospital capacity needed by the year 2050, according to an analysis in the Journal of Hospital Medicine.⁷ The estimate is based on a predicted 67% increase in the annual number of hospitalizations—assuming that other factors such as age-specific hospitalization rates and lengths of stay do not change—and derived from U.S. Census Bureau projections that by 2050 the U.S. population will increase by 41%. Total U.S. hospital capacity has steadily decreased for the past three decades.

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

The role of nonclinical factors in shaping rates of rehospitalization has been explored in several recent studies—and targeted through new legislation endorsed by the Society of Hospital Medicine. A study in Health Affairs compared hospital performance on 30-day readmissions for the first three diagnoses included in penalty calculations for CMS’ Hospital Readmissions Reduction Program (HRRP) and found that adjusting for patients’ socioeconomic status significantly reduced the rates of variation in readmissions between hospitals across the state of Missouri.¹

For patients discharged between 2009 and 2012, analysis using a model enriched with census tract socioeconomic data found that the range of variation in readmissions between hospitals decreased to 1.8% from 6.5% for patients with acute myocardial infarction; to 7.4% from 14.0% for congestive heart failure; and to 3.7% from 7.4% for pneumonia, compared with rates unadjusted for these socioeconomic factors. Another study in the same journal by researchers at an urban teaching hospital found that patients living in high-poverty neighborhoods were 24% more likely to be readmitted to the hospital within 30 days, after adjusting for demographic and clinical characteristics.²

For a factor that may be more amenable to intervention by hospitalists, a standardized rehabilitation medicine test measuring patients’ ability to perform everyday tasks of living, such as the ability to move independently from bed to chair, wheelchair, or toilet was found to be a good predictor of readmissions.³ Few hospitals currently require assessment of their patients’ functional ability, notes the study’s lead author Erik Hoyer, MD, assistant professor in the department of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine in Baltimore. But the score “is a direct reflection of the patient’s ability to heal [outside of the hospital].”

The Functional Independence Measure used in this study and in inpatient rehabilitation facilities nationwide is probably not the right tool for hospitalists because of its length and the training required to administer it, Dr. Hoyer says.

“There are other, easier tools that are available or in development that may also serve a similar purpose,” he says. “The main point is that routine functional assessment is important in the hospital setting, and developing strategies to improve patient function is likely an important way to improve outcomes such as hospital readmissions.”

The documented role of socioeconomic status in determining readmissions also is addressed by legislation introduced by Rep. Jim Renacci (R-Ohio) and supported by both the Society of Hospital Medicine and the American Hospital Association. The Establishing Beneficiary Equity in the Hospital Readmission Program Act (HR-4188) would adjust HRRP readmissions penalties to reflect “certain socioeconomic and health factors that increase the patient’s risk of readmissions.”

Larry Beresford is a freelance writer in Alameda, Calif.

The role of nonclinical factors in shaping rates of rehospitalization has been explored in several recent studies—and targeted through new legislation endorsed by the Society of Hospital Medicine. A study in Health Affairs compared hospital performance on 30-day readmissions for the first three diagnoses included in penalty calculations for CMS’ Hospital Readmissions Reduction Program (HRRP) and found that adjusting for patients’ socioeconomic status significantly reduced the rates of variation in readmissions between hospitals across the state of Missouri.¹

For patients discharged between 2009 and 2012, analysis using a model enriched with census tract socioeconomic data found that the range of variation in readmissions between hospitals decreased to 1.8% from 6.5% for patients with acute myocardial infarction; to 7.4% from 14.0% for congestive heart failure; and to 3.7% from 7.4% for pneumonia, compared with rates unadjusted for these socioeconomic factors. Another study in the same journal by researchers at an urban teaching hospital found that patients living in high-poverty neighborhoods were 24% more likely to be readmitted to the hospital within 30 days, after adjusting for demographic and clinical characteristics.²

For a factor that may be more amenable to intervention by hospitalists, a standardized rehabilitation medicine test measuring patients’ ability to perform everyday tasks of living, such as the ability to move independently from bed to chair, wheelchair, or toilet was found to be a good predictor of readmissions.³ Few hospitals currently require assessment of their patients’ functional ability, notes the study’s lead author Erik Hoyer, MD, assistant professor in the department of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine in Baltimore. But the score “is a direct reflection of the patient’s ability to heal [outside of the hospital].”

The Functional Independence Measure used in this study and in inpatient rehabilitation facilities nationwide is probably not the right tool for hospitalists because of its length and the training required to administer it, Dr. Hoyer says.

“There are other, easier tools that are available or in development that may also serve a similar purpose,” he says. “The main point is that routine functional assessment is important in the hospital setting, and developing strategies to improve patient function is likely an important way to improve outcomes such as hospital readmissions.”

The documented role of socioeconomic status in determining readmissions also is addressed by legislation introduced by Rep. Jim Renacci (R-Ohio) and supported by both the Society of Hospital Medicine and the American Hospital Association. The Establishing Beneficiary Equity in the Hospital Readmission Program Act (HR-4188) would adjust HRRP readmissions penalties to reflect “certain socioeconomic and health factors that increase the patient’s risk of readmissions.”

Larry Beresford is a freelance writer in Alameda, Calif.

The role of nonclinical factors in shaping rates of rehospitalization has been explored in several recent studies—and targeted through new legislation endorsed by the Society of Hospital Medicine. A study in Health Affairs compared hospital performance on 30-day readmissions for the first three diagnoses included in penalty calculations for CMS’ Hospital Readmissions Reduction Program (HRRP) and found that adjusting for patients’ socioeconomic status significantly reduced the rates of variation in readmissions between hospitals across the state of Missouri.¹

For patients discharged between 2009 and 2012, analysis using a model enriched with census tract socioeconomic data found that the range of variation in readmissions between hospitals decreased to 1.8% from 6.5% for patients with acute myocardial infarction; to 7.4% from 14.0% for congestive heart failure; and to 3.7% from 7.4% for pneumonia, compared with rates unadjusted for these socioeconomic factors. Another study in the same journal by researchers at an urban teaching hospital found that patients living in high-poverty neighborhoods were 24% more likely to be readmitted to the hospital within 30 days, after adjusting for demographic and clinical characteristics.²

For a factor that may be more amenable to intervention by hospitalists, a standardized rehabilitation medicine test measuring patients’ ability to perform everyday tasks of living, such as the ability to move independently from bed to chair, wheelchair, or toilet was found to be a good predictor of readmissions.³ Few hospitals currently require assessment of their patients’ functional ability, notes the study’s lead author Erik Hoyer, MD, assistant professor in the department of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine in Baltimore. But the score “is a direct reflection of the patient’s ability to heal [outside of the hospital].”

The Functional Independence Measure used in this study and in inpatient rehabilitation facilities nationwide is probably not the right tool for hospitalists because of its length and the training required to administer it, Dr. Hoyer says.

“There are other, easier tools that are available or in development that may also serve a similar purpose,” he says. “The main point is that routine functional assessment is important in the hospital setting, and developing strategies to improve patient function is likely an important way to improve outcomes such as hospital readmissions.”

The documented role of socioeconomic status in determining readmissions also is addressed by legislation introduced by Rep. Jim Renacci (R-Ohio) and supported by both the Society of Hospital Medicine and the American Hospital Association. The Establishing Beneficiary Equity in the Hospital Readmission Program Act (HR-4188) would adjust HRRP readmissions penalties to reflect “certain socioeconomic and health factors that increase the patient’s risk of readmissions.”

Larry Beresford is a freelance writer in Alameda, Calif.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: What is the effect of continuous positive airway pressure (CPAP) or supplemental oxygen on ambulatory blood pressures and markers of cardiovascular risk when combined with sleep hygiene education in patients with obstructive sleep apnea (OSA) and coronary artery disease or cardiac risk factors?

Background: OSA is considered a risk factor for the development of hypertension. One meta-analysis showed reduction of mean arterial pressure (MAP) with CPAP therapy, but randomized controlled data on blood pressure reduction with treatment of OSA is lacking.

Study design: Randomized, parallel-group trial.

Setting: Four outpatient cardiology practices.

Synopsis: Patients ages 45-75 with OSA were randomized to receive nocturnal CPAP and healthy lifestyle and sleep education (HLSE), nocturnal oxygen therapy and HSLE, or HSLE alone. The primary outcome was 24-hour MAP. Secondary outcomes included fasting blood glucose, lipid panel, insulin level, erythrocyte sedimentation rate, C-reactive protein (CRP), and N-terminal pro-brain naturetic peptide.

Participants had high rates of diabetes, hypertension, and coronary artery disease. At 12 weeks, the CPAP arm experienced greater reductions in 24-hour MAP compared to both the nocturnal oxygen and HSLE arms (-2.8 mmHg [P=0.02] and -2.4 mmHg [P=0.04], respectively). No significant decrease in MAP was identified in the nocturnal oxygen arm when compared to the HSLE arm. The only significant difference in secondary outcomes was a decrease in CRP in the CPAP arm when compared to the HSLE arm, the clinical significance of which is unclear.

Bottom line: CPAP therapy with sleep hygiene education appears superior to nocturnal oxygen therapy with sleep hygiene education and sleep hygiene education alone in decreasing 24-hour MAP in patients with OSA and coronary artery disease or cardiac risk factors.

Citation: Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med. 2014;370(24):2276-2285.

Clinical question: What is the effect of continuous positive airway pressure (CPAP) or supplemental oxygen on ambulatory blood pressures and markers of cardiovascular risk when combined with sleep hygiene education in patients with obstructive sleep apnea (OSA) and coronary artery disease or cardiac risk factors?

Background: OSA is considered a risk factor for the development of hypertension. One meta-analysis showed reduction of mean arterial pressure (MAP) with CPAP therapy, but randomized controlled data on blood pressure reduction with treatment of OSA is lacking.

Study design: Randomized, parallel-group trial.

Setting: Four outpatient cardiology practices.

Synopsis: Patients ages 45-75 with OSA were randomized to receive nocturnal CPAP and healthy lifestyle and sleep education (HLSE), nocturnal oxygen therapy and HSLE, or HSLE alone. The primary outcome was 24-hour MAP. Secondary outcomes included fasting blood glucose, lipid panel, insulin level, erythrocyte sedimentation rate, C-reactive protein (CRP), and N-terminal pro-brain naturetic peptide.

Participants had high rates of diabetes, hypertension, and coronary artery disease. At 12 weeks, the CPAP arm experienced greater reductions in 24-hour MAP compared to both the nocturnal oxygen and HSLE arms (-2.8 mmHg [P=0.02] and -2.4 mmHg [P=0.04], respectively). No significant decrease in MAP was identified in the nocturnal oxygen arm when compared to the HSLE arm. The only significant difference in secondary outcomes was a decrease in CRP in the CPAP arm when compared to the HSLE arm, the clinical significance of which is unclear.

Bottom line: CPAP therapy with sleep hygiene education appears superior to nocturnal oxygen therapy with sleep hygiene education and sleep hygiene education alone in decreasing 24-hour MAP in patients with OSA and coronary artery disease or cardiac risk factors.

Citation: Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med. 2014;370(24):2276-2285.

Clinical question: What is the effect of continuous positive airway pressure (CPAP) or supplemental oxygen on ambulatory blood pressures and markers of cardiovascular risk when combined with sleep hygiene education in patients with obstructive sleep apnea (OSA) and coronary artery disease or cardiac risk factors?

Background: OSA is considered a risk factor for the development of hypertension. One meta-analysis showed reduction of mean arterial pressure (MAP) with CPAP therapy, but randomized controlled data on blood pressure reduction with treatment of OSA is lacking.

Study design: Randomized, parallel-group trial.

Setting: Four outpatient cardiology practices.

Synopsis: Patients ages 45-75 with OSA were randomized to receive nocturnal CPAP and healthy lifestyle and sleep education (HLSE), nocturnal oxygen therapy and HSLE, or HSLE alone. The primary outcome was 24-hour MAP. Secondary outcomes included fasting blood glucose, lipid panel, insulin level, erythrocyte sedimentation rate, C-reactive protein (CRP), and N-terminal pro-brain naturetic peptide.

Participants had high rates of diabetes, hypertension, and coronary artery disease. At 12 weeks, the CPAP arm experienced greater reductions in 24-hour MAP compared to both the nocturnal oxygen and HSLE arms (-2.8 mmHg [P=0.02] and -2.4 mmHg [P=0.04], respectively). No significant decrease in MAP was identified in the nocturnal oxygen arm when compared to the HSLE arm. The only significant difference in secondary outcomes was a decrease in CRP in the CPAP arm when compared to the HSLE arm, the clinical significance of which is unclear.

Bottom line: CPAP therapy with sleep hygiene education appears superior to nocturnal oxygen therapy with sleep hygiene education and sleep hygiene education alone in decreasing 24-hour MAP in patients with OSA and coronary artery disease or cardiac risk factors.

Citation: Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med. 2014;370(24):2276-2285.

Clinical question: Is greater lactate clearance following resuscitation from cardiac arrest associated with lower mortality and better neurologic outcomes?

Background: Recommendations from the International Liaison Committee on Resuscitation for monitoring serial lactate levels in post-resuscitation patients are based primarily on extrapolation from other conditions such as sepsis. Two single-retrospective analyses found effective lactate clearance was associated with decreased mortality. This association had not previously been validated in a multicenter, prospective study.

Study design: Multicenter, prospective, observational study.

Setting: Four urban, tertiary-care teaching hospitals.

Synopsis: Absolute lactate levels and the differences in the percent lactate change over 24 hours were compared in 100 patients who suffered out-of-hospital cardiac arrest. Ninety-seven percent received therapeutic hypothermia, and overall survival was 46%. Survivors and patients with a good neurologic outcome had lower lactate levels at zero hours (4.1 vs. 7.3), 12 hours (2.2 vs. 6.0), and 24 hours (1.6 vs. 4.4) compared with nonsurvivors and patients with bad neurologic outcomes.

The percent lactate decreased was greater in survivors and in those with good neurologic outcomes (odds ratio, 2.2; 95% confidence interval, 1.1–4.4).

Nonsurvivors or those with poor neurologic outcomes were less likely to have received bystander CPR, to have suffered a witnessed arrest, or to have had a shockable rhythm at presentation. Superior lactate clearance in survivors and those with good neurologic outcomes suggests a potential role in developing markers of effective resuscitation.

Bottom line: Lower lactate levels and more effective clearance of lactate in patients following cardiac arrest are associated with improved survival and good neurologic outcome.

Citation: Donnino MW, Andersen LW, Giberson T, et al. Initial lactate and lactate change in post-cardiac arrest: a multicenter validation study. Crit Care Med. 2014;42(8):1804-1811.

Clinical question: Is greater lactate clearance following resuscitation from cardiac arrest associated with lower mortality and better neurologic outcomes?

Background: Recommendations from the International Liaison Committee on Resuscitation for monitoring serial lactate levels in post-resuscitation patients are based primarily on extrapolation from other conditions such as sepsis. Two single-retrospective analyses found effective lactate clearance was associated with decreased mortality. This association had not previously been validated in a multicenter, prospective study.

Study design: Multicenter, prospective, observational study.

Setting: Four urban, tertiary-care teaching hospitals.

Synopsis: Absolute lactate levels and the differences in the percent lactate change over 24 hours were compared in 100 patients who suffered out-of-hospital cardiac arrest. Ninety-seven percent received therapeutic hypothermia, and overall survival was 46%. Survivors and patients with a good neurologic outcome had lower lactate levels at zero hours (4.1 vs. 7.3), 12 hours (2.2 vs. 6.0), and 24 hours (1.6 vs. 4.4) compared with nonsurvivors and patients with bad neurologic outcomes.

The percent lactate decreased was greater in survivors and in those with good neurologic outcomes (odds ratio, 2.2; 95% confidence interval, 1.1–4.4).

Nonsurvivors or those with poor neurologic outcomes were less likely to have received bystander CPR, to have suffered a witnessed arrest, or to have had a shockable rhythm at presentation. Superior lactate clearance in survivors and those with good neurologic outcomes suggests a potential role in developing markers of effective resuscitation.

Bottom line: Lower lactate levels and more effective clearance of lactate in patients following cardiac arrest are associated with improved survival and good neurologic outcome.

Citation: Donnino MW, Andersen LW, Giberson T, et al. Initial lactate and lactate change in post-cardiac arrest: a multicenter validation study. Crit Care Med. 2014;42(8):1804-1811.

Clinical question: Is greater lactate clearance following resuscitation from cardiac arrest associated with lower mortality and better neurologic outcomes?

Background: Recommendations from the International Liaison Committee on Resuscitation for monitoring serial lactate levels in post-resuscitation patients are based primarily on extrapolation from other conditions such as sepsis. Two single-retrospective analyses found effective lactate clearance was associated with decreased mortality. This association had not previously been validated in a multicenter, prospective study.

Study design: Multicenter, prospective, observational study.

Setting: Four urban, tertiary-care teaching hospitals.

Synopsis: Absolute lactate levels and the differences in the percent lactate change over 24 hours were compared in 100 patients who suffered out-of-hospital cardiac arrest. Ninety-seven percent received therapeutic hypothermia, and overall survival was 46%. Survivors and patients with a good neurologic outcome had lower lactate levels at zero hours (4.1 vs. 7.3), 12 hours (2.2 vs. 6.0), and 24 hours (1.6 vs. 4.4) compared with nonsurvivors and patients with bad neurologic outcomes.

The percent lactate decreased was greater in survivors and in those with good neurologic outcomes (odds ratio, 2.2; 95% confidence interval, 1.1–4.4).

Nonsurvivors or those with poor neurologic outcomes were less likely to have received bystander CPR, to have suffered a witnessed arrest, or to have had a shockable rhythm at presentation. Superior lactate clearance in survivors and those with good neurologic outcomes suggests a potential role in developing markers of effective resuscitation.

Bottom line: Lower lactate levels and more effective clearance of lactate in patients following cardiac arrest are associated with improved survival and good neurologic outcome.

Citation: Donnino MW, Andersen LW, Giberson T, et al. Initial lactate and lactate change in post-cardiac arrest: a multicenter validation study. Crit Care Med. 2014;42(8):1804-1811.

Clinical question: Is earlier administration of epinephrine in patients with cardiac arrest due to nonshockable rhythms associated with increased return of spontaneous circulation, survival, and neurologically intact survival?

Background: About 200,000 hospitalized patients in the U.S. have a cardiac arrest, commonly due to nonshockable rhythms. Cardiopulmonary resuscitation has been the only efficacious intervention. There are no well-controlled trials of the use of epinephrine on survival and neurological outcomes.

Study design: Prospective cohort from a large multicenter registry of in-hospital cardiac arrests.

Setting: Data from 570 hospitals from 2000 to 2009.

Synopsis: Authors included 25,095 adults from 570 hospitals who had cardiac arrests in hospital with asystole or pulseless electrical activity as the initial rhythm. Time to first administration of epinephrine was recorded and then separated into quartiles, and odds ratios were evaluated using one to three minutes as the reference group. Outcomes of survival to hospital discharge (10%), return of spontaneous circulation (47%), and survival to hospital discharge with favorable neurologic status (7%) were assessed.

Survival to discharge decreased as the time to administration of the first dose of epinephrine increased. Of those patients receiving epinephrine in one minute, 12% survived. This dropped to 7% for those first receiving epinephrine after seven minutes. Return of spontaneous circulation and survival to discharge with favorable neurologic status showed a similar stepwise decrease with longer times to first administration of epinephrine.

Bottom line: Earlier administration of epinephrine to patients with cardiac arrest due to nonshockable rhythms is associated with improved survival to discharge, return of spontaneous circulation, and neurologically intact survival.

Citation: Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: restrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028.

Clinical question: Is earlier administration of epinephrine in patients with cardiac arrest due to nonshockable rhythms associated with increased return of spontaneous circulation, survival, and neurologically intact survival?

Background: About 200,000 hospitalized patients in the U.S. have a cardiac arrest, commonly due to nonshockable rhythms. Cardiopulmonary resuscitation has been the only efficacious intervention. There are no well-controlled trials of the use of epinephrine on survival and neurological outcomes.

Study design: Prospective cohort from a large multicenter registry of in-hospital cardiac arrests.

Setting: Data from 570 hospitals from 2000 to 2009.

Synopsis: Authors included 25,095 adults from 570 hospitals who had cardiac arrests in hospital with asystole or pulseless electrical activity as the initial rhythm. Time to first administration of epinephrine was recorded and then separated into quartiles, and odds ratios were evaluated using one to three minutes as the reference group. Outcomes of survival to hospital discharge (10%), return of spontaneous circulation (47%), and survival to hospital discharge with favorable neurologic status (7%) were assessed.

Survival to discharge decreased as the time to administration of the first dose of epinephrine increased. Of those patients receiving epinephrine in one minute, 12% survived. This dropped to 7% for those first receiving epinephrine after seven minutes. Return of spontaneous circulation and survival to discharge with favorable neurologic status showed a similar stepwise decrease with longer times to first administration of epinephrine.

Bottom line: Earlier administration of epinephrine to patients with cardiac arrest due to nonshockable rhythms is associated with improved survival to discharge, return of spontaneous circulation, and neurologically intact survival.

Citation: Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: restrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028.

Clinical question: Is earlier administration of epinephrine in patients with cardiac arrest due to nonshockable rhythms associated with increased return of spontaneous circulation, survival, and neurologically intact survival?

Background: About 200,000 hospitalized patients in the U.S. have a cardiac arrest, commonly due to nonshockable rhythms. Cardiopulmonary resuscitation has been the only efficacious intervention. There are no well-controlled trials of the use of epinephrine on survival and neurological outcomes.

Study design: Prospective cohort from a large multicenter registry of in-hospital cardiac arrests.

Setting: Data from 570 hospitals from 2000 to 2009.

Synopsis: Authors included 25,095 adults from 570 hospitals who had cardiac arrests in hospital with asystole or pulseless electrical activity as the initial rhythm. Time to first administration of epinephrine was recorded and then separated into quartiles, and odds ratios were evaluated using one to three minutes as the reference group. Outcomes of survival to hospital discharge (10%), return of spontaneous circulation (47%), and survival to hospital discharge with favorable neurologic status (7%) were assessed.

Survival to discharge decreased as the time to administration of the first dose of epinephrine increased. Of those patients receiving epinephrine in one minute, 12% survived. This dropped to 7% for those first receiving epinephrine after seven minutes. Return of spontaneous circulation and survival to discharge with favorable neurologic status showed a similar stepwise decrease with longer times to first administration of epinephrine.

Bottom line: Earlier administration of epinephrine to patients with cardiac arrest due to nonshockable rhythms is associated with improved survival to discharge, return of spontaneous circulation, and neurologically intact survival.

Citation: Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: restrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028.