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The Biggest Thing in Hospital Medicine Since Patient Safety?
Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.
The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.
The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.
How Does Bundled Payment Work?
The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.
Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.
The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.
Hospitalists and BPCI
Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.
Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.
Where Will Savings Come From?
Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.1 As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.
Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.
Conclusion
Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.
In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.
Reference
Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.
The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.
The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.
How Does Bundled Payment Work?
The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.
Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.
The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.
Hospitalists and BPCI
Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.
Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.
Where Will Savings Come From?
Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.1 As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.
Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.
Conclusion
Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.
In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.
Reference
Editor’s note: First of a two-part series examining bundled payments and hospital medicine. Additionally, Dr. Whitcomb works for a company that is an Awardee Convener in the CMS Bundled Payments for Care Improvement (BPCI) Initiative.
The Centers for Medicare and Medicaid Services’ (CMS) bundled payment initiative was announced in August 2011 and has been “live” since October 2013, when a handful of healthcare systems launched bundled payment programs. In 2014, the CMS initiative grew substantially as a result of large-scale interest on the part of hospitals, physician groups, skilled nursing facilities (SNFs), and others in testing the model, which can be described as a single payment for an episode of care.
The BPCI initiative will be a large-scale program by July 1; it starts with an April 1 cohort launch and will result in the program’s presence in all 50 states, with hundreds of physician practices and hospitals participating. The 2015 cohort will involve a large number of hospitalist practices, participating as “episode initiators” that bear clinical and economic responsibility for the bundle, or as “gainsharers” who are eligible to receive incentive payments if they can reduce costs while maintaining measurable quality for an episode of care.
How Does Bundled Payment Work?
The BPCI initiative is a large-scale, three- to five-year demonstration to test bundled payment in patients with fee-for-service Medicare. The most common model, referred to as Model 2, involves an inpatient hospitalization for one of 48 defined episodes, which include both medical and surgical conditions, followed by a recovery period lasting 30, 60, or 90 days.
Each hospital or physician practice that is considering entering the BPCI program receives prices for all 48 episodes based on a 2009-2012 historical average of Medicare part A and B claims associated with that hospital or physician group. After analyzing those prices, the hospital or physician practice may elect to choose the bundles that have a good chance of being successful—where actual spending comes in under the historical target price—based on care improvement expectations in their local system. In Model 2, CMS takes 2% off the target price for 90-day episodes and 3% off the target price for 30- and 60-day episodes, making it all the more important to choose bundles that demonstrate a high likelihood of success.
The revenue cycle for hospitals and physicians in the program does not change. They submit claims for their services and receive reimbursement as they always have; however, after the end of each quarter, when the majority of part A and B claims have been processed, a “look back” at actual spending for all participating episodes is reconciled against the baseline price derived from 2009-2012. If there is a net savings compared to the baseline, monies can be distributed to the participating providers—the hospital or physician practice—and those providers may further share some of the savings with other physicians/providers who have signed a gainsharing contract.
Hospitalists and BPCI
Hospitalist practices participate in the CMS program either as episode initiators or gainsharers. As episode initiators, they “own” the bundle, which means they bear economic risk for the program. In this capacity, overall savings will mean the hospitalist practice has a new revenue stream, which could be substantial; however, the practice is also responsible for any losses.
Other hospitalist practices have become gainsharers in the program, which means they have signed an agreement enabling them to receive payments in addition to professional fee revenues for activities that reduce costs while maintaining or improving quality. Such activities are referred to as “care redesign” in the program. Gainsharers do not bear financial risk.
Where Will Savings Come From?
Perhaps ironically for hospitalists, the main source of savings in the BPCI program comes from post-acute care and readmissions. For example, for common conditions like heart failure, COPD, and pneumonia, Medicare spends almost as much on post-acute care and readmissions in the first 30 days after discharge as it does on the index hospitalization.1 As a result, the BPCI program adds further emphasis on preventing readmissions when added to existing pressures, and there is a new premium placed on “right-sizing” the usage of SNF and other post-acute facilities, such as inpatient rehabilitation and long-term acute care hospitals. For hospitalists, this means that new rigor is needed to connect to the post-acute setting, such as determining why a patient is being discharged to a skilled facility.
Another savings pool, called “internal cost savings,” is available to reward decreasing inpatient utilization from, for example, testing, imaging, and implantable devices.
Conclusion
Bundled payment might be the biggest thing to come along for hospitalists since the patient safety movement launched some 16 years ago. Why? Although accountable care organizations have largely focused on ambulatory practice, bundled payment has a major focus on hospital care and on the post-acute care decisions that are made during the hospitalization. If bundled payment proves to be an effective way to pay for—and organize—care, hospitalists will play a central role in the success of this innovation.
In part two of this series, I will explore specific roles hospitalists play in successful bundled payment programs.
Reference
Rapid-Response Teams Help Hospitalists Manage Non-Medical Distress
A team that could respond quickly to social and behavioral concerns—and not medical issues per se—would have tremendous benefits for patients and caregivers.
I think there has been a steady increase, over the last 20 years or so, in the number of very unhappy, angry, or misbehaving patients (e.g. abusive/threatening to staff). In some cases, the hospital and caregivers have failed the patient. In other cases, their frustration arises out of things outside the hospital’s direct control, such as Medicare observation status, or perhaps the patient or family is just unreasonable or suffering from a psychiatric or substance abuse disorder.
I’m not talking about the common occurrence of a disappointed patient or family who might calmly complain about something. Instead, I want to focus on those patients who, whether we perceive them as justifiably unhappy or not, are so angry that they become very time consuming and distressing to deal with. Maybe they shout about how their lawyer will be suing us and the newspaper will be writing a story about how awful we are. Or they shout and throw things, and staff become afraid of them.
In my May 2013 column, I discussed care plans for patients like this who are admitted frequently, but such plans are not sufficient in every case.
A Haphazard Approach
Most hospitals have an informal process of dealing with these patients; it starts with the bedside nurse and/or doctor trying to apologize or make adjustments to satisfy and calm the patient. If that fails, then perhaps the manager of the nursing unit gets involved. Others may be recruited, such as someone from the hospital’s risk management or “patient advocate” departments and hospital executives such as the CNO, CMO, or CEO. Sometimes several of these people may meet as a group in an effort to come up with a plan to address the situation. But, most institutions do not have a clear and consistent approach to this important work, so the hospital personnel involved end up “reinventing the wheel” each time.
The growing awareness that hospital personnel don’t seem to have a robust and confident approach to addressing this type of situation can increase a patient’s distress, and it may embolden some to become even more demanding or threatening.
And all of this takes a significant toll on bedside caregivers, who often spend so much time dealing with the angry patient that they have less time to devote to other patients, who are in turn at least a little more likely to become unhappy or suffer as a result of a distressed and busy caregiver.
A Consistent Approach: RRT for Non-Medical Distress
I think the potential benefit for patients and caregivers is significant enough that hospitals should develop a standardized approach to managing such patients, and rapid response teams (RRTs) could serve as a model. To be clear, I’m not advocating that RRTs add management of very angry or distressed patients to their current role. Let’s call it an “RRT for non-medical distress.” And, while I think it is a worthwhile idea, and I am in the early steps of trying to develop it at “my” hospital, I’m not aware of any such team in place anywhere now.
To make it practical, I think this team should be available only during weekday business hours and would comprise something like six to 10 people with clinical backgrounds who do mostly administrative work. For example, the team members could include two nursing unit directors, a risk manager, a patient advocate (or patient satisfaction “czar”), a psychiatrist, the hospitalist medical director, the chief medical officer, and a few other individuals selected for their communication skills.
One of the team members would be on call for a day or week at a time and would carry the team’s pager during business hours. Any hospital caregiver could send a page requesting the team’s assistance, and the on-call team member would respond immediately by phone or, if possible, in person. After the on-call team member’s initial assessment, the whole team would meet later the same day or early the next day. On most days, a few members of the team would be off and unable to attend the meeting. So, if the team has eight members, each meeting of the team might average about five participants.
Non-Medical Distress RRT Processes
When meeting to establish a plan for addressing an extraordinarily distressed patient/family, the team should follow a standardized written approach. A designated person should lead the conversation—perhaps the on-call team member who responded first—and another should take notes. Using a form developed for this purpose, the note-taker would capture a standardized data set that is likely to be useful in determining a course of action, as well as valuable in helping the team fine-tune its approach by reviewing trends in aggregate data. The form might include things like patient demographics; the patient’s complaints and demands; potential complicating patient issues such as substance abuse, psychoactive drugs, or psychiatric history; location in the hospital; and names of bedside caregivers. Every effort should be made to keep the meetings efficient and as brief as practical—typically 30-60 minutes.
I’m convinced that when deciding how to respond to the situation, the team should try to limit itself to choosing one or more of eight to 10 standard interventions, rather than aiming for an entirely customized response in every case. Among the standardized interventions:
- Service recovery tools, such as a handwritten apology letter;
- A meeting between the patient/family and the hospital CEO or CMO;
- Security guard(s) at the door, on “high alert” to help if called; or
- A behavioral contract specifying the expectations for both patient and hospital staff behavior.
You might think of additional “tools” this team could have in their standardized response set.
Why limit the team as much as possible to a small set of standardized interventions? Developing customized responses in each situation is time consuming and, arguably, has a higher risk of failure, since it will be difficult to ensure that all staff caring for the patient can understand and execute them effectively. And the small set of interventions will make it easier to track their effectiveness over multiple patients so that the whole process can be improved over time.
Set a High Bar
The team should not be activated for every unhappy or difficult patient; that would be overkill and would result in many activations requiring dedicated staff with no other duties to serve on the team each day. Instead, I think the team should be activated only for the most difficult and distressing cases, at least for the first few years. In a 300-bed hospital, this would be approximately one to 1.5 activations per week.
Bedside caregivers would likely feel some reassurance knowing that they can reliably get help managing the most difficult patients, and, if the plan is executed well, these patients may get care that is safer for both themselves and staff. Who knows, medical outcomes might be improved for these patients also.
A team that could respond quickly to social and behavioral concerns—and not medical issues per se—would have tremendous benefits for patients and caregivers.
I think there has been a steady increase, over the last 20 years or so, in the number of very unhappy, angry, or misbehaving patients (e.g. abusive/threatening to staff). In some cases, the hospital and caregivers have failed the patient. In other cases, their frustration arises out of things outside the hospital’s direct control, such as Medicare observation status, or perhaps the patient or family is just unreasonable or suffering from a psychiatric or substance abuse disorder.
I’m not talking about the common occurrence of a disappointed patient or family who might calmly complain about something. Instead, I want to focus on those patients who, whether we perceive them as justifiably unhappy or not, are so angry that they become very time consuming and distressing to deal with. Maybe they shout about how their lawyer will be suing us and the newspaper will be writing a story about how awful we are. Or they shout and throw things, and staff become afraid of them.
In my May 2013 column, I discussed care plans for patients like this who are admitted frequently, but such plans are not sufficient in every case.
A Haphazard Approach
Most hospitals have an informal process of dealing with these patients; it starts with the bedside nurse and/or doctor trying to apologize or make adjustments to satisfy and calm the patient. If that fails, then perhaps the manager of the nursing unit gets involved. Others may be recruited, such as someone from the hospital’s risk management or “patient advocate” departments and hospital executives such as the CNO, CMO, or CEO. Sometimes several of these people may meet as a group in an effort to come up with a plan to address the situation. But, most institutions do not have a clear and consistent approach to this important work, so the hospital personnel involved end up “reinventing the wheel” each time.
The growing awareness that hospital personnel don’t seem to have a robust and confident approach to addressing this type of situation can increase a patient’s distress, and it may embolden some to become even more demanding or threatening.
And all of this takes a significant toll on bedside caregivers, who often spend so much time dealing with the angry patient that they have less time to devote to other patients, who are in turn at least a little more likely to become unhappy or suffer as a result of a distressed and busy caregiver.
A Consistent Approach: RRT for Non-Medical Distress
I think the potential benefit for patients and caregivers is significant enough that hospitals should develop a standardized approach to managing such patients, and rapid response teams (RRTs) could serve as a model. To be clear, I’m not advocating that RRTs add management of very angry or distressed patients to their current role. Let’s call it an “RRT for non-medical distress.” And, while I think it is a worthwhile idea, and I am in the early steps of trying to develop it at “my” hospital, I’m not aware of any such team in place anywhere now.
To make it practical, I think this team should be available only during weekday business hours and would comprise something like six to 10 people with clinical backgrounds who do mostly administrative work. For example, the team members could include two nursing unit directors, a risk manager, a patient advocate (or patient satisfaction “czar”), a psychiatrist, the hospitalist medical director, the chief medical officer, and a few other individuals selected for their communication skills.
One of the team members would be on call for a day or week at a time and would carry the team’s pager during business hours. Any hospital caregiver could send a page requesting the team’s assistance, and the on-call team member would respond immediately by phone or, if possible, in person. After the on-call team member’s initial assessment, the whole team would meet later the same day or early the next day. On most days, a few members of the team would be off and unable to attend the meeting. So, if the team has eight members, each meeting of the team might average about five participants.
Non-Medical Distress RRT Processes
When meeting to establish a plan for addressing an extraordinarily distressed patient/family, the team should follow a standardized written approach. A designated person should lead the conversation—perhaps the on-call team member who responded first—and another should take notes. Using a form developed for this purpose, the note-taker would capture a standardized data set that is likely to be useful in determining a course of action, as well as valuable in helping the team fine-tune its approach by reviewing trends in aggregate data. The form might include things like patient demographics; the patient’s complaints and demands; potential complicating patient issues such as substance abuse, psychoactive drugs, or psychiatric history; location in the hospital; and names of bedside caregivers. Every effort should be made to keep the meetings efficient and as brief as practical—typically 30-60 minutes.
I’m convinced that when deciding how to respond to the situation, the team should try to limit itself to choosing one or more of eight to 10 standard interventions, rather than aiming for an entirely customized response in every case. Among the standardized interventions:
- Service recovery tools, such as a handwritten apology letter;
- A meeting between the patient/family and the hospital CEO or CMO;
- Security guard(s) at the door, on “high alert” to help if called; or
- A behavioral contract specifying the expectations for both patient and hospital staff behavior.
You might think of additional “tools” this team could have in their standardized response set.
Why limit the team as much as possible to a small set of standardized interventions? Developing customized responses in each situation is time consuming and, arguably, has a higher risk of failure, since it will be difficult to ensure that all staff caring for the patient can understand and execute them effectively. And the small set of interventions will make it easier to track their effectiveness over multiple patients so that the whole process can be improved over time.
Set a High Bar
The team should not be activated for every unhappy or difficult patient; that would be overkill and would result in many activations requiring dedicated staff with no other duties to serve on the team each day. Instead, I think the team should be activated only for the most difficult and distressing cases, at least for the first few years. In a 300-bed hospital, this would be approximately one to 1.5 activations per week.
Bedside caregivers would likely feel some reassurance knowing that they can reliably get help managing the most difficult patients, and, if the plan is executed well, these patients may get care that is safer for both themselves and staff. Who knows, medical outcomes might be improved for these patients also.
A team that could respond quickly to social and behavioral concerns—and not medical issues per se—would have tremendous benefits for patients and caregivers.
I think there has been a steady increase, over the last 20 years or so, in the number of very unhappy, angry, or misbehaving patients (e.g. abusive/threatening to staff). In some cases, the hospital and caregivers have failed the patient. In other cases, their frustration arises out of things outside the hospital’s direct control, such as Medicare observation status, or perhaps the patient or family is just unreasonable or suffering from a psychiatric or substance abuse disorder.
I’m not talking about the common occurrence of a disappointed patient or family who might calmly complain about something. Instead, I want to focus on those patients who, whether we perceive them as justifiably unhappy or not, are so angry that they become very time consuming and distressing to deal with. Maybe they shout about how their lawyer will be suing us and the newspaper will be writing a story about how awful we are. Or they shout and throw things, and staff become afraid of them.
In my May 2013 column, I discussed care plans for patients like this who are admitted frequently, but such plans are not sufficient in every case.
A Haphazard Approach
Most hospitals have an informal process of dealing with these patients; it starts with the bedside nurse and/or doctor trying to apologize or make adjustments to satisfy and calm the patient. If that fails, then perhaps the manager of the nursing unit gets involved. Others may be recruited, such as someone from the hospital’s risk management or “patient advocate” departments and hospital executives such as the CNO, CMO, or CEO. Sometimes several of these people may meet as a group in an effort to come up with a plan to address the situation. But, most institutions do not have a clear and consistent approach to this important work, so the hospital personnel involved end up “reinventing the wheel” each time.
The growing awareness that hospital personnel don’t seem to have a robust and confident approach to addressing this type of situation can increase a patient’s distress, and it may embolden some to become even more demanding or threatening.
And all of this takes a significant toll on bedside caregivers, who often spend so much time dealing with the angry patient that they have less time to devote to other patients, who are in turn at least a little more likely to become unhappy or suffer as a result of a distressed and busy caregiver.
A Consistent Approach: RRT for Non-Medical Distress
I think the potential benefit for patients and caregivers is significant enough that hospitals should develop a standardized approach to managing such patients, and rapid response teams (RRTs) could serve as a model. To be clear, I’m not advocating that RRTs add management of very angry or distressed patients to their current role. Let’s call it an “RRT for non-medical distress.” And, while I think it is a worthwhile idea, and I am in the early steps of trying to develop it at “my” hospital, I’m not aware of any such team in place anywhere now.
To make it practical, I think this team should be available only during weekday business hours and would comprise something like six to 10 people with clinical backgrounds who do mostly administrative work. For example, the team members could include two nursing unit directors, a risk manager, a patient advocate (or patient satisfaction “czar”), a psychiatrist, the hospitalist medical director, the chief medical officer, and a few other individuals selected for their communication skills.
One of the team members would be on call for a day or week at a time and would carry the team’s pager during business hours. Any hospital caregiver could send a page requesting the team’s assistance, and the on-call team member would respond immediately by phone or, if possible, in person. After the on-call team member’s initial assessment, the whole team would meet later the same day or early the next day. On most days, a few members of the team would be off and unable to attend the meeting. So, if the team has eight members, each meeting of the team might average about five participants.
Non-Medical Distress RRT Processes
When meeting to establish a plan for addressing an extraordinarily distressed patient/family, the team should follow a standardized written approach. A designated person should lead the conversation—perhaps the on-call team member who responded first—and another should take notes. Using a form developed for this purpose, the note-taker would capture a standardized data set that is likely to be useful in determining a course of action, as well as valuable in helping the team fine-tune its approach by reviewing trends in aggregate data. The form might include things like patient demographics; the patient’s complaints and demands; potential complicating patient issues such as substance abuse, psychoactive drugs, or psychiatric history; location in the hospital; and names of bedside caregivers. Every effort should be made to keep the meetings efficient and as brief as practical—typically 30-60 minutes.
I’m convinced that when deciding how to respond to the situation, the team should try to limit itself to choosing one or more of eight to 10 standard interventions, rather than aiming for an entirely customized response in every case. Among the standardized interventions:
- Service recovery tools, such as a handwritten apology letter;
- A meeting between the patient/family and the hospital CEO or CMO;
- Security guard(s) at the door, on “high alert” to help if called; or
- A behavioral contract specifying the expectations for both patient and hospital staff behavior.
You might think of additional “tools” this team could have in their standardized response set.
Why limit the team as much as possible to a small set of standardized interventions? Developing customized responses in each situation is time consuming and, arguably, has a higher risk of failure, since it will be difficult to ensure that all staff caring for the patient can understand and execute them effectively. And the small set of interventions will make it easier to track their effectiveness over multiple patients so that the whole process can be improved over time.
Set a High Bar
The team should not be activated for every unhappy or difficult patient; that would be overkill and would result in many activations requiring dedicated staff with no other duties to serve on the team each day. Instead, I think the team should be activated only for the most difficult and distressing cases, at least for the first few years. In a 300-bed hospital, this would be approximately one to 1.5 activations per week.
Bedside caregivers would likely feel some reassurance knowing that they can reliably get help managing the most difficult patients, and, if the plan is executed well, these patients may get care that is safer for both themselves and staff. Who knows, medical outcomes might be improved for these patients also.
Does a family history of both breast and prostate cancer (vs breast only) put a woman at greater risk for future breast cancer?
The most common invasive cancers diagnosed in US women and men are breast and prostate cancers, respectively. This analysis from the Women’s Health Initiative observational study involved 78,171 women aged 50 to 79 years at enrollment. Invasive breast cancer was diagnosed in 3,506 women (4.5%) during a median of 132 months of follow-up. Having a first-degree relative with breast or prostate cancer was associated with an elevated adjusted hazard ratio of breast cancer of 1.42 and 1.14, respectively. Women who had a history of both cancers among first-degree relatives had an adjusted HR of 1.78. Although the difference did not achieve statistical significance, there was a suggestion that the elevated risk for breast cancer associated with relatives with prostate and breast cancer was higher in African-American women compared with white women. The risk for breast cancer was not elevated in women who had first-degree relatives with cancers other than breast or prostate.
The authors point out that another study also reported that a family history that includes both cancers is associated with a greater elevation in the risk for breast cancer than family history of prostate cancer alone. Although BRCA 1 and 2 mutations are associated with an elevated risk of not only breast but also prostate cancer, the authors indicate that such mutations account for only a small proportion of the observed aggregation of breast and prostate cancer in first-degree relatives of women with breast cancer in their analysis.
What this evidence means for practice
The associations observed by these authors underscore that, when taking family histories, women’s health clinicians should pay attention not only to breast but also to prostate cancer, and counsel patients regarding risk and screening practices accordingly.
—Andrew M. Kaunitz, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
The most common invasive cancers diagnosed in US women and men are breast and prostate cancers, respectively. This analysis from the Women’s Health Initiative observational study involved 78,171 women aged 50 to 79 years at enrollment. Invasive breast cancer was diagnosed in 3,506 women (4.5%) during a median of 132 months of follow-up. Having a first-degree relative with breast or prostate cancer was associated with an elevated adjusted hazard ratio of breast cancer of 1.42 and 1.14, respectively. Women who had a history of both cancers among first-degree relatives had an adjusted HR of 1.78. Although the difference did not achieve statistical significance, there was a suggestion that the elevated risk for breast cancer associated with relatives with prostate and breast cancer was higher in African-American women compared with white women. The risk for breast cancer was not elevated in women who had first-degree relatives with cancers other than breast or prostate.
The authors point out that another study also reported that a family history that includes both cancers is associated with a greater elevation in the risk for breast cancer than family history of prostate cancer alone. Although BRCA 1 and 2 mutations are associated with an elevated risk of not only breast but also prostate cancer, the authors indicate that such mutations account for only a small proportion of the observed aggregation of breast and prostate cancer in first-degree relatives of women with breast cancer in their analysis.
What this evidence means for practice
The associations observed by these authors underscore that, when taking family histories, women’s health clinicians should pay attention not only to breast but also to prostate cancer, and counsel patients regarding risk and screening practices accordingly.
—Andrew M. Kaunitz, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
The most common invasive cancers diagnosed in US women and men are breast and prostate cancers, respectively. This analysis from the Women’s Health Initiative observational study involved 78,171 women aged 50 to 79 years at enrollment. Invasive breast cancer was diagnosed in 3,506 women (4.5%) during a median of 132 months of follow-up. Having a first-degree relative with breast or prostate cancer was associated with an elevated adjusted hazard ratio of breast cancer of 1.42 and 1.14, respectively. Women who had a history of both cancers among first-degree relatives had an adjusted HR of 1.78. Although the difference did not achieve statistical significance, there was a suggestion that the elevated risk for breast cancer associated with relatives with prostate and breast cancer was higher in African-American women compared with white women. The risk for breast cancer was not elevated in women who had first-degree relatives with cancers other than breast or prostate.
The authors point out that another study also reported that a family history that includes both cancers is associated with a greater elevation in the risk for breast cancer than family history of prostate cancer alone. Although BRCA 1 and 2 mutations are associated with an elevated risk of not only breast but also prostate cancer, the authors indicate that such mutations account for only a small proportion of the observed aggregation of breast and prostate cancer in first-degree relatives of women with breast cancer in their analysis.
What this evidence means for practice
The associations observed by these authors underscore that, when taking family histories, women’s health clinicians should pay attention not only to breast but also to prostate cancer, and counsel patients regarding risk and screening practices accordingly.
—Andrew M. Kaunitz, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
What is the risk that a patient will have an occult uterine cancer at myomectomy?
Wright and colleagues analyzed the risk of diagnosing an occult uterine cancer at the time of myomectomy using an administrative database, which contained information on 41,777 myomectomy surgeries performed at 496 hospitals from 2006 to 2012. They reported that 76 uterine corpus cancers (ICD-9 codes 179.x and 182.x) were detected, for a rate of 1 occult cancer identified per 550 myomectomy cases. The risk of diagnosing an occult uterine cancer increased with age.
Study limitations
A major weakness of the study is that the administrative database did not provide information about the histologic type of uterine corpus cancer. Uterine leiomyosarcoma is a highly aggressive cancer, while endometrial stromal sarcoma is a more indolent cancer. Additionally, the authors were not able to perform a histologic reassessment of the slides of the 76 cases reported as having uterine corpus cancer in order to confirm the diagnosis. Although the investigators provide age-specific information about the risk of uterine cancer, they did not have information on the menopausal status of the women.
Strengths of the study
Prior to these study results there were few data about the risk of diagnosing an occult cancer at the time of myomectomy. This very large study of more than 41,000 myomectomy cases will help clinicians fully counsel women about the risk of detecting an occult uterine cancer at the time of myomectomy.
What this evidence means for practice
Women aged 50 years or older should be advised against having a myomectomy given the 1 in 154 and 1 in 31 risk of identifying an occult uterine corpus cancer at the time of surgery in women aged 50 to 59 years and 60 years or older, respectively. Given an average age of menopause of 51 years, these data support the guidance of the US Food and Drug Administration that open electric power morcellation should not be used in surgery on uterine tumors in women who are perimenopausal or postmenopausal.
–Robert L. Barbieri, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Wright and colleagues analyzed the risk of diagnosing an occult uterine cancer at the time of myomectomy using an administrative database, which contained information on 41,777 myomectomy surgeries performed at 496 hospitals from 2006 to 2012. They reported that 76 uterine corpus cancers (ICD-9 codes 179.x and 182.x) were detected, for a rate of 1 occult cancer identified per 550 myomectomy cases. The risk of diagnosing an occult uterine cancer increased with age.
Study limitations
A major weakness of the study is that the administrative database did not provide information about the histologic type of uterine corpus cancer. Uterine leiomyosarcoma is a highly aggressive cancer, while endometrial stromal sarcoma is a more indolent cancer. Additionally, the authors were not able to perform a histologic reassessment of the slides of the 76 cases reported as having uterine corpus cancer in order to confirm the diagnosis. Although the investigators provide age-specific information about the risk of uterine cancer, they did not have information on the menopausal status of the women.
Strengths of the study
Prior to these study results there were few data about the risk of diagnosing an occult cancer at the time of myomectomy. This very large study of more than 41,000 myomectomy cases will help clinicians fully counsel women about the risk of detecting an occult uterine cancer at the time of myomectomy.
What this evidence means for practice
Women aged 50 years or older should be advised against having a myomectomy given the 1 in 154 and 1 in 31 risk of identifying an occult uterine corpus cancer at the time of surgery in women aged 50 to 59 years and 60 years or older, respectively. Given an average age of menopause of 51 years, these data support the guidance of the US Food and Drug Administration that open electric power morcellation should not be used in surgery on uterine tumors in women who are perimenopausal or postmenopausal.
–Robert L. Barbieri, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Wright and colleagues analyzed the risk of diagnosing an occult uterine cancer at the time of myomectomy using an administrative database, which contained information on 41,777 myomectomy surgeries performed at 496 hospitals from 2006 to 2012. They reported that 76 uterine corpus cancers (ICD-9 codes 179.x and 182.x) were detected, for a rate of 1 occult cancer identified per 550 myomectomy cases. The risk of diagnosing an occult uterine cancer increased with age.
Study limitations
A major weakness of the study is that the administrative database did not provide information about the histologic type of uterine corpus cancer. Uterine leiomyosarcoma is a highly aggressive cancer, while endometrial stromal sarcoma is a more indolent cancer. Additionally, the authors were not able to perform a histologic reassessment of the slides of the 76 cases reported as having uterine corpus cancer in order to confirm the diagnosis. Although the investigators provide age-specific information about the risk of uterine cancer, they did not have information on the menopausal status of the women.
Strengths of the study
Prior to these study results there were few data about the risk of diagnosing an occult cancer at the time of myomectomy. This very large study of more than 41,000 myomectomy cases will help clinicians fully counsel women about the risk of detecting an occult uterine cancer at the time of myomectomy.
What this evidence means for practice
Women aged 50 years or older should be advised against having a myomectomy given the 1 in 154 and 1 in 31 risk of identifying an occult uterine corpus cancer at the time of surgery in women aged 50 to 59 years and 60 years or older, respectively. Given an average age of menopause of 51 years, these data support the guidance of the US Food and Drug Administration that open electric power morcellation should not be used in surgery on uterine tumors in women who are perimenopausal or postmenopausal.
–Robert L. Barbieri, MD
Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
VIDEO: Data support switching to transradial PCI access
SAN DIEGO – Cardiologists should switch from transfemoral to transradial access in acute coronary syndrome patients undergoing percutaneous coronary intervention, given the reduced mortality rates associated with the transradial approach in the MATRIX study and other studies, Dr. Cindy L. Grines said at the annual meeting of the American College of Cardiology.
Because U.S. interventionalists are “under the clock” when treating patients with ST-elevation myocardial infarction, “many physicians have been unwilling to risk having a difficult transradial case that would take too much time,” explained Dr. Grines, an interventional cardiologist at the Detroit Medical Center.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
For that and other reasons, American interventionalists have been “slow adopters” of the transradial approach, currently using it for about 20% of PCIs, compared with a worldwide rate of about 70%.
It may take instituting incentives to get U.S. cardiologists to change their practice, Dr. Grines suggested in an interview. That could involve increased reimbursement for PCIs done transradially, an increased allowance on acceptable door-to-balloon times for STEMI patients treated transradially, or imposition of new standards for quality assurance that mandate use of transradial in a certain percentage of PCI cases, she said.
The MATRIX study included a second, independent, prespecified analysis that compared outcomes in patients randomized to treatment with two different antithrombin drugs, either bivalirudin (Angiomax) or unfractionated heparin.
That part of the study showed that while treatment with either of the two drugs resulted in no statistically significant difference in the study’s two primary endpoints, treatment with bivalirudin led to statistically significant reductions in all-cause death and cardiovascular death, as well as in major bleeding events, compared with patients treated with unfractionated heparin (Lancet 2015 [doi:10.1016/S0140-6736(15)60292-6]).
Although bivalirudin has generally been the more commonly used antithrombin drug in this clinical setting by U.S. interventionalists in recent years, results reported last year from the HEAT-PCI trial (Lancet 2014;384:1849-58) that showed better outcomes with unfractionated heparin have led to reduced use of bivalirudin, Dr. Grines said.
The new results from MATRIX coupled with results from other trials that compared those drugs can make clinicians “more confident about the benefit of bivalirudin,” she said.
Dr. Grines has been a consultant to and received honoraria from the Medicines Company, which markets Angiomax, and from Abbott Vascular, Merck, and the Volcano Group.
On Twitter @mitchelzoler
SAN DIEGO – Cardiologists should switch from transfemoral to transradial access in acute coronary syndrome patients undergoing percutaneous coronary intervention, given the reduced mortality rates associated with the transradial approach in the MATRIX study and other studies, Dr. Cindy L. Grines said at the annual meeting of the American College of Cardiology.
Because U.S. interventionalists are “under the clock” when treating patients with ST-elevation myocardial infarction, “many physicians have been unwilling to risk having a difficult transradial case that would take too much time,” explained Dr. Grines, an interventional cardiologist at the Detroit Medical Center.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
For that and other reasons, American interventionalists have been “slow adopters” of the transradial approach, currently using it for about 20% of PCIs, compared with a worldwide rate of about 70%.
It may take instituting incentives to get U.S. cardiologists to change their practice, Dr. Grines suggested in an interview. That could involve increased reimbursement for PCIs done transradially, an increased allowance on acceptable door-to-balloon times for STEMI patients treated transradially, or imposition of new standards for quality assurance that mandate use of transradial in a certain percentage of PCI cases, she said.
The MATRIX study included a second, independent, prespecified analysis that compared outcomes in patients randomized to treatment with two different antithrombin drugs, either bivalirudin (Angiomax) or unfractionated heparin.
That part of the study showed that while treatment with either of the two drugs resulted in no statistically significant difference in the study’s two primary endpoints, treatment with bivalirudin led to statistically significant reductions in all-cause death and cardiovascular death, as well as in major bleeding events, compared with patients treated with unfractionated heparin (Lancet 2015 [doi:10.1016/S0140-6736(15)60292-6]).
Although bivalirudin has generally been the more commonly used antithrombin drug in this clinical setting by U.S. interventionalists in recent years, results reported last year from the HEAT-PCI trial (Lancet 2014;384:1849-58) that showed better outcomes with unfractionated heparin have led to reduced use of bivalirudin, Dr. Grines said.
The new results from MATRIX coupled with results from other trials that compared those drugs can make clinicians “more confident about the benefit of bivalirudin,” she said.
Dr. Grines has been a consultant to and received honoraria from the Medicines Company, which markets Angiomax, and from Abbott Vascular, Merck, and the Volcano Group.
On Twitter @mitchelzoler
SAN DIEGO – Cardiologists should switch from transfemoral to transradial access in acute coronary syndrome patients undergoing percutaneous coronary intervention, given the reduced mortality rates associated with the transradial approach in the MATRIX study and other studies, Dr. Cindy L. Grines said at the annual meeting of the American College of Cardiology.
Because U.S. interventionalists are “under the clock” when treating patients with ST-elevation myocardial infarction, “many physicians have been unwilling to risk having a difficult transradial case that would take too much time,” explained Dr. Grines, an interventional cardiologist at the Detroit Medical Center.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
For that and other reasons, American interventionalists have been “slow adopters” of the transradial approach, currently using it for about 20% of PCIs, compared with a worldwide rate of about 70%.
It may take instituting incentives to get U.S. cardiologists to change their practice, Dr. Grines suggested in an interview. That could involve increased reimbursement for PCIs done transradially, an increased allowance on acceptable door-to-balloon times for STEMI patients treated transradially, or imposition of new standards for quality assurance that mandate use of transradial in a certain percentage of PCI cases, she said.
The MATRIX study included a second, independent, prespecified analysis that compared outcomes in patients randomized to treatment with two different antithrombin drugs, either bivalirudin (Angiomax) or unfractionated heparin.
That part of the study showed that while treatment with either of the two drugs resulted in no statistically significant difference in the study’s two primary endpoints, treatment with bivalirudin led to statistically significant reductions in all-cause death and cardiovascular death, as well as in major bleeding events, compared with patients treated with unfractionated heparin (Lancet 2015 [doi:10.1016/S0140-6736(15)60292-6]).
Although bivalirudin has generally been the more commonly used antithrombin drug in this clinical setting by U.S. interventionalists in recent years, results reported last year from the HEAT-PCI trial (Lancet 2014;384:1849-58) that showed better outcomes with unfractionated heparin have led to reduced use of bivalirudin, Dr. Grines said.
The new results from MATRIX coupled with results from other trials that compared those drugs can make clinicians “more confident about the benefit of bivalirudin,” she said.
Dr. Grines has been a consultant to and received honoraria from the Medicines Company, which markets Angiomax, and from Abbott Vascular, Merck, and the Volcano Group.
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM ACC 15
VIDEO: Did the PROMISE trial keep its promise?
SAN DIEGO – Patients with new-onset, stable chest pain account for millions of stress tests annually in the United States, but randomized data are limited on which test is best and the impact of testing on clinical outcomes.
Results from the prospective PROMISE trial, presented at the annual meeting of the American College of Cardiology, show there is no Holy Grail testing strategy. First-line testing with CT angiography did not reduce hard clinical events compared with functional testing, but did cut the number of patients undergoing an invasive catheterization showing no obstructive coronary artery disease.
Listen here for our interview with ACC president Dr. Patrick O’Gara on how these results will impact patient care and potentially influence current guideline recommendations.
Dr. O’Gara reported no relevant financial conflicts.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN DIEGO – Patients with new-onset, stable chest pain account for millions of stress tests annually in the United States, but randomized data are limited on which test is best and the impact of testing on clinical outcomes.
Results from the prospective PROMISE trial, presented at the annual meeting of the American College of Cardiology, show there is no Holy Grail testing strategy. First-line testing with CT angiography did not reduce hard clinical events compared with functional testing, but did cut the number of patients undergoing an invasive catheterization showing no obstructive coronary artery disease.
Listen here for our interview with ACC president Dr. Patrick O’Gara on how these results will impact patient care and potentially influence current guideline recommendations.
Dr. O’Gara reported no relevant financial conflicts.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN DIEGO – Patients with new-onset, stable chest pain account for millions of stress tests annually in the United States, but randomized data are limited on which test is best and the impact of testing on clinical outcomes.
Results from the prospective PROMISE trial, presented at the annual meeting of the American College of Cardiology, show there is no Holy Grail testing strategy. First-line testing with CT angiography did not reduce hard clinical events compared with functional testing, but did cut the number of patients undergoing an invasive catheterization showing no obstructive coronary artery disease.
Listen here for our interview with ACC president Dr. Patrick O’Gara on how these results will impact patient care and potentially influence current guideline recommendations.
Dr. O’Gara reported no relevant financial conflicts.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT ACC 15
Association between breast cancer and depression may last as long as 8 years
Although it is generally accepted that women given a diagnosis of breast cancer are vulnerable to depression, studies investigating this association have been hampered by cross-sectional design, a short duration of follow-up, or a lack of clinical detail. In a new study from Denmark, Suppli and colleagues used the national health database to identify almost 2 million women with no history of cancer or inpatient care for depression whom they followed from 1988 to 2011. They identified incident cases of breast cancer in this population, as well as prescriptions for antidepressants and inpatient care for depression during the follow-up period.1
What they found may surprise you: Not only were women given a diagnosis of breast cancer three times more likely to fill a prescription for an antidepressant in the first year after diagnosis (rate ratio, 3.09; 95% confidence interval [CI], 2.95–3.22), but the rate ratio remained significantly elevated as far out as 8 years after diagnosis.
Suppli and colleagues also found that the rate ratio for hospitalization for depression was 1.70 in the first year (95% CI, 1.41–2.05). It, too, remained significantly elevated as far out as 5 years after diagnosis.
Women who were age 70 or older at the time of diagnosis were more likely to be treated for depression and to be hospitalized. Other risk factors for depression included comorbidity, node-positive disease, basic and vocational educational levels, and living alone.
The type of cancer treatment the women underwent appeared to have no bearing on the risk of depression.
What we can do about the risk of depression in cancer patients
The finding that breast cancer is associated with depression is not new, but the magnitude of the association documented in this large study from a Danish national registry clarifies the role of women’s health providers: We need to be mindful of the long-term impact this disease can have on our patients’ mental health so that we are better able to recognize and proactively address mood disorders in this vulnerable population.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Reference
- Suppli NP, Johansen C, Christensen J, Kessing LV, Kroman N, Dalton SO. Increased risk of depression after breast cancer: a nationwide population-based cohort study of associated factors in Denmark. J Clin Oncol. 2014;32(34):3831–3839.
Andrew M. Kaunitz, MD
Dr. Kaunitz is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. Dr. Kaunitz serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
Andrew M. Kaunitz, MD
Dr. Kaunitz is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. Dr. Kaunitz serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
Andrew M. Kaunitz, MD
Dr. Kaunitz is University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology, at the University of Florida College of Medicine–Jacksonville. Dr. Kaunitz serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
Although it is generally accepted that women given a diagnosis of breast cancer are vulnerable to depression, studies investigating this association have been hampered by cross-sectional design, a short duration of follow-up, or a lack of clinical detail. In a new study from Denmark, Suppli and colleagues used the national health database to identify almost 2 million women with no history of cancer or inpatient care for depression whom they followed from 1988 to 2011. They identified incident cases of breast cancer in this population, as well as prescriptions for antidepressants and inpatient care for depression during the follow-up period.1
What they found may surprise you: Not only were women given a diagnosis of breast cancer three times more likely to fill a prescription for an antidepressant in the first year after diagnosis (rate ratio, 3.09; 95% confidence interval [CI], 2.95–3.22), but the rate ratio remained significantly elevated as far out as 8 years after diagnosis.
Suppli and colleagues also found that the rate ratio for hospitalization for depression was 1.70 in the first year (95% CI, 1.41–2.05). It, too, remained significantly elevated as far out as 5 years after diagnosis.
Women who were age 70 or older at the time of diagnosis were more likely to be treated for depression and to be hospitalized. Other risk factors for depression included comorbidity, node-positive disease, basic and vocational educational levels, and living alone.
The type of cancer treatment the women underwent appeared to have no bearing on the risk of depression.
What we can do about the risk of depression in cancer patients
The finding that breast cancer is associated with depression is not new, but the magnitude of the association documented in this large study from a Danish national registry clarifies the role of women’s health providers: We need to be mindful of the long-term impact this disease can have on our patients’ mental health so that we are better able to recognize and proactively address mood disorders in this vulnerable population.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Although it is generally accepted that women given a diagnosis of breast cancer are vulnerable to depression, studies investigating this association have been hampered by cross-sectional design, a short duration of follow-up, or a lack of clinical detail. In a new study from Denmark, Suppli and colleagues used the national health database to identify almost 2 million women with no history of cancer or inpatient care for depression whom they followed from 1988 to 2011. They identified incident cases of breast cancer in this population, as well as prescriptions for antidepressants and inpatient care for depression during the follow-up period.1
What they found may surprise you: Not only were women given a diagnosis of breast cancer three times more likely to fill a prescription for an antidepressant in the first year after diagnosis (rate ratio, 3.09; 95% confidence interval [CI], 2.95–3.22), but the rate ratio remained significantly elevated as far out as 8 years after diagnosis.
Suppli and colleagues also found that the rate ratio for hospitalization for depression was 1.70 in the first year (95% CI, 1.41–2.05). It, too, remained significantly elevated as far out as 5 years after diagnosis.
Women who were age 70 or older at the time of diagnosis were more likely to be treated for depression and to be hospitalized. Other risk factors for depression included comorbidity, node-positive disease, basic and vocational educational levels, and living alone.
The type of cancer treatment the women underwent appeared to have no bearing on the risk of depression.
What we can do about the risk of depression in cancer patients
The finding that breast cancer is associated with depression is not new, but the magnitude of the association documented in this large study from a Danish national registry clarifies the role of women’s health providers: We need to be mindful of the long-term impact this disease can have on our patients’ mental health so that we are better able to recognize and proactively address mood disorders in this vulnerable population.
Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
Reference
- Suppli NP, Johansen C, Christensen J, Kessing LV, Kroman N, Dalton SO. Increased risk of depression after breast cancer: a nationwide population-based cohort study of associated factors in Denmark. J Clin Oncol. 2014;32(34):3831–3839.
Reference
- Suppli NP, Johansen C, Christensen J, Kessing LV, Kroman N, Dalton SO. Increased risk of depression after breast cancer: a nationwide population-based cohort study of associated factors in Denmark. J Clin Oncol. 2014;32(34):3831–3839.
Nailing VT as the cause of wide complex tachycardia
SNOWMASS, COLO. – An ECG can offer a handful of easily interpreted clues that raise to 99% the certainty of diagnosing ventricular tachycardia as the cause of a patient’s wide complex tachycardia, according to Dr. Samuel J. Asirvatham.
The first thing to realize about wide complex tachycardias (WCTs), as defined by a heart rate in excess of 100 bpm and a QRS duration greater than 120 milliseconds, is that the cause is ventricular tachycardia (VT) rather than supraventricular tachycardia in 80% of cases, he said at the Annual Cardiovascular Conference at Snowmass.
“When you diagnose wide complex tachycardia as not VT, you’re much more likely to make a mistake than if you just closed your eyes and said VT,” said Dr. Asirvatham, professor of medicine and pediatrics at the Mayo Clinic, Rochester, Minn.
The history also provides a valuable clue: “If there’s anything wrong with the heart – a prior MI, structural disease, a scar on the heart from previous surgery, sarcoid – there’s a 95% chance that the WCT is due to VT,” he said.
Key ECG features will boost the diagnostic certainty of VT from 95% to 99%. Here are Dr. Asirvatham’s favorites:
• Atrioventricular dissociation. When the ventricular rate is faster than the atrial rate, the result is atrioventricular dissocation. In the setting of WCT, it’s highly specific for VT, and it’s present on the ECGs of up to 50% of affected patients.
“This is a very useful clue. I like looking for this. If you see it, you can be convinced the patient has VT,” he said.
• The wide QRS. The wider the wide QRS, the more likely it’s VT.If the QRS duration is greater than 150 milliseconds, there’s nearly a 98% likelihood of VT.
• Northwest axis. If both lead I and the inferior leads show negative deflection – that is, the electrical wave is moving away from the positive electrodes located over the left shoulder and closest to the feet – that means the wave is moving toward the northwest on the frontal plane axis. The odds are extremely high that this is VT.
• Chest lead concordance. If all of the chest leads V1-6 are positive or they’re all negative, that’s “powerful information” indicating VT, according to Dr. Asirvatham.
• Time from onset of R wave to S wave nadir. Even if chest concordance isn’t present, VT can be diagnosed with near-absolute certainty simply by measuring the time from onset of the R wave to the lowest point on the S wave. If it’s longer than 100 milliseconds, that finding strongly favors VT.
“Remember these ECG features and 99% of the time you will correctly diagnose VT,” the cardiologist said.
Dr. Asirvatham reported serving as a consultant to a dozen medical device companies.
SNOWMASS, COLO. – An ECG can offer a handful of easily interpreted clues that raise to 99% the certainty of diagnosing ventricular tachycardia as the cause of a patient’s wide complex tachycardia, according to Dr. Samuel J. Asirvatham.
The first thing to realize about wide complex tachycardias (WCTs), as defined by a heart rate in excess of 100 bpm and a QRS duration greater than 120 milliseconds, is that the cause is ventricular tachycardia (VT) rather than supraventricular tachycardia in 80% of cases, he said at the Annual Cardiovascular Conference at Snowmass.
“When you diagnose wide complex tachycardia as not VT, you’re much more likely to make a mistake than if you just closed your eyes and said VT,” said Dr. Asirvatham, professor of medicine and pediatrics at the Mayo Clinic, Rochester, Minn.
The history also provides a valuable clue: “If there’s anything wrong with the heart – a prior MI, structural disease, a scar on the heart from previous surgery, sarcoid – there’s a 95% chance that the WCT is due to VT,” he said.
Key ECG features will boost the diagnostic certainty of VT from 95% to 99%. Here are Dr. Asirvatham’s favorites:
• Atrioventricular dissociation. When the ventricular rate is faster than the atrial rate, the result is atrioventricular dissocation. In the setting of WCT, it’s highly specific for VT, and it’s present on the ECGs of up to 50% of affected patients.
“This is a very useful clue. I like looking for this. If you see it, you can be convinced the patient has VT,” he said.
• The wide QRS. The wider the wide QRS, the more likely it’s VT.If the QRS duration is greater than 150 milliseconds, there’s nearly a 98% likelihood of VT.
• Northwest axis. If both lead I and the inferior leads show negative deflection – that is, the electrical wave is moving away from the positive electrodes located over the left shoulder and closest to the feet – that means the wave is moving toward the northwest on the frontal plane axis. The odds are extremely high that this is VT.
• Chest lead concordance. If all of the chest leads V1-6 are positive or they’re all negative, that’s “powerful information” indicating VT, according to Dr. Asirvatham.
• Time from onset of R wave to S wave nadir. Even if chest concordance isn’t present, VT can be diagnosed with near-absolute certainty simply by measuring the time from onset of the R wave to the lowest point on the S wave. If it’s longer than 100 milliseconds, that finding strongly favors VT.
“Remember these ECG features and 99% of the time you will correctly diagnose VT,” the cardiologist said.
Dr. Asirvatham reported serving as a consultant to a dozen medical device companies.
SNOWMASS, COLO. – An ECG can offer a handful of easily interpreted clues that raise to 99% the certainty of diagnosing ventricular tachycardia as the cause of a patient’s wide complex tachycardia, according to Dr. Samuel J. Asirvatham.
The first thing to realize about wide complex tachycardias (WCTs), as defined by a heart rate in excess of 100 bpm and a QRS duration greater than 120 milliseconds, is that the cause is ventricular tachycardia (VT) rather than supraventricular tachycardia in 80% of cases, he said at the Annual Cardiovascular Conference at Snowmass.
“When you diagnose wide complex tachycardia as not VT, you’re much more likely to make a mistake than if you just closed your eyes and said VT,” said Dr. Asirvatham, professor of medicine and pediatrics at the Mayo Clinic, Rochester, Minn.
The history also provides a valuable clue: “If there’s anything wrong with the heart – a prior MI, structural disease, a scar on the heart from previous surgery, sarcoid – there’s a 95% chance that the WCT is due to VT,” he said.
Key ECG features will boost the diagnostic certainty of VT from 95% to 99%. Here are Dr. Asirvatham’s favorites:
• Atrioventricular dissociation. When the ventricular rate is faster than the atrial rate, the result is atrioventricular dissocation. In the setting of WCT, it’s highly specific for VT, and it’s present on the ECGs of up to 50% of affected patients.
“This is a very useful clue. I like looking for this. If you see it, you can be convinced the patient has VT,” he said.
• The wide QRS. The wider the wide QRS, the more likely it’s VT.If the QRS duration is greater than 150 milliseconds, there’s nearly a 98% likelihood of VT.
• Northwest axis. If both lead I and the inferior leads show negative deflection – that is, the electrical wave is moving away from the positive electrodes located over the left shoulder and closest to the feet – that means the wave is moving toward the northwest on the frontal plane axis. The odds are extremely high that this is VT.
• Chest lead concordance. If all of the chest leads V1-6 are positive or they’re all negative, that’s “powerful information” indicating VT, according to Dr. Asirvatham.
• Time from onset of R wave to S wave nadir. Even if chest concordance isn’t present, VT can be diagnosed with near-absolute certainty simply by measuring the time from onset of the R wave to the lowest point on the S wave. If it’s longer than 100 milliseconds, that finding strongly favors VT.
“Remember these ECG features and 99% of the time you will correctly diagnose VT,” the cardiologist said.
Dr. Asirvatham reported serving as a consultant to a dozen medical device companies.
EXPERT ANALYSIS FROM THE CARDIOVASCULAR CONFERENCE AT SNOWMASS
Tide turns in favor of multivessel PCI in STEMI
SNOWMASS, COLO. – Recent data seem to refute the 2013 American Heart Association/American College of Cardiology class III recommendation to avoid multivessel percutaneous coronary intervention at the time of primary PCI for ST-elevation MI, Dr. David R. Holmes Jr. observed at the Annual Cardiovascular Conference at Snowmass.
“The current AHA/ACC guidelines for STEMI should be and are being reevaluated regarding clarifications for the indications and timing of non–infarct artery revascularization,” according to Dr. Holmes, a cardiologist at the Mayo Clinic in Rochester, Minn., and an ACC past president.
Indeed, the ACC has already withdrawn from its ‘Choosing Wisely’ campaign its former recommendation discouraging multivessel revascularization at the time of primary PCI for STEMI. The college cited “new science showing that complete revascularization of all significant blocked arteries leads to better outcomes in some heart attack patients.”
Dr. Holmes was coauthor of a meta-analysis of 4 prospective and 14 retrospective studies involving more than 40,000 patients that concluded multivessel PCI for STEMI should be discouraged, and that significant nonculprit lesions should only be treated during staged procedures (J. Am. Coll. Cardiol. 2011;58:692-703). This meta-analysis was influential in the creation of the class III ‘don’t do it’ recommendation in the AHA/ACC guidelines. But Dr. Holmes said that in hindsight, the data included in the meta-analysis were something of a mishmash and “wound up being very hard to interpret.”
Greater clarity has been brought by two more recent randomized trials: PRAMI and CvLPRIT. Both were relatively small by cardiology standards, but they ended up showing similarly striking advantages in favor of using the STEMI hospitalization to perform preventive PCI of both the infarct-related artery and non–infarct arteries with major stenoses.
PRAMI included 465 acute STEMI patients who underwent infarct artery PCI and were then randomized to preventive PCI or infarct artery–only PCI. At a mean follow-up of 23 months, the preventive multivessel PCI group had a 65% reduction in the relative risk of the primary outcome, a composite of cardiac death, nonfatal MI, or refractory angina (N. Engl. J. Med. 2013;369:1115-23).
The yet-to-be-published CvLPRIT study was presented at the 2014 European Society of Cardiology meeting in Barcelona. The multicenter study included 296 STEMI patients with angiographically established significant multivessel disease who were randomized to primary PCI of the culprit vessel only or to complete revascularization. The primary outcome, the 12-month composite of all-cause mortality, recurrent MI, heart failure, or ischemia-driven revascularization, occurred in 10% of the complete revascularization group, compared with 21.2% of patients assigned to culprit artery–only PCI.
Also at the ESC conference, CvLPRIT investigator Dr. Anthony Gershlick of the University of Leicester (England) presented a meta-analysis combining the weighted results of PRAMI, CvLPRIT, and two earlier randomized trials: HELP AMI (Int. J. Cardiovasc. Intervent. 2004;6:128-33) and an Italian trial (Heart 2010;96:662-7). The results strongly favored multivessel PCI, with a 45% reduction in mortality and a 61% decrease in recurrent MI, compared with culprit vessel–only PCI at the time of admission for STEMI.
“Maybe there aren’t any innocent bystanders,” commented Dr. Holmes. “Maybe if you have somebody who has multivessel disease and you see something you think might be an innocent bystander but is a significant lesion, maybe it’s not so innocent. Maybe by treating them all at the time of the initial intervention the patient is going to do better.”
He reported having no financial conflicts of interest regarding his presentation.
SNOWMASS, COLO. – Recent data seem to refute the 2013 American Heart Association/American College of Cardiology class III recommendation to avoid multivessel percutaneous coronary intervention at the time of primary PCI for ST-elevation MI, Dr. David R. Holmes Jr. observed at the Annual Cardiovascular Conference at Snowmass.
“The current AHA/ACC guidelines for STEMI should be and are being reevaluated regarding clarifications for the indications and timing of non–infarct artery revascularization,” according to Dr. Holmes, a cardiologist at the Mayo Clinic in Rochester, Minn., and an ACC past president.
Indeed, the ACC has already withdrawn from its ‘Choosing Wisely’ campaign its former recommendation discouraging multivessel revascularization at the time of primary PCI for STEMI. The college cited “new science showing that complete revascularization of all significant blocked arteries leads to better outcomes in some heart attack patients.”
Dr. Holmes was coauthor of a meta-analysis of 4 prospective and 14 retrospective studies involving more than 40,000 patients that concluded multivessel PCI for STEMI should be discouraged, and that significant nonculprit lesions should only be treated during staged procedures (J. Am. Coll. Cardiol. 2011;58:692-703). This meta-analysis was influential in the creation of the class III ‘don’t do it’ recommendation in the AHA/ACC guidelines. But Dr. Holmes said that in hindsight, the data included in the meta-analysis were something of a mishmash and “wound up being very hard to interpret.”
Greater clarity has been brought by two more recent randomized trials: PRAMI and CvLPRIT. Both were relatively small by cardiology standards, but they ended up showing similarly striking advantages in favor of using the STEMI hospitalization to perform preventive PCI of both the infarct-related artery and non–infarct arteries with major stenoses.
PRAMI included 465 acute STEMI patients who underwent infarct artery PCI and were then randomized to preventive PCI or infarct artery–only PCI. At a mean follow-up of 23 months, the preventive multivessel PCI group had a 65% reduction in the relative risk of the primary outcome, a composite of cardiac death, nonfatal MI, or refractory angina (N. Engl. J. Med. 2013;369:1115-23).
The yet-to-be-published CvLPRIT study was presented at the 2014 European Society of Cardiology meeting in Barcelona. The multicenter study included 296 STEMI patients with angiographically established significant multivessel disease who were randomized to primary PCI of the culprit vessel only or to complete revascularization. The primary outcome, the 12-month composite of all-cause mortality, recurrent MI, heart failure, or ischemia-driven revascularization, occurred in 10% of the complete revascularization group, compared with 21.2% of patients assigned to culprit artery–only PCI.
Also at the ESC conference, CvLPRIT investigator Dr. Anthony Gershlick of the University of Leicester (England) presented a meta-analysis combining the weighted results of PRAMI, CvLPRIT, and two earlier randomized trials: HELP AMI (Int. J. Cardiovasc. Intervent. 2004;6:128-33) and an Italian trial (Heart 2010;96:662-7). The results strongly favored multivessel PCI, with a 45% reduction in mortality and a 61% decrease in recurrent MI, compared with culprit vessel–only PCI at the time of admission for STEMI.
“Maybe there aren’t any innocent bystanders,” commented Dr. Holmes. “Maybe if you have somebody who has multivessel disease and you see something you think might be an innocent bystander but is a significant lesion, maybe it’s not so innocent. Maybe by treating them all at the time of the initial intervention the patient is going to do better.”
He reported having no financial conflicts of interest regarding his presentation.
SNOWMASS, COLO. – Recent data seem to refute the 2013 American Heart Association/American College of Cardiology class III recommendation to avoid multivessel percutaneous coronary intervention at the time of primary PCI for ST-elevation MI, Dr. David R. Holmes Jr. observed at the Annual Cardiovascular Conference at Snowmass.
“The current AHA/ACC guidelines for STEMI should be and are being reevaluated regarding clarifications for the indications and timing of non–infarct artery revascularization,” according to Dr. Holmes, a cardiologist at the Mayo Clinic in Rochester, Minn., and an ACC past president.
Indeed, the ACC has already withdrawn from its ‘Choosing Wisely’ campaign its former recommendation discouraging multivessel revascularization at the time of primary PCI for STEMI. The college cited “new science showing that complete revascularization of all significant blocked arteries leads to better outcomes in some heart attack patients.”
Dr. Holmes was coauthor of a meta-analysis of 4 prospective and 14 retrospective studies involving more than 40,000 patients that concluded multivessel PCI for STEMI should be discouraged, and that significant nonculprit lesions should only be treated during staged procedures (J. Am. Coll. Cardiol. 2011;58:692-703). This meta-analysis was influential in the creation of the class III ‘don’t do it’ recommendation in the AHA/ACC guidelines. But Dr. Holmes said that in hindsight, the data included in the meta-analysis were something of a mishmash and “wound up being very hard to interpret.”
Greater clarity has been brought by two more recent randomized trials: PRAMI and CvLPRIT. Both were relatively small by cardiology standards, but they ended up showing similarly striking advantages in favor of using the STEMI hospitalization to perform preventive PCI of both the infarct-related artery and non–infarct arteries with major stenoses.
PRAMI included 465 acute STEMI patients who underwent infarct artery PCI and were then randomized to preventive PCI or infarct artery–only PCI. At a mean follow-up of 23 months, the preventive multivessel PCI group had a 65% reduction in the relative risk of the primary outcome, a composite of cardiac death, nonfatal MI, or refractory angina (N. Engl. J. Med. 2013;369:1115-23).
The yet-to-be-published CvLPRIT study was presented at the 2014 European Society of Cardiology meeting in Barcelona. The multicenter study included 296 STEMI patients with angiographically established significant multivessel disease who were randomized to primary PCI of the culprit vessel only or to complete revascularization. The primary outcome, the 12-month composite of all-cause mortality, recurrent MI, heart failure, or ischemia-driven revascularization, occurred in 10% of the complete revascularization group, compared with 21.2% of patients assigned to culprit artery–only PCI.
Also at the ESC conference, CvLPRIT investigator Dr. Anthony Gershlick of the University of Leicester (England) presented a meta-analysis combining the weighted results of PRAMI, CvLPRIT, and two earlier randomized trials: HELP AMI (Int. J. Cardiovasc. Intervent. 2004;6:128-33) and an Italian trial (Heart 2010;96:662-7). The results strongly favored multivessel PCI, with a 45% reduction in mortality and a 61% decrease in recurrent MI, compared with culprit vessel–only PCI at the time of admission for STEMI.
“Maybe there aren’t any innocent bystanders,” commented Dr. Holmes. “Maybe if you have somebody who has multivessel disease and you see something you think might be an innocent bystander but is a significant lesion, maybe it’s not so innocent. Maybe by treating them all at the time of the initial intervention the patient is going to do better.”
He reported having no financial conflicts of interest regarding his presentation.
EXPERT ANALYSIS FROM THE CARDIOVASCULAR CONFERENCE AT SNOWMASS
Emergency department holds key to early readmissions for heart failure
SNOWMASS, COLO. – Under intense fiscal pressure to curb early hospital readmissions for heart failure, cardiologists and hospital administrators are taking a hard look at the traditional role of the emergency department as the point of triage for patients with decompensated heart failure.
“Alternatives to the emergency department for ambulatory triage and intervention are essential,” Dr. Akshay Desai said at the Annual Cardiovascular Conference at Snowmass.
“Traditionally, when our patients become decompensated, we send them from our office or clinic to the ED. And 80%-90% of those who present to the ED with the diagnosis of heart failure are admitted to the hospital. So this means that the ED is a pretty ineffective triage point for heart failure patients. Most ED staff are concerned about ambulatory follow-up and feel it’s safer to follow patients in the hospital. The message here is we need a more robust ambulatory framework to manage patients with milder decompensation so they don’t all need to come into the hospital,” said Dr. Desai of Brigham and Women’s Hospital and Harvard Medical School, Boston.
Hospital admission is of questionable value for a large fraction of decompensating heart failure patients. After all, not that much happens to them in the hospital that couldn’t take place in a less costly setting.
“For the most part, our patients in the hospital for decompensated heart failure get IV diuretics, with an average weight loss of about 4 kg. Surveillance is typically once- or twice-daily laboratory tests and a bedside clinical visit by a physician at 7:30 in the morning. Few patients get much else. There’s little diagnostic testing, few other therapies that require intensive monitoring, and most patients feel a little better by their first day in the hospital,” he said.
This suggests the need for what he called “an evolved model of heart failure care” in which the ED is replaced as the point of service by some form of ambulatory center that can serve as a buffer limiting the number of patients who need to come into the hospital.
“It could be a home-based strategy of IV diuretic administration, a clinic-based strategy of outpatient diuretic administration, or an observation unit based in the ED. All of these are now being tested in various models across the country as alternatives to help manage the readmission problem, and also to make life better for our patients, who’d prefer not to be in the hospital if they could be managed in other ways,” Dr. Desai continued.
Reducing 30-day readmission rates after a hospitalization for heart failure is seen by health policy makers as an opportunity to simultaneously improve care and reduce costs. But studies show only about half of readmissions in patients with heart failure are cardiovascular related, just half of those cardiovascular readmissions are heart failure related, and only about 30% of heart failure readmissions are truly preventable. However, wide variation exists across the country in risk-adjusted 30-day readmission rates, suggesting there is an opportunity for improvement in outlier hospitals.
Numerous factors have been linked to high heart failure readmission rates, including patient sociodemographic characteristics, comorbid conditions, and serum markers of heart failure severity. One underappreciated factor, in Dr. Desai’s view, is that readmission rates are significantly higher in hospitals that are financially and clinically resource poor, as shown in a Harvard School of Public Health analysis of Medicare claims data for more than 900,000 heart failure discharges. These resource-poor hospitals provide care for underserved populations, and they are experiencing a disproportionate burden of the financial penalties imposed for early readmission.
“As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care,” according to the Harvard investigators (Circ. Cardiovasc. Qual. Outcomes 2011;4:53-9).
Dr. Desai reported serving as a consultant to 5AM Ventures, AtCor Medical, Novartis, and St. Jude Medical.
SNOWMASS, COLO. – Under intense fiscal pressure to curb early hospital readmissions for heart failure, cardiologists and hospital administrators are taking a hard look at the traditional role of the emergency department as the point of triage for patients with decompensated heart failure.
“Alternatives to the emergency department for ambulatory triage and intervention are essential,” Dr. Akshay Desai said at the Annual Cardiovascular Conference at Snowmass.
“Traditionally, when our patients become decompensated, we send them from our office or clinic to the ED. And 80%-90% of those who present to the ED with the diagnosis of heart failure are admitted to the hospital. So this means that the ED is a pretty ineffective triage point for heart failure patients. Most ED staff are concerned about ambulatory follow-up and feel it’s safer to follow patients in the hospital. The message here is we need a more robust ambulatory framework to manage patients with milder decompensation so they don’t all need to come into the hospital,” said Dr. Desai of Brigham and Women’s Hospital and Harvard Medical School, Boston.
Hospital admission is of questionable value for a large fraction of decompensating heart failure patients. After all, not that much happens to them in the hospital that couldn’t take place in a less costly setting.
“For the most part, our patients in the hospital for decompensated heart failure get IV diuretics, with an average weight loss of about 4 kg. Surveillance is typically once- or twice-daily laboratory tests and a bedside clinical visit by a physician at 7:30 in the morning. Few patients get much else. There’s little diagnostic testing, few other therapies that require intensive monitoring, and most patients feel a little better by their first day in the hospital,” he said.
This suggests the need for what he called “an evolved model of heart failure care” in which the ED is replaced as the point of service by some form of ambulatory center that can serve as a buffer limiting the number of patients who need to come into the hospital.
“It could be a home-based strategy of IV diuretic administration, a clinic-based strategy of outpatient diuretic administration, or an observation unit based in the ED. All of these are now being tested in various models across the country as alternatives to help manage the readmission problem, and also to make life better for our patients, who’d prefer not to be in the hospital if they could be managed in other ways,” Dr. Desai continued.
Reducing 30-day readmission rates after a hospitalization for heart failure is seen by health policy makers as an opportunity to simultaneously improve care and reduce costs. But studies show only about half of readmissions in patients with heart failure are cardiovascular related, just half of those cardiovascular readmissions are heart failure related, and only about 30% of heart failure readmissions are truly preventable. However, wide variation exists across the country in risk-adjusted 30-day readmission rates, suggesting there is an opportunity for improvement in outlier hospitals.
Numerous factors have been linked to high heart failure readmission rates, including patient sociodemographic characteristics, comorbid conditions, and serum markers of heart failure severity. One underappreciated factor, in Dr. Desai’s view, is that readmission rates are significantly higher in hospitals that are financially and clinically resource poor, as shown in a Harvard School of Public Health analysis of Medicare claims data for more than 900,000 heart failure discharges. These resource-poor hospitals provide care for underserved populations, and they are experiencing a disproportionate burden of the financial penalties imposed for early readmission.
“As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care,” according to the Harvard investigators (Circ. Cardiovasc. Qual. Outcomes 2011;4:53-9).
Dr. Desai reported serving as a consultant to 5AM Ventures, AtCor Medical, Novartis, and St. Jude Medical.
SNOWMASS, COLO. – Under intense fiscal pressure to curb early hospital readmissions for heart failure, cardiologists and hospital administrators are taking a hard look at the traditional role of the emergency department as the point of triage for patients with decompensated heart failure.
“Alternatives to the emergency department for ambulatory triage and intervention are essential,” Dr. Akshay Desai said at the Annual Cardiovascular Conference at Snowmass.
“Traditionally, when our patients become decompensated, we send them from our office or clinic to the ED. And 80%-90% of those who present to the ED with the diagnosis of heart failure are admitted to the hospital. So this means that the ED is a pretty ineffective triage point for heart failure patients. Most ED staff are concerned about ambulatory follow-up and feel it’s safer to follow patients in the hospital. The message here is we need a more robust ambulatory framework to manage patients with milder decompensation so they don’t all need to come into the hospital,” said Dr. Desai of Brigham and Women’s Hospital and Harvard Medical School, Boston.
Hospital admission is of questionable value for a large fraction of decompensating heart failure patients. After all, not that much happens to them in the hospital that couldn’t take place in a less costly setting.
“For the most part, our patients in the hospital for decompensated heart failure get IV diuretics, with an average weight loss of about 4 kg. Surveillance is typically once- or twice-daily laboratory tests and a bedside clinical visit by a physician at 7:30 in the morning. Few patients get much else. There’s little diagnostic testing, few other therapies that require intensive monitoring, and most patients feel a little better by their first day in the hospital,” he said.
This suggests the need for what he called “an evolved model of heart failure care” in which the ED is replaced as the point of service by some form of ambulatory center that can serve as a buffer limiting the number of patients who need to come into the hospital.
“It could be a home-based strategy of IV diuretic administration, a clinic-based strategy of outpatient diuretic administration, or an observation unit based in the ED. All of these are now being tested in various models across the country as alternatives to help manage the readmission problem, and also to make life better for our patients, who’d prefer not to be in the hospital if they could be managed in other ways,” Dr. Desai continued.
Reducing 30-day readmission rates after a hospitalization for heart failure is seen by health policy makers as an opportunity to simultaneously improve care and reduce costs. But studies show only about half of readmissions in patients with heart failure are cardiovascular related, just half of those cardiovascular readmissions are heart failure related, and only about 30% of heart failure readmissions are truly preventable. However, wide variation exists across the country in risk-adjusted 30-day readmission rates, suggesting there is an opportunity for improvement in outlier hospitals.
Numerous factors have been linked to high heart failure readmission rates, including patient sociodemographic characteristics, comorbid conditions, and serum markers of heart failure severity. One underappreciated factor, in Dr. Desai’s view, is that readmission rates are significantly higher in hospitals that are financially and clinically resource poor, as shown in a Harvard School of Public Health analysis of Medicare claims data for more than 900,000 heart failure discharges. These resource-poor hospitals provide care for underserved populations, and they are experiencing a disproportionate burden of the financial penalties imposed for early readmission.
“As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care,” according to the Harvard investigators (Circ. Cardiovasc. Qual. Outcomes 2011;4:53-9).
Dr. Desai reported serving as a consultant to 5AM Ventures, AtCor Medical, Novartis, and St. Jude Medical.
EXPERT ANALYSIS FROM THE CARDIOVASCULAR CONFERENCE AT SNOWMASS