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When is it safe to resume anticoagulation in my patient with hemorrhagic stroke?
Balancing risk is critical to decision making
Department of Medicine, Massachusetts General Hospital, Boston
Case
A 75 year-old woman with a history of hypertension, diabetes mellitus, heart failure and nonvalvular atrial fibrillation (CHA2DS2-VASc score, 8) on anticoagulation is admitted with weakness and dysarthria. Exam is notable for hypertension and right-sided hemiparesis. CT of the head shows an intraparenchymal hemorrhage in the left putamen. Her anticoagulation is reversed and blood pressure well controlled. She is discharged 12 days later.
Brief overview of the issue
Intracranial hemorrhage (ICH) is the second most common cause of stroke and is associated with high morbidity and mortality.1 It is estimated that 10%-15% of spontaneous ICH cases occur in patients on therapeutic anticoagulation for atrial fibrillation.2 As our population ages and more people develop atrial fibrillation, anticoagulation for primary or secondary prevention of embolic stroke also will likely increase, placing more people at risk for ICH. Even stringently controlled therapeutic international normalized ratios (INRs) between 2 and 3 may double the risk of ICH.3
Patients with ICH require close monitoring and treatment, including blood pressure control, reversal of anticoagulation, reduction of intracranial pressure and, at times, neurosurgery.4 Although anticoagulation is discontinued and reversed at the onset of ICH, no clear consensus exists as to when it is safe to resume it. Although anticoagulation decreases the risk of stroke/thromboembolism, it may also increase the amount of bleeding associated with the initial ICH or lead to its recurrence.
Factors that may contribute to rebleeding include uncontrolled hypertension, advanced age, time to resumption of anticoagulation, and lobar location of ICH (i.e., in cerebral cortex and/or underlying white matter).5 Traditionally, lobar ICH has high incidence of cerebral amyloid angiopathy and has been associated with higher bleeding rates than has deep ICH (i.e., involving the thalami, basal ganglia, cerebellum, or brainstem) where cerebral amyloid angiopathy is rare and ICH is usually from hypertensive vessel disease. However, in patients with active thromboembolic disease, high-risk atrial fibrillation, and mechanical valves, withholding anticoagulation could place them at high risk of stroke.
Two questions should be addressed in the case presented: Is it safe to restart therapeutic anticoagulation; and if so, what is the optimal time interval between ICH and reinitiation of anticoagulation?
Overview of the data
There is limited guidance from major professional societies regarding the reinitiation of anticoagulation and the optimal timing of safely resuming anticoagulation in patients with prior ICH.
Current European Stroke Organization guidelines provide no specific recommendations for anticoagulation resumption after ICH.7 The American Heart Association/American Stroke Association guideline has a class IIA (weak) recommendation to avoid anticoagulation in spontaneous lobar ICH and a class IIB (very weak) recommendation to consider resuming anticoagulation in nonlobar ICH on a case-by-case basis.4
Two recent meta-analyses have examined outcomes of resuming anticoagulation after ICH. In a meta-analysis of 5,300 patients with nonlobar ICH involving eight retrospective studies, Murthy et al. evaluated the risk of thromboembolic events (described as a composite outcome of MI and stroke) and the risk of recurrent ICH.8 They reported that resumption of therapeutic anticoagulation was associated with a decrease in the rate of thromboembolic events (6.7% vs. 17.6%; risk ratio, 0.35; 95% confidence interval, 0.25-0.45) with no significant change in the rate of repeat ICH (8.7% vs. 7.8%).
A second meta-analysis of three retrospective trials conducted by Biffi et al. examined anticoagulation resumption in 1,012 patients with ICH solely in the setting of thromboprophylaxis for nonvalvular atrial fibrillation.9 Reinitiation of anticoagulation after ICH was associated with decreased mortality (hazard ratio, 0.27; 95% CI, 0.19-0.40; P less than .0001), improved functional outcome (HR, 4.15; 95% CI, 2.92-5.90; P less than .0001), and reduction in all-cause stroke recurrence (HR 0.47; 95% CI, 0.36-0.64; P less than .0001). There was no significant difference in the rate of recurrent ICH when anticoagulation was resumed. Despite the notion that patients with cerebral amyloid angiopathy are at high risk of rebleeding, this positive association still held irrespective of lobar vs. nonlobar location of ICH.
Collectively, these studies suggest that resumption of anticoagulation may be effective in decreasing the rates of thromboembolism, as well as provide a functional and mortality benefit without increasing the risk of rebleeding, irrespective of the location of the bleed.
Less is known about the optimal timing of resumption of therapeutic anticoagulation, with data ranging from 72 hours to 30 weeks.10 The American Heart Association/American Stroke Association has a class IIB (very weak) recommendation to avoid anticoagulation for at least 4 weeks in patients without mechanical heart valves.4 The median time to resumption of therapeutic anticoagulation in aforementioned meta-analyses ranged from 10 to 44 days.8,9
A recent observational study of 2,619 ICH survivors explored the relationship between the timing of reinitiation of anticoagulation and the incidence of thrombotic events (defined as ischemic stroke or death because of MI or systemic arterial thromboembolism) and hemorrhagic events (defined as recurrent ICH or bleeding event leading to death) occurring at least 28 days after initial ICH in patients with atrial fibrillation.11
A decrease in thrombotic events was demonstrated if anticoagulation was started 4-16 weeks after ICH. However, when anticoagulation was started more than 16 weeks after ICH, no benefit was seen. Additionally, there was no significant difference in hemorrhagic events between men and women who resumed anticoagulation. In patients with high venous thromboembolism risk based on CHA2DS2-VASc score, resumption of anticoagulation was associated with a decreased predicted incidence of vascular death and nonfatal stroke, with the greatest benefit observed when anticoagulation was started at 7-8 weeks after ICH.
Unfortunately, published literature to date on anticoagulation after ICH is based entirely on retrospective studies – not randomized, controlled studies – making it more likely that anticoagulation would have been resumed in healthier patients, not those left debilitated by the ICH.
Furthermore, information on the location and size of the hemorrhages – which may serve as another confounding factor – often has not been reported. This is important since patients with smaller hemorrhages in less precarious areas also may be more likely to have resumption of anticoagulation. Another limitation of the current literature is that warfarin is the most common anticoagulant studied, with few studies involving the increasingly prescribed newer direct oral anticoagulants. It is also important to stress that a causal relationship between use of anticoagulants and certain outcomes or adverse effects following ICH may be more difficult to invoke in the absence of randomized controlled study designs.
Application of the data to our patient
Resumption of anticoagulation in our patient with ICH requires balancing the risk of hemorrhage expansion and recurrent ICH with the risk of thromboembolic disease.
Our patient is at higher risk of bleeding because of her advanced age, but adequate control of her blood pressure and nonlobar location of her ICH in the basal ganglia also may decrease her risk of recurrent ICH. Her high CHA2DS2-VASc score places her at high risk of thromboembolic event and stroke, making it more likely for reinitiation of anticoagulation to confer a mortality benefit.
Based on AHA guidelines,4 we should wait at least 4 weeks, or possibly wait until weeks 7-8 after ICH when the greatest benefit may be expected based on prediction models.11
Bottom line
It would likely be safe to resume anticoagulation 4-8 weeks after ICH in our patient.
Dr. Gibson, Dr. Restrepo, Dr. Sasidhara, and Dr. Manian are hospitalists at Massachusetts General Hospital, Boston.
References
1. An SJ et al. Epidemiology, risk factors, and clinical features of intracerebral hemorrhage: An update. J Stroke. 2017 Jan;19:3-10.
2. Horstmann S et al. Intracerebral hemorrhage during anticoagulation with vitamin K antagonists: a consecutive observational study. J Neurol. 2013 Aug;260:2046-51.
3. Rosand J et al. The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Intern Med. 2004 Apr 26;164:880-4.
4. Hemphill JC et al. Guidelines for the management of spontaneous intracerebral hemorrhage. Stroke. 2015 Jul;46:2032-60.
5. Aguillar MI et al. Update in intracerebral hemorrhage. Neurohospitalist. 2011;1:148-59.
6. Hill MD et al. Rate of stroke recurrence in patients with primary intracerebral hemorrhage. Stroke. 2000;31:123-7.
7. Steiner T et al. European Stroke Organization (ESO) guidelines for the management of spontaneous cerebral hemorrhage. Int J Stroke. 2014;9:840-55.
8. Murthy SB et al. Restarting anticoagulation therapy after intracranial hemorrhage: A systematic review and meta-analysis. Stroke. 2017 Jun;48:1594-600.
9. Biffi A et al. Oral anticoagulation and functional outcome after intracerebral hemorrhage. Ann Neurol. 2017 Nov;82:755-65.
10. Witt DM. What to do after the bleed: Resuming anticoagulation after major bleeding. Hematology Am Soc Hematol Educ Program. 2016 Dec 2;206:620-4.
11. Pennlert J et al. Optimal timing of anticoagulant treatment after intracerebral hemorrhage in patients with atrial fibrillation. Stroke. 2017 Feb;48:314-20.
Key Points
- Robust scientific data on when to resume anticoagulation after ICH does not exist.
- Retrospective studies have shown that anticoagulation resumption after 4-8 weeks decreases the risk of thromboembolic events, decreases mortality, and improves functional status following ICH with no significant change in the risk of its recurrence.
- Prospective, randomized controlled trials are needed to explore risks/benefits of anticoagulation resumption and better define its optimal timing in relation to ICH.
Quiz
Which of the following is false regarding ICH?
A. Lobar ICHs are usually associated with cerebral amyloid angiopathy which are prone to bleeding.
B. Randomized, controlled studies have helped guide the decision as to when to resume anticoagulation in patients with ICH.
C. Current guidelines suggest deferring therapeutic anticoagulation for at least 4 weeks following ICH.
D. Resumption of anticoagulation after 4-8 weeks does not lead to increased risk of rebleeding in patients with prior ICH.
The false answer is B: Current recommendations regarding resumption of anticoagulation in patients with ICH are based solely on retrospective observational studies; there are no randomized, control trials to date.
A is true: In contrast to hypertensive vessel disease associated with deep ICH, lobar hemorrhages are usually associated with cerebral amyloid angiopathy, which are more prone to bleeding.
C is true: The AHA/ASA has a class IIB recommendation to avoid anticoagulation for at least 4 weeks after ICH in patients without mechanical heart valves.
D is true: Several studies have shown that resumption of anticoagulation 4-8 weeks after ICH does not increase the risk of rebleeding.
Balancing risk is critical to decision making
Balancing risk is critical to decision making
Department of Medicine, Massachusetts General Hospital, Boston
Case
A 75 year-old woman with a history of hypertension, diabetes mellitus, heart failure and nonvalvular atrial fibrillation (CHA2DS2-VASc score, 8) on anticoagulation is admitted with weakness and dysarthria. Exam is notable for hypertension and right-sided hemiparesis. CT of the head shows an intraparenchymal hemorrhage in the left putamen. Her anticoagulation is reversed and blood pressure well controlled. She is discharged 12 days later.
Brief overview of the issue
Intracranial hemorrhage (ICH) is the second most common cause of stroke and is associated with high morbidity and mortality.1 It is estimated that 10%-15% of spontaneous ICH cases occur in patients on therapeutic anticoagulation for atrial fibrillation.2 As our population ages and more people develop atrial fibrillation, anticoagulation for primary or secondary prevention of embolic stroke also will likely increase, placing more people at risk for ICH. Even stringently controlled therapeutic international normalized ratios (INRs) between 2 and 3 may double the risk of ICH.3
Patients with ICH require close monitoring and treatment, including blood pressure control, reversal of anticoagulation, reduction of intracranial pressure and, at times, neurosurgery.4 Although anticoagulation is discontinued and reversed at the onset of ICH, no clear consensus exists as to when it is safe to resume it. Although anticoagulation decreases the risk of stroke/thromboembolism, it may also increase the amount of bleeding associated with the initial ICH or lead to its recurrence.
Factors that may contribute to rebleeding include uncontrolled hypertension, advanced age, time to resumption of anticoagulation, and lobar location of ICH (i.e., in cerebral cortex and/or underlying white matter).5 Traditionally, lobar ICH has high incidence of cerebral amyloid angiopathy and has been associated with higher bleeding rates than has deep ICH (i.e., involving the thalami, basal ganglia, cerebellum, or brainstem) where cerebral amyloid angiopathy is rare and ICH is usually from hypertensive vessel disease. However, in patients with active thromboembolic disease, high-risk atrial fibrillation, and mechanical valves, withholding anticoagulation could place them at high risk of stroke.
Two questions should be addressed in the case presented: Is it safe to restart therapeutic anticoagulation; and if so, what is the optimal time interval between ICH and reinitiation of anticoagulation?
Overview of the data
There is limited guidance from major professional societies regarding the reinitiation of anticoagulation and the optimal timing of safely resuming anticoagulation in patients with prior ICH.
Current European Stroke Organization guidelines provide no specific recommendations for anticoagulation resumption after ICH.7 The American Heart Association/American Stroke Association guideline has a class IIA (weak) recommendation to avoid anticoagulation in spontaneous lobar ICH and a class IIB (very weak) recommendation to consider resuming anticoagulation in nonlobar ICH on a case-by-case basis.4
Two recent meta-analyses have examined outcomes of resuming anticoagulation after ICH. In a meta-analysis of 5,300 patients with nonlobar ICH involving eight retrospective studies, Murthy et al. evaluated the risk of thromboembolic events (described as a composite outcome of MI and stroke) and the risk of recurrent ICH.8 They reported that resumption of therapeutic anticoagulation was associated with a decrease in the rate of thromboembolic events (6.7% vs. 17.6%; risk ratio, 0.35; 95% confidence interval, 0.25-0.45) with no significant change in the rate of repeat ICH (8.7% vs. 7.8%).
A second meta-analysis of three retrospective trials conducted by Biffi et al. examined anticoagulation resumption in 1,012 patients with ICH solely in the setting of thromboprophylaxis for nonvalvular atrial fibrillation.9 Reinitiation of anticoagulation after ICH was associated with decreased mortality (hazard ratio, 0.27; 95% CI, 0.19-0.40; P less than .0001), improved functional outcome (HR, 4.15; 95% CI, 2.92-5.90; P less than .0001), and reduction in all-cause stroke recurrence (HR 0.47; 95% CI, 0.36-0.64; P less than .0001). There was no significant difference in the rate of recurrent ICH when anticoagulation was resumed. Despite the notion that patients with cerebral amyloid angiopathy are at high risk of rebleeding, this positive association still held irrespective of lobar vs. nonlobar location of ICH.
Collectively, these studies suggest that resumption of anticoagulation may be effective in decreasing the rates of thromboembolism, as well as provide a functional and mortality benefit without increasing the risk of rebleeding, irrespective of the location of the bleed.
Less is known about the optimal timing of resumption of therapeutic anticoagulation, with data ranging from 72 hours to 30 weeks.10 The American Heart Association/American Stroke Association has a class IIB (very weak) recommendation to avoid anticoagulation for at least 4 weeks in patients without mechanical heart valves.4 The median time to resumption of therapeutic anticoagulation in aforementioned meta-analyses ranged from 10 to 44 days.8,9
A recent observational study of 2,619 ICH survivors explored the relationship between the timing of reinitiation of anticoagulation and the incidence of thrombotic events (defined as ischemic stroke or death because of MI or systemic arterial thromboembolism) and hemorrhagic events (defined as recurrent ICH or bleeding event leading to death) occurring at least 28 days after initial ICH in patients with atrial fibrillation.11
A decrease in thrombotic events was demonstrated if anticoagulation was started 4-16 weeks after ICH. However, when anticoagulation was started more than 16 weeks after ICH, no benefit was seen. Additionally, there was no significant difference in hemorrhagic events between men and women who resumed anticoagulation. In patients with high venous thromboembolism risk based on CHA2DS2-VASc score, resumption of anticoagulation was associated with a decreased predicted incidence of vascular death and nonfatal stroke, with the greatest benefit observed when anticoagulation was started at 7-8 weeks after ICH.
Unfortunately, published literature to date on anticoagulation after ICH is based entirely on retrospective studies – not randomized, controlled studies – making it more likely that anticoagulation would have been resumed in healthier patients, not those left debilitated by the ICH.
Furthermore, information on the location and size of the hemorrhages – which may serve as another confounding factor – often has not been reported. This is important since patients with smaller hemorrhages in less precarious areas also may be more likely to have resumption of anticoagulation. Another limitation of the current literature is that warfarin is the most common anticoagulant studied, with few studies involving the increasingly prescribed newer direct oral anticoagulants. It is also important to stress that a causal relationship between use of anticoagulants and certain outcomes or adverse effects following ICH may be more difficult to invoke in the absence of randomized controlled study designs.
Application of the data to our patient
Resumption of anticoagulation in our patient with ICH requires balancing the risk of hemorrhage expansion and recurrent ICH with the risk of thromboembolic disease.
Our patient is at higher risk of bleeding because of her advanced age, but adequate control of her blood pressure and nonlobar location of her ICH in the basal ganglia also may decrease her risk of recurrent ICH. Her high CHA2DS2-VASc score places her at high risk of thromboembolic event and stroke, making it more likely for reinitiation of anticoagulation to confer a mortality benefit.
Based on AHA guidelines,4 we should wait at least 4 weeks, or possibly wait until weeks 7-8 after ICH when the greatest benefit may be expected based on prediction models.11
Bottom line
It would likely be safe to resume anticoagulation 4-8 weeks after ICH in our patient.
Dr. Gibson, Dr. Restrepo, Dr. Sasidhara, and Dr. Manian are hospitalists at Massachusetts General Hospital, Boston.
References
1. An SJ et al. Epidemiology, risk factors, and clinical features of intracerebral hemorrhage: An update. J Stroke. 2017 Jan;19:3-10.
2. Horstmann S et al. Intracerebral hemorrhage during anticoagulation with vitamin K antagonists: a consecutive observational study. J Neurol. 2013 Aug;260:2046-51.
3. Rosand J et al. The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Intern Med. 2004 Apr 26;164:880-4.
4. Hemphill JC et al. Guidelines for the management of spontaneous intracerebral hemorrhage. Stroke. 2015 Jul;46:2032-60.
5. Aguillar MI et al. Update in intracerebral hemorrhage. Neurohospitalist. 2011;1:148-59.
6. Hill MD et al. Rate of stroke recurrence in patients with primary intracerebral hemorrhage. Stroke. 2000;31:123-7.
7. Steiner T et al. European Stroke Organization (ESO) guidelines for the management of spontaneous cerebral hemorrhage. Int J Stroke. 2014;9:840-55.
8. Murthy SB et al. Restarting anticoagulation therapy after intracranial hemorrhage: A systematic review and meta-analysis. Stroke. 2017 Jun;48:1594-600.
9. Biffi A et al. Oral anticoagulation and functional outcome after intracerebral hemorrhage. Ann Neurol. 2017 Nov;82:755-65.
10. Witt DM. What to do after the bleed: Resuming anticoagulation after major bleeding. Hematology Am Soc Hematol Educ Program. 2016 Dec 2;206:620-4.
11. Pennlert J et al. Optimal timing of anticoagulant treatment after intracerebral hemorrhage in patients with atrial fibrillation. Stroke. 2017 Feb;48:314-20.
Key Points
- Robust scientific data on when to resume anticoagulation after ICH does not exist.
- Retrospective studies have shown that anticoagulation resumption after 4-8 weeks decreases the risk of thromboembolic events, decreases mortality, and improves functional status following ICH with no significant change in the risk of its recurrence.
- Prospective, randomized controlled trials are needed to explore risks/benefits of anticoagulation resumption and better define its optimal timing in relation to ICH.
Quiz
Which of the following is false regarding ICH?
A. Lobar ICHs are usually associated with cerebral amyloid angiopathy which are prone to bleeding.
B. Randomized, controlled studies have helped guide the decision as to when to resume anticoagulation in patients with ICH.
C. Current guidelines suggest deferring therapeutic anticoagulation for at least 4 weeks following ICH.
D. Resumption of anticoagulation after 4-8 weeks does not lead to increased risk of rebleeding in patients with prior ICH.
The false answer is B: Current recommendations regarding resumption of anticoagulation in patients with ICH are based solely on retrospective observational studies; there are no randomized, control trials to date.
A is true: In contrast to hypertensive vessel disease associated with deep ICH, lobar hemorrhages are usually associated with cerebral amyloid angiopathy, which are more prone to bleeding.
C is true: The AHA/ASA has a class IIB recommendation to avoid anticoagulation for at least 4 weeks after ICH in patients without mechanical heart valves.
D is true: Several studies have shown that resumption of anticoagulation 4-8 weeks after ICH does not increase the risk of rebleeding.
Department of Medicine, Massachusetts General Hospital, Boston
Case
A 75 year-old woman with a history of hypertension, diabetes mellitus, heart failure and nonvalvular atrial fibrillation (CHA2DS2-VASc score, 8) on anticoagulation is admitted with weakness and dysarthria. Exam is notable for hypertension and right-sided hemiparesis. CT of the head shows an intraparenchymal hemorrhage in the left putamen. Her anticoagulation is reversed and blood pressure well controlled. She is discharged 12 days later.
Brief overview of the issue
Intracranial hemorrhage (ICH) is the second most common cause of stroke and is associated with high morbidity and mortality.1 It is estimated that 10%-15% of spontaneous ICH cases occur in patients on therapeutic anticoagulation for atrial fibrillation.2 As our population ages and more people develop atrial fibrillation, anticoagulation for primary or secondary prevention of embolic stroke also will likely increase, placing more people at risk for ICH. Even stringently controlled therapeutic international normalized ratios (INRs) between 2 and 3 may double the risk of ICH.3
Patients with ICH require close monitoring and treatment, including blood pressure control, reversal of anticoagulation, reduction of intracranial pressure and, at times, neurosurgery.4 Although anticoagulation is discontinued and reversed at the onset of ICH, no clear consensus exists as to when it is safe to resume it. Although anticoagulation decreases the risk of stroke/thromboembolism, it may also increase the amount of bleeding associated with the initial ICH or lead to its recurrence.
Factors that may contribute to rebleeding include uncontrolled hypertension, advanced age, time to resumption of anticoagulation, and lobar location of ICH (i.e., in cerebral cortex and/or underlying white matter).5 Traditionally, lobar ICH has high incidence of cerebral amyloid angiopathy and has been associated with higher bleeding rates than has deep ICH (i.e., involving the thalami, basal ganglia, cerebellum, or brainstem) where cerebral amyloid angiopathy is rare and ICH is usually from hypertensive vessel disease. However, in patients with active thromboembolic disease, high-risk atrial fibrillation, and mechanical valves, withholding anticoagulation could place them at high risk of stroke.
Two questions should be addressed in the case presented: Is it safe to restart therapeutic anticoagulation; and if so, what is the optimal time interval between ICH and reinitiation of anticoagulation?
Overview of the data
There is limited guidance from major professional societies regarding the reinitiation of anticoagulation and the optimal timing of safely resuming anticoagulation in patients with prior ICH.
Current European Stroke Organization guidelines provide no specific recommendations for anticoagulation resumption after ICH.7 The American Heart Association/American Stroke Association guideline has a class IIA (weak) recommendation to avoid anticoagulation in spontaneous lobar ICH and a class IIB (very weak) recommendation to consider resuming anticoagulation in nonlobar ICH on a case-by-case basis.4
Two recent meta-analyses have examined outcomes of resuming anticoagulation after ICH. In a meta-analysis of 5,300 patients with nonlobar ICH involving eight retrospective studies, Murthy et al. evaluated the risk of thromboembolic events (described as a composite outcome of MI and stroke) and the risk of recurrent ICH.8 They reported that resumption of therapeutic anticoagulation was associated with a decrease in the rate of thromboembolic events (6.7% vs. 17.6%; risk ratio, 0.35; 95% confidence interval, 0.25-0.45) with no significant change in the rate of repeat ICH (8.7% vs. 7.8%).
A second meta-analysis of three retrospective trials conducted by Biffi et al. examined anticoagulation resumption in 1,012 patients with ICH solely in the setting of thromboprophylaxis for nonvalvular atrial fibrillation.9 Reinitiation of anticoagulation after ICH was associated with decreased mortality (hazard ratio, 0.27; 95% CI, 0.19-0.40; P less than .0001), improved functional outcome (HR, 4.15; 95% CI, 2.92-5.90; P less than .0001), and reduction in all-cause stroke recurrence (HR 0.47; 95% CI, 0.36-0.64; P less than .0001). There was no significant difference in the rate of recurrent ICH when anticoagulation was resumed. Despite the notion that patients with cerebral amyloid angiopathy are at high risk of rebleeding, this positive association still held irrespective of lobar vs. nonlobar location of ICH.
Collectively, these studies suggest that resumption of anticoagulation may be effective in decreasing the rates of thromboembolism, as well as provide a functional and mortality benefit without increasing the risk of rebleeding, irrespective of the location of the bleed.
Less is known about the optimal timing of resumption of therapeutic anticoagulation, with data ranging from 72 hours to 30 weeks.10 The American Heart Association/American Stroke Association has a class IIB (very weak) recommendation to avoid anticoagulation for at least 4 weeks in patients without mechanical heart valves.4 The median time to resumption of therapeutic anticoagulation in aforementioned meta-analyses ranged from 10 to 44 days.8,9
A recent observational study of 2,619 ICH survivors explored the relationship between the timing of reinitiation of anticoagulation and the incidence of thrombotic events (defined as ischemic stroke or death because of MI or systemic arterial thromboembolism) and hemorrhagic events (defined as recurrent ICH or bleeding event leading to death) occurring at least 28 days after initial ICH in patients with atrial fibrillation.11
A decrease in thrombotic events was demonstrated if anticoagulation was started 4-16 weeks after ICH. However, when anticoagulation was started more than 16 weeks after ICH, no benefit was seen. Additionally, there was no significant difference in hemorrhagic events between men and women who resumed anticoagulation. In patients with high venous thromboembolism risk based on CHA2DS2-VASc score, resumption of anticoagulation was associated with a decreased predicted incidence of vascular death and nonfatal stroke, with the greatest benefit observed when anticoagulation was started at 7-8 weeks after ICH.
Unfortunately, published literature to date on anticoagulation after ICH is based entirely on retrospective studies – not randomized, controlled studies – making it more likely that anticoagulation would have been resumed in healthier patients, not those left debilitated by the ICH.
Furthermore, information on the location and size of the hemorrhages – which may serve as another confounding factor – often has not been reported. This is important since patients with smaller hemorrhages in less precarious areas also may be more likely to have resumption of anticoagulation. Another limitation of the current literature is that warfarin is the most common anticoagulant studied, with few studies involving the increasingly prescribed newer direct oral anticoagulants. It is also important to stress that a causal relationship between use of anticoagulants and certain outcomes or adverse effects following ICH may be more difficult to invoke in the absence of randomized controlled study designs.
Application of the data to our patient
Resumption of anticoagulation in our patient with ICH requires balancing the risk of hemorrhage expansion and recurrent ICH with the risk of thromboembolic disease.
Our patient is at higher risk of bleeding because of her advanced age, but adequate control of her blood pressure and nonlobar location of her ICH in the basal ganglia also may decrease her risk of recurrent ICH. Her high CHA2DS2-VASc score places her at high risk of thromboembolic event and stroke, making it more likely for reinitiation of anticoagulation to confer a mortality benefit.
Based on AHA guidelines,4 we should wait at least 4 weeks, or possibly wait until weeks 7-8 after ICH when the greatest benefit may be expected based on prediction models.11
Bottom line
It would likely be safe to resume anticoagulation 4-8 weeks after ICH in our patient.
Dr. Gibson, Dr. Restrepo, Dr. Sasidhara, and Dr. Manian are hospitalists at Massachusetts General Hospital, Boston.
References
1. An SJ et al. Epidemiology, risk factors, and clinical features of intracerebral hemorrhage: An update. J Stroke. 2017 Jan;19:3-10.
2. Horstmann S et al. Intracerebral hemorrhage during anticoagulation with vitamin K antagonists: a consecutive observational study. J Neurol. 2013 Aug;260:2046-51.
3. Rosand J et al. The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Intern Med. 2004 Apr 26;164:880-4.
4. Hemphill JC et al. Guidelines for the management of spontaneous intracerebral hemorrhage. Stroke. 2015 Jul;46:2032-60.
5. Aguillar MI et al. Update in intracerebral hemorrhage. Neurohospitalist. 2011;1:148-59.
6. Hill MD et al. Rate of stroke recurrence in patients with primary intracerebral hemorrhage. Stroke. 2000;31:123-7.
7. Steiner T et al. European Stroke Organization (ESO) guidelines for the management of spontaneous cerebral hemorrhage. Int J Stroke. 2014;9:840-55.
8. Murthy SB et al. Restarting anticoagulation therapy after intracranial hemorrhage: A systematic review and meta-analysis. Stroke. 2017 Jun;48:1594-600.
9. Biffi A et al. Oral anticoagulation and functional outcome after intracerebral hemorrhage. Ann Neurol. 2017 Nov;82:755-65.
10. Witt DM. What to do after the bleed: Resuming anticoagulation after major bleeding. Hematology Am Soc Hematol Educ Program. 2016 Dec 2;206:620-4.
11. Pennlert J et al. Optimal timing of anticoagulant treatment after intracerebral hemorrhage in patients with atrial fibrillation. Stroke. 2017 Feb;48:314-20.
Key Points
- Robust scientific data on when to resume anticoagulation after ICH does not exist.
- Retrospective studies have shown that anticoagulation resumption after 4-8 weeks decreases the risk of thromboembolic events, decreases mortality, and improves functional status following ICH with no significant change in the risk of its recurrence.
- Prospective, randomized controlled trials are needed to explore risks/benefits of anticoagulation resumption and better define its optimal timing in relation to ICH.
Quiz
Which of the following is false regarding ICH?
A. Lobar ICHs are usually associated with cerebral amyloid angiopathy which are prone to bleeding.
B. Randomized, controlled studies have helped guide the decision as to when to resume anticoagulation in patients with ICH.
C. Current guidelines suggest deferring therapeutic anticoagulation for at least 4 weeks following ICH.
D. Resumption of anticoagulation after 4-8 weeks does not lead to increased risk of rebleeding in patients with prior ICH.
The false answer is B: Current recommendations regarding resumption of anticoagulation in patients with ICH are based solely on retrospective observational studies; there are no randomized, control trials to date.
A is true: In contrast to hypertensive vessel disease associated with deep ICH, lobar hemorrhages are usually associated with cerebral amyloid angiopathy, which are more prone to bleeding.
C is true: The AHA/ASA has a class IIB recommendation to avoid anticoagulation for at least 4 weeks after ICH in patients without mechanical heart valves.
D is true: Several studies have shown that resumption of anticoagulation 4-8 weeks after ICH does not increase the risk of rebleeding.
Defeating the opioid epidemic
The U.S. Surgeon General weighs in.
Vice Admiral Jerome M. Adams, MD, MPH, is the 20th Surgeon General of the United States, a post created in 1871.
Dr. Adams holds degrees in biochemistry and psychology from the University of Maryland, Baltimore County; a master’s degree in public health from the University of California, Berkeley; and a medical degree from the Indiana University, Indianapolis. He is a board-certified anesthesiologist and associate clinical professor of anesthesia at Indiana University.
At the 2018 Executive Advisory Board meeting of the Doctors Company, Richard E. Anderson, MD, FACP, chairman and chief executive officer of the Doctors Company, spoke with Dr. Adams about the opioid epidemic’s enormous impact on communities and health services in the United States.
Dr. Anderson: Dr. Adams, you’ve been busy since taking over as Surgeon General of the United States. What are some of the key challenges that you’re facing in this office?
Dr. Adams: You know, there are many challenges facing our country, but it boils down to a lack of wellness. We know that only 10% of health is due to health care, 20% of health is genetics, and the rest is a combination of behavior and environment.
My motto is “better health through better partnerships,” because I firmly believe that if we break out of our silos and reach across the traditional barriers that have been put up by funding, by reimbursement, and by infrastructure, then we can ultimately achieve wellness in our communities.
You asked what I’ve been focused on as Surgeon General. Well, I’m focused on three main areas right now.
No. 1 is the opioid epidemic. It is a scourge across our country. A person dies every 12½ minutes from an opioid overdose and that’s far too many. Especially when we know that many of those deaths can be prevented.
Another area I’m focused on is demonstrating the link between community health and economic prosperity. We want folks to invest in health because we know that not only will it achieve better health for individuals and communities but it will create a more prosperous nation, also.
And finally, I’m raising awareness about the links between our nation’s health and our safety and security – particularly our national security. Unfortunately, 7 out of 10 young people between the ages of 18 and 24 years old in our country are ineligible for military service. That’s because they can’t pass the physical, they can’t meet the educational requirements, or they have a criminal record.
So, our nation’s poor health is not just a matter of diabetes or heart disease 20 or 30 years down the road. We are literally a less-safe country right now because we’re an unhealthy country.
Dr. Anderson: Regarding the opioid epidemic, what are some of the programs that are available today that you find effective? What would you like to see us do as a nation to respond to the epidemic?
Dr. Adams: Recently, I was at a hospital in Alaska where they have implemented a neonatal abstinence syndrome protocol and program that is being looked at around the country – and others are attempting to replicate it.
We know that if you keep mom and baby together, baby does better, mom does better, hospital stays are shorter, costs go down, and you’re keeping that family unit intact. This prevents future problems for both the baby and the mother. That’s just one small example.
I’m also very happy to see that the prescribing of opioids is going down 20%-25% across the country. And there are even larger decreases in the military and veteran communities. That’s really a testament to doctors and the medical profession finally waking up. And I say this as a physician myself, as an anesthesiologist, as someone who is involved in acute and chronic pain management.
Four out of five people with substance use disorder say they started with a prescription opioid. Many physicians will say, “Those aren’t my patients,” but unfortunately when we look at the PDMP [prescription drug monitoring program] data across the country we do a poor job of predicting who is and who isn’t going to divert. It may not be your patient, but it could be their son or the babysitter who is diverting those overprescribed opioids.
One thing that I really think we need to lean into as health care practitioners is providing medication-assisted treatment, or MAT. We know that the gold standard for treatment and recovery is medication-assisted treatment of some form. But we also know it’s not nearly available enough and that there are barriers on the federal and state levels.
We need you to continue to talk to your congressional representatives and let them know which barriers you perceive because the data waiver comes directly from Congress.
Still, any ER can prescribe up to 3 days of MAT to someone. I’d much rather have our ER doctors putting patients on MAT and then connecting them to treatment, than sending them back out into the arms of a drug dealer after they put them into acute withdrawal with naloxone.
We also have too many pregnant women who want help but can’t find any treatment because no one out there will take care of pregnant moms. We need folks to step up to the plate and get that data waiver in our ob/gyn and primary care sectors.
Ultimately, we need hospitals and health care leaders to create an environment that makes providers feel comfortable providing that service by giving them the training and the support to be able to do it.
We also need to make sure we’re co-prescribing naloxone for those who are at risk for opioid overdose.
Dr. Anderson: Just so we are clear, are you in favor of regular prescribing of naloxone, along with prescriptions for opioids? Is that correct?
Dr. Adams: I issued the first Surgeon General’s advisory from more than 10 years earlier this year to help folks understand that over half of our opioid overdoses occur in a home setting. We all know that an anoxic brain injury occurs in 4-5 minutes. We also know that most ambulances and first responders aren’t going to show up in 4-5 minutes.
If we want to make a dent in this overdose epidemic, we need everyone to consider themselves a first responder. We need to look at it the same as we look at CPR; we need everyone carrying naloxone. That was one of the big pushes from my Surgeon General’s advisory.
How can providers help? Well, they can coprescribe naloxone to folks on high morphine milligram equivalents (MME) who are at risk. If grandma has naloxone at home and her grandson overdoses in the garage, then at least it’s in the same house. Naloxone is not the treatment for the opioid epidemic. But we can’t get someone who is dead into treatment.
I have no illusions that simply making naloxone available is going to turn the tide, but it certainly is an important part of it.
Dr. Anderson: From your unique viewpoint, how much progress do you see in relation to the opioid epidemic? Do you think we’re approaching an inflection point, or do you think there’s a long way to go before this starts to turn around?
Dr. Adams: When I talk about the opioid epidemic, I have two angles. No.1, I want to raise awareness about the opioid epidemic – the severity of it, and how everyone can lean into it in their own way. Whether it’s community citizens, providers, law enforcement, the business community, whomever.
But in addition to raising awareness, I want to instill hope.
I was in Huntington, West Virginia, just a few weeks ago at the epicenter of the opioid epidemic. They’ve been able to turn their opioid overdose rates around by providing peer recovery coaches to individuals and making sure naloxone is available throughout the community. You save the life and then you connect them to care.
We know that the folks who are at highest risk for overdose deaths are the ones who just overdosed. They come out of the ER where we’ve watched them for a few hours and then we send them right back out into the arms of the drug dealer to do exactly what we know they will do medically because we’ve thrown them into withdrawal and they try to get their next fix.
If we can partner with law enforcement, then we can turn our opioid overdose rates around.
A story of recovery that I want to share with you is about a guy named Jonathan, who I met when I was in Rhode Island.
Jonathan overdosed, but his roommate had access to naloxone, which he administered. Jonathan was taken to the ER and then connected with a peer recovery coach. He is now in recovery and has actually become a peer recovery coach himself. Saving this one life will now enable us to save many more.
Yet we still prescribe more than 80% of the world’s opioids to less than 5% of the world’s population. So, we still have an overprescribing epidemic, but we’ve surpassed the inflection point there. Prescribing is coming down.
But another part of this epidemic was that we squeezed the balloon in one place and, as prescribing opioids went down, lots of people switched over to heroin. That’s when we really first started to see overdose rates go up.
Well, it’s important for folks to know that, through law enforcement, through partnerships with the public health community, through an increase in syringe service programs, and through other touch points, heroin use is now going down in most places.
Unfortunately, now we’re seeing the third wave of the epidemic, and that’s fentanyl and carfentanil.
The U.S. Surgeon General weighs in.
The U.S. Surgeon General weighs in.
Vice Admiral Jerome M. Adams, MD, MPH, is the 20th Surgeon General of the United States, a post created in 1871.
Dr. Adams holds degrees in biochemistry and psychology from the University of Maryland, Baltimore County; a master’s degree in public health from the University of California, Berkeley; and a medical degree from the Indiana University, Indianapolis. He is a board-certified anesthesiologist and associate clinical professor of anesthesia at Indiana University.
At the 2018 Executive Advisory Board meeting of the Doctors Company, Richard E. Anderson, MD, FACP, chairman and chief executive officer of the Doctors Company, spoke with Dr. Adams about the opioid epidemic’s enormous impact on communities and health services in the United States.
Dr. Anderson: Dr. Adams, you’ve been busy since taking over as Surgeon General of the United States. What are some of the key challenges that you’re facing in this office?
Dr. Adams: You know, there are many challenges facing our country, but it boils down to a lack of wellness. We know that only 10% of health is due to health care, 20% of health is genetics, and the rest is a combination of behavior and environment.
My motto is “better health through better partnerships,” because I firmly believe that if we break out of our silos and reach across the traditional barriers that have been put up by funding, by reimbursement, and by infrastructure, then we can ultimately achieve wellness in our communities.
You asked what I’ve been focused on as Surgeon General. Well, I’m focused on three main areas right now.
No. 1 is the opioid epidemic. It is a scourge across our country. A person dies every 12½ minutes from an opioid overdose and that’s far too many. Especially when we know that many of those deaths can be prevented.
Another area I’m focused on is demonstrating the link between community health and economic prosperity. We want folks to invest in health because we know that not only will it achieve better health for individuals and communities but it will create a more prosperous nation, also.
And finally, I’m raising awareness about the links between our nation’s health and our safety and security – particularly our national security. Unfortunately, 7 out of 10 young people between the ages of 18 and 24 years old in our country are ineligible for military service. That’s because they can’t pass the physical, they can’t meet the educational requirements, or they have a criminal record.
So, our nation’s poor health is not just a matter of diabetes or heart disease 20 or 30 years down the road. We are literally a less-safe country right now because we’re an unhealthy country.
Dr. Anderson: Regarding the opioid epidemic, what are some of the programs that are available today that you find effective? What would you like to see us do as a nation to respond to the epidemic?
Dr. Adams: Recently, I was at a hospital in Alaska where they have implemented a neonatal abstinence syndrome protocol and program that is being looked at around the country – and others are attempting to replicate it.
We know that if you keep mom and baby together, baby does better, mom does better, hospital stays are shorter, costs go down, and you’re keeping that family unit intact. This prevents future problems for both the baby and the mother. That’s just one small example.
I’m also very happy to see that the prescribing of opioids is going down 20%-25% across the country. And there are even larger decreases in the military and veteran communities. That’s really a testament to doctors and the medical profession finally waking up. And I say this as a physician myself, as an anesthesiologist, as someone who is involved in acute and chronic pain management.
Four out of five people with substance use disorder say they started with a prescription opioid. Many physicians will say, “Those aren’t my patients,” but unfortunately when we look at the PDMP [prescription drug monitoring program] data across the country we do a poor job of predicting who is and who isn’t going to divert. It may not be your patient, but it could be their son or the babysitter who is diverting those overprescribed opioids.
One thing that I really think we need to lean into as health care practitioners is providing medication-assisted treatment, or MAT. We know that the gold standard for treatment and recovery is medication-assisted treatment of some form. But we also know it’s not nearly available enough and that there are barriers on the federal and state levels.
We need you to continue to talk to your congressional representatives and let them know which barriers you perceive because the data waiver comes directly from Congress.
Still, any ER can prescribe up to 3 days of MAT to someone. I’d much rather have our ER doctors putting patients on MAT and then connecting them to treatment, than sending them back out into the arms of a drug dealer after they put them into acute withdrawal with naloxone.
We also have too many pregnant women who want help but can’t find any treatment because no one out there will take care of pregnant moms. We need folks to step up to the plate and get that data waiver in our ob/gyn and primary care sectors.
Ultimately, we need hospitals and health care leaders to create an environment that makes providers feel comfortable providing that service by giving them the training and the support to be able to do it.
We also need to make sure we’re co-prescribing naloxone for those who are at risk for opioid overdose.
Dr. Anderson: Just so we are clear, are you in favor of regular prescribing of naloxone, along with prescriptions for opioids? Is that correct?
Dr. Adams: I issued the first Surgeon General’s advisory from more than 10 years earlier this year to help folks understand that over half of our opioid overdoses occur in a home setting. We all know that an anoxic brain injury occurs in 4-5 minutes. We also know that most ambulances and first responders aren’t going to show up in 4-5 minutes.
If we want to make a dent in this overdose epidemic, we need everyone to consider themselves a first responder. We need to look at it the same as we look at CPR; we need everyone carrying naloxone. That was one of the big pushes from my Surgeon General’s advisory.
How can providers help? Well, they can coprescribe naloxone to folks on high morphine milligram equivalents (MME) who are at risk. If grandma has naloxone at home and her grandson overdoses in the garage, then at least it’s in the same house. Naloxone is not the treatment for the opioid epidemic. But we can’t get someone who is dead into treatment.
I have no illusions that simply making naloxone available is going to turn the tide, but it certainly is an important part of it.
Dr. Anderson: From your unique viewpoint, how much progress do you see in relation to the opioid epidemic? Do you think we’re approaching an inflection point, or do you think there’s a long way to go before this starts to turn around?
Dr. Adams: When I talk about the opioid epidemic, I have two angles. No.1, I want to raise awareness about the opioid epidemic – the severity of it, and how everyone can lean into it in their own way. Whether it’s community citizens, providers, law enforcement, the business community, whomever.
But in addition to raising awareness, I want to instill hope.
I was in Huntington, West Virginia, just a few weeks ago at the epicenter of the opioid epidemic. They’ve been able to turn their opioid overdose rates around by providing peer recovery coaches to individuals and making sure naloxone is available throughout the community. You save the life and then you connect them to care.
We know that the folks who are at highest risk for overdose deaths are the ones who just overdosed. They come out of the ER where we’ve watched them for a few hours and then we send them right back out into the arms of the drug dealer to do exactly what we know they will do medically because we’ve thrown them into withdrawal and they try to get their next fix.
If we can partner with law enforcement, then we can turn our opioid overdose rates around.
A story of recovery that I want to share with you is about a guy named Jonathan, who I met when I was in Rhode Island.
Jonathan overdosed, but his roommate had access to naloxone, which he administered. Jonathan was taken to the ER and then connected with a peer recovery coach. He is now in recovery and has actually become a peer recovery coach himself. Saving this one life will now enable us to save many more.
Yet we still prescribe more than 80% of the world’s opioids to less than 5% of the world’s population. So, we still have an overprescribing epidemic, but we’ve surpassed the inflection point there. Prescribing is coming down.
But another part of this epidemic was that we squeezed the balloon in one place and, as prescribing opioids went down, lots of people switched over to heroin. That’s when we really first started to see overdose rates go up.
Well, it’s important for folks to know that, through law enforcement, through partnerships with the public health community, through an increase in syringe service programs, and through other touch points, heroin use is now going down in most places.
Unfortunately, now we’re seeing the third wave of the epidemic, and that’s fentanyl and carfentanil.
Vice Admiral Jerome M. Adams, MD, MPH, is the 20th Surgeon General of the United States, a post created in 1871.
Dr. Adams holds degrees in biochemistry and psychology from the University of Maryland, Baltimore County; a master’s degree in public health from the University of California, Berkeley; and a medical degree from the Indiana University, Indianapolis. He is a board-certified anesthesiologist and associate clinical professor of anesthesia at Indiana University.
At the 2018 Executive Advisory Board meeting of the Doctors Company, Richard E. Anderson, MD, FACP, chairman and chief executive officer of the Doctors Company, spoke with Dr. Adams about the opioid epidemic’s enormous impact on communities and health services in the United States.
Dr. Anderson: Dr. Adams, you’ve been busy since taking over as Surgeon General of the United States. What are some of the key challenges that you’re facing in this office?
Dr. Adams: You know, there are many challenges facing our country, but it boils down to a lack of wellness. We know that only 10% of health is due to health care, 20% of health is genetics, and the rest is a combination of behavior and environment.
My motto is “better health through better partnerships,” because I firmly believe that if we break out of our silos and reach across the traditional barriers that have been put up by funding, by reimbursement, and by infrastructure, then we can ultimately achieve wellness in our communities.
You asked what I’ve been focused on as Surgeon General. Well, I’m focused on three main areas right now.
No. 1 is the opioid epidemic. It is a scourge across our country. A person dies every 12½ minutes from an opioid overdose and that’s far too many. Especially when we know that many of those deaths can be prevented.
Another area I’m focused on is demonstrating the link between community health and economic prosperity. We want folks to invest in health because we know that not only will it achieve better health for individuals and communities but it will create a more prosperous nation, also.
And finally, I’m raising awareness about the links between our nation’s health and our safety and security – particularly our national security. Unfortunately, 7 out of 10 young people between the ages of 18 and 24 years old in our country are ineligible for military service. That’s because they can’t pass the physical, they can’t meet the educational requirements, or they have a criminal record.
So, our nation’s poor health is not just a matter of diabetes or heart disease 20 or 30 years down the road. We are literally a less-safe country right now because we’re an unhealthy country.
Dr. Anderson: Regarding the opioid epidemic, what are some of the programs that are available today that you find effective? What would you like to see us do as a nation to respond to the epidemic?
Dr. Adams: Recently, I was at a hospital in Alaska where they have implemented a neonatal abstinence syndrome protocol and program that is being looked at around the country – and others are attempting to replicate it.
We know that if you keep mom and baby together, baby does better, mom does better, hospital stays are shorter, costs go down, and you’re keeping that family unit intact. This prevents future problems for both the baby and the mother. That’s just one small example.
I’m also very happy to see that the prescribing of opioids is going down 20%-25% across the country. And there are even larger decreases in the military and veteran communities. That’s really a testament to doctors and the medical profession finally waking up. And I say this as a physician myself, as an anesthesiologist, as someone who is involved in acute and chronic pain management.
Four out of five people with substance use disorder say they started with a prescription opioid. Many physicians will say, “Those aren’t my patients,” but unfortunately when we look at the PDMP [prescription drug monitoring program] data across the country we do a poor job of predicting who is and who isn’t going to divert. It may not be your patient, but it could be their son or the babysitter who is diverting those overprescribed opioids.
One thing that I really think we need to lean into as health care practitioners is providing medication-assisted treatment, or MAT. We know that the gold standard for treatment and recovery is medication-assisted treatment of some form. But we also know it’s not nearly available enough and that there are barriers on the federal and state levels.
We need you to continue to talk to your congressional representatives and let them know which barriers you perceive because the data waiver comes directly from Congress.
Still, any ER can prescribe up to 3 days of MAT to someone. I’d much rather have our ER doctors putting patients on MAT and then connecting them to treatment, than sending them back out into the arms of a drug dealer after they put them into acute withdrawal with naloxone.
We also have too many pregnant women who want help but can’t find any treatment because no one out there will take care of pregnant moms. We need folks to step up to the plate and get that data waiver in our ob/gyn and primary care sectors.
Ultimately, we need hospitals and health care leaders to create an environment that makes providers feel comfortable providing that service by giving them the training and the support to be able to do it.
We also need to make sure we’re co-prescribing naloxone for those who are at risk for opioid overdose.
Dr. Anderson: Just so we are clear, are you in favor of regular prescribing of naloxone, along with prescriptions for opioids? Is that correct?
Dr. Adams: I issued the first Surgeon General’s advisory from more than 10 years earlier this year to help folks understand that over half of our opioid overdoses occur in a home setting. We all know that an anoxic brain injury occurs in 4-5 minutes. We also know that most ambulances and first responders aren’t going to show up in 4-5 minutes.
If we want to make a dent in this overdose epidemic, we need everyone to consider themselves a first responder. We need to look at it the same as we look at CPR; we need everyone carrying naloxone. That was one of the big pushes from my Surgeon General’s advisory.
How can providers help? Well, they can coprescribe naloxone to folks on high morphine milligram equivalents (MME) who are at risk. If grandma has naloxone at home and her grandson overdoses in the garage, then at least it’s in the same house. Naloxone is not the treatment for the opioid epidemic. But we can’t get someone who is dead into treatment.
I have no illusions that simply making naloxone available is going to turn the tide, but it certainly is an important part of it.
Dr. Anderson: From your unique viewpoint, how much progress do you see in relation to the opioid epidemic? Do you think we’re approaching an inflection point, or do you think there’s a long way to go before this starts to turn around?
Dr. Adams: When I talk about the opioid epidemic, I have two angles. No.1, I want to raise awareness about the opioid epidemic – the severity of it, and how everyone can lean into it in their own way. Whether it’s community citizens, providers, law enforcement, the business community, whomever.
But in addition to raising awareness, I want to instill hope.
I was in Huntington, West Virginia, just a few weeks ago at the epicenter of the opioid epidemic. They’ve been able to turn their opioid overdose rates around by providing peer recovery coaches to individuals and making sure naloxone is available throughout the community. You save the life and then you connect them to care.
We know that the folks who are at highest risk for overdose deaths are the ones who just overdosed. They come out of the ER where we’ve watched them for a few hours and then we send them right back out into the arms of the drug dealer to do exactly what we know they will do medically because we’ve thrown them into withdrawal and they try to get their next fix.
If we can partner with law enforcement, then we can turn our opioid overdose rates around.
A story of recovery that I want to share with you is about a guy named Jonathan, who I met when I was in Rhode Island.
Jonathan overdosed, but his roommate had access to naloxone, which he administered. Jonathan was taken to the ER and then connected with a peer recovery coach. He is now in recovery and has actually become a peer recovery coach himself. Saving this one life will now enable us to save many more.
Yet we still prescribe more than 80% of the world’s opioids to less than 5% of the world’s population. So, we still have an overprescribing epidemic, but we’ve surpassed the inflection point there. Prescribing is coming down.
But another part of this epidemic was that we squeezed the balloon in one place and, as prescribing opioids went down, lots of people switched over to heroin. That’s when we really first started to see overdose rates go up.
Well, it’s important for folks to know that, through law enforcement, through partnerships with the public health community, through an increase in syringe service programs, and through other touch points, heroin use is now going down in most places.
Unfortunately, now we’re seeing the third wave of the epidemic, and that’s fentanyl and carfentanil.
Hospitalist PA and health system leader: Emilie Thornhill Davis
Building a collaborative practice
Emilie Thornhill Davis, PA-C, is the assistant vice president for advanced practice providers at Ochsner Health System in New Orleans. She is the former chair of SHM’s Nurse Practitioner and Physician Assistant (NP/PA) Committee, and has spoken multiple times at the SHM Annual Conference.
In honor of the inaugural National Hospitalist Day, to be held on Thursday, March 7, 2019, The Hospitalist spoke with Ms. Davis about the unique contributions of NP and PA hospitalists to the specialty of hospital medicine.
Where did you get your education?
I got my undergraduate degree from Mercer University and then went on to get my prerequisites for PA school, and worked clinically for a year prior to starting graduate school in Savannah, Georgia, at South University.
Was your intention always to be a PA?
During my sophomore year of college, Mercer was starting a PA program. Having been taken care of by PAs for most of my life, I realized that this was a profession I was very interested in. I shadowed a lot of PAs and found that they had extremely high levels of satisfaction. I saw the versatility to do so many types of medicine as a PA.
How did you become interested in hospital medicine?
When I was in PA school, we had small groups that were led by a PA who practiced clinically. The PA who was my small group leader was a hospitalist and was a fantastic role model. I did a clinical rotation with her team, and then went on to do my elective with her team in hospital medicine. When I graduated, I got my first job with the hospital medicine group that I had done those clinical rotations with in Savannah. And then in 2013, after about a year and a half, life brought me to New Orleans and I started working at Ochsner in the department of hospital medicine. I was one of the first two PAs that this group had employed.
What is your current role and title at Ochsner?
From 2013 to 2018, I worked in the department of hospital medicine, and for the last 2 years I functioned as the system lead for advanced practice providers in the department of hospital medicine. In September of 2018, I accepted the role of assistant vice president of advanced practice providers for Ochsner Health System.
What are your areas of interest or research?
I’ve had the opportunity to speak at the annual Society of Hospital Medicine Conference for 3 years in a row on innovative models of care, and nurse practitioner and PA utilization in hospital medicine. I was the chair for the NP/PA committee, and during that time we developed a toolkit aimed at providing a resource to hospital medicine groups around nurse practitioner and PA integration to practice in full utilization.
What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?
Nurse practitioners and PAs are perfectly set up to integrate into practice in hospital medicine. Training for PAs specifically is based on the medicine model, where you have a year of didactic and a year of clinical work in all the major disciplines of medicine. And so in a clinical year as a PA, I would rotate through primary care, internal medicine, general surgery, ob.gyn., psychiatry, emergency medicine, pediatrics. When I come out of school, I’m generalist trained, and depending on where your emphasis was during clinical rotations, that could include a lot of inpatient experience.
I transitioned very smoothly into my first role in hospital medicine as a PA, because I had gained that experience while I was a student on clinical rotations. PAs and nurse practitioners are – when they’re utilized appropriately and at the top of their experience and training – able to provide services to patients that can improve quality outcomes, enhance throughput, decrease length of stay, and improve all the different areas that we focus on as hospitalists.
What roles can a PA occupy in relation to physicians and nurse practitioners in hospital medicine?
When you’re looking at a PA versus a nurse practitioner in hospital medicine, you’ll notice that there are differences in the way that PAs and nurse practitioners are trained. All PAs are trained on a medical model and have a very similar kind of generalist background, whereas a nurse practitioner is typically schooled with nursing training that includes bedside experience that you can’t always guarantee with PAs. But once we enter into practice, our scope and the way that we take care of patients over time becomes very similar. So a PA and a nurse practitioner for the most part can function in very similar capacities in hospital medicine.
The only thing that creates a difference for PAs and NPs are federal and state rules and regulations, as well as hospital policies that might create “scope of practice” barriers. For instance, when I first moved to Louisiana, PAs were not able to prescribe Schedule II medications. That created a barrier whenever I was discharging patients who needed prescriptions for Schedule II. That has since changed in the state of Louisiana; now both PAs and NPs have full prescriptive authority in the state.
I would compare the work of PAs and NPs to that of physicians like this: Once you have NPs or PAs who are trained and have experience in the specialty that they are working in, they are able to provide services that would otherwise be provided by physicians.
How does a hospitalist PA work differently from a PA in other care settings?
The scope of practice for a PA is defined by the physician they’re working with. So my day-to-day work as a PA in hospital medicine looked very similar to a physician’s day-to-day work in hospital medicine. In cardiology, for example, the same would likely hold true, but with tasks unique to that specialty.
How does SHM support hospitalist PAs?
SHM is the home where you have physicians, nurse practitioners, and PAs all represented by one society, which I think is really important whenever we’re talking about a membership organization that reflects what things truly look like in practice. When I am a member of SHM, and the physician I work with is a member of SHM, we are getting the same journals and are both familiar with the changes that occur nationally in our specialty; this really helps us to align ourselves clinically, and to understand what’s going on across the country.
What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?
I think the first thing we have to do is make sure that we’re getting the nomenclature right, that we’re referring to nurse practitioners and physician assistants by their appropriate names and recognizing their role in hospital medicine. Every year that I spoke at the SHM Annual Conference, I had many hospital medicine leaders come up to me and say they needed help with incorporating NPs and PAs, not only clinically, but also making sure they were represented within their hospital system. That’s why we developed the toolkit, which provides resources for integrating NPs and PAs into practice.
There is an investment early on when you bring PAs into your group to train them. We often use the SHM core competencies when we are referring to a training guide for PAs or NPs as a way to categorize the different materials that they would need to know to practice efficiently, but I do think those could be expanded upon.
What’s on the horizon for NPs and PAs in hospital medicine?
One national trend I see is an increase in the number of NPs and PAs entering hospital medicine. The other big trend is the formal development of postgraduate fellowships for PAs in hospital medicine. As the complexity of our health systems continues to grow, the feeling is that to get a nurse practitioner and PA the training they need, there are benefits to having a protected postgrad year to learn.
One unique thing about nurse practitioners and PAs is their versatility and their ability to move among the various medical specialties. As a PA or a nurse practitioner, if I’m working in hospital medicine and I have a really strong foundation, there’s nothing to say that I couldn’t then accept a job in CV surgery or cardiology and bring those skills with me from hospital medicine.
But this is kind of a double-edged sword, because it also means that you may have a PA or NP leave your HM group after 1-2 years. That kind of turnover is a difficult thing to address, because it means dealing with issues such as workplace culture and compensation. But that shows why training and engagement is important early on in that first year – to make sure that NPs and PAs feel fully supported to meet the demands that hospital medicine requires. All of those things really factor into whether an NP or PA will choose to continue in the field.
Building a collaborative practice
Building a collaborative practice
Emilie Thornhill Davis, PA-C, is the assistant vice president for advanced practice providers at Ochsner Health System in New Orleans. She is the former chair of SHM’s Nurse Practitioner and Physician Assistant (NP/PA) Committee, and has spoken multiple times at the SHM Annual Conference.
In honor of the inaugural National Hospitalist Day, to be held on Thursday, March 7, 2019, The Hospitalist spoke with Ms. Davis about the unique contributions of NP and PA hospitalists to the specialty of hospital medicine.
Where did you get your education?
I got my undergraduate degree from Mercer University and then went on to get my prerequisites for PA school, and worked clinically for a year prior to starting graduate school in Savannah, Georgia, at South University.
Was your intention always to be a PA?
During my sophomore year of college, Mercer was starting a PA program. Having been taken care of by PAs for most of my life, I realized that this was a profession I was very interested in. I shadowed a lot of PAs and found that they had extremely high levels of satisfaction. I saw the versatility to do so many types of medicine as a PA.
How did you become interested in hospital medicine?
When I was in PA school, we had small groups that were led by a PA who practiced clinically. The PA who was my small group leader was a hospitalist and was a fantastic role model. I did a clinical rotation with her team, and then went on to do my elective with her team in hospital medicine. When I graduated, I got my first job with the hospital medicine group that I had done those clinical rotations with in Savannah. And then in 2013, after about a year and a half, life brought me to New Orleans and I started working at Ochsner in the department of hospital medicine. I was one of the first two PAs that this group had employed.
What is your current role and title at Ochsner?
From 2013 to 2018, I worked in the department of hospital medicine, and for the last 2 years I functioned as the system lead for advanced practice providers in the department of hospital medicine. In September of 2018, I accepted the role of assistant vice president of advanced practice providers for Ochsner Health System.
What are your areas of interest or research?
I’ve had the opportunity to speak at the annual Society of Hospital Medicine Conference for 3 years in a row on innovative models of care, and nurse practitioner and PA utilization in hospital medicine. I was the chair for the NP/PA committee, and during that time we developed a toolkit aimed at providing a resource to hospital medicine groups around nurse practitioner and PA integration to practice in full utilization.
What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?
Nurse practitioners and PAs are perfectly set up to integrate into practice in hospital medicine. Training for PAs specifically is based on the medicine model, where you have a year of didactic and a year of clinical work in all the major disciplines of medicine. And so in a clinical year as a PA, I would rotate through primary care, internal medicine, general surgery, ob.gyn., psychiatry, emergency medicine, pediatrics. When I come out of school, I’m generalist trained, and depending on where your emphasis was during clinical rotations, that could include a lot of inpatient experience.
I transitioned very smoothly into my first role in hospital medicine as a PA, because I had gained that experience while I was a student on clinical rotations. PAs and nurse practitioners are – when they’re utilized appropriately and at the top of their experience and training – able to provide services to patients that can improve quality outcomes, enhance throughput, decrease length of stay, and improve all the different areas that we focus on as hospitalists.
What roles can a PA occupy in relation to physicians and nurse practitioners in hospital medicine?
When you’re looking at a PA versus a nurse practitioner in hospital medicine, you’ll notice that there are differences in the way that PAs and nurse practitioners are trained. All PAs are trained on a medical model and have a very similar kind of generalist background, whereas a nurse practitioner is typically schooled with nursing training that includes bedside experience that you can’t always guarantee with PAs. But once we enter into practice, our scope and the way that we take care of patients over time becomes very similar. So a PA and a nurse practitioner for the most part can function in very similar capacities in hospital medicine.
The only thing that creates a difference for PAs and NPs are federal and state rules and regulations, as well as hospital policies that might create “scope of practice” barriers. For instance, when I first moved to Louisiana, PAs were not able to prescribe Schedule II medications. That created a barrier whenever I was discharging patients who needed prescriptions for Schedule II. That has since changed in the state of Louisiana; now both PAs and NPs have full prescriptive authority in the state.
I would compare the work of PAs and NPs to that of physicians like this: Once you have NPs or PAs who are trained and have experience in the specialty that they are working in, they are able to provide services that would otherwise be provided by physicians.
How does a hospitalist PA work differently from a PA in other care settings?
The scope of practice for a PA is defined by the physician they’re working with. So my day-to-day work as a PA in hospital medicine looked very similar to a physician’s day-to-day work in hospital medicine. In cardiology, for example, the same would likely hold true, but with tasks unique to that specialty.
How does SHM support hospitalist PAs?
SHM is the home where you have physicians, nurse practitioners, and PAs all represented by one society, which I think is really important whenever we’re talking about a membership organization that reflects what things truly look like in practice. When I am a member of SHM, and the physician I work with is a member of SHM, we are getting the same journals and are both familiar with the changes that occur nationally in our specialty; this really helps us to align ourselves clinically, and to understand what’s going on across the country.
What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?
I think the first thing we have to do is make sure that we’re getting the nomenclature right, that we’re referring to nurse practitioners and physician assistants by their appropriate names and recognizing their role in hospital medicine. Every year that I spoke at the SHM Annual Conference, I had many hospital medicine leaders come up to me and say they needed help with incorporating NPs and PAs, not only clinically, but also making sure they were represented within their hospital system. That’s why we developed the toolkit, which provides resources for integrating NPs and PAs into practice.
There is an investment early on when you bring PAs into your group to train them. We often use the SHM core competencies when we are referring to a training guide for PAs or NPs as a way to categorize the different materials that they would need to know to practice efficiently, but I do think those could be expanded upon.
What’s on the horizon for NPs and PAs in hospital medicine?
One national trend I see is an increase in the number of NPs and PAs entering hospital medicine. The other big trend is the formal development of postgraduate fellowships for PAs in hospital medicine. As the complexity of our health systems continues to grow, the feeling is that to get a nurse practitioner and PA the training they need, there are benefits to having a protected postgrad year to learn.
One unique thing about nurse practitioners and PAs is their versatility and their ability to move among the various medical specialties. As a PA or a nurse practitioner, if I’m working in hospital medicine and I have a really strong foundation, there’s nothing to say that I couldn’t then accept a job in CV surgery or cardiology and bring those skills with me from hospital medicine.
But this is kind of a double-edged sword, because it also means that you may have a PA or NP leave your HM group after 1-2 years. That kind of turnover is a difficult thing to address, because it means dealing with issues such as workplace culture and compensation. But that shows why training and engagement is important early on in that first year – to make sure that NPs and PAs feel fully supported to meet the demands that hospital medicine requires. All of those things really factor into whether an NP or PA will choose to continue in the field.
Emilie Thornhill Davis, PA-C, is the assistant vice president for advanced practice providers at Ochsner Health System in New Orleans. She is the former chair of SHM’s Nurse Practitioner and Physician Assistant (NP/PA) Committee, and has spoken multiple times at the SHM Annual Conference.
In honor of the inaugural National Hospitalist Day, to be held on Thursday, March 7, 2019, The Hospitalist spoke with Ms. Davis about the unique contributions of NP and PA hospitalists to the specialty of hospital medicine.
Where did you get your education?
I got my undergraduate degree from Mercer University and then went on to get my prerequisites for PA school, and worked clinically for a year prior to starting graduate school in Savannah, Georgia, at South University.
Was your intention always to be a PA?
During my sophomore year of college, Mercer was starting a PA program. Having been taken care of by PAs for most of my life, I realized that this was a profession I was very interested in. I shadowed a lot of PAs and found that they had extremely high levels of satisfaction. I saw the versatility to do so many types of medicine as a PA.
How did you become interested in hospital medicine?
When I was in PA school, we had small groups that were led by a PA who practiced clinically. The PA who was my small group leader was a hospitalist and was a fantastic role model. I did a clinical rotation with her team, and then went on to do my elective with her team in hospital medicine. When I graduated, I got my first job with the hospital medicine group that I had done those clinical rotations with in Savannah. And then in 2013, after about a year and a half, life brought me to New Orleans and I started working at Ochsner in the department of hospital medicine. I was one of the first two PAs that this group had employed.
What is your current role and title at Ochsner?
From 2013 to 2018, I worked in the department of hospital medicine, and for the last 2 years I functioned as the system lead for advanced practice providers in the department of hospital medicine. In September of 2018, I accepted the role of assistant vice president of advanced practice providers for Ochsner Health System.
What are your areas of interest or research?
I’ve had the opportunity to speak at the annual Society of Hospital Medicine Conference for 3 years in a row on innovative models of care, and nurse practitioner and PA utilization in hospital medicine. I was the chair for the NP/PA committee, and during that time we developed a toolkit aimed at providing a resource to hospital medicine groups around nurse practitioner and PA integration to practice in full utilization.
What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?
Nurse practitioners and PAs are perfectly set up to integrate into practice in hospital medicine. Training for PAs specifically is based on the medicine model, where you have a year of didactic and a year of clinical work in all the major disciplines of medicine. And so in a clinical year as a PA, I would rotate through primary care, internal medicine, general surgery, ob.gyn., psychiatry, emergency medicine, pediatrics. When I come out of school, I’m generalist trained, and depending on where your emphasis was during clinical rotations, that could include a lot of inpatient experience.
I transitioned very smoothly into my first role in hospital medicine as a PA, because I had gained that experience while I was a student on clinical rotations. PAs and nurse practitioners are – when they’re utilized appropriately and at the top of their experience and training – able to provide services to patients that can improve quality outcomes, enhance throughput, decrease length of stay, and improve all the different areas that we focus on as hospitalists.
What roles can a PA occupy in relation to physicians and nurse practitioners in hospital medicine?
When you’re looking at a PA versus a nurse practitioner in hospital medicine, you’ll notice that there are differences in the way that PAs and nurse practitioners are trained. All PAs are trained on a medical model and have a very similar kind of generalist background, whereas a nurse practitioner is typically schooled with nursing training that includes bedside experience that you can’t always guarantee with PAs. But once we enter into practice, our scope and the way that we take care of patients over time becomes very similar. So a PA and a nurse practitioner for the most part can function in very similar capacities in hospital medicine.
The only thing that creates a difference for PAs and NPs are federal and state rules and regulations, as well as hospital policies that might create “scope of practice” barriers. For instance, when I first moved to Louisiana, PAs were not able to prescribe Schedule II medications. That created a barrier whenever I was discharging patients who needed prescriptions for Schedule II. That has since changed in the state of Louisiana; now both PAs and NPs have full prescriptive authority in the state.
I would compare the work of PAs and NPs to that of physicians like this: Once you have NPs or PAs who are trained and have experience in the specialty that they are working in, they are able to provide services that would otherwise be provided by physicians.
How does a hospitalist PA work differently from a PA in other care settings?
The scope of practice for a PA is defined by the physician they’re working with. So my day-to-day work as a PA in hospital medicine looked very similar to a physician’s day-to-day work in hospital medicine. In cardiology, for example, the same would likely hold true, but with tasks unique to that specialty.
How does SHM support hospitalist PAs?
SHM is the home where you have physicians, nurse practitioners, and PAs all represented by one society, which I think is really important whenever we’re talking about a membership organization that reflects what things truly look like in practice. When I am a member of SHM, and the physician I work with is a member of SHM, we are getting the same journals and are both familiar with the changes that occur nationally in our specialty; this really helps us to align ourselves clinically, and to understand what’s going on across the country.
What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?
I think the first thing we have to do is make sure that we’re getting the nomenclature right, that we’re referring to nurse practitioners and physician assistants by their appropriate names and recognizing their role in hospital medicine. Every year that I spoke at the SHM Annual Conference, I had many hospital medicine leaders come up to me and say they needed help with incorporating NPs and PAs, not only clinically, but also making sure they were represented within their hospital system. That’s why we developed the toolkit, which provides resources for integrating NPs and PAs into practice.
There is an investment early on when you bring PAs into your group to train them. We often use the SHM core competencies when we are referring to a training guide for PAs or NPs as a way to categorize the different materials that they would need to know to practice efficiently, but I do think those could be expanded upon.
What’s on the horizon for NPs and PAs in hospital medicine?
One national trend I see is an increase in the number of NPs and PAs entering hospital medicine. The other big trend is the formal development of postgraduate fellowships for PAs in hospital medicine. As the complexity of our health systems continues to grow, the feeling is that to get a nurse practitioner and PA the training they need, there are benefits to having a protected postgrad year to learn.
One unique thing about nurse practitioners and PAs is their versatility and their ability to move among the various medical specialties. As a PA or a nurse practitioner, if I’m working in hospital medicine and I have a really strong foundation, there’s nothing to say that I couldn’t then accept a job in CV surgery or cardiology and bring those skills with me from hospital medicine.
But this is kind of a double-edged sword, because it also means that you may have a PA or NP leave your HM group after 1-2 years. That kind of turnover is a difficult thing to address, because it means dealing with issues such as workplace culture and compensation. But that shows why training and engagement is important early on in that first year – to make sure that NPs and PAs feel fully supported to meet the demands that hospital medicine requires. All of those things really factor into whether an NP or PA will choose to continue in the field.
Revised U.S. A fib guidelines revamp anticoagulation
The first update to U.S. medical-society guidelines for managing atrial fibrillation since 2014 raised the threshold for starting anticoagulant therapy in women, pegged the direct-acting oral anticoagulants (DOACs) as preferred over warfarin, and introduced for the first time weight loss as an important intervention tool for treating patients with an atrial arrhythmia.
On January 28, the American College of Cardiology, American Heart Association, and Heart Rhythm Society posted online a 2019 focused update (Circulation. 2019 Jan 28. doi: 10.1161/CIR.0000000000000665) to the 2014 atrial fibrillation (AF) management guidelines that the groups had previously published (J Am Coll Cardiol. 2014 Dec 2;64[21]:2246-80).
Perhaps the two most important changes, as well as the two that lead off the new document, were a pair of class I recommendations on using oral anticoagulation in AF patients.
This brought U.S. guidelines in line with European guidelines, set by the European Society of Cardiology in 2016 (Eur Heart J. 2016 Oct 7;37[38]:2893-962). It will now also mean that, because of the way the CHA2DS2-VASc score is calculated, women with AF who are at least 65 years old will no longer automatically get flagged as needing oral anticoagulant therapy.
“This is a really important shift. It’s recognition that female sex is not as important a risk factor [for AF-associated stroke] as once was thought,” commented Hugh Calkins, MD, professor of medicine at Johns Hopkins Medicine in Baltimore and a member of the panel that wrote the update. “This will change the number of women with AF who go on anticoagulation,” predicted Dr. Calkins, who directs the cardiac arrhythmia service at his center. “We have been struggling with the notion that all women 65 or older with AF had to be on an anticoagulant. Now a clinician has more leeway. In general, patients with AF remain underanticoagulated, but this clarifies practice and brings us in line with the European guidelines.”
The second important change to the anticoagulation recommendations was to specify the DOACs as recommended over warfarin in AF patients eligible for oral anticoagulation and without moderate to severe mitral stenosis or a mechanical heart valve, which also matches the 2016 European guidelines and updates the prior, 2014, U.S. guidelines, which didn’t even mention DOACs.
Prescribing a DOAC preferentially to AF patients has already become routine among electrophysiologists, but possibly not as routine among primary care physicians, so this change has the potential to shift practice, said Dr. Calkins. But the higher price for DOACs, compared with warfarin, can pose problems. “The cost of DOACs remains an issue that can be a serious limitation to some patients,” said Craig T. January, MD, professor of medicine at the University of Wisconsin in Madison and chair of the guideline-writing panel. He also bemoaned the absence of head-to-head comparisons of individual DOACs that could inform selecting among apixaban, dabigatran, edoxaban, and rivaroxaban.
Another notable change in the 2019 update was inclusion for the first time of weight loss as a recommended intervention, along with other risk factor modification, an addition that Dr. Calkins called “long overdue.”
“This is a new recommendation, and it will potentially be important,” said Dr. January, although the guidelines do not spell out how aggressive clinicians should be about having patients achieve weight loss, how much loss patients should achieve, or how they should do it. “There are a lot of observational data and basic science data suggesting the importance of weight loss. Most electrophysiologists already address weight loss. The problem is how to get patients to do it,” commented Vivek Reddy, MD, professor of medicine and director of cardiac arrhythmia services at Mount Sinai Hospital in New York.
Dr. Reddy expressed surprise over two other features of the updated guidelines. For the first time, the guidelines now address percutaneous left atrial appendage (LAA) occlusion and say: “Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation.” The guidelines’ text acknowledges that this runs counter to the Food and Drug Administration labeling for the Watchman LAA occlusion device, which restricts the device to patients “deemed suitable for long-term warfarin (mirroring the inclusion criteria for enrollment in the clinical trials) but had an appropriate rationale to seek a nonpharmacological alternative to warfarin.”
“We do not take a position on the FDA’s” actions, Dr. January said in an interview.
“The ACC, AHA, and HRS guidelines should reflect what the FDA decided,” Dr. Reddy said in an interview. “I’m a little surprised the guidelines said that anticoagulation had to be contraindicated.
The 2019 update also added a class IIb, “may be reasonable” recommendation for catheter ablation of AF in patients with heart failure with reduced ejection fraction.
“I think a IIb recommendation is unfair; I think it should be a IIa recommendation because there have been positive results from two large, randomized, multicenter trials – CASTLE-AF [Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF; N Engl J Med. 2018 Feb 1;378(5):417-27] and AATAC [Ablation vs Amiodarone for Treatment of AFib in Patients With CHF and an ICD; Circulation. 2016 Apr 26;133(7):1637-44], as well as positive results from several smaller randomized studies,” Dr. Reddy said. “I’m really surprised” that the recommendation was not stronger.
Dr. Calkins has been a consultant to Abbott, Altathera, AtriCare, Boehringer-Ingelheim, King, Medtronic, and St. Jude and has received research funding from Boehringer-Ingelheim, Boston Scientific, and St. Jude. Dr. January had no disclosures. Dr. Reddy has been a consultant to, received research funding from, or has an equity interest in more than three dozen companies.
The first update to U.S. medical-society guidelines for managing atrial fibrillation since 2014 raised the threshold for starting anticoagulant therapy in women, pegged the direct-acting oral anticoagulants (DOACs) as preferred over warfarin, and introduced for the first time weight loss as an important intervention tool for treating patients with an atrial arrhythmia.
On January 28, the American College of Cardiology, American Heart Association, and Heart Rhythm Society posted online a 2019 focused update (Circulation. 2019 Jan 28. doi: 10.1161/CIR.0000000000000665) to the 2014 atrial fibrillation (AF) management guidelines that the groups had previously published (J Am Coll Cardiol. 2014 Dec 2;64[21]:2246-80).
Perhaps the two most important changes, as well as the two that lead off the new document, were a pair of class I recommendations on using oral anticoagulation in AF patients.
This brought U.S. guidelines in line with European guidelines, set by the European Society of Cardiology in 2016 (Eur Heart J. 2016 Oct 7;37[38]:2893-962). It will now also mean that, because of the way the CHA2DS2-VASc score is calculated, women with AF who are at least 65 years old will no longer automatically get flagged as needing oral anticoagulant therapy.
“This is a really important shift. It’s recognition that female sex is not as important a risk factor [for AF-associated stroke] as once was thought,” commented Hugh Calkins, MD, professor of medicine at Johns Hopkins Medicine in Baltimore and a member of the panel that wrote the update. “This will change the number of women with AF who go on anticoagulation,” predicted Dr. Calkins, who directs the cardiac arrhythmia service at his center. “We have been struggling with the notion that all women 65 or older with AF had to be on an anticoagulant. Now a clinician has more leeway. In general, patients with AF remain underanticoagulated, but this clarifies practice and brings us in line with the European guidelines.”
The second important change to the anticoagulation recommendations was to specify the DOACs as recommended over warfarin in AF patients eligible for oral anticoagulation and without moderate to severe mitral stenosis or a mechanical heart valve, which also matches the 2016 European guidelines and updates the prior, 2014, U.S. guidelines, which didn’t even mention DOACs.
Prescribing a DOAC preferentially to AF patients has already become routine among electrophysiologists, but possibly not as routine among primary care physicians, so this change has the potential to shift practice, said Dr. Calkins. But the higher price for DOACs, compared with warfarin, can pose problems. “The cost of DOACs remains an issue that can be a serious limitation to some patients,” said Craig T. January, MD, professor of medicine at the University of Wisconsin in Madison and chair of the guideline-writing panel. He also bemoaned the absence of head-to-head comparisons of individual DOACs that could inform selecting among apixaban, dabigatran, edoxaban, and rivaroxaban.
Another notable change in the 2019 update was inclusion for the first time of weight loss as a recommended intervention, along with other risk factor modification, an addition that Dr. Calkins called “long overdue.”
“This is a new recommendation, and it will potentially be important,” said Dr. January, although the guidelines do not spell out how aggressive clinicians should be about having patients achieve weight loss, how much loss patients should achieve, or how they should do it. “There are a lot of observational data and basic science data suggesting the importance of weight loss. Most electrophysiologists already address weight loss. The problem is how to get patients to do it,” commented Vivek Reddy, MD, professor of medicine and director of cardiac arrhythmia services at Mount Sinai Hospital in New York.
Dr. Reddy expressed surprise over two other features of the updated guidelines. For the first time, the guidelines now address percutaneous left atrial appendage (LAA) occlusion and say: “Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation.” The guidelines’ text acknowledges that this runs counter to the Food and Drug Administration labeling for the Watchman LAA occlusion device, which restricts the device to patients “deemed suitable for long-term warfarin (mirroring the inclusion criteria for enrollment in the clinical trials) but had an appropriate rationale to seek a nonpharmacological alternative to warfarin.”
“We do not take a position on the FDA’s” actions, Dr. January said in an interview.
“The ACC, AHA, and HRS guidelines should reflect what the FDA decided,” Dr. Reddy said in an interview. “I’m a little surprised the guidelines said that anticoagulation had to be contraindicated.
The 2019 update also added a class IIb, “may be reasonable” recommendation for catheter ablation of AF in patients with heart failure with reduced ejection fraction.
“I think a IIb recommendation is unfair; I think it should be a IIa recommendation because there have been positive results from two large, randomized, multicenter trials – CASTLE-AF [Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF; N Engl J Med. 2018 Feb 1;378(5):417-27] and AATAC [Ablation vs Amiodarone for Treatment of AFib in Patients With CHF and an ICD; Circulation. 2016 Apr 26;133(7):1637-44], as well as positive results from several smaller randomized studies,” Dr. Reddy said. “I’m really surprised” that the recommendation was not stronger.
Dr. Calkins has been a consultant to Abbott, Altathera, AtriCare, Boehringer-Ingelheim, King, Medtronic, and St. Jude and has received research funding from Boehringer-Ingelheim, Boston Scientific, and St. Jude. Dr. January had no disclosures. Dr. Reddy has been a consultant to, received research funding from, or has an equity interest in more than three dozen companies.
The first update to U.S. medical-society guidelines for managing atrial fibrillation since 2014 raised the threshold for starting anticoagulant therapy in women, pegged the direct-acting oral anticoagulants (DOACs) as preferred over warfarin, and introduced for the first time weight loss as an important intervention tool for treating patients with an atrial arrhythmia.
On January 28, the American College of Cardiology, American Heart Association, and Heart Rhythm Society posted online a 2019 focused update (Circulation. 2019 Jan 28. doi: 10.1161/CIR.0000000000000665) to the 2014 atrial fibrillation (AF) management guidelines that the groups had previously published (J Am Coll Cardiol. 2014 Dec 2;64[21]:2246-80).
Perhaps the two most important changes, as well as the two that lead off the new document, were a pair of class I recommendations on using oral anticoagulation in AF patients.
This brought U.S. guidelines in line with European guidelines, set by the European Society of Cardiology in 2016 (Eur Heart J. 2016 Oct 7;37[38]:2893-962). It will now also mean that, because of the way the CHA2DS2-VASc score is calculated, women with AF who are at least 65 years old will no longer automatically get flagged as needing oral anticoagulant therapy.
“This is a really important shift. It’s recognition that female sex is not as important a risk factor [for AF-associated stroke] as once was thought,” commented Hugh Calkins, MD, professor of medicine at Johns Hopkins Medicine in Baltimore and a member of the panel that wrote the update. “This will change the number of women with AF who go on anticoagulation,” predicted Dr. Calkins, who directs the cardiac arrhythmia service at his center. “We have been struggling with the notion that all women 65 or older with AF had to be on an anticoagulant. Now a clinician has more leeway. In general, patients with AF remain underanticoagulated, but this clarifies practice and brings us in line with the European guidelines.”
The second important change to the anticoagulation recommendations was to specify the DOACs as recommended over warfarin in AF patients eligible for oral anticoagulation and without moderate to severe mitral stenosis or a mechanical heart valve, which also matches the 2016 European guidelines and updates the prior, 2014, U.S. guidelines, which didn’t even mention DOACs.
Prescribing a DOAC preferentially to AF patients has already become routine among electrophysiologists, but possibly not as routine among primary care physicians, so this change has the potential to shift practice, said Dr. Calkins. But the higher price for DOACs, compared with warfarin, can pose problems. “The cost of DOACs remains an issue that can be a serious limitation to some patients,” said Craig T. January, MD, professor of medicine at the University of Wisconsin in Madison and chair of the guideline-writing panel. He also bemoaned the absence of head-to-head comparisons of individual DOACs that could inform selecting among apixaban, dabigatran, edoxaban, and rivaroxaban.
Another notable change in the 2019 update was inclusion for the first time of weight loss as a recommended intervention, along with other risk factor modification, an addition that Dr. Calkins called “long overdue.”
“This is a new recommendation, and it will potentially be important,” said Dr. January, although the guidelines do not spell out how aggressive clinicians should be about having patients achieve weight loss, how much loss patients should achieve, or how they should do it. “There are a lot of observational data and basic science data suggesting the importance of weight loss. Most electrophysiologists already address weight loss. The problem is how to get patients to do it,” commented Vivek Reddy, MD, professor of medicine and director of cardiac arrhythmia services at Mount Sinai Hospital in New York.
Dr. Reddy expressed surprise over two other features of the updated guidelines. For the first time, the guidelines now address percutaneous left atrial appendage (LAA) occlusion and say: “Percutaneous LAA occlusion may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation.” The guidelines’ text acknowledges that this runs counter to the Food and Drug Administration labeling for the Watchman LAA occlusion device, which restricts the device to patients “deemed suitable for long-term warfarin (mirroring the inclusion criteria for enrollment in the clinical trials) but had an appropriate rationale to seek a nonpharmacological alternative to warfarin.”
“We do not take a position on the FDA’s” actions, Dr. January said in an interview.
“The ACC, AHA, and HRS guidelines should reflect what the FDA decided,” Dr. Reddy said in an interview. “I’m a little surprised the guidelines said that anticoagulation had to be contraindicated.
The 2019 update also added a class IIb, “may be reasonable” recommendation for catheter ablation of AF in patients with heart failure with reduced ejection fraction.
“I think a IIb recommendation is unfair; I think it should be a IIa recommendation because there have been positive results from two large, randomized, multicenter trials – CASTLE-AF [Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF; N Engl J Med. 2018 Feb 1;378(5):417-27] and AATAC [Ablation vs Amiodarone for Treatment of AFib in Patients With CHF and an ICD; Circulation. 2016 Apr 26;133(7):1637-44], as well as positive results from several smaller randomized studies,” Dr. Reddy said. “I’m really surprised” that the recommendation was not stronger.
Dr. Calkins has been a consultant to Abbott, Altathera, AtriCare, Boehringer-Ingelheim, King, Medtronic, and St. Jude and has received research funding from Boehringer-Ingelheim, Boston Scientific, and St. Jude. Dr. January had no disclosures. Dr. Reddy has been a consultant to, received research funding from, or has an equity interest in more than three dozen companies.
Pediatric hospitalist and researcher: Dr. Samir Shah
Stoking collaboration between adult and pediatric clinicians
Samir S. Shah, MD, MSCE, director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center, believes that pediatric and adult hospitalists have much to learn from each other. And he aims to promote that mutual education in his new role as editor in chief of the Journal of Hospital Medicine.
Dr. Shah is the first pediatric hospitalist to hold this position for JHM, the official journal of the Society of Hospital Medicine. He says his new position, which became effective Jan. 1, is primed for fostering interaction between pediatric and adult hospitalists. “Pediatric hospital medicine is such a vibrant community of its own. There are many opportunities for partnership and collaboration between adult and pediatric hospitalists,” he said.
The field of pediatric hospital medicine has started down the path toward becoming recognized as a board-certified subspecialty.1 “That will place a greater emphasis on our role in fellowship training, which is important to ensure that pediatric hospitalists have a clearly defined skill set,” Dr. Shah said. “So much of what we learn in medical school is oriented to the medical care of adults. If you go into pediatrics, you’ve already had a fair amount of grounding in the healthy physiology and common diseases of adults. Pediatric hospital medicine fellowships offer an opportunity to refine clinical skill sets, as well as develop new skills in domains such as research and leadership.”
An emphasis on diversity
Although he has praised the innovative work of his predecessors, Mark Williams, MD, MHM, and Andrew Auerbach, MD, MPH, MHM, in shepherding the journal to its current strong position, Dr. Shah brings ideas for new features and directions.
“We as a field really benefit from a diversity of skill sets and perspectives. I’m excited to create processes to ensure equity and diversity in everything we do, starting with adding more women and more pediatric hospitalists to the journal’s leadership team, as well as purposefully developing a diverse leadership pipeline for the journal and for the field,” he said.
“We are intentionally reaching out to pediatricians to emphasize the extent to which JHM is invested in their field. For example, we have increased by seven the number of pediatricians as part of the JHM leadership team.” But pediatric hospitalists have always seen JHM as a home for their work, and Dr. Shah himself has published a couple dozen research papers in the journal. “It has always felt to me like a welcoming place,” he said.
“The great thing for me is that I’m not doing this alone. We have a marvelous crew of senior deputy editors, deputy editors, associate editors, and advisors. The opportunity I have is to leverage the phenomenal expertise and enthusiasm of this exceptional team.”
The journal under Dr. Auerbach’s lead created an editorial fellowship program offering opportunities for 1-year mentored exposure to the publication of academic scholarship and to different aspects of how a medical journal works. “We’re excited to continue investing in this program and included an editorial about it and an application form in the January 2019 issue of the Journal,” Dr. Shah said. He encourages editorial fellowship applications from physicians who historically have been underrepresented in academic medicine leadership.
“We’re also creating a column on leadership and professional development so that leaders in different fields can share their perspective and wisdom with our readers. We’ll be presenting a new, shorter review format; distilling clinical practice guidelines; and working on redesigning the journal’s web presence. We believe that our readers interact with the journal differently than they did five years ago, and increasingly are leveraging social media,” he said.
“I’m eager to broaden the scope of the journal. In the past, we focused on quality, value in health care and transitions of care in and out of the hospital, which are important topics. But I’m also excited about the adoption of new technologies, how to evaluate them and incorporate them into medical practice – things like Apple Watch for measuring heart rhythm,” Dr. Shah.
He wants to explore other technology-related topics like alarm fatigue and the use of monitors. Another big subject is the management of health of populations under new, emerging, risk-based payment models, with their pressures on health systems to take greater responsibility for risk. JHM is a medical journal and an official society journal, Dr. Shah said. “But our readership and submitters are not limited to hospitalists. As editor in chief, I’m here to make sure the journal is relevant to our members and to our other constituencies.”
Dr. Shah joined JHM’s editorial leadership team in 2009, then he became its deputy editor in 2012 and its senior deputy editor in 2015. A founding associate editor of the Journal of the Pediatric Infectious Diseases Society, he has also served on the editorial board of JAMA Pediatrics. He is editor or coeditor of 12 books in the fields of pediatrics and infectious diseases, including coauthoring “The Philadelphia Guide: Inpatient Pediatrics for McGraw-Hill Education” while still a fellow in academic general pediatrics and pediatric infectious diseases at Children’s Hospital of Philadelphia (CHOP) and, more recently, “Pediatric Infectious Diseases: Essentials for Practice,” a textbook for the pediatric generalist.
Broad scope of activities
Dr. Shah started practicing pediatric hospital medicine in 2001 during his fellowship training. He joined the faculty at CHOP and the University of Pennsylvania, also in Philadelphia, in 2005. In 2011 he arrived at Cincinnati Children’s Hospital, a facility with more than 600 beds that’s affiliated with the University of Cincinnati, where he is professor in the department of pediatrics and holds the James M. Ewell Endowed Chair, to lead a newly created division of hospital medicine. That division now includes more than 55 physician faculty members, 10 nurse practitioners, and nine 3-year fellows.
Collectively the staff represent a broad scope of clinical and research activities along with consulting and surgical comanagement roles and a unique service staffed by med/peds hospitalists for adult patients who have been followed at the hospital since they were children. “Years ago, those patients would not have survived beyond childhood, but with medical advances, they have. Although they continue to benefit from pediatric expertise, these adults also require internal medicine expertise for their adult health needs,” he explained. Examples include patients with neurologic impairments, dependence on medical technology, or congenital heart defects.
Dr. Shah’s own schedule is 28% clinical. He also serves as the hospital’s chief metrics officer, and his research interests include serious infectious diseases, such as pneumonia and meningitis. He is studying the comparative effectiveness of different antibiotic treatments for community-acquired pneumonia and how to improve outcomes for hospital-acquired pneumonia.
Dr. Shah has tried to be deliberate in leading efforts to grow researchers within the field, both nationally and locally. He serves as the chair of the National Childhood Pneumonia Guidelines Committee of the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society, and he also is vice chair of the Pediatric Research in Inpatient Settings (PRIS) Network, which facilitates multicenter cost-effectiveness studies among its 120 hospital members. For example, a series of studies funded by the Patient- Centered Outcomes Research Institute has demonstrated the comparable effectiveness of oral and intravenous antibiotics for osteomyelitis and complicated pneumonia.
Sustainable positions
When he was asked whether he felt pediatric hospitalists face particular challenges in trying to take their place in the burgeoning field of hospital medicine, Dr. Shah said he and his colleagues don’t really think of it in those terms. “Hospital medicine is such a dynamic field. For example, pediatric hospital medicine has charted its own course by pursuing subspecialty certification and fellowship training. Yet support from the field broadly has been quite strong, and SHM has embraced pediatricians, who serve on its board of directors and on numerous committees.”
SHM’s commitment to supporting pediatric hospital medicine practice and research includes its cosponsorship, with the Academic Pediatric Association and the American Academy of Pediatrics, an annual pediatric hospital medicine educational and research conference, which will next be held July 25-28, 2019, in Seattle. “In my recent meetings with society leaders I have seen exceptional enthusiasm for increasing the presence of pediatric hospitalists in the society’s work. Many pediatric hospitalists already attend SHM’s annual meeting and submit their research, but we all recognize that a strong pediatric presence is important for the society.”
Dr. Shah credits Cincinnati Children’s Hospital for supporting a sustainable work schedule for its hospitalists and for a team-oriented culture that emphasizes both professional and personal development and encourages a diversity of skill sets and perspectives, skills development, and additional training. “Individuals are recognized for their achievements within and beyond the confines of the hospital. The mentorship structure we set up here is incredible. Each faculty member has a primary mentor, a peer mentor, and access to a career development committee. Additionally, there is broad participation in clinical operations, educational scholarship, research, and quality improvement.”
Dr. Shah’s professional interests in academics, research, and infectious diseases trace back in part to a thesis project he did on neonatal infections while in medical school at Yale University, New Haven, Conn. “I was working with basic sciences in a hematology lab under the direction of the neonatologist Dr. Patrick Gallagher, whose research focused on pediatric blood cell membrane disorders.” Dr. Gallagher, who directs the Yale Center for Blood Disorders, had a keen interest in infections in infants, Dr. Shah recalled.
“He would share with me interesting cases from his practice. What particularly captured my attention was realizing how the research I could do might have a direct impact on patients and families.” Thus inspired to do an additional year of medical school training at Yale before graduating in 1998, Dr. Shah used that year to focus on research, including a placement at the Centers for Disease Control and Prevention to investigate infectious disease outbreaks, which offered real-world mysteries to solve.
“When I was a resident, pediatric hospital medicine had not yet been recognized as a specialty. But during my fellowships, most of my work was focused on the inpatient side of medicine,” he said. That made hospital medicine a natural career path.
Dr. Shah describes himself as a devoted soccer fan with season tickets for himself, his wife, and their three children to the Major League Soccer team FC Cincinnati. He’s also a movie buff and a former avid bicyclist who’s now trying to get back into cycling. He encourages readers of The Hospitalist to contact him with input on any aspect of the Journal of Hospital Medicine. Email him at [email protected] and follow him on Twitter: @samirshahmd.
Reference
1. Barrett DJ et al. Pediatric hospital medicine: A proposed new subspecialty. Pediatrics. 2017 March;139(3):e20161823.
Stoking collaboration between adult and pediatric clinicians
Stoking collaboration between adult and pediatric clinicians
Samir S. Shah, MD, MSCE, director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center, believes that pediatric and adult hospitalists have much to learn from each other. And he aims to promote that mutual education in his new role as editor in chief of the Journal of Hospital Medicine.
Dr. Shah is the first pediatric hospitalist to hold this position for JHM, the official journal of the Society of Hospital Medicine. He says his new position, which became effective Jan. 1, is primed for fostering interaction between pediatric and adult hospitalists. “Pediatric hospital medicine is such a vibrant community of its own. There are many opportunities for partnership and collaboration between adult and pediatric hospitalists,” he said.
The field of pediatric hospital medicine has started down the path toward becoming recognized as a board-certified subspecialty.1 “That will place a greater emphasis on our role in fellowship training, which is important to ensure that pediatric hospitalists have a clearly defined skill set,” Dr. Shah said. “So much of what we learn in medical school is oriented to the medical care of adults. If you go into pediatrics, you’ve already had a fair amount of grounding in the healthy physiology and common diseases of adults. Pediatric hospital medicine fellowships offer an opportunity to refine clinical skill sets, as well as develop new skills in domains such as research and leadership.”
An emphasis on diversity
Although he has praised the innovative work of his predecessors, Mark Williams, MD, MHM, and Andrew Auerbach, MD, MPH, MHM, in shepherding the journal to its current strong position, Dr. Shah brings ideas for new features and directions.
“We as a field really benefit from a diversity of skill sets and perspectives. I’m excited to create processes to ensure equity and diversity in everything we do, starting with adding more women and more pediatric hospitalists to the journal’s leadership team, as well as purposefully developing a diverse leadership pipeline for the journal and for the field,” he said.
“We are intentionally reaching out to pediatricians to emphasize the extent to which JHM is invested in their field. For example, we have increased by seven the number of pediatricians as part of the JHM leadership team.” But pediatric hospitalists have always seen JHM as a home for their work, and Dr. Shah himself has published a couple dozen research papers in the journal. “It has always felt to me like a welcoming place,” he said.
“The great thing for me is that I’m not doing this alone. We have a marvelous crew of senior deputy editors, deputy editors, associate editors, and advisors. The opportunity I have is to leverage the phenomenal expertise and enthusiasm of this exceptional team.”
The journal under Dr. Auerbach’s lead created an editorial fellowship program offering opportunities for 1-year mentored exposure to the publication of academic scholarship and to different aspects of how a medical journal works. “We’re excited to continue investing in this program and included an editorial about it and an application form in the January 2019 issue of the Journal,” Dr. Shah said. He encourages editorial fellowship applications from physicians who historically have been underrepresented in academic medicine leadership.
“We’re also creating a column on leadership and professional development so that leaders in different fields can share their perspective and wisdom with our readers. We’ll be presenting a new, shorter review format; distilling clinical practice guidelines; and working on redesigning the journal’s web presence. We believe that our readers interact with the journal differently than they did five years ago, and increasingly are leveraging social media,” he said.
“I’m eager to broaden the scope of the journal. In the past, we focused on quality, value in health care and transitions of care in and out of the hospital, which are important topics. But I’m also excited about the adoption of new technologies, how to evaluate them and incorporate them into medical practice – things like Apple Watch for measuring heart rhythm,” Dr. Shah.
He wants to explore other technology-related topics like alarm fatigue and the use of monitors. Another big subject is the management of health of populations under new, emerging, risk-based payment models, with their pressures on health systems to take greater responsibility for risk. JHM is a medical journal and an official society journal, Dr. Shah said. “But our readership and submitters are not limited to hospitalists. As editor in chief, I’m here to make sure the journal is relevant to our members and to our other constituencies.”
Dr. Shah joined JHM’s editorial leadership team in 2009, then he became its deputy editor in 2012 and its senior deputy editor in 2015. A founding associate editor of the Journal of the Pediatric Infectious Diseases Society, he has also served on the editorial board of JAMA Pediatrics. He is editor or coeditor of 12 books in the fields of pediatrics and infectious diseases, including coauthoring “The Philadelphia Guide: Inpatient Pediatrics for McGraw-Hill Education” while still a fellow in academic general pediatrics and pediatric infectious diseases at Children’s Hospital of Philadelphia (CHOP) and, more recently, “Pediatric Infectious Diseases: Essentials for Practice,” a textbook for the pediatric generalist.
Broad scope of activities
Dr. Shah started practicing pediatric hospital medicine in 2001 during his fellowship training. He joined the faculty at CHOP and the University of Pennsylvania, also in Philadelphia, in 2005. In 2011 he arrived at Cincinnati Children’s Hospital, a facility with more than 600 beds that’s affiliated with the University of Cincinnati, where he is professor in the department of pediatrics and holds the James M. Ewell Endowed Chair, to lead a newly created division of hospital medicine. That division now includes more than 55 physician faculty members, 10 nurse practitioners, and nine 3-year fellows.
Collectively the staff represent a broad scope of clinical and research activities along with consulting and surgical comanagement roles and a unique service staffed by med/peds hospitalists for adult patients who have been followed at the hospital since they were children. “Years ago, those patients would not have survived beyond childhood, but with medical advances, they have. Although they continue to benefit from pediatric expertise, these adults also require internal medicine expertise for their adult health needs,” he explained. Examples include patients with neurologic impairments, dependence on medical technology, or congenital heart defects.
Dr. Shah’s own schedule is 28% clinical. He also serves as the hospital’s chief metrics officer, and his research interests include serious infectious diseases, such as pneumonia and meningitis. He is studying the comparative effectiveness of different antibiotic treatments for community-acquired pneumonia and how to improve outcomes for hospital-acquired pneumonia.
Dr. Shah has tried to be deliberate in leading efforts to grow researchers within the field, both nationally and locally. He serves as the chair of the National Childhood Pneumonia Guidelines Committee of the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society, and he also is vice chair of the Pediatric Research in Inpatient Settings (PRIS) Network, which facilitates multicenter cost-effectiveness studies among its 120 hospital members. For example, a series of studies funded by the Patient- Centered Outcomes Research Institute has demonstrated the comparable effectiveness of oral and intravenous antibiotics for osteomyelitis and complicated pneumonia.
Sustainable positions
When he was asked whether he felt pediatric hospitalists face particular challenges in trying to take their place in the burgeoning field of hospital medicine, Dr. Shah said he and his colleagues don’t really think of it in those terms. “Hospital medicine is such a dynamic field. For example, pediatric hospital medicine has charted its own course by pursuing subspecialty certification and fellowship training. Yet support from the field broadly has been quite strong, and SHM has embraced pediatricians, who serve on its board of directors and on numerous committees.”
SHM’s commitment to supporting pediatric hospital medicine practice and research includes its cosponsorship, with the Academic Pediatric Association and the American Academy of Pediatrics, an annual pediatric hospital medicine educational and research conference, which will next be held July 25-28, 2019, in Seattle. “In my recent meetings with society leaders I have seen exceptional enthusiasm for increasing the presence of pediatric hospitalists in the society’s work. Many pediatric hospitalists already attend SHM’s annual meeting and submit their research, but we all recognize that a strong pediatric presence is important for the society.”
Dr. Shah credits Cincinnati Children’s Hospital for supporting a sustainable work schedule for its hospitalists and for a team-oriented culture that emphasizes both professional and personal development and encourages a diversity of skill sets and perspectives, skills development, and additional training. “Individuals are recognized for their achievements within and beyond the confines of the hospital. The mentorship structure we set up here is incredible. Each faculty member has a primary mentor, a peer mentor, and access to a career development committee. Additionally, there is broad participation in clinical operations, educational scholarship, research, and quality improvement.”
Dr. Shah’s professional interests in academics, research, and infectious diseases trace back in part to a thesis project he did on neonatal infections while in medical school at Yale University, New Haven, Conn. “I was working with basic sciences in a hematology lab under the direction of the neonatologist Dr. Patrick Gallagher, whose research focused on pediatric blood cell membrane disorders.” Dr. Gallagher, who directs the Yale Center for Blood Disorders, had a keen interest in infections in infants, Dr. Shah recalled.
“He would share with me interesting cases from his practice. What particularly captured my attention was realizing how the research I could do might have a direct impact on patients and families.” Thus inspired to do an additional year of medical school training at Yale before graduating in 1998, Dr. Shah used that year to focus on research, including a placement at the Centers for Disease Control and Prevention to investigate infectious disease outbreaks, which offered real-world mysteries to solve.
“When I was a resident, pediatric hospital medicine had not yet been recognized as a specialty. But during my fellowships, most of my work was focused on the inpatient side of medicine,” he said. That made hospital medicine a natural career path.
Dr. Shah describes himself as a devoted soccer fan with season tickets for himself, his wife, and their three children to the Major League Soccer team FC Cincinnati. He’s also a movie buff and a former avid bicyclist who’s now trying to get back into cycling. He encourages readers of The Hospitalist to contact him with input on any aspect of the Journal of Hospital Medicine. Email him at [email protected] and follow him on Twitter: @samirshahmd.
Reference
1. Barrett DJ et al. Pediatric hospital medicine: A proposed new subspecialty. Pediatrics. 2017 March;139(3):e20161823.
Samir S. Shah, MD, MSCE, director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center, believes that pediatric and adult hospitalists have much to learn from each other. And he aims to promote that mutual education in his new role as editor in chief of the Journal of Hospital Medicine.
Dr. Shah is the first pediatric hospitalist to hold this position for JHM, the official journal of the Society of Hospital Medicine. He says his new position, which became effective Jan. 1, is primed for fostering interaction between pediatric and adult hospitalists. “Pediatric hospital medicine is such a vibrant community of its own. There are many opportunities for partnership and collaboration between adult and pediatric hospitalists,” he said.
The field of pediatric hospital medicine has started down the path toward becoming recognized as a board-certified subspecialty.1 “That will place a greater emphasis on our role in fellowship training, which is important to ensure that pediatric hospitalists have a clearly defined skill set,” Dr. Shah said. “So much of what we learn in medical school is oriented to the medical care of adults. If you go into pediatrics, you’ve already had a fair amount of grounding in the healthy physiology and common diseases of adults. Pediatric hospital medicine fellowships offer an opportunity to refine clinical skill sets, as well as develop new skills in domains such as research and leadership.”
An emphasis on diversity
Although he has praised the innovative work of his predecessors, Mark Williams, MD, MHM, and Andrew Auerbach, MD, MPH, MHM, in shepherding the journal to its current strong position, Dr. Shah brings ideas for new features and directions.
“We as a field really benefit from a diversity of skill sets and perspectives. I’m excited to create processes to ensure equity and diversity in everything we do, starting with adding more women and more pediatric hospitalists to the journal’s leadership team, as well as purposefully developing a diverse leadership pipeline for the journal and for the field,” he said.
“We are intentionally reaching out to pediatricians to emphasize the extent to which JHM is invested in their field. For example, we have increased by seven the number of pediatricians as part of the JHM leadership team.” But pediatric hospitalists have always seen JHM as a home for their work, and Dr. Shah himself has published a couple dozen research papers in the journal. “It has always felt to me like a welcoming place,” he said.
“The great thing for me is that I’m not doing this alone. We have a marvelous crew of senior deputy editors, deputy editors, associate editors, and advisors. The opportunity I have is to leverage the phenomenal expertise and enthusiasm of this exceptional team.”
The journal under Dr. Auerbach’s lead created an editorial fellowship program offering opportunities for 1-year mentored exposure to the publication of academic scholarship and to different aspects of how a medical journal works. “We’re excited to continue investing in this program and included an editorial about it and an application form in the January 2019 issue of the Journal,” Dr. Shah said. He encourages editorial fellowship applications from physicians who historically have been underrepresented in academic medicine leadership.
“We’re also creating a column on leadership and professional development so that leaders in different fields can share their perspective and wisdom with our readers. We’ll be presenting a new, shorter review format; distilling clinical practice guidelines; and working on redesigning the journal’s web presence. We believe that our readers interact with the journal differently than they did five years ago, and increasingly are leveraging social media,” he said.
“I’m eager to broaden the scope of the journal. In the past, we focused on quality, value in health care and transitions of care in and out of the hospital, which are important topics. But I’m also excited about the adoption of new technologies, how to evaluate them and incorporate them into medical practice – things like Apple Watch for measuring heart rhythm,” Dr. Shah.
He wants to explore other technology-related topics like alarm fatigue and the use of monitors. Another big subject is the management of health of populations under new, emerging, risk-based payment models, with their pressures on health systems to take greater responsibility for risk. JHM is a medical journal and an official society journal, Dr. Shah said. “But our readership and submitters are not limited to hospitalists. As editor in chief, I’m here to make sure the journal is relevant to our members and to our other constituencies.”
Dr. Shah joined JHM’s editorial leadership team in 2009, then he became its deputy editor in 2012 and its senior deputy editor in 2015. A founding associate editor of the Journal of the Pediatric Infectious Diseases Society, he has also served on the editorial board of JAMA Pediatrics. He is editor or coeditor of 12 books in the fields of pediatrics and infectious diseases, including coauthoring “The Philadelphia Guide: Inpatient Pediatrics for McGraw-Hill Education” while still a fellow in academic general pediatrics and pediatric infectious diseases at Children’s Hospital of Philadelphia (CHOP) and, more recently, “Pediatric Infectious Diseases: Essentials for Practice,” a textbook for the pediatric generalist.
Broad scope of activities
Dr. Shah started practicing pediatric hospital medicine in 2001 during his fellowship training. He joined the faculty at CHOP and the University of Pennsylvania, also in Philadelphia, in 2005. In 2011 he arrived at Cincinnati Children’s Hospital, a facility with more than 600 beds that’s affiliated with the University of Cincinnati, where he is professor in the department of pediatrics and holds the James M. Ewell Endowed Chair, to lead a newly created division of hospital medicine. That division now includes more than 55 physician faculty members, 10 nurse practitioners, and nine 3-year fellows.
Collectively the staff represent a broad scope of clinical and research activities along with consulting and surgical comanagement roles and a unique service staffed by med/peds hospitalists for adult patients who have been followed at the hospital since they were children. “Years ago, those patients would not have survived beyond childhood, but with medical advances, they have. Although they continue to benefit from pediatric expertise, these adults also require internal medicine expertise for their adult health needs,” he explained. Examples include patients with neurologic impairments, dependence on medical technology, or congenital heart defects.
Dr. Shah’s own schedule is 28% clinical. He also serves as the hospital’s chief metrics officer, and his research interests include serious infectious diseases, such as pneumonia and meningitis. He is studying the comparative effectiveness of different antibiotic treatments for community-acquired pneumonia and how to improve outcomes for hospital-acquired pneumonia.
Dr. Shah has tried to be deliberate in leading efforts to grow researchers within the field, both nationally and locally. He serves as the chair of the National Childhood Pneumonia Guidelines Committee of the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society, and he also is vice chair of the Pediatric Research in Inpatient Settings (PRIS) Network, which facilitates multicenter cost-effectiveness studies among its 120 hospital members. For example, a series of studies funded by the Patient- Centered Outcomes Research Institute has demonstrated the comparable effectiveness of oral and intravenous antibiotics for osteomyelitis and complicated pneumonia.
Sustainable positions
When he was asked whether he felt pediatric hospitalists face particular challenges in trying to take their place in the burgeoning field of hospital medicine, Dr. Shah said he and his colleagues don’t really think of it in those terms. “Hospital medicine is such a dynamic field. For example, pediatric hospital medicine has charted its own course by pursuing subspecialty certification and fellowship training. Yet support from the field broadly has been quite strong, and SHM has embraced pediatricians, who serve on its board of directors and on numerous committees.”
SHM’s commitment to supporting pediatric hospital medicine practice and research includes its cosponsorship, with the Academic Pediatric Association and the American Academy of Pediatrics, an annual pediatric hospital medicine educational and research conference, which will next be held July 25-28, 2019, in Seattle. “In my recent meetings with society leaders I have seen exceptional enthusiasm for increasing the presence of pediatric hospitalists in the society’s work. Many pediatric hospitalists already attend SHM’s annual meeting and submit their research, but we all recognize that a strong pediatric presence is important for the society.”
Dr. Shah credits Cincinnati Children’s Hospital for supporting a sustainable work schedule for its hospitalists and for a team-oriented culture that emphasizes both professional and personal development and encourages a diversity of skill sets and perspectives, skills development, and additional training. “Individuals are recognized for their achievements within and beyond the confines of the hospital. The mentorship structure we set up here is incredible. Each faculty member has a primary mentor, a peer mentor, and access to a career development committee. Additionally, there is broad participation in clinical operations, educational scholarship, research, and quality improvement.”
Dr. Shah’s professional interests in academics, research, and infectious diseases trace back in part to a thesis project he did on neonatal infections while in medical school at Yale University, New Haven, Conn. “I was working with basic sciences in a hematology lab under the direction of the neonatologist Dr. Patrick Gallagher, whose research focused on pediatric blood cell membrane disorders.” Dr. Gallagher, who directs the Yale Center for Blood Disorders, had a keen interest in infections in infants, Dr. Shah recalled.
“He would share with me interesting cases from his practice. What particularly captured my attention was realizing how the research I could do might have a direct impact on patients and families.” Thus inspired to do an additional year of medical school training at Yale before graduating in 1998, Dr. Shah used that year to focus on research, including a placement at the Centers for Disease Control and Prevention to investigate infectious disease outbreaks, which offered real-world mysteries to solve.
“When I was a resident, pediatric hospital medicine had not yet been recognized as a specialty. But during my fellowships, most of my work was focused on the inpatient side of medicine,” he said. That made hospital medicine a natural career path.
Dr. Shah describes himself as a devoted soccer fan with season tickets for himself, his wife, and their three children to the Major League Soccer team FC Cincinnati. He’s also a movie buff and a former avid bicyclist who’s now trying to get back into cycling. He encourages readers of The Hospitalist to contact him with input on any aspect of the Journal of Hospital Medicine. Email him at [email protected] and follow him on Twitter: @samirshahmd.
Reference
1. Barrett DJ et al. Pediatric hospital medicine: A proposed new subspecialty. Pediatrics. 2017 March;139(3):e20161823.
Tamsulosin not effective in promoting stone expulsion in symptomatic patients
Clinical question: Does tamsulosin provide benefit in ureteral stone expulsion for patients who present with a symptomatic stone less than 9 mm?
Background: Treatment of urinary stone disease often includes the use of alpha-blockers such as tamsulosin to promote stone passage, and between 15% and 55% of patients presenting to EDs for renal colic are prescribed alpha-blockers. Current treatment guidelines support the use of tamsulosin, with recent evidence suggesting that this treatment is more effective for larger stones (5-10 mm). However, other prospective trials have called these guidelines into question.
Study design: Double-blind, placebo-controlled study.
Setting: Six emergency departments at U.S. tertiary-care hospitals.
Synopsis: 512 participants with symptomatic ureteral stones were randomized to either tamsulosin or placebo. At the end of a 28-day treatment period, the rate of urinary stone passage was 49.6% in the tamsulosin group vs. 47.3% in the placebo group (95.8% confidence interval, 0.87-1.27; P = .60). The time to stone passage also was not different between treatment groups (P = .92). A second phase of the trial also evaluated stone passage by CT scan at 28 days, with stone passage rates of 83.6% in the tamsulosin group and 77.6% in the placebo group (95% CI, 0.95-1.22; P = .24). This study is the largest of its kind in the United States, with findings similar to those of two recent international multisite trials, increasing the evidence that tamsulosin is not beneficial for larger stone passage.
Bottom line: For patients presenting to the ED for renal colic from ureteral stones smaller than 9 mm, tamsulosin does not appear to promote stone passage.
Citation: Meltzer AC et al. Effect of tamsulosin on passage of symptomatic ureteral stones: A randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-7. Published online June 18, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: Does tamsulosin provide benefit in ureteral stone expulsion for patients who present with a symptomatic stone less than 9 mm?
Background: Treatment of urinary stone disease often includes the use of alpha-blockers such as tamsulosin to promote stone passage, and between 15% and 55% of patients presenting to EDs for renal colic are prescribed alpha-blockers. Current treatment guidelines support the use of tamsulosin, with recent evidence suggesting that this treatment is more effective for larger stones (5-10 mm). However, other prospective trials have called these guidelines into question.
Study design: Double-blind, placebo-controlled study.
Setting: Six emergency departments at U.S. tertiary-care hospitals.
Synopsis: 512 participants with symptomatic ureteral stones were randomized to either tamsulosin or placebo. At the end of a 28-day treatment period, the rate of urinary stone passage was 49.6% in the tamsulosin group vs. 47.3% in the placebo group (95.8% confidence interval, 0.87-1.27; P = .60). The time to stone passage also was not different between treatment groups (P = .92). A second phase of the trial also evaluated stone passage by CT scan at 28 days, with stone passage rates of 83.6% in the tamsulosin group and 77.6% in the placebo group (95% CI, 0.95-1.22; P = .24). This study is the largest of its kind in the United States, with findings similar to those of two recent international multisite trials, increasing the evidence that tamsulosin is not beneficial for larger stone passage.
Bottom line: For patients presenting to the ED for renal colic from ureteral stones smaller than 9 mm, tamsulosin does not appear to promote stone passage.
Citation: Meltzer AC et al. Effect of tamsulosin on passage of symptomatic ureteral stones: A randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-7. Published online June 18, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: Does tamsulosin provide benefit in ureteral stone expulsion for patients who present with a symptomatic stone less than 9 mm?
Background: Treatment of urinary stone disease often includes the use of alpha-blockers such as tamsulosin to promote stone passage, and between 15% and 55% of patients presenting to EDs for renal colic are prescribed alpha-blockers. Current treatment guidelines support the use of tamsulosin, with recent evidence suggesting that this treatment is more effective for larger stones (5-10 mm). However, other prospective trials have called these guidelines into question.
Study design: Double-blind, placebo-controlled study.
Setting: Six emergency departments at U.S. tertiary-care hospitals.
Synopsis: 512 participants with symptomatic ureteral stones were randomized to either tamsulosin or placebo. At the end of a 28-day treatment period, the rate of urinary stone passage was 49.6% in the tamsulosin group vs. 47.3% in the placebo group (95.8% confidence interval, 0.87-1.27; P = .60). The time to stone passage also was not different between treatment groups (P = .92). A second phase of the trial also evaluated stone passage by CT scan at 28 days, with stone passage rates of 83.6% in the tamsulosin group and 77.6% in the placebo group (95% CI, 0.95-1.22; P = .24). This study is the largest of its kind in the United States, with findings similar to those of two recent international multisite trials, increasing the evidence that tamsulosin is not beneficial for larger stone passage.
Bottom line: For patients presenting to the ED for renal colic from ureteral stones smaller than 9 mm, tamsulosin does not appear to promote stone passage.
Citation: Meltzer AC et al. Effect of tamsulosin on passage of symptomatic ureteral stones: A randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-7. Published online June 18, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Mortality risk remains high for survivors of opioid overdose
Clinical question: What are the causes and risks of mortality in the first year after nonfatal opioid overdose?
Background: The current opioid epidemic has led to increasing hospitalizations and ED presentations for nonfatal opioid overdose. Despite this, little is known about the subsequent causes of mortality in these patients. Additional information could suggest potential interventions to decrease subsequent risk of death.
Study design: Retrospective cohort study.
Setting: U.S. national cohort of Medicaid beneficiaries, aged 18-64 years, during 2001-2007.
Synopsis: This cohort included 76,325 adults with nonfatal opioid overdose with 66,736 person-years of follow-up. In the first year after overdose, there were 5,194 deaths, and the crude death rate was 778.3 per 10,000 person-years. Compared with a demographically matched general population, the standardized mortality rate ratios (SMRs) for this cohort were 24.2 times higher for all-cause mortality and 132.1 times higher for drug use–associated disease. The SMRs also were elevated for conditions including HIV (45.9), chronic respiratory disease (41.1), viral hepatitis (30.6), and suicide (25.9). Though limited to billing data from Medicaid beneficiaries during 2001-2007, this study is important in identifying a relatively young population at high risk of preventable death and suggests that additional resources and interventions may be important in this population.
Bottom line: Adults surviving opioid overdose remain at high risk of death over the following year and may benefit from multidisciplinary interventions targeted at coordinating medical care and treatment of mental health and substance use disorders following hospitalization and emergency department presentations.
Citation: Olfson M et al. Causes of death after nonfatal opioid overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-7. Published online June 20, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: What are the causes and risks of mortality in the first year after nonfatal opioid overdose?
Background: The current opioid epidemic has led to increasing hospitalizations and ED presentations for nonfatal opioid overdose. Despite this, little is known about the subsequent causes of mortality in these patients. Additional information could suggest potential interventions to decrease subsequent risk of death.
Study design: Retrospective cohort study.
Setting: U.S. national cohort of Medicaid beneficiaries, aged 18-64 years, during 2001-2007.
Synopsis: This cohort included 76,325 adults with nonfatal opioid overdose with 66,736 person-years of follow-up. In the first year after overdose, there were 5,194 deaths, and the crude death rate was 778.3 per 10,000 person-years. Compared with a demographically matched general population, the standardized mortality rate ratios (SMRs) for this cohort were 24.2 times higher for all-cause mortality and 132.1 times higher for drug use–associated disease. The SMRs also were elevated for conditions including HIV (45.9), chronic respiratory disease (41.1), viral hepatitis (30.6), and suicide (25.9). Though limited to billing data from Medicaid beneficiaries during 2001-2007, this study is important in identifying a relatively young population at high risk of preventable death and suggests that additional resources and interventions may be important in this population.
Bottom line: Adults surviving opioid overdose remain at high risk of death over the following year and may benefit from multidisciplinary interventions targeted at coordinating medical care and treatment of mental health and substance use disorders following hospitalization and emergency department presentations.
Citation: Olfson M et al. Causes of death after nonfatal opioid overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-7. Published online June 20, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: What are the causes and risks of mortality in the first year after nonfatal opioid overdose?
Background: The current opioid epidemic has led to increasing hospitalizations and ED presentations for nonfatal opioid overdose. Despite this, little is known about the subsequent causes of mortality in these patients. Additional information could suggest potential interventions to decrease subsequent risk of death.
Study design: Retrospective cohort study.
Setting: U.S. national cohort of Medicaid beneficiaries, aged 18-64 years, during 2001-2007.
Synopsis: This cohort included 76,325 adults with nonfatal opioid overdose with 66,736 person-years of follow-up. In the first year after overdose, there were 5,194 deaths, and the crude death rate was 778.3 per 10,000 person-years. Compared with a demographically matched general population, the standardized mortality rate ratios (SMRs) for this cohort were 24.2 times higher for all-cause mortality and 132.1 times higher for drug use–associated disease. The SMRs also were elevated for conditions including HIV (45.9), chronic respiratory disease (41.1), viral hepatitis (30.6), and suicide (25.9). Though limited to billing data from Medicaid beneficiaries during 2001-2007, this study is important in identifying a relatively young population at high risk of preventable death and suggests that additional resources and interventions may be important in this population.
Bottom line: Adults surviving opioid overdose remain at high risk of death over the following year and may benefit from multidisciplinary interventions targeted at coordinating medical care and treatment of mental health and substance use disorders following hospitalization and emergency department presentations.
Citation: Olfson M et al. Causes of death after nonfatal opioid overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-7. Published online June 20, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Increasing inpatient attending supervision does not decrease medical errors
Clinical question: What is the effect of increasing attending physician supervision on a resident inpatient team for both patient safety and education?
Background: Residents need autonomy to help develop their clinical skills and to gain competence to practice independently; however, there is rising concern that increased supervision is needed for patient safety.
Study Design: Randomized, crossover clinical trial.
Setting: 1,100-bed academic medical center at Massachusetts General Hospital, Boston.
Synopsis: Twenty-two attending physicians participated in the study over 44 2-week teaching blocks with a total of 1,259 patient hospitalizations on the general medicine teaching service. In the intervention arm, attendings were present during work rounds; in the control arm, attendings discussed established patients with the resident via card flip. New patients were discussed at the bedside in both arms. There was no statistically significant difference in the number of medical errors or patient safety events between the two groups. Residents in the intervention group, however, felt less efficient and autonomous and were less able to make independent decisions. Limitations include this being a single-center study at a program emphasizing resident autonomy and therefore may limit generalizability. Current literature on supervision and patient safety has variable results. This study suggests that increasing attending supervision may not increase patient safety, but may negatively affect resident education and autonomy.
Bottom line: Attending physician presence on work rounds does not improve patient safety and may have deleterious effects on resident education.
Citation: Finn KM et al. Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education. JAMA Intern Med. 2018;178(7):925-59
Dr. Ciarkowski is clinical instructor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: What is the effect of increasing attending physician supervision on a resident inpatient team for both patient safety and education?
Background: Residents need autonomy to help develop their clinical skills and to gain competence to practice independently; however, there is rising concern that increased supervision is needed for patient safety.
Study Design: Randomized, crossover clinical trial.
Setting: 1,100-bed academic medical center at Massachusetts General Hospital, Boston.
Synopsis: Twenty-two attending physicians participated in the study over 44 2-week teaching blocks with a total of 1,259 patient hospitalizations on the general medicine teaching service. In the intervention arm, attendings were present during work rounds; in the control arm, attendings discussed established patients with the resident via card flip. New patients were discussed at the bedside in both arms. There was no statistically significant difference in the number of medical errors or patient safety events between the two groups. Residents in the intervention group, however, felt less efficient and autonomous and were less able to make independent decisions. Limitations include this being a single-center study at a program emphasizing resident autonomy and therefore may limit generalizability. Current literature on supervision and patient safety has variable results. This study suggests that increasing attending supervision may not increase patient safety, but may negatively affect resident education and autonomy.
Bottom line: Attending physician presence on work rounds does not improve patient safety and may have deleterious effects on resident education.
Citation: Finn KM et al. Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education. JAMA Intern Med. 2018;178(7):925-59
Dr. Ciarkowski is clinical instructor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: What is the effect of increasing attending physician supervision on a resident inpatient team for both patient safety and education?
Background: Residents need autonomy to help develop their clinical skills and to gain competence to practice independently; however, there is rising concern that increased supervision is needed for patient safety.
Study Design: Randomized, crossover clinical trial.
Setting: 1,100-bed academic medical center at Massachusetts General Hospital, Boston.
Synopsis: Twenty-two attending physicians participated in the study over 44 2-week teaching blocks with a total of 1,259 patient hospitalizations on the general medicine teaching service. In the intervention arm, attendings were present during work rounds; in the control arm, attendings discussed established patients with the resident via card flip. New patients were discussed at the bedside in both arms. There was no statistically significant difference in the number of medical errors or patient safety events between the two groups. Residents in the intervention group, however, felt less efficient and autonomous and were less able to make independent decisions. Limitations include this being a single-center study at a program emphasizing resident autonomy and therefore may limit generalizability. Current literature on supervision and patient safety has variable results. This study suggests that increasing attending supervision may not increase patient safety, but may negatively affect resident education and autonomy.
Bottom line: Attending physician presence on work rounds does not improve patient safety and may have deleterious effects on resident education.
Citation: Finn KM et al. Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education. JAMA Intern Med. 2018;178(7):925-59
Dr. Ciarkowski is clinical instructor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
In the Literature: Short Takes
A second medical emergency team (MET) activation more likely in patients with recent MET activation
A prospective cohort study examined 471 MET activatios where the patient was not transferred to a higher level of care found that 18% had a second MET event. These second events were more likely to occur in the first 8-12 hours and to occur in patients recently discharged from the ICU.
Citation: Still MD et al. Predictors of a second medical emergency team activation within 24 hours of index event. J Nurs Care Qual 2018;33(2): 157-65
Risk of CV events in patients with TIA or minor stroke decreases significantly after first year
A prospective cohort study following TIA or minor stroke patients from the TIAregistry.org project shows that the risk of additional events (death from cardiovascular cause, nonfatal stroke, or nonfatal acute coronary syndrome) in the following 5 years is 12.9% with half of those events occuring in the first year.
Citation: Amarenco P et al. Five-year risk of stroke after TIA or minor ischemic stroke. N Engl J Med. 2018;378:2182-90.
Maintenance of certification associated with better physician performance scores
Physicians who still participated in Maintenance of Certification (MOC) programs 20 years after their initial certification scored higher on a variety of physician performance scores on Medicare patients.
Citation: Gray BG et al. Associations between American Board of Internal Medicine Maintenance of Certificate status and performance on a set of healthcare effectiveness data and information set (HEDIS) process measures. Ann Intern Med. 2018;169(2):97-105.
A second medical emergency team (MET) activation more likely in patients with recent MET activation
A prospective cohort study examined 471 MET activatios where the patient was not transferred to a higher level of care found that 18% had a second MET event. These second events were more likely to occur in the first 8-12 hours and to occur in patients recently discharged from the ICU.
Citation: Still MD et al. Predictors of a second medical emergency team activation within 24 hours of index event. J Nurs Care Qual 2018;33(2): 157-65
Risk of CV events in patients with TIA or minor stroke decreases significantly after first year
A prospective cohort study following TIA or minor stroke patients from the TIAregistry.org project shows that the risk of additional events (death from cardiovascular cause, nonfatal stroke, or nonfatal acute coronary syndrome) in the following 5 years is 12.9% with half of those events occuring in the first year.
Citation: Amarenco P et al. Five-year risk of stroke after TIA or minor ischemic stroke. N Engl J Med. 2018;378:2182-90.
Maintenance of certification associated with better physician performance scores
Physicians who still participated in Maintenance of Certification (MOC) programs 20 years after their initial certification scored higher on a variety of physician performance scores on Medicare patients.
Citation: Gray BG et al. Associations between American Board of Internal Medicine Maintenance of Certificate status and performance on a set of healthcare effectiveness data and information set (HEDIS) process measures. Ann Intern Med. 2018;169(2):97-105.
A second medical emergency team (MET) activation more likely in patients with recent MET activation
A prospective cohort study examined 471 MET activatios where the patient was not transferred to a higher level of care found that 18% had a second MET event. These second events were more likely to occur in the first 8-12 hours and to occur in patients recently discharged from the ICU.
Citation: Still MD et al. Predictors of a second medical emergency team activation within 24 hours of index event. J Nurs Care Qual 2018;33(2): 157-65
Risk of CV events in patients with TIA or minor stroke decreases significantly after first year
A prospective cohort study following TIA or minor stroke patients from the TIAregistry.org project shows that the risk of additional events (death from cardiovascular cause, nonfatal stroke, or nonfatal acute coronary syndrome) in the following 5 years is 12.9% with half of those events occuring in the first year.
Citation: Amarenco P et al. Five-year risk of stroke after TIA or minor ischemic stroke. N Engl J Med. 2018;378:2182-90.
Maintenance of certification associated with better physician performance scores
Physicians who still participated in Maintenance of Certification (MOC) programs 20 years after their initial certification scored higher on a variety of physician performance scores on Medicare patients.
Citation: Gray BG et al. Associations between American Board of Internal Medicine Maintenance of Certificate status and performance on a set of healthcare effectiveness data and information set (HEDIS) process measures. Ann Intern Med. 2018;169(2):97-105.
CTPA may not rule out VTE in high-risk patients
Clinical question: Does a negative computed tomography pulmonary angiography rule out venous thromboembolism (VTE)?
Background: Computed tomography pulmonary angiography (CTPA) is the most common diagnostic modality used to diagnose pulmonary embolism (PE) and has a high negative predictive value in patients with a low 3-month risk of VTE. In patients with higher pretest probability of PE, it is unknown whether CTPA is sufficient to rule out VTE.
Study design: Meta-analysis.
Setting: Published prospective outcome studies of patients with suspected PE using CTPA as a diagnostic strategy.
Synopsis: The authors reviewed 3,143 publications from MEDLINE, EMBASE, and the Cochrane Library and identified 22 prospective outcome studies to include in their meta-analysis. A VTE was diagnosed in 3,923 out of 11,872 participants (33%) using CTPA. Of the 7,863 patients with a negative CTPA, 148 patients had an acute VTE confirmed by venous ultrasound, ventilation/perfusion scan, or angiography, and 74 patients experienced VTE during a 3-month follow-up period, yielding an overall proportion of 2.4% of patients (95% confidence interval, 1.3%-3.8%).
Subgroup analysis showed that cumulative occurrence of VTE was related to pretest prevalence. In the subgroup of patients with a VTE prevalence greater than 40%, VTE was observed in 8.1% of patients with a negative CTPA (95% CI, 3.4%-14.5%).
Bottom line: CTPA may be insufficient to rule out VTE in patients with a high pretest probability of PE.
Citation: Belzile D et al. Outcomes following a negative computed tomography pulmonary angiography according to pulmonary embolism prevalence: a meta-analysisof the management outcome studies. J Thromb Haemost. 2018 Jun;16(6):1107-20.
Dr. Jenkins is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: Does a negative computed tomography pulmonary angiography rule out venous thromboembolism (VTE)?
Background: Computed tomography pulmonary angiography (CTPA) is the most common diagnostic modality used to diagnose pulmonary embolism (PE) and has a high negative predictive value in patients with a low 3-month risk of VTE. In patients with higher pretest probability of PE, it is unknown whether CTPA is sufficient to rule out VTE.
Study design: Meta-analysis.
Setting: Published prospective outcome studies of patients with suspected PE using CTPA as a diagnostic strategy.
Synopsis: The authors reviewed 3,143 publications from MEDLINE, EMBASE, and the Cochrane Library and identified 22 prospective outcome studies to include in their meta-analysis. A VTE was diagnosed in 3,923 out of 11,872 participants (33%) using CTPA. Of the 7,863 patients with a negative CTPA, 148 patients had an acute VTE confirmed by venous ultrasound, ventilation/perfusion scan, or angiography, and 74 patients experienced VTE during a 3-month follow-up period, yielding an overall proportion of 2.4% of patients (95% confidence interval, 1.3%-3.8%).
Subgroup analysis showed that cumulative occurrence of VTE was related to pretest prevalence. In the subgroup of patients with a VTE prevalence greater than 40%, VTE was observed in 8.1% of patients with a negative CTPA (95% CI, 3.4%-14.5%).
Bottom line: CTPA may be insufficient to rule out VTE in patients with a high pretest probability of PE.
Citation: Belzile D et al. Outcomes following a negative computed tomography pulmonary angiography according to pulmonary embolism prevalence: a meta-analysisof the management outcome studies. J Thromb Haemost. 2018 Jun;16(6):1107-20.
Dr. Jenkins is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: Does a negative computed tomography pulmonary angiography rule out venous thromboembolism (VTE)?
Background: Computed tomography pulmonary angiography (CTPA) is the most common diagnostic modality used to diagnose pulmonary embolism (PE) and has a high negative predictive value in patients with a low 3-month risk of VTE. In patients with higher pretest probability of PE, it is unknown whether CTPA is sufficient to rule out VTE.
Study design: Meta-analysis.
Setting: Published prospective outcome studies of patients with suspected PE using CTPA as a diagnostic strategy.
Synopsis: The authors reviewed 3,143 publications from MEDLINE, EMBASE, and the Cochrane Library and identified 22 prospective outcome studies to include in their meta-analysis. A VTE was diagnosed in 3,923 out of 11,872 participants (33%) using CTPA. Of the 7,863 patients with a negative CTPA, 148 patients had an acute VTE confirmed by venous ultrasound, ventilation/perfusion scan, or angiography, and 74 patients experienced VTE during a 3-month follow-up period, yielding an overall proportion of 2.4% of patients (95% confidence interval, 1.3%-3.8%).
Subgroup analysis showed that cumulative occurrence of VTE was related to pretest prevalence. In the subgroup of patients with a VTE prevalence greater than 40%, VTE was observed in 8.1% of patients with a negative CTPA (95% CI, 3.4%-14.5%).
Bottom line: CTPA may be insufficient to rule out VTE in patients with a high pretest probability of PE.
Citation: Belzile D et al. Outcomes following a negative computed tomography pulmonary angiography according to pulmonary embolism prevalence: a meta-analysisof the management outcome studies. J Thromb Haemost. 2018 Jun;16(6):1107-20.
Dr. Jenkins is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.