Latest News for HOSP

Clinical question: In patients with hypertension, chronic kidney disease, or heart failure presenting with a musculoskeletal disorder, how frequently are prescription NSAIDs dispensed and are there associated short-term (between 7-38 days of visit) safety-related outcomes?

Background: Multiple expert panels recommend against the use of NSAIDs in patients with hypertension (HTN), chronic kidney disease (CKD), or heart failure (HF). Previous studies have demonstrated an increased risk of cardiovascular events and renal injury with long-term NSAID use.

Study design: Retrospective cohort study.

Setting: Population-based administrative claims database identified primary care visits in Ontario.

Dr. Stanley is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: In patients with hypertension, chronic kidney disease, or heart failure presenting with a musculoskeletal disorder, how frequently are prescription NSAIDs dispensed and are there associated short-term (between 7-38 days of visit) safety-related outcomes?

Background: Multiple expert panels recommend against the use of NSAIDs in patients with hypertension (HTN), chronic kidney disease (CKD), or heart failure (HF). Previous studies have demonstrated an increased risk of cardiovascular events and renal injury with long-term NSAID use.

Study design: Retrospective cohort study.

Setting: Population-based administrative claims database identified primary care visits in Ontario.

Dr. Stanley is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: In patients with hypertension, chronic kidney disease, or heart failure presenting with a musculoskeletal disorder, how frequently are prescription NSAIDs dispensed and are there associated short-term (between 7-38 days of visit) safety-related outcomes?

Background: Multiple expert panels recommend against the use of NSAIDs in patients with hypertension (HTN), chronic kidney disease (CKD), or heart failure (HF). Previous studies have demonstrated an increased risk of cardiovascular events and renal injury with long-term NSAID use.

Study design: Retrospective cohort study.

Setting: Population-based administrative claims database identified primary care visits in Ontario.

Dr. Stanley is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: DOACs have been shown to be efficacious in randomized, controlled trials, but these trials did not include high-risk patients. This trial studies the efficacy and safety of DOACs in elderly patients with new-onset atrial fibrillation who are at high risk of both ischemic stroke and major bleeding.

Researchers then used three-way propensity matching, accounting for each morbidity category and anticoagulation medication to compare outcomes. Cox proportion regression models were used to adjust for risk and compare outcomes of ischemic stroke and major hemorrhage in matched participants in each anticoagulant group.

Primary outcomes of the study were ischemic stroke and major hemorrhage, which were determined based on ICD-9 codes. The investigators did not find a significant difference among anticoagulants regardless of the morbidity level for risk-adjusted ischemic stroke rates. Participants in the dabigatran group had lower rates of risk-adjusted major hemorrhage, compared with the warfarin group, regardless of morbidity category. The dabigatran group also had lower major hemorrhage risk, compared with the rivaroxaban group, especially in moderate- and high-morbidity category. Lastly, risk-adjusted rates of mortality were lower in the dabigatran and rivaroxaban groups, compared with the warfarin group, and there was no difference between the dabigatran and rivaroxaban groups with regards to mortality.

Bottom line: Rivaroxaban and dabigatran are each equally effective, compared with warfarin, in preventing ischemic strokes in elderly patients with new-onset atrial fibrillation and multiple comorbidities. However, patients on dabigatran appear to be at less risk of major bleeding, compared with warfarin and rivaroxaban.

Citation: Mentias A et al. Assessment of outcomes of treatment with oral anticoagulants in patients with atrial fibrillation and multiple chronic conditions. JAMA Netw Open. 2018 Sep 28;1(5):e182870.

Dr. Puri is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: DOACs have been shown to be efficacious in randomized, controlled trials, but these trials did not include high-risk patients. This trial studies the efficacy and safety of DOACs in elderly patients with new-onset atrial fibrillation who are at high risk of both ischemic stroke and major bleeding.

Researchers then used three-way propensity matching, accounting for each morbidity category and anticoagulation medication to compare outcomes. Cox proportion regression models were used to adjust for risk and compare outcomes of ischemic stroke and major hemorrhage in matched participants in each anticoagulant group.

Primary outcomes of the study were ischemic stroke and major hemorrhage, which were determined based on ICD-9 codes. The investigators did not find a significant difference among anticoagulants regardless of the morbidity level for risk-adjusted ischemic stroke rates. Participants in the dabigatran group had lower rates of risk-adjusted major hemorrhage, compared with the warfarin group, regardless of morbidity category. The dabigatran group also had lower major hemorrhage risk, compared with the rivaroxaban group, especially in moderate- and high-morbidity category. Lastly, risk-adjusted rates of mortality were lower in the dabigatran and rivaroxaban groups, compared with the warfarin group, and there was no difference between the dabigatran and rivaroxaban groups with regards to mortality.

Bottom line: Rivaroxaban and dabigatran are each equally effective, compared with warfarin, in preventing ischemic strokes in elderly patients with new-onset atrial fibrillation and multiple comorbidities. However, patients on dabigatran appear to be at less risk of major bleeding, compared with warfarin and rivaroxaban.

Citation: Mentias A et al. Assessment of outcomes of treatment with oral anticoagulants in patients with atrial fibrillation and multiple chronic conditions. JAMA Netw Open. 2018 Sep 28;1(5):e182870.

Dr. Puri is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: DOACs have been shown to be efficacious in randomized, controlled trials, but these trials did not include high-risk patients. This trial studies the efficacy and safety of DOACs in elderly patients with new-onset atrial fibrillation who are at high risk of both ischemic stroke and major bleeding.

Researchers then used three-way propensity matching, accounting for each morbidity category and anticoagulation medication to compare outcomes. Cox proportion regression models were used to adjust for risk and compare outcomes of ischemic stroke and major hemorrhage in matched participants in each anticoagulant group.

Primary outcomes of the study were ischemic stroke and major hemorrhage, which were determined based on ICD-9 codes. The investigators did not find a significant difference among anticoagulants regardless of the morbidity level for risk-adjusted ischemic stroke rates. Participants in the dabigatran group had lower rates of risk-adjusted major hemorrhage, compared with the warfarin group, regardless of morbidity category. The dabigatran group also had lower major hemorrhage risk, compared with the rivaroxaban group, especially in moderate- and high-morbidity category. Lastly, risk-adjusted rates of mortality were lower in the dabigatran and rivaroxaban groups, compared with the warfarin group, and there was no difference between the dabigatran and rivaroxaban groups with regards to mortality.

Bottom line: Rivaroxaban and dabigatran are each equally effective, compared with warfarin, in preventing ischemic strokes in elderly patients with new-onset atrial fibrillation and multiple comorbidities. However, patients on dabigatran appear to be at less risk of major bleeding, compared with warfarin and rivaroxaban.

Citation: Mentias A et al. Assessment of outcomes of treatment with oral anticoagulants in patients with atrial fibrillation and multiple chronic conditions. JAMA Netw Open. 2018 Sep 28;1(5):e182870.

Dr. Puri is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: Prophylactic proton pump inhibitors (PPIs) are used frequently in an ICU setting for acid suppression, but this is an off-label use and the evidence in support of using PPI prophylactically is limited. In fact, PPIs have been associated with adverse effects in recent literature including Clostridium difficile infection, myocardial ischemia, and pneumonia.

The researchers also used a composite outcome comprising clinically important gastrointestinal bleeding, Clostridium difficile infection, new onset pneumonia, and acute myocardial ischemia. Overall, 21.9% in the pantoprazole group and 22.6% participants in the placebo group had the composite outcome – a relative risk of 0.96 (95% CI, 0.83-1.11). Clinically important gastrointestinal bleeding was the only component of the composite outcome that was significantly different between groups, occurring less often in the pantoprazole group – the relative risk was 0.58 (95% CI, 0.40-0.86).

Bottom line: Pantoprazole does not differ significantly, compared with placebo, with regard to 90-day mortality and a composite outcome of clinically significant events.

Citation: Krag M et al. Pantoprazole in patients at risk of gastrointestinal bleeding in the ICU. N Eng J Med. 2018 Dec 6;379(23):2199-208.

Dr. Puri is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: Prophylactic proton pump inhibitors (PPIs) are used frequently in an ICU setting for acid suppression, but this is an off-label use and the evidence in support of using PPI prophylactically is limited. In fact, PPIs have been associated with adverse effects in recent literature including Clostridium difficile infection, myocardial ischemia, and pneumonia.

The researchers also used a composite outcome comprising clinically important gastrointestinal bleeding, Clostridium difficile infection, new onset pneumonia, and acute myocardial ischemia. Overall, 21.9% in the pantoprazole group and 22.6% participants in the placebo group had the composite outcome – a relative risk of 0.96 (95% CI, 0.83-1.11). Clinically important gastrointestinal bleeding was the only component of the composite outcome that was significantly different between groups, occurring less often in the pantoprazole group – the relative risk was 0.58 (95% CI, 0.40-0.86).

Bottom line: Pantoprazole does not differ significantly, compared with placebo, with regard to 90-day mortality and a composite outcome of clinically significant events.

Citation: Krag M et al. Pantoprazole in patients at risk of gastrointestinal bleeding in the ICU. N Eng J Med. 2018 Dec 6;379(23):2199-208.

Dr. Puri is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: Prophylactic proton pump inhibitors (PPIs) are used frequently in an ICU setting for acid suppression, but this is an off-label use and the evidence in support of using PPI prophylactically is limited. In fact, PPIs have been associated with adverse effects in recent literature including Clostridium difficile infection, myocardial ischemia, and pneumonia.

The researchers also used a composite outcome comprising clinically important gastrointestinal bleeding, Clostridium difficile infection, new onset pneumonia, and acute myocardial ischemia. Overall, 21.9% in the pantoprazole group and 22.6% participants in the placebo group had the composite outcome – a relative risk of 0.96 (95% CI, 0.83-1.11). Clinically important gastrointestinal bleeding was the only component of the composite outcome that was significantly different between groups, occurring less often in the pantoprazole group – the relative risk was 0.58 (95% CI, 0.40-0.86).

Bottom line: Pantoprazole does not differ significantly, compared with placebo, with regard to 90-day mortality and a composite outcome of clinically significant events.

Citation: Krag M et al. Pantoprazole in patients at risk of gastrointestinal bleeding in the ICU. N Eng J Med. 2018 Dec 6;379(23):2199-208.

Dr. Puri is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: Is a low-dose tricyclic antidepressant effective in the treatment of chronic low back pain?

Background: Lower back pain is the leading cause of disability globally and effective treatments are limited. Furthermore, opioid usage for lower back pain is a large contributor to the current opioid epidemic. A recent Cochrane review showed no clear evidence that antidepressant use in the treatment of back pain is effective, but it did note a lack of high-quality trials of sufficient rigor or length.

Study design: Double-blind, randomized controlled trial.

Setting: Single center trial in Melbourne.

Synopsis: Overall, 146 patients aged 18-75 with chronic lower back pain of no specific cause for more than 3 months were included. Exclusions included pathological cause, major coexisting illness, psychosis, or diagnosed depression. Patients were given amitriptyline 25 mg daily or benztropine mesylate 1 mg daily. Benztropine has similar anticholinergic side effects, without the antidepressant effect. Participants were assessed and followed by calls at 2 weeks, 1-2 months, 3 months, 4-5 months, and 6 months. Adherence was noted by the return of empty medication bottles at 6 months. Six-month surveys were completed by 81% and found that 70% of each group was adherent and 12% in each group withdrew because of adverse effects.

The primary outcome was level of pain at 6 months using a visual analog and descriptor scales. Secondary outcomes were measurement of disability, work missed, global improvement, general health, fear of movement, and depression.

The primary outcome was reduction in pain intensity of 12.6 (standard error, 2.7) with amitriptyline at 6 months, compared with 4.8 (SE 2.9) with benztropine, which did not meet statistical significance. There was a statistically significant difference in disability at 3 months, but not at 6 months.

Bottom line: This trial suggests that there may be a place for prescribed amitriptyline for chronic lower back pain, but it failed to show statistical significance. The study may not have been sufficiently powered to detect the difference.

Citations: Urquhart DM et al. Efficacy of low-dose amitriptyline for chronic low back pain: A randomized clinical trial. JAMA Intern Med. 2018;178(11):1474-81.

Dr. Lennon is an instructor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: Is a low-dose tricyclic antidepressant effective in the treatment of chronic low back pain?

Background: Lower back pain is the leading cause of disability globally and effective treatments are limited. Furthermore, opioid usage for lower back pain is a large contributor to the current opioid epidemic. A recent Cochrane review showed no clear evidence that antidepressant use in the treatment of back pain is effective, but it did note a lack of high-quality trials of sufficient rigor or length.

Study design: Double-blind, randomized controlled trial.

Setting: Single center trial in Melbourne.

Synopsis: Overall, 146 patients aged 18-75 with chronic lower back pain of no specific cause for more than 3 months were included. Exclusions included pathological cause, major coexisting illness, psychosis, or diagnosed depression. Patients were given amitriptyline 25 mg daily or benztropine mesylate 1 mg daily. Benztropine has similar anticholinergic side effects, without the antidepressant effect. Participants were assessed and followed by calls at 2 weeks, 1-2 months, 3 months, 4-5 months, and 6 months. Adherence was noted by the return of empty medication bottles at 6 months. Six-month surveys were completed by 81% and found that 70% of each group was adherent and 12% in each group withdrew because of adverse effects.

The primary outcome was level of pain at 6 months using a visual analog and descriptor scales. Secondary outcomes were measurement of disability, work missed, global improvement, general health, fear of movement, and depression.

The primary outcome was reduction in pain intensity of 12.6 (standard error, 2.7) with amitriptyline at 6 months, compared with 4.8 (SE 2.9) with benztropine, which did not meet statistical significance. There was a statistically significant difference in disability at 3 months, but not at 6 months.

Bottom line: This trial suggests that there may be a place for prescribed amitriptyline for chronic lower back pain, but it failed to show statistical significance. The study may not have been sufficiently powered to detect the difference.

Citations: Urquhart DM et al. Efficacy of low-dose amitriptyline for chronic low back pain: A randomized clinical trial. JAMA Intern Med. 2018;178(11):1474-81.

Dr. Lennon is an instructor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: Is a low-dose tricyclic antidepressant effective in the treatment of chronic low back pain?

Background: Lower back pain is the leading cause of disability globally and effective treatments are limited. Furthermore, opioid usage for lower back pain is a large contributor to the current opioid epidemic. A recent Cochrane review showed no clear evidence that antidepressant use in the treatment of back pain is effective, but it did note a lack of high-quality trials of sufficient rigor or length.

Study design: Double-blind, randomized controlled trial.

Setting: Single center trial in Melbourne.

Synopsis: Overall, 146 patients aged 18-75 with chronic lower back pain of no specific cause for more than 3 months were included. Exclusions included pathological cause, major coexisting illness, psychosis, or diagnosed depression. Patients were given amitriptyline 25 mg daily or benztropine mesylate 1 mg daily. Benztropine has similar anticholinergic side effects, without the antidepressant effect. Participants were assessed and followed by calls at 2 weeks, 1-2 months, 3 months, 4-5 months, and 6 months. Adherence was noted by the return of empty medication bottles at 6 months. Six-month surveys were completed by 81% and found that 70% of each group was adherent and 12% in each group withdrew because of adverse effects.

The primary outcome was level of pain at 6 months using a visual analog and descriptor scales. Secondary outcomes were measurement of disability, work missed, global improvement, general health, fear of movement, and depression.

The primary outcome was reduction in pain intensity of 12.6 (standard error, 2.7) with amitriptyline at 6 months, compared with 4.8 (SE 2.9) with benztropine, which did not meet statistical significance. There was a statistically significant difference in disability at 3 months, but not at 6 months.

Bottom line: This trial suggests that there may be a place for prescribed amitriptyline for chronic lower back pain, but it failed to show statistical significance. The study may not have been sufficiently powered to detect the difference.

Citations: Urquhart DM et al. Efficacy of low-dose amitriptyline for chronic low back pain: A randomized clinical trial. JAMA Intern Med. 2018;178(11):1474-81.

Dr. Lennon is an instructor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: Is 6 months of dual antiplatelet therapy (DAPT) therapy noninferior to 12 months, following ST-elevation myocardial infarction (STEMI) with placement of second-generation drug-eluting stents?

Background: DAPT has been the standard of care to prevent abrupt thrombotic closure of vessels following percutaneous coronary intervention (PCI) and placement of stents. The recommended duration of DAPT was lengthened from at least 30 days in bare metal stents to at least 12 months in earlier-generation drug-eluting stents after observation of high rates of in-stent thrombosis of drug-eluting stents.

Trials have shown that there is no difference in outcomes comparing 6 month vs. 12 months in DAPT for PCI in the cases of non-ST-elevation MI and unstable angina. However, there are no randomized controlled studies comparing 6 vs. 12 months of DAPT with newer drug-eluting stents following STEMI. Newer drug-eluting stents are made of biocompatible polymers with thinner struts and are thought to be fully absorbed by 3 months. International guidelines still recommend 12 months of DAPT following drug-eluting stent placement following STEMI.

Study design: Prospective, unblinded, randomized, multicenter noninferiority trial.

Setting: The study was performed at 17 sites in the Netherlands, Norway, Poland, and Switzerland.

Synopsis: This study enrolled 1100 patients with STEMI started on DAPT during December 2011-June 2015. Overall, 870 patients were randomized to continue DAPT or to change to single antiplatelet therapy (SAPT) at 6 months. Exclusions included embolic events, cardiogenic shock, revascularization, bleeding, or being on anticoagulation. Patients were followed for 24 months.

The primary endpoint was a composite of all-cause mortality, any MI, any revascularization, stroke, or thrombolysis. Incidence of the composite endpoint was 4.8% of SAPT cases, and 6.6% of DAPT cases. Noninferiority was met (P = .004) because the upper 95% confidence interval of 1.27 was smaller than the prespecified noninferiority margin of 1.66. The secondary endpoint of safety and bleeding at 18 months was 3.2% for SAPT, and 4.3% for DAPT with HR of 0.75.

Medtronic’s new stent was used in 92% of the cases of this industry-sponsored study. Despite usage of a composite endpoint, there was no difference in the individual elements of the composite in subgroup analyses. There was a low event rate in both arms likely because of the exclusions that led to a lower-risk population. The individual operators were able to choose the P2Y12 inhibitor.

Bottom line: This industry-sponsored randomized, control trial showed noninferiority of 6 months of DAPT to 12 months of therapy following STEMI to prevent in-stent thrombosis with newer second- generation drug-eluting stents. However, the study’s results may be limited to lower-risk patients, without need for revascularization, oral anticoagulation, or with stroke or cardiogenic shock.

Citation: Kedhi E et al. Six months versus 12 months of dual antiplatelet therapy after drug-eluting stent implantation in ST-elevation myocardial infarction (DAPT-STEMI): Randomised, multicenter, noninferiority trial. BMJ. 2018;363:k3793.

Dr. Lennon is an instructor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: Is 6 months of dual antiplatelet therapy (DAPT) therapy noninferior to 12 months, following ST-elevation myocardial infarction (STEMI) with placement of second-generation drug-eluting stents?

Background: DAPT has been the standard of care to prevent abrupt thrombotic closure of vessels following percutaneous coronary intervention (PCI) and placement of stents. The recommended duration of DAPT was lengthened from at least 30 days in bare metal stents to at least 12 months in earlier-generation drug-eluting stents after observation of high rates of in-stent thrombosis of drug-eluting stents.

Trials have shown that there is no difference in outcomes comparing 6 month vs. 12 months in DAPT for PCI in the cases of non-ST-elevation MI and unstable angina. However, there are no randomized controlled studies comparing 6 vs. 12 months of DAPT with newer drug-eluting stents following STEMI. Newer drug-eluting stents are made of biocompatible polymers with thinner struts and are thought to be fully absorbed by 3 months. International guidelines still recommend 12 months of DAPT following drug-eluting stent placement following STEMI.

Study design: Prospective, unblinded, randomized, multicenter noninferiority trial.

Setting: The study was performed at 17 sites in the Netherlands, Norway, Poland, and Switzerland.

Synopsis: This study enrolled 1100 patients with STEMI started on DAPT during December 2011-June 2015. Overall, 870 patients were randomized to continue DAPT or to change to single antiplatelet therapy (SAPT) at 6 months. Exclusions included embolic events, cardiogenic shock, revascularization, bleeding, or being on anticoagulation. Patients were followed for 24 months.

The primary endpoint was a composite of all-cause mortality, any MI, any revascularization, stroke, or thrombolysis. Incidence of the composite endpoint was 4.8% of SAPT cases, and 6.6% of DAPT cases. Noninferiority was met (P = .004) because the upper 95% confidence interval of 1.27 was smaller than the prespecified noninferiority margin of 1.66. The secondary endpoint of safety and bleeding at 18 months was 3.2% for SAPT, and 4.3% for DAPT with HR of 0.75.

Medtronic’s new stent was used in 92% of the cases of this industry-sponsored study. Despite usage of a composite endpoint, there was no difference in the individual elements of the composite in subgroup analyses. There was a low event rate in both arms likely because of the exclusions that led to a lower-risk population. The individual operators were able to choose the P2Y12 inhibitor.

Bottom line: This industry-sponsored randomized, control trial showed noninferiority of 6 months of DAPT to 12 months of therapy following STEMI to prevent in-stent thrombosis with newer second- generation drug-eluting stents. However, the study’s results may be limited to lower-risk patients, without need for revascularization, oral anticoagulation, or with stroke or cardiogenic shock.

Citation: Kedhi E et al. Six months versus 12 months of dual antiplatelet therapy after drug-eluting stent implantation in ST-elevation myocardial infarction (DAPT-STEMI): Randomised, multicenter, noninferiority trial. BMJ. 2018;363:k3793.

Dr. Lennon is an instructor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Clinical question: Is 6 months of dual antiplatelet therapy (DAPT) therapy noninferior to 12 months, following ST-elevation myocardial infarction (STEMI) with placement of second-generation drug-eluting stents?

Background: DAPT has been the standard of care to prevent abrupt thrombotic closure of vessels following percutaneous coronary intervention (PCI) and placement of stents. The recommended duration of DAPT was lengthened from at least 30 days in bare metal stents to at least 12 months in earlier-generation drug-eluting stents after observation of high rates of in-stent thrombosis of drug-eluting stents.

Trials have shown that there is no difference in outcomes comparing 6 month vs. 12 months in DAPT for PCI in the cases of non-ST-elevation MI and unstable angina. However, there are no randomized controlled studies comparing 6 vs. 12 months of DAPT with newer drug-eluting stents following STEMI. Newer drug-eluting stents are made of biocompatible polymers with thinner struts and are thought to be fully absorbed by 3 months. International guidelines still recommend 12 months of DAPT following drug-eluting stent placement following STEMI.

Study design: Prospective, unblinded, randomized, multicenter noninferiority trial.

Setting: The study was performed at 17 sites in the Netherlands, Norway, Poland, and Switzerland.

Synopsis: This study enrolled 1100 patients with STEMI started on DAPT during December 2011-June 2015. Overall, 870 patients were randomized to continue DAPT or to change to single antiplatelet therapy (SAPT) at 6 months. Exclusions included embolic events, cardiogenic shock, revascularization, bleeding, or being on anticoagulation. Patients were followed for 24 months.

The primary endpoint was a composite of all-cause mortality, any MI, any revascularization, stroke, or thrombolysis. Incidence of the composite endpoint was 4.8% of SAPT cases, and 6.6% of DAPT cases. Noninferiority was met (P = .004) because the upper 95% confidence interval of 1.27 was smaller than the prespecified noninferiority margin of 1.66. The secondary endpoint of safety and bleeding at 18 months was 3.2% for SAPT, and 4.3% for DAPT with HR of 0.75.

Medtronic’s new stent was used in 92% of the cases of this industry-sponsored study. Despite usage of a composite endpoint, there was no difference in the individual elements of the composite in subgroup analyses. There was a low event rate in both arms likely because of the exclusions that led to a lower-risk population. The individual operators were able to choose the P2Y12 inhibitor.

Bottom line: This industry-sponsored randomized, control trial showed noninferiority of 6 months of DAPT to 12 months of therapy following STEMI to prevent in-stent thrombosis with newer second- generation drug-eluting stents. However, the study’s results may be limited to lower-risk patients, without need for revascularization, oral anticoagulation, or with stroke or cardiogenic shock.

Citation: Kedhi E et al. Six months versus 12 months of dual antiplatelet therapy after drug-eluting stent implantation in ST-elevation myocardial infarction (DAPT-STEMI): Randomised, multicenter, noninferiority trial. BMJ. 2018;363:k3793.

Dr. Lennon is an instructor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: Delirium is commonly seen in the ICU and has been associated with increased morbidity and mortality. While haloperidol, as well as atypical antipsychotics, often are used to manage ICU delirium, evidence has been mixed as to whether these medications shorten the duration of either hyperactive or hypoactive delirium.

Only 11% of patients experienced hyperactive delirium, which makes these results less generalizable to patients whose delirium presents as agitation.

Bottom line: The use of antipsychotics in ICU delirium does not affect the duration of delirium in patient with respiratory failure or shock.

Citation: Girard TD et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Eng J Med. 2018 Dec 27;379(26):2506-16.

Dr. Defoe is an instructor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: Delirium is commonly seen in the ICU and has been associated with increased morbidity and mortality. While haloperidol, as well as atypical antipsychotics, often are used to manage ICU delirium, evidence has been mixed as to whether these medications shorten the duration of either hyperactive or hypoactive delirium.

Only 11% of patients experienced hyperactive delirium, which makes these results less generalizable to patients whose delirium presents as agitation.

Bottom line: The use of antipsychotics in ICU delirium does not affect the duration of delirium in patient with respiratory failure or shock.

Citation: Girard TD et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Eng J Med. 2018 Dec 27;379(26):2506-16.

Dr. Defoe is an instructor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: Delirium is commonly seen in the ICU and has been associated with increased morbidity and mortality. While haloperidol, as well as atypical antipsychotics, often are used to manage ICU delirium, evidence has been mixed as to whether these medications shorten the duration of either hyperactive or hypoactive delirium.

Only 11% of patients experienced hyperactive delirium, which makes these results less generalizable to patients whose delirium presents as agitation.

Bottom line: The use of antipsychotics in ICU delirium does not affect the duration of delirium in patient with respiratory failure or shock.

Citation: Girard TD et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Eng J Med. 2018 Dec 27;379(26):2506-16.

Dr. Defoe is an instructor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

I had just received my sign-out for the day. My pager beeped, and I heard it overhead “Code Blue Room X.” Hospitalist physicians lead the code team in our hospital; I quickly headed to the room.

A young man in his forties was found to be unconscious on the floor. One of the nurses had started cardiopulmonary resuscitation (CPR) as the patient was unconscious and had no palpable pulse. It was a long, drawn-out battle: CPR, cracking bones, shouting, lots of needles – an extreme roller-coaster-style situation. The patient had recently had a hip surgery and our suspicion was a massive pulmonary embolism. We ran the exhaustive code for more than an hour and then I started to debrief with my code team; discussed that treatment was getting futile and asked for opinions. Finally, I asked the team to stop and pronounced the patient dead. I felt terrible. Later that day I returned to my house, tossed my bag in the corner, and sympathized with myself – “Hello Dr. B, It was a tough one.”

Stopping resuscitation was one of the toughest decisions I had ever made, and I wondered if I would be able to make such a decision the next day. What if I had carried on? I had led code teams during my residency training and as an attending physician; but there was something different that day. This patient was a young man with no history of medical problems. Every physician knows how to initiate resuscitation for cardiopulmonary arrest (CPA); only a few know when to stop it. Did I miss this learning during my internal medicine training? I checked my red pocket leaflet with advanced cardiac life support (ACLS) algorithms, and it had no mention of it. I searched Google Scholar, PubMed, and UpToDate and surprisingly, I found no predetermined rule but only a few recommendations on when CPR should be stopped. The American Heart Association is clear that the decision to terminate resuscitative efforts rests with the treating physician in the hospital.

In my experience, the length of time to continue a code can vary widely and is mostly dependent on the physician running the code. I have seen it last 15 minutes (which is reasonable) and I have seen it last for 50 minutes when the initial rhythm was ventricular fibrillation. And if perhaps the patient regains a pulse temporarily, only to lose it again, we restart the clock. One needs to take into account various factors including time to CPR, time to defibrillation, comorbid disease, prearrest state, and initial arrest rhythm in making these decisions. It’s well understood that none of these factors alone or in combination is clearly predictive of outcome.¹

Some selected patients potentially have good outcomes with prolonged, aggressive resuscitation. So when should we stop, and when should we continue resuscitation? This is always challenging. Physicians hate to stop CPR even when they know it’s time. We are guided by the Hippocratic Oath to save lives. Sometimes, even if we want to stop, we tend to continue to avoid being criticized for stopping; we are systematically biased against stopping CPR. We routinely run long codes, in part because we are not sure which patients we can bring back.

A 2012 Lancet study highlighted that the median duration of resuscitation was 12 minutes for patients achieving the return of spontaneous circulation and 20 minutes for nonsurvivors.² The ethical guidelines issued by AHA in 2018 highlight that, in the absence of mitigating factors, prolonged resuscitative efforts for adults and children are unlikely to be successful and can be discontinued if there is no return of spontaneous circulation at any time during 30 minutes of cumulative ACLS. If the return of spontaneous circulation of any duration occurs at any time, however, it may be appropriate to consider extending the resuscitative effort.³

I believe a careful balance of the patient’s prognosis for both length of life and quality of life will determine whether continued CPR is appropriate. The responsible clinician should stop the resuscitative effort when he or she determines with a high degree of certainty that the arrest victim will not respond to further efforts. But what will help me guide my decisions next time if I ever come across this situation again?

I discussed my dilemma with one of our intensivist physicians; he expressed that in a similar scenario he would ask for opinions from other members of the code team. The role of good communication among code team members is necessary to exchange relevant knowledge in real time in a collaborative, nonhierarchical environment. The code team can provide the team leader with quick, accurate information about the patient’s clinical history that is critical to good decision making.

Family support is also an essential part of any resuscitation. Health care providers need to offer the opportunity to be present to family members during the resuscitation attempts whenever possible. One team member should be assigned to the family to answer questions, clarify information, and offer comfort, but physicians should not be asking family members to decide to stop the code. It is important to note that the decision should be made by the team leader and not the patient’s family members. Regardless of the age or condition of the patient, the loss of a loved one is difficult to deal with, even if expected. The issue becomes more difficult with changes in legal, cultural, or personal perspectives.

The AHA in 2018 stated that the treating physician is expected to understand the patient and the arrest features, and the system factors that have prognostic importance for resuscitation.³ For clinicians who work in critical care settings, the framework presented by AHA is intuitive. As a code leader, I can always give more epinephrine, try a clot-busting drug or deliver another shock. Situations vary greatly during a code, and the amount of time spent resuscitating a patient before terminating efforts is not set in stone. In many cases, it is a judgment call. The process of CPR is almost as disheartening as its bleak outcomes.

In-hospital CPAs are inevitably gruesome. Each day as an attending physician, we are faced with difficult decisions, but experiencing these incredibly difficult and life-changing events can make for good learning. A CPA situation in action is very difficult for all concerned, particularly when there is almost no chance of success. But an unsuccessful or aborted resuscitation is also a huge loss for both the family and the code team. One of the critical functions of the code team leader is to review the events of a code and exercise judgment while evaluating the length of a code. This can be an intense and emotional experience, but with these principles in mind, we can feel reassured that we are making the best decision possible, for the patient, the family, and our team.

Dr. Basnet is a hospitalist physician in the department of internal medicine at Eastern New Mexico Medical Center, Roswell.

References

1. Part 2: Ethical aspects of CPR and ECC. Circulation. 2000;102(8):I12.

2. Goldberger ZD et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: An observational study. The Lancet. 2012;380(9852):1473-81.

3. Sirbaugh PE et al. A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med. 1999;33(2):174-84.

I had just received my sign-out for the day. My pager beeped, and I heard it overhead “Code Blue Room X.” Hospitalist physicians lead the code team in our hospital; I quickly headed to the room.

A young man in his forties was found to be unconscious on the floor. One of the nurses had started cardiopulmonary resuscitation (CPR) as the patient was unconscious and had no palpable pulse. It was a long, drawn-out battle: CPR, cracking bones, shouting, lots of needles – an extreme roller-coaster-style situation. The patient had recently had a hip surgery and our suspicion was a massive pulmonary embolism. We ran the exhaustive code for more than an hour and then I started to debrief with my code team; discussed that treatment was getting futile and asked for opinions. Finally, I asked the team to stop and pronounced the patient dead. I felt terrible. Later that day I returned to my house, tossed my bag in the corner, and sympathized with myself – “Hello Dr. B, It was a tough one.”

Stopping resuscitation was one of the toughest decisions I had ever made, and I wondered if I would be able to make such a decision the next day. What if I had carried on? I had led code teams during my residency training and as an attending physician; but there was something different that day. This patient was a young man with no history of medical problems. Every physician knows how to initiate resuscitation for cardiopulmonary arrest (CPA); only a few know when to stop it. Did I miss this learning during my internal medicine training? I checked my red pocket leaflet with advanced cardiac life support (ACLS) algorithms, and it had no mention of it. I searched Google Scholar, PubMed, and UpToDate and surprisingly, I found no predetermined rule but only a few recommendations on when CPR should be stopped. The American Heart Association is clear that the decision to terminate resuscitative efforts rests with the treating physician in the hospital.

In my experience, the length of time to continue a code can vary widely and is mostly dependent on the physician running the code. I have seen it last 15 minutes (which is reasonable) and I have seen it last for 50 minutes when the initial rhythm was ventricular fibrillation. And if perhaps the patient regains a pulse temporarily, only to lose it again, we restart the clock. One needs to take into account various factors including time to CPR, time to defibrillation, comorbid disease, prearrest state, and initial arrest rhythm in making these decisions. It’s well understood that none of these factors alone or in combination is clearly predictive of outcome.¹

Some selected patients potentially have good outcomes with prolonged, aggressive resuscitation. So when should we stop, and when should we continue resuscitation? This is always challenging. Physicians hate to stop CPR even when they know it’s time. We are guided by the Hippocratic Oath to save lives. Sometimes, even if we want to stop, we tend to continue to avoid being criticized for stopping; we are systematically biased against stopping CPR. We routinely run long codes, in part because we are not sure which patients we can bring back.

A 2012 Lancet study highlighted that the median duration of resuscitation was 12 minutes for patients achieving the return of spontaneous circulation and 20 minutes for nonsurvivors.² The ethical guidelines issued by AHA in 2018 highlight that, in the absence of mitigating factors, prolonged resuscitative efforts for adults and children are unlikely to be successful and can be discontinued if there is no return of spontaneous circulation at any time during 30 minutes of cumulative ACLS. If the return of spontaneous circulation of any duration occurs at any time, however, it may be appropriate to consider extending the resuscitative effort.³

I believe a careful balance of the patient’s prognosis for both length of life and quality of life will determine whether continued CPR is appropriate. The responsible clinician should stop the resuscitative effort when he or she determines with a high degree of certainty that the arrest victim will not respond to further efforts. But what will help me guide my decisions next time if I ever come across this situation again?

I discussed my dilemma with one of our intensivist physicians; he expressed that in a similar scenario he would ask for opinions from other members of the code team. The role of good communication among code team members is necessary to exchange relevant knowledge in real time in a collaborative, nonhierarchical environment. The code team can provide the team leader with quick, accurate information about the patient’s clinical history that is critical to good decision making.

Family support is also an essential part of any resuscitation. Health care providers need to offer the opportunity to be present to family members during the resuscitation attempts whenever possible. One team member should be assigned to the family to answer questions, clarify information, and offer comfort, but physicians should not be asking family members to decide to stop the code. It is important to note that the decision should be made by the team leader and not the patient’s family members. Regardless of the age or condition of the patient, the loss of a loved one is difficult to deal with, even if expected. The issue becomes more difficult with changes in legal, cultural, or personal perspectives.

The AHA in 2018 stated that the treating physician is expected to understand the patient and the arrest features, and the system factors that have prognostic importance for resuscitation.³ For clinicians who work in critical care settings, the framework presented by AHA is intuitive. As a code leader, I can always give more epinephrine, try a clot-busting drug or deliver another shock. Situations vary greatly during a code, and the amount of time spent resuscitating a patient before terminating efforts is not set in stone. In many cases, it is a judgment call. The process of CPR is almost as disheartening as its bleak outcomes.

In-hospital CPAs are inevitably gruesome. Each day as an attending physician, we are faced with difficult decisions, but experiencing these incredibly difficult and life-changing events can make for good learning. A CPA situation in action is very difficult for all concerned, particularly when there is almost no chance of success. But an unsuccessful or aborted resuscitation is also a huge loss for both the family and the code team. One of the critical functions of the code team leader is to review the events of a code and exercise judgment while evaluating the length of a code. This can be an intense and emotional experience, but with these principles in mind, we can feel reassured that we are making the best decision possible, for the patient, the family, and our team.

Dr. Basnet is a hospitalist physician in the department of internal medicine at Eastern New Mexico Medical Center, Roswell.

References

1. Part 2: Ethical aspects of CPR and ECC. Circulation. 2000;102(8):I12.

2. Goldberger ZD et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: An observational study. The Lancet. 2012;380(9852):1473-81.

3. Sirbaugh PE et al. A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med. 1999;33(2):174-84.

I had just received my sign-out for the day. My pager beeped, and I heard it overhead “Code Blue Room X.” Hospitalist physicians lead the code team in our hospital; I quickly headed to the room.

A young man in his forties was found to be unconscious on the floor. One of the nurses had started cardiopulmonary resuscitation (CPR) as the patient was unconscious and had no palpable pulse. It was a long, drawn-out battle: CPR, cracking bones, shouting, lots of needles – an extreme roller-coaster-style situation. The patient had recently had a hip surgery and our suspicion was a massive pulmonary embolism. We ran the exhaustive code for more than an hour and then I started to debrief with my code team; discussed that treatment was getting futile and asked for opinions. Finally, I asked the team to stop and pronounced the patient dead. I felt terrible. Later that day I returned to my house, tossed my bag in the corner, and sympathized with myself – “Hello Dr. B, It was a tough one.”

Stopping resuscitation was one of the toughest decisions I had ever made, and I wondered if I would be able to make such a decision the next day. What if I had carried on? I had led code teams during my residency training and as an attending physician; but there was something different that day. This patient was a young man with no history of medical problems. Every physician knows how to initiate resuscitation for cardiopulmonary arrest (CPA); only a few know when to stop it. Did I miss this learning during my internal medicine training? I checked my red pocket leaflet with advanced cardiac life support (ACLS) algorithms, and it had no mention of it. I searched Google Scholar, PubMed, and UpToDate and surprisingly, I found no predetermined rule but only a few recommendations on when CPR should be stopped. The American Heart Association is clear that the decision to terminate resuscitative efforts rests with the treating physician in the hospital.

In my experience, the length of time to continue a code can vary widely and is mostly dependent on the physician running the code. I have seen it last 15 minutes (which is reasonable) and I have seen it last for 50 minutes when the initial rhythm was ventricular fibrillation. And if perhaps the patient regains a pulse temporarily, only to lose it again, we restart the clock. One needs to take into account various factors including time to CPR, time to defibrillation, comorbid disease, prearrest state, and initial arrest rhythm in making these decisions. It’s well understood that none of these factors alone or in combination is clearly predictive of outcome.¹

Some selected patients potentially have good outcomes with prolonged, aggressive resuscitation. So when should we stop, and when should we continue resuscitation? This is always challenging. Physicians hate to stop CPR even when they know it’s time. We are guided by the Hippocratic Oath to save lives. Sometimes, even if we want to stop, we tend to continue to avoid being criticized for stopping; we are systematically biased against stopping CPR. We routinely run long codes, in part because we are not sure which patients we can bring back.

A 2012 Lancet study highlighted that the median duration of resuscitation was 12 minutes for patients achieving the return of spontaneous circulation and 20 minutes for nonsurvivors.² The ethical guidelines issued by AHA in 2018 highlight that, in the absence of mitigating factors, prolonged resuscitative efforts for adults and children are unlikely to be successful and can be discontinued if there is no return of spontaneous circulation at any time during 30 minutes of cumulative ACLS. If the return of spontaneous circulation of any duration occurs at any time, however, it may be appropriate to consider extending the resuscitative effort.³

I believe a careful balance of the patient’s prognosis for both length of life and quality of life will determine whether continued CPR is appropriate. The responsible clinician should stop the resuscitative effort when he or she determines with a high degree of certainty that the arrest victim will not respond to further efforts. But what will help me guide my decisions next time if I ever come across this situation again?

I discussed my dilemma with one of our intensivist physicians; he expressed that in a similar scenario he would ask for opinions from other members of the code team. The role of good communication among code team members is necessary to exchange relevant knowledge in real time in a collaborative, nonhierarchical environment. The code team can provide the team leader with quick, accurate information about the patient’s clinical history that is critical to good decision making.

Family support is also an essential part of any resuscitation. Health care providers need to offer the opportunity to be present to family members during the resuscitation attempts whenever possible. One team member should be assigned to the family to answer questions, clarify information, and offer comfort, but physicians should not be asking family members to decide to stop the code. It is important to note that the decision should be made by the team leader and not the patient’s family members. Regardless of the age or condition of the patient, the loss of a loved one is difficult to deal with, even if expected. The issue becomes more difficult with changes in legal, cultural, or personal perspectives.

The AHA in 2018 stated that the treating physician is expected to understand the patient and the arrest features, and the system factors that have prognostic importance for resuscitation.³ For clinicians who work in critical care settings, the framework presented by AHA is intuitive. As a code leader, I can always give more epinephrine, try a clot-busting drug or deliver another shock. Situations vary greatly during a code, and the amount of time spent resuscitating a patient before terminating efforts is not set in stone. In many cases, it is a judgment call. The process of CPR is almost as disheartening as its bleak outcomes.

In-hospital CPAs are inevitably gruesome. Each day as an attending physician, we are faced with difficult decisions, but experiencing these incredibly difficult and life-changing events can make for good learning. A CPA situation in action is very difficult for all concerned, particularly when there is almost no chance of success. But an unsuccessful or aborted resuscitation is also a huge loss for both the family and the code team. One of the critical functions of the code team leader is to review the events of a code and exercise judgment while evaluating the length of a code. This can be an intense and emotional experience, but with these principles in mind, we can feel reassured that we are making the best decision possible, for the patient, the family, and our team.

Dr. Basnet is a hospitalist physician in the department of internal medicine at Eastern New Mexico Medical Center, Roswell.

References

1. Part 2: Ethical aspects of CPR and ECC. Circulation. 2000;102(8):I12.

2. Goldberger ZD et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: An observational study. The Lancet. 2012;380(9852):1473-81.

3. Sirbaugh PE et al. A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med. 1999;33(2):174-84.

Background: Acute cystitis is a common condition in women and associated with morbidity. A commonly recommended preventative measure is increased oral hydration, but there is limited evidence to support this claim.

Though antibiotic prophylaxis is more effective at reducing cystitis, increased daily water intake is a safe and inexpensive method to prevent cystitis without increasing exposure to antimicrobial therapy. This study did rely on information obtained from phone calls with patients. It is also an open-label study design in which patients were not blinded to their assigned group. This would be less of an issue if episodes of cystitis were confirmed with culture. Another limitation of this study is that it included only ambulatory patients and excluded patients with pyelonephritis, so it may be less applicable to our hospitalized patients.

Bottom line: This study shows a benefit in recurrent cystitis by increased water intake in premenopausal women.

Citation: Hooton TM et al. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections. JAMA Intern Med. 2018 Nov;178(11):1509-15.

Dr. Astik is medical director, clinical documentation, at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: Acute cystitis is a common condition in women and associated with morbidity. A commonly recommended preventative measure is increased oral hydration, but there is limited evidence to support this claim.

Though antibiotic prophylaxis is more effective at reducing cystitis, increased daily water intake is a safe and inexpensive method to prevent cystitis without increasing exposure to antimicrobial therapy. This study did rely on information obtained from phone calls with patients. It is also an open-label study design in which patients were not blinded to their assigned group. This would be less of an issue if episodes of cystitis were confirmed with culture. Another limitation of this study is that it included only ambulatory patients and excluded patients with pyelonephritis, so it may be less applicable to our hospitalized patients.

Bottom line: This study shows a benefit in recurrent cystitis by increased water intake in premenopausal women.

Citation: Hooton TM et al. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections. JAMA Intern Med. 2018 Nov;178(11):1509-15.

Dr. Astik is medical director, clinical documentation, at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Background: Acute cystitis is a common condition in women and associated with morbidity. A commonly recommended preventative measure is increased oral hydration, but there is limited evidence to support this claim.

Though antibiotic prophylaxis is more effective at reducing cystitis, increased daily water intake is a safe and inexpensive method to prevent cystitis without increasing exposure to antimicrobial therapy. This study did rely on information obtained from phone calls with patients. It is also an open-label study design in which patients were not blinded to their assigned group. This would be less of an issue if episodes of cystitis were confirmed with culture. Another limitation of this study is that it included only ambulatory patients and excluded patients with pyelonephritis, so it may be less applicable to our hospitalized patients.

Bottom line: This study shows a benefit in recurrent cystitis by increased water intake in premenopausal women.

Citation: Hooton TM et al. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections. JAMA Intern Med. 2018 Nov;178(11):1509-15.

Dr. Astik is medical director, clinical documentation, at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.

Everyone always told me that my time in residency would fly by, and the 3 years of internal medicine training really did seem to pass in just a few moments. Before I knew it, I had passed my internal medicine boards and practiced hospital medicine at an academic medical center.

One day last fall, I received notice from the American Board of Internal Medicine that it was time to recertify. I was surprised – had it already been 10 years? What did I have to do to maintain my certification?

As I investigated what it would take to maintain certification, I discovered that the recertification process provided more flexibility, compared with original board certification. I now had the option to recertify in internal medicine with a Focused Practice in Hospital Medicine (FPHM). Beginning in 2014, ABIM offered hospitalists, or internists whose clinical practice is mainly in the inpatient setting, the option to recertify in internal medicine, but with the designation that highlighted their clinical practice in the inpatient setting.

The first step in recertification for me was deciding to recertify with the focus in hospital medicine or maintain the traditional internal medicine certification. I talked with several colleagues who are also practicing hospitalists and weighed their reasons for opting for FPHM. Ultimately, my decision to pursue a recertification with a focus in hospital medicine relied on three factors: First, my clinical practice since completing residency was exclusively in the inpatient setting. Day in and day out, I care for patients who are acutely ill and require inpatient medical care. Second, I wanted my board certification to reflect what I consider to be my area of clinical expertise, which is inpatient adult medicine. Pursuing the FPHM would provide that recognition. Finally, I wanted to study and be tested on topics that I could utilize in my day-to-day practice. Because I exclusively practiced hospital medicine since graduation, areas of clinical internal medicine that I did not frequently encounter in my daily practice became less accessible in my knowledge base.

The next step then was to enter the FPHM Maintenance of Certification (MOC) program.

The ABIM requires two attestations to verify that I met the requirements to be a hospitalist. First was a self-attestation confirming at least 3 years of unsupervised inpatient care practice experience, and meeting patient encounter thresholds in the inpatient setting. The second attestation was from a “Senior Hospital Officer” confirming the information in the self-attestation was accurate.

Once entered into the program and having an unrestricted medical license to practice, I had to complete the remaining requirements of earning MOC points and then passing a knowledge-based assessment. I had to accumulate a total of 100 MOC points in the past 5 years, which I succeeded in doing through participating in quality improvement projects, recording CME credits, studying for the exam, and even taking the exam. I could track my point totals through the ABIM Physician Portal, which updated my point tally automatically for activities that counted toward MOC, such as attending SHM’s annual conference.

The final component was to pass the knowledge assessment, the dreaded exam. In 2018, I had the option to take the 10-year FPHM exam or do a general internal medicine Knowledge Check-In. Beginning in 2020, candidates will be able to sit for either the 10-year Focused Practice in Hospital Medicine exam or begin the Hospital Medicine Knowledge Check-In pathway. I had already decided to pursue FPHM and began to prepare to sit for an exam. I scheduled my exam through the ABIM portal at a local testing center.

The exam was scheduled for a full day, consisting of four sections broken up by a lunch break and section breaks. Specifically, the 220 single best answer, multiple-choice exam covered diagnosis, testing, treatment decisions, epidemiology, and basic science content through patient scenarios that reflected the scope of practice of a hospitalist. The ABIM provided an exam blueprint that detailed the specific clinical topics and the likelihood that a question pertaining to that topic would show up on the exam. Content was described as high, medium, or low importance and the number of questions related to the content was 75% for high importance, no more than 25% for medium importance, and no questions for low-importance content. In addition, content was distributed in a way that was reflective of my clinical practice as a hospitalist: 63.5% inpatient and traditional care; 6.5% palliative care; 15% consultative comanagement; and 15% quality, safety, and clinical reasoning.

Beginning 6 months prior to my scheduled exam, I purchased two critical resources to guide my studying efforts: the SHM Spark Self-Assessment Tool and the American College of Physicians Medical Knowledge Self-Assessment Program to review subject matter content and also do practice questions.

The latest version of SHM’s program, Spark Edition 2, provides updated questions and resources tailored to the hospital medicine exams. I appreciated the ability to answer questions online, as well as on my phone so I could do questions on the go. Moreover, I was able to track which content areas were stronger or weaker for me, and focus attention on areas that needed more work. Importantly, the questions I answered using the Spark self-assessment tool closely aligned with the subject matter I encountered in the exam, as well as the clinical cases I encounter every day in my practice.

While the day-long exam was challenging, I was gratified to receive notice from the ABIM that I had successfully recertified in internal medicine with a Focused Practice in Hospital Medicine!

Dr. Tad-y is a hospitalist at the University of Colorado at Denver, Aurora, and associate vice chair of quality in the department of medicine at the University of Colorado.

Everyone always told me that my time in residency would fly by, and the 3 years of internal medicine training really did seem to pass in just a few moments. Before I knew it, I had passed my internal medicine boards and practiced hospital medicine at an academic medical center.

One day last fall, I received notice from the American Board of Internal Medicine that it was time to recertify. I was surprised – had it already been 10 years? What did I have to do to maintain my certification?

As I investigated what it would take to maintain certification, I discovered that the recertification process provided more flexibility, compared with original board certification. I now had the option to recertify in internal medicine with a Focused Practice in Hospital Medicine (FPHM). Beginning in 2014, ABIM offered hospitalists, or internists whose clinical practice is mainly in the inpatient setting, the option to recertify in internal medicine, but with the designation that highlighted their clinical practice in the inpatient setting.

The first step in recertification for me was deciding to recertify with the focus in hospital medicine or maintain the traditional internal medicine certification. I talked with several colleagues who are also practicing hospitalists and weighed their reasons for opting for FPHM. Ultimately, my decision to pursue a recertification with a focus in hospital medicine relied on three factors: First, my clinical practice since completing residency was exclusively in the inpatient setting. Day in and day out, I care for patients who are acutely ill and require inpatient medical care. Second, I wanted my board certification to reflect what I consider to be my area of clinical expertise, which is inpatient adult medicine. Pursuing the FPHM would provide that recognition. Finally, I wanted to study and be tested on topics that I could utilize in my day-to-day practice. Because I exclusively practiced hospital medicine since graduation, areas of clinical internal medicine that I did not frequently encounter in my daily practice became less accessible in my knowledge base.

The next step then was to enter the FPHM Maintenance of Certification (MOC) program.

The ABIM requires two attestations to verify that I met the requirements to be a hospitalist. First was a self-attestation confirming at least 3 years of unsupervised inpatient care practice experience, and meeting patient encounter thresholds in the inpatient setting. The second attestation was from a “Senior Hospital Officer” confirming the information in the self-attestation was accurate.

Once entered into the program and having an unrestricted medical license to practice, I had to complete the remaining requirements of earning MOC points and then passing a knowledge-based assessment. I had to accumulate a total of 100 MOC points in the past 5 years, which I succeeded in doing through participating in quality improvement projects, recording CME credits, studying for the exam, and even taking the exam. I could track my point totals through the ABIM Physician Portal, which updated my point tally automatically for activities that counted toward MOC, such as attending SHM’s annual conference.

The final component was to pass the knowledge assessment, the dreaded exam. In 2018, I had the option to take the 10-year FPHM exam or do a general internal medicine Knowledge Check-In. Beginning in 2020, candidates will be able to sit for either the 10-year Focused Practice in Hospital Medicine exam or begin the Hospital Medicine Knowledge Check-In pathway. I had already decided to pursue FPHM and began to prepare to sit for an exam. I scheduled my exam through the ABIM portal at a local testing center.

The exam was scheduled for a full day, consisting of four sections broken up by a lunch break and section breaks. Specifically, the 220 single best answer, multiple-choice exam covered diagnosis, testing, treatment decisions, epidemiology, and basic science content through patient scenarios that reflected the scope of practice of a hospitalist. The ABIM provided an exam blueprint that detailed the specific clinical topics and the likelihood that a question pertaining to that topic would show up on the exam. Content was described as high, medium, or low importance and the number of questions related to the content was 75% for high importance, no more than 25% for medium importance, and no questions for low-importance content. In addition, content was distributed in a way that was reflective of my clinical practice as a hospitalist: 63.5% inpatient and traditional care; 6.5% palliative care; 15% consultative comanagement; and 15% quality, safety, and clinical reasoning.

Beginning 6 months prior to my scheduled exam, I purchased two critical resources to guide my studying efforts: the SHM Spark Self-Assessment Tool and the American College of Physicians Medical Knowledge Self-Assessment Program to review subject matter content and also do practice questions.

The latest version of SHM’s program, Spark Edition 2, provides updated questions and resources tailored to the hospital medicine exams. I appreciated the ability to answer questions online, as well as on my phone so I could do questions on the go. Moreover, I was able to track which content areas were stronger or weaker for me, and focus attention on areas that needed more work. Importantly, the questions I answered using the Spark self-assessment tool closely aligned with the subject matter I encountered in the exam, as well as the clinical cases I encounter every day in my practice.

While the day-long exam was challenging, I was gratified to receive notice from the ABIM that I had successfully recertified in internal medicine with a Focused Practice in Hospital Medicine!

Dr. Tad-y is a hospitalist at the University of Colorado at Denver, Aurora, and associate vice chair of quality in the department of medicine at the University of Colorado.

Everyone always told me that my time in residency would fly by, and the 3 years of internal medicine training really did seem to pass in just a few moments. Before I knew it, I had passed my internal medicine boards and practiced hospital medicine at an academic medical center.

One day last fall, I received notice from the American Board of Internal Medicine that it was time to recertify. I was surprised – had it already been 10 years? What did I have to do to maintain my certification?

As I investigated what it would take to maintain certification, I discovered that the recertification process provided more flexibility, compared with original board certification. I now had the option to recertify in internal medicine with a Focused Practice in Hospital Medicine (FPHM). Beginning in 2014, ABIM offered hospitalists, or internists whose clinical practice is mainly in the inpatient setting, the option to recertify in internal medicine, but with the designation that highlighted their clinical practice in the inpatient setting.

The first step in recertification for me was deciding to recertify with the focus in hospital medicine or maintain the traditional internal medicine certification. I talked with several colleagues who are also practicing hospitalists and weighed their reasons for opting for FPHM. Ultimately, my decision to pursue a recertification with a focus in hospital medicine relied on three factors: First, my clinical practice since completing residency was exclusively in the inpatient setting. Day in and day out, I care for patients who are acutely ill and require inpatient medical care. Second, I wanted my board certification to reflect what I consider to be my area of clinical expertise, which is inpatient adult medicine. Pursuing the FPHM would provide that recognition. Finally, I wanted to study and be tested on topics that I could utilize in my day-to-day practice. Because I exclusively practiced hospital medicine since graduation, areas of clinical internal medicine that I did not frequently encounter in my daily practice became less accessible in my knowledge base.

The next step then was to enter the FPHM Maintenance of Certification (MOC) program.

The ABIM requires two attestations to verify that I met the requirements to be a hospitalist. First was a self-attestation confirming at least 3 years of unsupervised inpatient care practice experience, and meeting patient encounter thresholds in the inpatient setting. The second attestation was from a “Senior Hospital Officer” confirming the information in the self-attestation was accurate.

Once entered into the program and having an unrestricted medical license to practice, I had to complete the remaining requirements of earning MOC points and then passing a knowledge-based assessment. I had to accumulate a total of 100 MOC points in the past 5 years, which I succeeded in doing through participating in quality improvement projects, recording CME credits, studying for the exam, and even taking the exam. I could track my point totals through the ABIM Physician Portal, which updated my point tally automatically for activities that counted toward MOC, such as attending SHM’s annual conference.

The final component was to pass the knowledge assessment, the dreaded exam. In 2018, I had the option to take the 10-year FPHM exam or do a general internal medicine Knowledge Check-In. Beginning in 2020, candidates will be able to sit for either the 10-year Focused Practice in Hospital Medicine exam or begin the Hospital Medicine Knowledge Check-In pathway. I had already decided to pursue FPHM and began to prepare to sit for an exam. I scheduled my exam through the ABIM portal at a local testing center.

The exam was scheduled for a full day, consisting of four sections broken up by a lunch break and section breaks. Specifically, the 220 single best answer, multiple-choice exam covered diagnosis, testing, treatment decisions, epidemiology, and basic science content through patient scenarios that reflected the scope of practice of a hospitalist. The ABIM provided an exam blueprint that detailed the specific clinical topics and the likelihood that a question pertaining to that topic would show up on the exam. Content was described as high, medium, or low importance and the number of questions related to the content was 75% for high importance, no more than 25% for medium importance, and no questions for low-importance content. In addition, content was distributed in a way that was reflective of my clinical practice as a hospitalist: 63.5% inpatient and traditional care; 6.5% palliative care; 15% consultative comanagement; and 15% quality, safety, and clinical reasoning.

Beginning 6 months prior to my scheduled exam, I purchased two critical resources to guide my studying efforts: the SHM Spark Self-Assessment Tool and the American College of Physicians Medical Knowledge Self-Assessment Program to review subject matter content and also do practice questions.

The latest version of SHM’s program, Spark Edition 2, provides updated questions and resources tailored to the hospital medicine exams. I appreciated the ability to answer questions online, as well as on my phone so I could do questions on the go. Moreover, I was able to track which content areas were stronger or weaker for me, and focus attention on areas that needed more work. Importantly, the questions I answered using the Spark self-assessment tool closely aligned with the subject matter I encountered in the exam, as well as the clinical cases I encounter every day in my practice.

While the day-long exam was challenging, I was gratified to receive notice from the ABIM that I had successfully recertified in internal medicine with a Focused Practice in Hospital Medicine!

Dr. Tad-y is a hospitalist at the University of Colorado at Denver, Aurora, and associate vice chair of quality in the department of medicine at the University of Colorado.

Physician employment contracts increasingly include value- and quality-based metrics as bases for production bonuses, according to an analysis of recruitment searches from April 1, 2018, to March 31, 2019.

Metrics such as physician satisfaction rates, proper use of EHRs, following treatment protocols, and others that don’t directly measure volume are becoming more commonplace in employment contracts, though volume measures still are included, according to Phil Miller, vice president of communications at health care recruiting firm Merritt Hawkins and author of the company’s 2019 report on physician and advanced practitioner recruiting incentives, released July 8.

Of 70% of searches that offered a production bonus, 56% featured a bonus based at least in part on quality metrics, up from 43% in 2018. The finding represents the highest percent of contracts offering a quality-based bonus that the company has tracked, according to the report.

Merritt Hawkins’ review is based on a sample of the 3,131 permanent physician and advanced practitioner search assignments that Merritt Hawkins and its sister physician staffing companies at AMN Healthcare have ongoing or were engaged to conduct from April 1, 2018 to March 31, 2019.

Other common value-based metrics include reduction in hospital readmissions, cost containment, and proper coding.

While value-based incentives are on the rise, “facilities that employ physicians want to ensure they stay productive, and ‘productivity’ still is measured in part by what are essentially fee-for-service metrics, including relative value units [RVUs], net collections, and number of patients seen.”

RVUs were used in 70% of production formulas tracked in the 2019 review, up from 50% in the previous year and also a record high.

Mr. Miller noted that employers are seeking the “Goldilocks’ zone,” a balance point between traditional productivity measures and value-based metrics, very much a work in progress right now.

A possible corollary to the increase in production bonuses is a flattening of signing bonuses. During the current review period, 71% of contracts came with a signing bonus, up slightly from 70% in the previous year’s report and down from 76% 2 years ago.

Signing bonuses in the review period for the 2019 report averaged $32,692, down from $33,707 during the 2018 report’s review period.

Overall, family practice physicians remain the highest in demand for job searches, but specialty practice is gaining ground.

For the 2018-2019 review, family medicine was the most requested search by specialty, with 457 searches requested. While the ranking remains No. 1, as it has for the past 13 years, the number of searches has been on a steady decline. Last year, there were 497 searches, which was down from 607 2 years ago and 734 4 years ago.

Mr. Miller said there were a few reasons for the lower number of searches. “One is just the momentum shifts that are kind of inherent to recruiting. People put all of their resources into one area, typically, and in this case it was primary care and they realized, ‘Hey wait a minute, we need some specialists for these doctors to refer to, so now we have to put some of our chips in the specialty basket.’ ”

The Baby Boomers also is having an effect – as they age and are experiencing more health issues, more specialists are needed.

“[Older patients] visit the doctor twice or three times the rate of a younger person and they also generate a much higher percentage of inpatient procedures and tests and diagnoses,” he said.

On the opposite end of the spectrum, “younger people are less likely to have a primary care doctor who coordinates their care,” Mr. Miller said. “What they typically do is go to an urgent care center, a retail clinic, maybe even [use] telemedicine so they are not accessing the system in the same way or necessarily through the same provider.”

Demand for psychiatrists remained strong for the fourth year in a row, but the number of searches has declined for the last several years. For the current review period, there were 199 searches, down from 243 the previous year, 256 2 years ago, and 250 3 years ago.

There is “pretty much a crisis in behavioral health care now because there are so few psychiatrists and the demand has increased,” Mr. Miller noted.

[email protected]

Physician employment contracts increasingly include value- and quality-based metrics as bases for production bonuses, according to an analysis of recruitment searches from April 1, 2018, to March 31, 2019.

Metrics such as physician satisfaction rates, proper use of EHRs, following treatment protocols, and others that don’t directly measure volume are becoming more commonplace in employment contracts, though volume measures still are included, according to Phil Miller, vice president of communications at health care recruiting firm Merritt Hawkins and author of the company’s 2019 report on physician and advanced practitioner recruiting incentives, released July 8.

Of 70% of searches that offered a production bonus, 56% featured a bonus based at least in part on quality metrics, up from 43% in 2018. The finding represents the highest percent of contracts offering a quality-based bonus that the company has tracked, according to the report.

Merritt Hawkins’ review is based on a sample of the 3,131 permanent physician and advanced practitioner search assignments that Merritt Hawkins and its sister physician staffing companies at AMN Healthcare have ongoing or were engaged to conduct from April 1, 2018 to March 31, 2019.

Other common value-based metrics include reduction in hospital readmissions, cost containment, and proper coding.

While value-based incentives are on the rise, “facilities that employ physicians want to ensure they stay productive, and ‘productivity’ still is measured in part by what are essentially fee-for-service metrics, including relative value units [RVUs], net collections, and number of patients seen.”

RVUs were used in 70% of production formulas tracked in the 2019 review, up from 50% in the previous year and also a record high.

Mr. Miller noted that employers are seeking the “Goldilocks’ zone,” a balance point between traditional productivity measures and value-based metrics, very much a work in progress right now.

A possible corollary to the increase in production bonuses is a flattening of signing bonuses. During the current review period, 71% of contracts came with a signing bonus, up slightly from 70% in the previous year’s report and down from 76% 2 years ago.

Signing bonuses in the review period for the 2019 report averaged $32,692, down from $33,707 during the 2018 report’s review period.

Overall, family practice physicians remain the highest in demand for job searches, but specialty practice is gaining ground.

For the 2018-2019 review, family medicine was the most requested search by specialty, with 457 searches requested. While the ranking remains No. 1, as it has for the past 13 years, the number of searches has been on a steady decline. Last year, there were 497 searches, which was down from 607 2 years ago and 734 4 years ago.

Mr. Miller said there were a few reasons for the lower number of searches. “One is just the momentum shifts that are kind of inherent to recruiting. People put all of their resources into one area, typically, and in this case it was primary care and they realized, ‘Hey wait a minute, we need some specialists for these doctors to refer to, so now we have to put some of our chips in the specialty basket.’ ”

The Baby Boomers also is having an effect – as they age and are experiencing more health issues, more specialists are needed.

“[Older patients] visit the doctor twice or three times the rate of a younger person and they also generate a much higher percentage of inpatient procedures and tests and diagnoses,” he said.

On the opposite end of the spectrum, “younger people are less likely to have a primary care doctor who coordinates their care,” Mr. Miller said. “What they typically do is go to an urgent care center, a retail clinic, maybe even [use] telemedicine so they are not accessing the system in the same way or necessarily through the same provider.”

Demand for psychiatrists remained strong for the fourth year in a row, but the number of searches has declined for the last several years. For the current review period, there were 199 searches, down from 243 the previous year, 256 2 years ago, and 250 3 years ago.

There is “pretty much a crisis in behavioral health care now because there are so few psychiatrists and the demand has increased,” Mr. Miller noted.

[email protected]

Physician employment contracts increasingly include value- and quality-based metrics as bases for production bonuses, according to an analysis of recruitment searches from April 1, 2018, to March 31, 2019.

Metrics such as physician satisfaction rates, proper use of EHRs, following treatment protocols, and others that don’t directly measure volume are becoming more commonplace in employment contracts, though volume measures still are included, according to Phil Miller, vice president of communications at health care recruiting firm Merritt Hawkins and author of the company’s 2019 report on physician and advanced practitioner recruiting incentives, released July 8.

Of 70% of searches that offered a production bonus, 56% featured a bonus based at least in part on quality metrics, up from 43% in 2018. The finding represents the highest percent of contracts offering a quality-based bonus that the company has tracked, according to the report.

Merritt Hawkins’ review is based on a sample of the 3,131 permanent physician and advanced practitioner search assignments that Merritt Hawkins and its sister physician staffing companies at AMN Healthcare have ongoing or were engaged to conduct from April 1, 2018 to March 31, 2019.

Other common value-based metrics include reduction in hospital readmissions, cost containment, and proper coding.

While value-based incentives are on the rise, “facilities that employ physicians want to ensure they stay productive, and ‘productivity’ still is measured in part by what are essentially fee-for-service metrics, including relative value units [RVUs], net collections, and number of patients seen.”

RVUs were used in 70% of production formulas tracked in the 2019 review, up from 50% in the previous year and also a record high.

Mr. Miller noted that employers are seeking the “Goldilocks’ zone,” a balance point between traditional productivity measures and value-based metrics, very much a work in progress right now.

A possible corollary to the increase in production bonuses is a flattening of signing bonuses. During the current review period, 71% of contracts came with a signing bonus, up slightly from 70% in the previous year’s report and down from 76% 2 years ago.

Signing bonuses in the review period for the 2019 report averaged $32,692, down from $33,707 during the 2018 report’s review period.

Overall, family practice physicians remain the highest in demand for job searches, but specialty practice is gaining ground.

For the 2018-2019 review, family medicine was the most requested search by specialty, with 457 searches requested. While the ranking remains No. 1, as it has for the past 13 years, the number of searches has been on a steady decline. Last year, there were 497 searches, which was down from 607 2 years ago and 734 4 years ago.

Mr. Miller said there were a few reasons for the lower number of searches. “One is just the momentum shifts that are kind of inherent to recruiting. People put all of their resources into one area, typically, and in this case it was primary care and they realized, ‘Hey wait a minute, we need some specialists for these doctors to refer to, so now we have to put some of our chips in the specialty basket.’ ”

The Baby Boomers also is having an effect – as they age and are experiencing more health issues, more specialists are needed.

“[Older patients] visit the doctor twice or three times the rate of a younger person and they also generate a much higher percentage of inpatient procedures and tests and diagnoses,” he said.

On the opposite end of the spectrum, “younger people are less likely to have a primary care doctor who coordinates their care,” Mr. Miller said. “What they typically do is go to an urgent care center, a retail clinic, maybe even [use] telemedicine so they are not accessing the system in the same way or necessarily through the same provider.”

Demand for psychiatrists remained strong for the fourth year in a row, but the number of searches has declined for the last several years. For the current review period, there were 199 searches, down from 243 the previous year, 256 2 years ago, and 250 3 years ago.

There is “pretty much a crisis in behavioral health care now because there are so few psychiatrists and the demand has increased,” Mr. Miller noted.

[email protected]