Quality

At the Kaiser Permanente Medical Center in San Rafael, Calif., the 20 members of the hospitalist group were encouraged to study together in preparation for the October 2012 HPM boards. The group undertook weekly study sessions for the five months leading up to the exam. Sixteen hospitalists sat for the exam, along with oncologists, nephrologists, pulmonologists, and primary care physicians from the medical center.

All passed.

“For years, our hospitalist group has been doing actual rounding with the palliative care team on their own patients,” says Shideh Shadan, MD, the hospitalist group leader. “Everyone was on board with palliative care. It is now part of our daily care, and all we had to do was to sit down and study for the exam.”

Most of Kaiser’s HMO medical centers have designated interdisciplinary palliative care consultation teams. The one at San Rafael includes nurses, social workers, chaplains, and a part-time physician who is a hospitalist, Clay Angel, MD. Dr. Angel agrees that a cultural transformation has come about at Kaiser San Rafael through this collaboration. The two services are separate but closely connected.

“In hospital medicine, if you keep farming out what you do to specialists—if you’re not embracing palliative care as a hospitalist—you lose part of your practice,” he says.

Dr. Shadan says the study group “helped us to be more cohesive and more comfortable going to each other to ask for help. Palliative care is part of what we do—part of hospital medicine and of providing good care.”

Meanwhile, North Hollywood, Calif.-based IPC The Hospitalist Company, which is well-established in post-acute and long-term-care settings beyond the hospital walls, is now starting to explore palliative care approaches at the local level in a few of its 35 markets. Heather Zinzella-Cox, MD, who was part of a panel presentation on palliative care at HM13, is hospitalist practice group leader for IPC-Delaware. She also works part time as an associate medical director for a community hospice and helped to develop an inpatient palliative care team at a local community hospital.

“For me, as a post-acute hospitalist, every patient I see, I think about whether palliative care might benefit them,” says Dr. Zinzella-Cox, who is board certified in pain and in hospice and palliative medicine.

She says hospitalists need tools for identifying appropriate palliative care patients, along with training for how to communicate with them around goals of care, including simple language to help cue these conversations. She notes a “significant voltage drop” in information at the time of discharge, and the most careful discharge plans can fall apart in a hurry after the patient goes home.

IPC’s national practice group does not have a current policy or initiative for palliative care; however, there may be opportunities for further integrating palliative care with hospital medicine, says hospitalist Thomas Mathew, MD.

Larry Beresford is a freelance writer in San Francisco.

At the Kaiser Permanente Medical Center in San Rafael, Calif., the 20 members of the hospitalist group were encouraged to study together in preparation for the October 2012 HPM boards. The group undertook weekly study sessions for the five months leading up to the exam. Sixteen hospitalists sat for the exam, along with oncologists, nephrologists, pulmonologists, and primary care physicians from the medical center.

All passed.

“For years, our hospitalist group has been doing actual rounding with the palliative care team on their own patients,” says Shideh Shadan, MD, the hospitalist group leader. “Everyone was on board with palliative care. It is now part of our daily care, and all we had to do was to sit down and study for the exam.”

Most of Kaiser’s HMO medical centers have designated interdisciplinary palliative care consultation teams. The one at San Rafael includes nurses, social workers, chaplains, and a part-time physician who is a hospitalist, Clay Angel, MD. Dr. Angel agrees that a cultural transformation has come about at Kaiser San Rafael through this collaboration. The two services are separate but closely connected.

“In hospital medicine, if you keep farming out what you do to specialists—if you’re not embracing palliative care as a hospitalist—you lose part of your practice,” he says.

Dr. Shadan says the study group “helped us to be more cohesive and more comfortable going to each other to ask for help. Palliative care is part of what we do—part of hospital medicine and of providing good care.”

Meanwhile, North Hollywood, Calif.-based IPC The Hospitalist Company, which is well-established in post-acute and long-term-care settings beyond the hospital walls, is now starting to explore palliative care approaches at the local level in a few of its 35 markets. Heather Zinzella-Cox, MD, who was part of a panel presentation on palliative care at HM13, is hospitalist practice group leader for IPC-Delaware. She also works part time as an associate medical director for a community hospice and helped to develop an inpatient palliative care team at a local community hospital.

“For me, as a post-acute hospitalist, every patient I see, I think about whether palliative care might benefit them,” says Dr. Zinzella-Cox, who is board certified in pain and in hospice and palliative medicine.

She says hospitalists need tools for identifying appropriate palliative care patients, along with training for how to communicate with them around goals of care, including simple language to help cue these conversations. She notes a “significant voltage drop” in information at the time of discharge, and the most careful discharge plans can fall apart in a hurry after the patient goes home.

IPC’s national practice group does not have a current policy or initiative for palliative care; however, there may be opportunities for further integrating palliative care with hospital medicine, says hospitalist Thomas Mathew, MD.

Larry Beresford is a freelance writer in San Francisco.

At the Kaiser Permanente Medical Center in San Rafael, Calif., the 20 members of the hospitalist group were encouraged to study together in preparation for the October 2012 HPM boards. The group undertook weekly study sessions for the five months leading up to the exam. Sixteen hospitalists sat for the exam, along with oncologists, nephrologists, pulmonologists, and primary care physicians from the medical center.

All passed.

“For years, our hospitalist group has been doing actual rounding with the palliative care team on their own patients,” says Shideh Shadan, MD, the hospitalist group leader. “Everyone was on board with palliative care. It is now part of our daily care, and all we had to do was to sit down and study for the exam.”

Most of Kaiser’s HMO medical centers have designated interdisciplinary palliative care consultation teams. The one at San Rafael includes nurses, social workers, chaplains, and a part-time physician who is a hospitalist, Clay Angel, MD. Dr. Angel agrees that a cultural transformation has come about at Kaiser San Rafael through this collaboration. The two services are separate but closely connected.

“In hospital medicine, if you keep farming out what you do to specialists—if you’re not embracing palliative care as a hospitalist—you lose part of your practice,” he says.

Dr. Shadan says the study group “helped us to be more cohesive and more comfortable going to each other to ask for help. Palliative care is part of what we do—part of hospital medicine and of providing good care.”

Meanwhile, North Hollywood, Calif.-based IPC The Hospitalist Company, which is well-established in post-acute and long-term-care settings beyond the hospital walls, is now starting to explore palliative care approaches at the local level in a few of its 35 markets. Heather Zinzella-Cox, MD, who was part of a panel presentation on palliative care at HM13, is hospitalist practice group leader for IPC-Delaware. She also works part time as an associate medical director for a community hospice and helped to develop an inpatient palliative care team at a local community hospital.

“For me, as a post-acute hospitalist, every patient I see, I think about whether palliative care might benefit them,” says Dr. Zinzella-Cox, who is board certified in pain and in hospice and palliative medicine.

She says hospitalists need tools for identifying appropriate palliative care patients, along with training for how to communicate with them around goals of care, including simple language to help cue these conversations. She notes a “significant voltage drop” in information at the time of discharge, and the most careful discharge plans can fall apart in a hurry after the patient goes home.

IPC’s national practice group does not have a current policy or initiative for palliative care; however, there may be opportunities for further integrating palliative care with hospital medicine, says hospitalist Thomas Mathew, MD.

Larry Beresford is a freelance writer in San Francisco.

Conscientious handling of urinary catheters is one of the main responsibilities hospitalists have in caring for patients with urological disorders—and, of course, anyone else with a urinary catheter.

Treatment of patients with urological disorders often involves special circumstances requiring physician discretion when deciding whether to remove a catheter or leave it in—removing it too soon could cause problems far worse than an infection. But two compelling studies, nationwide in scope, point to the benefits of systems that help ensure prompt removal of urinary catheters when appropriate.

One, published in 2010, was a review of interventional studies that used reminders to physicians or nurses that a urinary catheter was in use or stop orders to trigger catheter removal in hospitalized adults.

Researchers found that the rate of catheter-associated urinary tract infections, measured as episodes per 1,000 catheter-days, was reduced by 52% (P<0.001) with use of a reminder or stop order. The average duration of catheterization decreased by 37%. That amounted to 2.61 fewer days of catheterization per patient in the intervention compared to control groups.

In a 2013 study published in JAMA Internal Medicine, researchers surveyed infection prevention specialists at a sample of hospitals across the U.S.—and at all hospitals in Michigan, home to a statewide CAUTI-prevention initiative started in 2007. They asked about CAUTI prevention practices and standardized infection ratios on CAUTI.

Michigan hospitals, compared with those elsewhere in the U.S., more frequently participated in collaboratives to reduce healthcare-associated infection—94% to 67%. They also used bladder scanners to measure bladder volume more frequently (53% to 39%), along with catheter reminders or stop orders and/or nurse-initiated discontinuation (44% to 23%).

CAUTI rates in the state of Michigan saw a 25% reduction, significantly greater than the 6% decrease observed in the rest of the U.S.

Sanjay Saint, MD, MPH, a hospitalist and professor of internal medicine at the University of Michigan, says the study verifies how important it is for hospitalists to remove urinary catheters early.

"The data will set us free," he says. "It’s probably better to remove a few of these catheters prematurely and then have to reinsert them than keep all catheters in long past their due date." TH

Tom Collins is a freelance author in South Florida.

Conscientious handling of urinary catheters is one of the main responsibilities hospitalists have in caring for patients with urological disorders—and, of course, anyone else with a urinary catheter.

Treatment of patients with urological disorders often involves special circumstances requiring physician discretion when deciding whether to remove a catheter or leave it in—removing it too soon could cause problems far worse than an infection. But two compelling studies, nationwide in scope, point to the benefits of systems that help ensure prompt removal of urinary catheters when appropriate.

One, published in 2010, was a review of interventional studies that used reminders to physicians or nurses that a urinary catheter was in use or stop orders to trigger catheter removal in hospitalized adults.

Researchers found that the rate of catheter-associated urinary tract infections, measured as episodes per 1,000 catheter-days, was reduced by 52% (P<0.001) with use of a reminder or stop order. The average duration of catheterization decreased by 37%. That amounted to 2.61 fewer days of catheterization per patient in the intervention compared to control groups.

In a 2013 study published in JAMA Internal Medicine, researchers surveyed infection prevention specialists at a sample of hospitals across the U.S.—and at all hospitals in Michigan, home to a statewide CAUTI-prevention initiative started in 2007. They asked about CAUTI prevention practices and standardized infection ratios on CAUTI.

Michigan hospitals, compared with those elsewhere in the U.S., more frequently participated in collaboratives to reduce healthcare-associated infection—94% to 67%. They also used bladder scanners to measure bladder volume more frequently (53% to 39%), along with catheter reminders or stop orders and/or nurse-initiated discontinuation (44% to 23%).

CAUTI rates in the state of Michigan saw a 25% reduction, significantly greater than the 6% decrease observed in the rest of the U.S.

Sanjay Saint, MD, MPH, a hospitalist and professor of internal medicine at the University of Michigan, says the study verifies how important it is for hospitalists to remove urinary catheters early.

"The data will set us free," he says. "It’s probably better to remove a few of these catheters prematurely and then have to reinsert them than keep all catheters in long past their due date." TH

Tom Collins is a freelance author in South Florida.

Conscientious handling of urinary catheters is one of the main responsibilities hospitalists have in caring for patients with urological disorders—and, of course, anyone else with a urinary catheter.

Treatment of patients with urological disorders often involves special circumstances requiring physician discretion when deciding whether to remove a catheter or leave it in—removing it too soon could cause problems far worse than an infection. But two compelling studies, nationwide in scope, point to the benefits of systems that help ensure prompt removal of urinary catheters when appropriate.

One, published in 2010, was a review of interventional studies that used reminders to physicians or nurses that a urinary catheter was in use or stop orders to trigger catheter removal in hospitalized adults.

Researchers found that the rate of catheter-associated urinary tract infections, measured as episodes per 1,000 catheter-days, was reduced by 52% (P<0.001) with use of a reminder or stop order. The average duration of catheterization decreased by 37%. That amounted to 2.61 fewer days of catheterization per patient in the intervention compared to control groups.

In a 2013 study published in JAMA Internal Medicine, researchers surveyed infection prevention specialists at a sample of hospitals across the U.S.—and at all hospitals in Michigan, home to a statewide CAUTI-prevention initiative started in 2007. They asked about CAUTI prevention practices and standardized infection ratios on CAUTI.

Michigan hospitals, compared with those elsewhere in the U.S., more frequently participated in collaboratives to reduce healthcare-associated infection—94% to 67%. They also used bladder scanners to measure bladder volume more frequently (53% to 39%), along with catheter reminders or stop orders and/or nurse-initiated discontinuation (44% to 23%).

CAUTI rates in the state of Michigan saw a 25% reduction, significantly greater than the 6% decrease observed in the rest of the U.S.

Sanjay Saint, MD, MPH, a hospitalist and professor of internal medicine at the University of Michigan, says the study verifies how important it is for hospitalists to remove urinary catheters early.

"The data will set us free," he says. "It’s probably better to remove a few of these catheters prematurely and then have to reinsert them than keep all catheters in long past their due date." TH

Tom Collins is a freelance author in South Florida.

Click here to listen to excerpts of our interview with John Bulger, DO, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania.

Click here to listen to excerpts of our interview with John Bulger, DO, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania.

Click here to listen to excerpts of our interview with John Bulger, DO, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania.

Click here for excerpts of our interview with Porter Storey, MD, executive vice president of the American Academy of Hospice and Palliative Medicine.

Click here for excerpts of our interview with Porter Storey, MD, executive vice president of the American Academy of Hospice and Palliative Medicine.

Click here for excerpts of our interview with Porter Storey, MD, executive vice president of the American Academy of Hospice and Palliative Medicine.

Danielle Scheurer, MD, MSCR, SFHM

We talk a lot about value in healthcare these days. Most everyone in healthcare knows the infamous quality/cost equation: the lower the cost and the higher the quality, the higher the value. Seems like a pretty straightforward equation; there aren’t even any coefficients, factorials, exponents, or square roots. Just two simple terms: quality and cost. How complicated could that possibly be?

The problem with the value equation is not its complexity on paper but the reinforcing barriers in our healthcare system that have made it impossible to improve the value equation on a large scale. Despite millions of hard-working, well-intentioned people in the healthcare industry, quality continues to be variable at best, and cost continues to rise. Healthcare currently consumes nearly 18% of the U.S. gross domestic product, threatening other aspects of the American economy, notably education and other federally subsidized programs.

A series of articles published between The New England Journal of Medicine and the Harvard Business Review aims to discover and suggest solutions to the issues currently ailing the U.S. healthcare system.¹ The first installment focused on how to improve value on a large scale. The authors discuss the major barriers to realizing the value equation, along with some propositions for overcoming these barriers on a large scale.² Although all six barriers are extremely difficult to surmount, the authors argue that because they are all mutually reinforcing in the current state, all will need to be addressed swiftly, tenaciously, and simultaneously.

Outlined here is a summary of the proposed interventions, and how these can and will affect hospitalists.

1

Providers need to organize themselves around what patients need, instead of around what providers do and how they are reimbursed. This will entail a shift from individual, discrete services to comprehensive, patient-focused care of medical conditions. The authors term these “Integrated Practice Units (IPU),” in which an entire team of providers organize themselves around the patient’s disease and provide comprehensive care across the range of the severity of the disease and the locations in which that disease is best served.

For hospitalists, working in multidisciplinary teams will come as second nature, but this also will require hospitalists to enhance the flexibility with which they see the patients and provide services exactly as the patients need, rather than based on arbitrary schedules and conveniences. Many hospitalists are already involved in comprehensive specialty care of high-volume surgical conditions, such as total hip and total knee patients, who usually come with a relatively predictable set of co-morbid conditions, such as hypertension, diabetes, rheumatologic disease, or sickle cell anemia. The literature has clearly established the fact that high-volume specialty care centers can and do deliver higher value care (higher quality at lower cost), compared to lower volume, less “well-oiled” centers.

2

Providers need transparent and readily available information on quality and cost to move the value equation. As we all know, you can’t improve what you don’t measure. Hospitalists need to work collaboratively with their hospital systems to collect and widely report on quality and cost metrics for the patients they serve. These quality metrics should not only focus on those process and outcome measures that must currently be reported (internally or externally); hospitalists should seek out the metrics that really matter to patients, such as achieving functional status (ambulating, eating, being pain free), shortening recovery time (getting back to work, playing with the grandchildren), and sustaining recovery for as long as possible (relapse, readmission, reoperation).

Hospitalists should embrace the transparency of these metrics and encourage attribution of the metrics to individual providers or provider groups. Metric transparency stimulates rapid improvements and fosters goal alignment. Measurement and reporting of cost is absolutely essential in moving the value equation. Hospitalists should advocate for widespread transparency of the costs of tests, products, supplies, and manpower, and these should be freely and openly shared with patients and their families, to engage them in discussions about value.

3

Reimbursement for services should reflect the actual cost of the service and should be bundled. Many hospitalists are likely already involved in some demonstration projects around bundled payments for care across a continuum. Many CMS demonstration projects have focused on high-volume, predictable conditions (total hip arthroplasty, for instance) or high-volume, less predictable but costly conditions (such as congestive heart failure or COPD). Some large employers also are contracting with high volume hospitals to perform semi-elective procedures such as coronary artery bypass grafting, and sending their employees out of state to these centers of excellence. Most hospitalists are already at least conceptually comfortable with being held accountable for the cost and quality of certain patient types, including reducing unnecessary variation and spending and avoiding preventable complications.

4

Care should be integrated into a smaller number of large delivery systems, instead of a large number of small, “do-it-all” systems. These large systems have to actually work for the good of the patients, integrating their care and not just providing duplicate services in each location. Each center should be able to deliver excellent care in some conditions, not adequate care in all conditions. The more complicated, complex care should be delivered in tertiary care centers, and the more predictable, less heterogeneous care conditions should be addressed in lower-cost, community settings. Integrated systems can direct the right patients to the right location, to enhance both quality and cost.

5

On a related thread, healthcare systems need to focus patients on getting the right care in the right location and teach them to be less concerned about geography. In the days when hospital length of stays were routinely in the double digits, patients naturally opted to receive any and all care in a location close to their home and family. But now that hospital stays are generally in single digits, proximity to home is less important than good value of care, and healthcare systems need to steer patients to the best care delivery site, even if it is not near their homes. Some large employers have started reimbursing patients and their families for the cost associated with traveling to the correct site of care. With the availability of easy, low-cost travel options, this can and should be feasible for most patients and their families.

6

Information technology systems need to enable patient-centered care. Although this seemed to be the premise of EHRs, in reality, most have focused on enhancing billing, revenue, and documentation, rather than closely tracking the health, wellness, outcomes, and cost of individual patients throughout the care continuum. In the healthcare system of the future, the patient-centered EHR has to be readily accessible to all care providers, as well as to the patients themselves; it has to be easy to input and extract data; and it has to use common definitions for data.

Hospitalists would welcome such EHRs and should work tirelessly to achieve them within the healthcare system.

Conclusion

Although no single suggestion is wholly unappealing to the field of hospital medicine, accomplishing all of these quickly and simultaneously will be extremely challenging. It will take tremendous leadership and a bit of faith in the end goal. But the status quo is not an option, and current healthcare spending threatens the American Dream. Hospitalists can—and should—be pivotal in leading, or at least cooperating in, the achievement of this future-state, high-value healthcare system.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Curfman GD, Morrissey S, Drazen JM. High-value health care–a sustainable proposition. N Engl J Med. 2013;369:1163-1164.
2. Leading health care innovation. Available at: www.hbr.org/special-collections/insight/leading-health-care-innovation. Accessed October 22, 2013.

Danielle Scheurer, MD, MSCR, SFHM

We talk a lot about value in healthcare these days. Most everyone in healthcare knows the infamous quality/cost equation: the lower the cost and the higher the quality, the higher the value. Seems like a pretty straightforward equation; there aren’t even any coefficients, factorials, exponents, or square roots. Just two simple terms: quality and cost. How complicated could that possibly be?

The problem with the value equation is not its complexity on paper but the reinforcing barriers in our healthcare system that have made it impossible to improve the value equation on a large scale. Despite millions of hard-working, well-intentioned people in the healthcare industry, quality continues to be variable at best, and cost continues to rise. Healthcare currently consumes nearly 18% of the U.S. gross domestic product, threatening other aspects of the American economy, notably education and other federally subsidized programs.

A series of articles published between The New England Journal of Medicine and the Harvard Business Review aims to discover and suggest solutions to the issues currently ailing the U.S. healthcare system.¹ The first installment focused on how to improve value on a large scale. The authors discuss the major barriers to realizing the value equation, along with some propositions for overcoming these barriers on a large scale.² Although all six barriers are extremely difficult to surmount, the authors argue that because they are all mutually reinforcing in the current state, all will need to be addressed swiftly, tenaciously, and simultaneously.

Outlined here is a summary of the proposed interventions, and how these can and will affect hospitalists.

1

Providers need to organize themselves around what patients need, instead of around what providers do and how they are reimbursed. This will entail a shift from individual, discrete services to comprehensive, patient-focused care of medical conditions. The authors term these “Integrated Practice Units (IPU),” in which an entire team of providers organize themselves around the patient’s disease and provide comprehensive care across the range of the severity of the disease and the locations in which that disease is best served.

For hospitalists, working in multidisciplinary teams will come as second nature, but this also will require hospitalists to enhance the flexibility with which they see the patients and provide services exactly as the patients need, rather than based on arbitrary schedules and conveniences. Many hospitalists are already involved in comprehensive specialty care of high-volume surgical conditions, such as total hip and total knee patients, who usually come with a relatively predictable set of co-morbid conditions, such as hypertension, diabetes, rheumatologic disease, or sickle cell anemia. The literature has clearly established the fact that high-volume specialty care centers can and do deliver higher value care (higher quality at lower cost), compared to lower volume, less “well-oiled” centers.

2

Providers need transparent and readily available information on quality and cost to move the value equation. As we all know, you can’t improve what you don’t measure. Hospitalists need to work collaboratively with their hospital systems to collect and widely report on quality and cost metrics for the patients they serve. These quality metrics should not only focus on those process and outcome measures that must currently be reported (internally or externally); hospitalists should seek out the metrics that really matter to patients, such as achieving functional status (ambulating, eating, being pain free), shortening recovery time (getting back to work, playing with the grandchildren), and sustaining recovery for as long as possible (relapse, readmission, reoperation).

Hospitalists should embrace the transparency of these metrics and encourage attribution of the metrics to individual providers or provider groups. Metric transparency stimulates rapid improvements and fosters goal alignment. Measurement and reporting of cost is absolutely essential in moving the value equation. Hospitalists should advocate for widespread transparency of the costs of tests, products, supplies, and manpower, and these should be freely and openly shared with patients and their families, to engage them in discussions about value.

3

Reimbursement for services should reflect the actual cost of the service and should be bundled. Many hospitalists are likely already involved in some demonstration projects around bundled payments for care across a continuum. Many CMS demonstration projects have focused on high-volume, predictable conditions (total hip arthroplasty, for instance) or high-volume, less predictable but costly conditions (such as congestive heart failure or COPD). Some large employers also are contracting with high volume hospitals to perform semi-elective procedures such as coronary artery bypass grafting, and sending their employees out of state to these centers of excellence. Most hospitalists are already at least conceptually comfortable with being held accountable for the cost and quality of certain patient types, including reducing unnecessary variation and spending and avoiding preventable complications.

4

Care should be integrated into a smaller number of large delivery systems, instead of a large number of small, “do-it-all” systems. These large systems have to actually work for the good of the patients, integrating their care and not just providing duplicate services in each location. Each center should be able to deliver excellent care in some conditions, not adequate care in all conditions. The more complicated, complex care should be delivered in tertiary care centers, and the more predictable, less heterogeneous care conditions should be addressed in lower-cost, community settings. Integrated systems can direct the right patients to the right location, to enhance both quality and cost.

5

On a related thread, healthcare systems need to focus patients on getting the right care in the right location and teach them to be less concerned about geography. In the days when hospital length of stays were routinely in the double digits, patients naturally opted to receive any and all care in a location close to their home and family. But now that hospital stays are generally in single digits, proximity to home is less important than good value of care, and healthcare systems need to steer patients to the best care delivery site, even if it is not near their homes. Some large employers have started reimbursing patients and their families for the cost associated with traveling to the correct site of care. With the availability of easy, low-cost travel options, this can and should be feasible for most patients and their families.

6

Information technology systems need to enable patient-centered care. Although this seemed to be the premise of EHRs, in reality, most have focused on enhancing billing, revenue, and documentation, rather than closely tracking the health, wellness, outcomes, and cost of individual patients throughout the care continuum. In the healthcare system of the future, the patient-centered EHR has to be readily accessible to all care providers, as well as to the patients themselves; it has to be easy to input and extract data; and it has to use common definitions for data.

Hospitalists would welcome such EHRs and should work tirelessly to achieve them within the healthcare system.

Conclusion

Although no single suggestion is wholly unappealing to the field of hospital medicine, accomplishing all of these quickly and simultaneously will be extremely challenging. It will take tremendous leadership and a bit of faith in the end goal. But the status quo is not an option, and current healthcare spending threatens the American Dream. Hospitalists can—and should—be pivotal in leading, or at least cooperating in, the achievement of this future-state, high-value healthcare system.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Curfman GD, Morrissey S, Drazen JM. High-value health care–a sustainable proposition. N Engl J Med. 2013;369:1163-1164.
2. Leading health care innovation. Available at: www.hbr.org/special-collections/insight/leading-health-care-innovation. Accessed October 22, 2013.

Danielle Scheurer, MD, MSCR, SFHM

We talk a lot about value in healthcare these days. Most everyone in healthcare knows the infamous quality/cost equation: the lower the cost and the higher the quality, the higher the value. Seems like a pretty straightforward equation; there aren’t even any coefficients, factorials, exponents, or square roots. Just two simple terms: quality and cost. How complicated could that possibly be?

The problem with the value equation is not its complexity on paper but the reinforcing barriers in our healthcare system that have made it impossible to improve the value equation on a large scale. Despite millions of hard-working, well-intentioned people in the healthcare industry, quality continues to be variable at best, and cost continues to rise. Healthcare currently consumes nearly 18% of the U.S. gross domestic product, threatening other aspects of the American economy, notably education and other federally subsidized programs.

A series of articles published between The New England Journal of Medicine and the Harvard Business Review aims to discover and suggest solutions to the issues currently ailing the U.S. healthcare system.¹ The first installment focused on how to improve value on a large scale. The authors discuss the major barriers to realizing the value equation, along with some propositions for overcoming these barriers on a large scale.² Although all six barriers are extremely difficult to surmount, the authors argue that because they are all mutually reinforcing in the current state, all will need to be addressed swiftly, tenaciously, and simultaneously.

Outlined here is a summary of the proposed interventions, and how these can and will affect hospitalists.

1

Providers need to organize themselves around what patients need, instead of around what providers do and how they are reimbursed. This will entail a shift from individual, discrete services to comprehensive, patient-focused care of medical conditions. The authors term these “Integrated Practice Units (IPU),” in which an entire team of providers organize themselves around the patient’s disease and provide comprehensive care across the range of the severity of the disease and the locations in which that disease is best served.

For hospitalists, working in multidisciplinary teams will come as second nature, but this also will require hospitalists to enhance the flexibility with which they see the patients and provide services exactly as the patients need, rather than based on arbitrary schedules and conveniences. Many hospitalists are already involved in comprehensive specialty care of high-volume surgical conditions, such as total hip and total knee patients, who usually come with a relatively predictable set of co-morbid conditions, such as hypertension, diabetes, rheumatologic disease, or sickle cell anemia. The literature has clearly established the fact that high-volume specialty care centers can and do deliver higher value care (higher quality at lower cost), compared to lower volume, less “well-oiled” centers.

2

Providers need transparent and readily available information on quality and cost to move the value equation. As we all know, you can’t improve what you don’t measure. Hospitalists need to work collaboratively with their hospital systems to collect and widely report on quality and cost metrics for the patients they serve. These quality metrics should not only focus on those process and outcome measures that must currently be reported (internally or externally); hospitalists should seek out the metrics that really matter to patients, such as achieving functional status (ambulating, eating, being pain free), shortening recovery time (getting back to work, playing with the grandchildren), and sustaining recovery for as long as possible (relapse, readmission, reoperation).

Hospitalists should embrace the transparency of these metrics and encourage attribution of the metrics to individual providers or provider groups. Metric transparency stimulates rapid improvements and fosters goal alignment. Measurement and reporting of cost is absolutely essential in moving the value equation. Hospitalists should advocate for widespread transparency of the costs of tests, products, supplies, and manpower, and these should be freely and openly shared with patients and their families, to engage them in discussions about value.

3

Reimbursement for services should reflect the actual cost of the service and should be bundled. Many hospitalists are likely already involved in some demonstration projects around bundled payments for care across a continuum. Many CMS demonstration projects have focused on high-volume, predictable conditions (total hip arthroplasty, for instance) or high-volume, less predictable but costly conditions (such as congestive heart failure or COPD). Some large employers also are contracting with high volume hospitals to perform semi-elective procedures such as coronary artery bypass grafting, and sending their employees out of state to these centers of excellence. Most hospitalists are already at least conceptually comfortable with being held accountable for the cost and quality of certain patient types, including reducing unnecessary variation and spending and avoiding preventable complications.

4

Care should be integrated into a smaller number of large delivery systems, instead of a large number of small, “do-it-all” systems. These large systems have to actually work for the good of the patients, integrating their care and not just providing duplicate services in each location. Each center should be able to deliver excellent care in some conditions, not adequate care in all conditions. The more complicated, complex care should be delivered in tertiary care centers, and the more predictable, less heterogeneous care conditions should be addressed in lower-cost, community settings. Integrated systems can direct the right patients to the right location, to enhance both quality and cost.

5

On a related thread, healthcare systems need to focus patients on getting the right care in the right location and teach them to be less concerned about geography. In the days when hospital length of stays were routinely in the double digits, patients naturally opted to receive any and all care in a location close to their home and family. But now that hospital stays are generally in single digits, proximity to home is less important than good value of care, and healthcare systems need to steer patients to the best care delivery site, even if it is not near their homes. Some large employers have started reimbursing patients and their families for the cost associated with traveling to the correct site of care. With the availability of easy, low-cost travel options, this can and should be feasible for most patients and their families.

6

Information technology systems need to enable patient-centered care. Although this seemed to be the premise of EHRs, in reality, most have focused on enhancing billing, revenue, and documentation, rather than closely tracking the health, wellness, outcomes, and cost of individual patients throughout the care continuum. In the healthcare system of the future, the patient-centered EHR has to be readily accessible to all care providers, as well as to the patients themselves; it has to be easy to input and extract data; and it has to use common definitions for data.

Hospitalists would welcome such EHRs and should work tirelessly to achieve them within the healthcare system.

Conclusion

Although no single suggestion is wholly unappealing to the field of hospital medicine, accomplishing all of these quickly and simultaneously will be extremely challenging. It will take tremendous leadership and a bit of faith in the end goal. But the status quo is not an option, and current healthcare spending threatens the American Dream. Hospitalists can—and should—be pivotal in leading, or at least cooperating in, the achievement of this future-state, high-value healthcare system.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Curfman GD, Morrissey S, Drazen JM. High-value health care–a sustainable proposition. N Engl J Med. 2013;369:1163-1164.
2. Leading health care innovation. Available at: www.hbr.org/special-collections/insight/leading-health-care-innovation. Accessed October 22, 2013.

Dr. Whitcomb

Dr. Whitcomb

When I visit hospitalist programs, one of the things I am most interested in learning about is the degree to which the hospitalists enjoy their work and why. On a recent visit, in my usual meeting with the hospitalist group, we talked a lot about what it is like to be a hospitalist. When I asked them what the greatest threat to their job satisfaction was, there was a chorus of consistency in their answers: interruptions. The hospitalists were deeply frustrated by minute-to-minute intrusions into their workflow. The emergency department, nurses, pharmacy, the admitting department, the lab, radiology—you name it, everyone wants a piece of them.

Constant interruptions are a career satisfaction issue for hospitalists. But for patients, the interruptions represent a safety and quality of care issue. Why?

The Myth of Multi-tasking

Some of us take pride in our ability to multi-task. Others freely admit they aren’t very good at it. In any case, we know through cognitive psychology that the brain cannot multi-task, at least in the realm of conscious work. (The brain, of course, carries out basic, life-sustaining functions while we are doing other work cognitively.) The brain is actually a “sequential processor,” and multi-tasking actually is “task-switching.” Those of us who “multi-task” well are able to switch tasks easily and effectively.

But, task switching comes at a cost. When we switch tasks, we are prone to errors in the performance of those tasks. Two psychologists, Rogers and Monsell, demonstrated this in a study that looked at error rates when subjects performed tasks involving numerical or letter manipulations.¹ The tasks involved classifying either the digit member of a pair of characters as even/odd or the letter member as consonant/vowel. When subjects performed the tasks while switching among multiple tasks, the error rate was fourfold the rate with no task switching (see Figure 1).¹ These findings have been replicated since the original study. Further, there is now well-developed literature devoted to interruptions and patient safety.

Dr. Whitcomb

Dr. Whitcomb

It Takes Time

We also know that switching between tasks takes time. Why? Because changing one’s attention from one subject to another involves neurologic processes that are not instantaneous. In a simulated driving study comparing mean reaction times between intoxicated subjects (blood alcohol 0.08%) and those talking on a cell phone, Strayer and Drews found the mean time to brake onset was significantly slower in the cell phone group than in the drunk driving group, presumably because cell phone users had to switch tasks.²

How Can We Tame Interruptions?

I submit that we need to be realistic about our ability to control the number of interruptions hospitalists experience in a given workday. One approach is to identify “high stakes moments” that are protected from excessive interruptions. Taking an example from aviation, airplane takeoffs and landings are “no interruption” zones, meaning that no needless talking or tasking is allowed in the cockpit during these tasks. Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But is it realistic to think that we can cordon off hospitalists during these tasks?

Another approach is to establish practices that may decrease interruptions. Interruptions likely are reduced by:

• Having unit-based hospitalist staffing;
• Holding multidisciplinary rounds;
• Training nurses to batch pages;
• Conducting structured evening and night rounds on all nursing units for non-urgent matters; and
• Developing paging “levels” so that a receiving physician knows if a call back is needed and, if so, if it is urgent or not.

In talking to hospitalists who cite interruptions as job dissatisfiers, it occurs to me that anything that erodes career engagement also threatens patient safety. If we could figure out how to control interruptions, we would kill two birds with one stone.

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

References

1. Rogers RD, Monsell S. Costs of a predictable switch between simple cognitive tasks. J Exp Psych. 1995;124(2):207-231.
2. Strayer DL, Drews FA, Crouch DJ. A comparison of the cell phone driver and the drunk driver. Hum Factors. 2006;48(2):381-391.

Dr. Whitcomb

Dr. Whitcomb

When I visit hospitalist programs, one of the things I am most interested in learning about is the degree to which the hospitalists enjoy their work and why. On a recent visit, in my usual meeting with the hospitalist group, we talked a lot about what it is like to be a hospitalist. When I asked them what the greatest threat to their job satisfaction was, there was a chorus of consistency in their answers: interruptions. The hospitalists were deeply frustrated by minute-to-minute intrusions into their workflow. The emergency department, nurses, pharmacy, the admitting department, the lab, radiology—you name it, everyone wants a piece of them.

Constant interruptions are a career satisfaction issue for hospitalists. But for patients, the interruptions represent a safety and quality of care issue. Why?

The Myth of Multi-tasking

Some of us take pride in our ability to multi-task. Others freely admit they aren’t very good at it. In any case, we know through cognitive psychology that the brain cannot multi-task, at least in the realm of conscious work. (The brain, of course, carries out basic, life-sustaining functions while we are doing other work cognitively.) The brain is actually a “sequential processor,” and multi-tasking actually is “task-switching.” Those of us who “multi-task” well are able to switch tasks easily and effectively.

But, task switching comes at a cost. When we switch tasks, we are prone to errors in the performance of those tasks. Two psychologists, Rogers and Monsell, demonstrated this in a study that looked at error rates when subjects performed tasks involving numerical or letter manipulations.¹ The tasks involved classifying either the digit member of a pair of characters as even/odd or the letter member as consonant/vowel. When subjects performed the tasks while switching among multiple tasks, the error rate was fourfold the rate with no task switching (see Figure 1).¹ These findings have been replicated since the original study. Further, there is now well-developed literature devoted to interruptions and patient safety.

Dr. Whitcomb

Dr. Whitcomb

It Takes Time

We also know that switching between tasks takes time. Why? Because changing one’s attention from one subject to another involves neurologic processes that are not instantaneous. In a simulated driving study comparing mean reaction times between intoxicated subjects (blood alcohol 0.08%) and those talking on a cell phone, Strayer and Drews found the mean time to brake onset was significantly slower in the cell phone group than in the drunk driving group, presumably because cell phone users had to switch tasks.²

How Can We Tame Interruptions?

I submit that we need to be realistic about our ability to control the number of interruptions hospitalists experience in a given workday. One approach is to identify “high stakes moments” that are protected from excessive interruptions. Taking an example from aviation, airplane takeoffs and landings are “no interruption” zones, meaning that no needless talking or tasking is allowed in the cockpit during these tasks. Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But is it realistic to think that we can cordon off hospitalists during these tasks?

Another approach is to establish practices that may decrease interruptions. Interruptions likely are reduced by:

• Having unit-based hospitalist staffing;
• Holding multidisciplinary rounds;
• Training nurses to batch pages;
• Conducting structured evening and night rounds on all nursing units for non-urgent matters; and
• Developing paging “levels” so that a receiving physician knows if a call back is needed and, if so, if it is urgent or not.

In talking to hospitalists who cite interruptions as job dissatisfiers, it occurs to me that anything that erodes career engagement also threatens patient safety. If we could figure out how to control interruptions, we would kill two birds with one stone.

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

References

1. Rogers RD, Monsell S. Costs of a predictable switch between simple cognitive tasks. J Exp Psych. 1995;124(2):207-231.
2. Strayer DL, Drews FA, Crouch DJ. A comparison of the cell phone driver and the drunk driver. Hum Factors. 2006;48(2):381-391.

Dr. Whitcomb

Dr. Whitcomb

When I visit hospitalist programs, one of the things I am most interested in learning about is the degree to which the hospitalists enjoy their work and why. On a recent visit, in my usual meeting with the hospitalist group, we talked a lot about what it is like to be a hospitalist. When I asked them what the greatest threat to their job satisfaction was, there was a chorus of consistency in their answers: interruptions. The hospitalists were deeply frustrated by minute-to-minute intrusions into their workflow. The emergency department, nurses, pharmacy, the admitting department, the lab, radiology—you name it, everyone wants a piece of them.

Constant interruptions are a career satisfaction issue for hospitalists. But for patients, the interruptions represent a safety and quality of care issue. Why?

The Myth of Multi-tasking

Some of us take pride in our ability to multi-task. Others freely admit they aren’t very good at it. In any case, we know through cognitive psychology that the brain cannot multi-task, at least in the realm of conscious work. (The brain, of course, carries out basic, life-sustaining functions while we are doing other work cognitively.) The brain is actually a “sequential processor,” and multi-tasking actually is “task-switching.” Those of us who “multi-task” well are able to switch tasks easily and effectively.

But, task switching comes at a cost. When we switch tasks, we are prone to errors in the performance of those tasks. Two psychologists, Rogers and Monsell, demonstrated this in a study that looked at error rates when subjects performed tasks involving numerical or letter manipulations.¹ The tasks involved classifying either the digit member of a pair of characters as even/odd or the letter member as consonant/vowel. When subjects performed the tasks while switching among multiple tasks, the error rate was fourfold the rate with no task switching (see Figure 1).¹ These findings have been replicated since the original study. Further, there is now well-developed literature devoted to interruptions and patient safety.

Dr. Whitcomb

Dr. Whitcomb

It Takes Time

We also know that switching between tasks takes time. Why? Because changing one’s attention from one subject to another involves neurologic processes that are not instantaneous. In a simulated driving study comparing mean reaction times between intoxicated subjects (blood alcohol 0.08%) and those talking on a cell phone, Strayer and Drews found the mean time to brake onset was significantly slower in the cell phone group than in the drunk driving group, presumably because cell phone users had to switch tasks.²

How Can We Tame Interruptions?

I submit that we need to be realistic about our ability to control the number of interruptions hospitalists experience in a given workday. One approach is to identify “high stakes moments” that are protected from excessive interruptions. Taking an example from aviation, airplane takeoffs and landings are “no interruption” zones, meaning that no needless talking or tasking is allowed in the cockpit during these tasks. Potential “no interruption” zones in hospital medicine might include times when hospitalists are developing an assessment and plan, engaged in complex decision-making, or performing medication reconciliation.

But is it realistic to think that we can cordon off hospitalists during these tasks?

Another approach is to establish practices that may decrease interruptions. Interruptions likely are reduced by:

• Having unit-based hospitalist staffing;
• Holding multidisciplinary rounds;
• Training nurses to batch pages;
• Conducting structured evening and night rounds on all nursing units for non-urgent matters; and
• Developing paging “levels” so that a receiving physician knows if a call back is needed and, if so, if it is urgent or not.

In talking to hospitalists who cite interruptions as job dissatisfiers, it occurs to me that anything that erodes career engagement also threatens patient safety. If we could figure out how to control interruptions, we would kill two birds with one stone.

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

References

1. Rogers RD, Monsell S. Costs of a predictable switch between simple cognitive tasks. J Exp Psych. 1995;124(2):207-231.
2. Strayer DL, Drews FA, Crouch DJ. A comparison of the cell phone driver and the drunk driver. Hum Factors. 2006;48(2):381-391.

click for large version

Two Cases

A 76-year-old female with a history of hypertension, diabetes, atrial fibrillation, and diverticulosis is admitted with acute onset of dizziness and several episodes of bright red blood per rectum. Her labs show a new anemia at hemoglobin level 6.9 g/dL and an international normalized ratio (INR) of 2.7. She is transfused several units of packed red blood cells and fresh frozen plasma without further bleeding. She undergoes an esophagogastroduodenoscopy (EGD) and colonoscopy, which are notable only for extensive diverticulosis. In preparing the discharge medication reconciliation, you are uncertain what to do with the patient’s anticoagulation.

An 85-year-old male with coronary artery disease status post-percutaneous coronary intervention, with placement of a drug-eluting stent several years prior, is admitted with multiple weeks of epigastric discomfort and acute onset of hematemesis. His laboratory tests are notable for a new anemia at hemoglobin level 6.5 g/dL. Urgent EGD demonstrates a bleeding ulcer, which is cauterized. He is started on a proton-pump inhibitor (PPI). He inquires as to when he can restart his home medications, including aspirin.

Overview

Gastrointestinal (GI) bleeding is a serious complication of anticoagulant and antiplatelet therapy. Risks for GI bleeding include older age, history of peptic ulcer disease, NSAID or steroid use, and the use of antiplatelet or anticoagulation therapy. The estimated incidence of GI bleeding in the general population is 48 to 160 cases (upper GI) and 21 cases (lower GI) per 1,000 adults per year, with a case-mortality rate between 5% and 14%.¹

Although there is consensus on ceasing anticoagulant and antiplatelet agents during an acute GI bleed, debate remains over the appropriate approach to restarting these agents.

Anticoagulant Resumption

A recent study published in Archives of Internal Medicine supports a quick resumption of anticoagulation following a GI bleed.2 Although previous studies on restarting anticoagulants were small and demonstrated mixed results, this retrospective cohort study examined more than 442 warfarin-associated GI bleeds. After adjusting for various clinical indicators (e.g. clinical seriousness of bleeding, requirement of transfusions), the investigators found that the decision not to resume warfarin within 90 days of an initial GI hemorrhage was associated with an increased risk of thrombosis and death. Of note, in those patients restarted on warfarin, the mean time to medication initiation was four days following the initial GI bleed. In those not restarted on warfarin, the earliest incidence of thrombosis was documented at eight days following cessation of anticoagulation.²

Though its clinical implications are limited by the retrospective design, this study is helpful in guiding management decisions. Randomized control trials and society recommendations on this topic are lacking, so the decision to resume anticoagulants rests on patient-specific estimates of the risk of recurrent bleeding and the benefits of resuming anticoagulants.

In identifying those patients most likely to benefit from restarting anticoagulation, the risk of thromboembolism should be determined using an established risk stratification framework, such as Antithrombotic Therapy and Prevention of Thrombosis, 9th edition (see Table 1).³ According to the guidelines, patients at highest risk of thromboembolism (in the absence of anticoagulation) are those with:

• mitral valve prostheses;
• atrial fibrillation with a CHADS2 score of five to six or cerebrovascular accidents (CVA) within the last three months; and/or
• venous thromboembolism (VTE) within the last three months or history of severe thrombophilia.

Patients at the lowest risk of thromboembolism are those with:

• mechanical aortic prostheses with no other stroke risk factors;
• atrial fibrillation with a CHADS2 score of zero to two; and/or
• a single VTE that occurred >12 months prior.

There are several approaches to identifying patients at greatest risk for bleeding. Location-specific modeling for upper GI bleeds (e.g. Rockall score) and lower GI bleeds (e.g. BLEED score) focus on the clinical presentation and/or endoscopic findings. General hemorrhage risk scores (e.g. HAS-BLED, ATRIA) focus on medical comorbidities. While easy to use, the predictive value of such scores as part of anticoagulation resumption after a GI hemorrhage remains uncertain.

Based on the above methods of risk stratification, patients at higher risk of thromboembolism and lower risk of bleeding will likely benefit from waiting only a short time interval before restarting anticoagulation. Based on the trial conducted by Witt and colleagues, anticoagulation typically can be reinitiated within four days of obtaining hemostatic and hemodynamic stability.² Conversely, those at highest risk of bleeding and lower risk of thromboembolism will benefit from a delayed resumption of anticoagulation. Involvement of a specialist, such as a gastroenterologist, could help further clarify the risk of rebleeding.

The ideal approach for patients with a high risk of both bleeding and thromboembolism remains uncertain. Such cases highlight the need for an informed discussion with the patient and any involved caregivers, as well as involvement of inpatient subspecialists and outpatient longitudinal providers.

There remains a lack of evidence on the best method to restart anticoagulation. Based on small and retrospective trials, we recommend restarting warfarin at the patient’s previous home dose. The duration of inpatient monitoring following warfarin initiation should be individualized, but warfarin is not expected to impair coagulation for four to six days after initiation.

Little data is available with respect to the role of novel oral anticoagulants after a GI bleed. Given the lack of reversing agents for these drugs, we recommend exercising caution in populations with a high risk of rebleeding. Theoretically, given that these agents reach peak effect faster than warfarin, waiting an additional four days after the time frame recommended for starting warfarin is a prudent resumption strategy for novel oral anticoagulants.

click for large version

Resumption of Antiplatelet Agents

The decision to resume antiplatelet therapy should also be highly individualized. In addition to weighing the risk of bleeding (as described in the previous section), the physician must also estimate the benefits of antiplatelet therapy in decreasing the risk of cardiovascular events.

In low-risk patients on antiplatelet therapy (i.e., for primary cardiovascular prevention) reinitiation after a bleeding episode can be reasonably delayed, because the risk of rebleeding likely outweighs the potential benefit of restarting therapy.

For patients who are at intermediate risk (i.e., those on antiplatelet agents for secondary prevention of cardiovascular disease), emerging evidence argues for early reinstitution after a GI bleed. In a trial published in Annals of Internal Medicine, Sung and colleagues randomized 156 patients to aspirin or placebo therapy immediately following endoscopically obtained hemostasis for peptic ulcer bleeding.⁴ All patients received PPIs. There was no significant difference in bleeding rates between the two groups, but delayed resumption of aspirin was associated with a significant increase in all-cause mortality.

Two recent meta-analyses provide further insight into the risks of withholding aspirin therapy. The first, which included 50,279 patients on aspirin for secondary prevention, found that aspirin non-adherence or withdrawal after a GI bleed was associated with a three-fold higher risk of major adverse cardiac events.⁵ Cardiac event rates were highest in the subgroup of patients with a history of prior percutaneous coronary stenting.

A second meta-analysis evaluated patients who had aspirin held perioperatively. In a population of patients on aspirin for secondary prevention, the mean time after withholding aspirin was 8.5 days to coronary events, 14.3 days to cerebrovascular events, and 25.8 days to peripheral arterial events.⁶ Events occurred as early as five days after withdrawal of aspirin.

Patients with recent intracoronary stenting are at highest risk of thrombosis. In patients with a bare metal stent placed within six weeks, or a drug-eluting stent placed within six months, every effort should be made to minimize interruptions of dual antiplatelet therapy.

Based on the data presented above, for patients at intermediate and/or high risk of adverse cardiac events, we recommend reinstitution of aspirin as soon as possible following a GI hemorrhage, preferably within five days. PPI co-therapy is a mainstay for secondary prevention of upper GI bleeding in patients on antiplatelet therapy. Current research and guidelines have not addressed specifically the role of withholding and reinitiating aspirin in lower GI bleeding, non-peptic ulcer, or upper-GI bleeding, however, a similar strategy is likely appropriate. As with the decision for restarting anticoagulants, discussion with relevant specialists is essential to best define the risk of re-bleeding.

Back to the Cases

Given her CHADS2 score of three, the patient with a diverticular bleed has a 9.6% annual risk of stroke if she does not resume anticoagulation. Using the HAS-BLED and ATRIA scores, this patient has 2.6% to 5.8% annual risk of hemorrhage. We recommend resuming warfarin anticoagulation therapy within four days of achieving hemostasis.

For the patient with coronary artery disease with remote drug-eluting stent placement and upper GI bleed, evidence supports early resumption of appropriate antiplatelet therapy following endoscopic therapy and hemostasis. We recommend resuming aspirin during the current hospitalization and concomitant treatment with a PPI indefinitely.

Bottom Line

Following a GI bleed, the risks and benefits of restarting anticoagulant and antiplatelet agents need to be carefully considered. In patients on oral anticoagulants at high risk for thromboembolism and low risk for rebleeding, consider restarting anticoagulation within four to five days. Patients on antiplatelet agents for secondary prevention should have the medication restarted during hospitalization after endoscopically obtained hemostasis of a peptic ulcer.

In all cases, hospitalists should engage the patient, gastroenterologist, and outpatient provider to best determine when resumption of anticoagulant and/or antiplatelet agents should occur.

Dr. Allen-Dicker is a hospitalist and clinical instructor at Mount Sinai Medical Center in New York City. Dr. Briones is director of perioperative services in the division of hospital medicine and an assistant professor; Dr. Berman is a hospitalist and a clinical instructor, and Dr. Dunn is a professor of medicine and chief of the division of hospital medicine, all at Mount Sinai Medical Center.

References

1. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101-113.
2. Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012;172(19):1484-1491.
3. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S-350S.
4. Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: A randomized trial. Ann Intern Med. 2010;152(1):1-9.
5. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27(22):2667-2674.
6. Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med. 2005;257(5):399-414.

click for large version

Two Cases

A 76-year-old female with a history of hypertension, diabetes, atrial fibrillation, and diverticulosis is admitted with acute onset of dizziness and several episodes of bright red blood per rectum. Her labs show a new anemia at hemoglobin level 6.9 g/dL and an international normalized ratio (INR) of 2.7. She is transfused several units of packed red blood cells and fresh frozen plasma without further bleeding. She undergoes an esophagogastroduodenoscopy (EGD) and colonoscopy, which are notable only for extensive diverticulosis. In preparing the discharge medication reconciliation, you are uncertain what to do with the patient’s anticoagulation.

An 85-year-old male with coronary artery disease status post-percutaneous coronary intervention, with placement of a drug-eluting stent several years prior, is admitted with multiple weeks of epigastric discomfort and acute onset of hematemesis. His laboratory tests are notable for a new anemia at hemoglobin level 6.5 g/dL. Urgent EGD demonstrates a bleeding ulcer, which is cauterized. He is started on a proton-pump inhibitor (PPI). He inquires as to when he can restart his home medications, including aspirin.

Overview

Gastrointestinal (GI) bleeding is a serious complication of anticoagulant and antiplatelet therapy. Risks for GI bleeding include older age, history of peptic ulcer disease, NSAID or steroid use, and the use of antiplatelet or anticoagulation therapy. The estimated incidence of GI bleeding in the general population is 48 to 160 cases (upper GI) and 21 cases (lower GI) per 1,000 adults per year, with a case-mortality rate between 5% and 14%.¹

Although there is consensus on ceasing anticoagulant and antiplatelet agents during an acute GI bleed, debate remains over the appropriate approach to restarting these agents.

Anticoagulant Resumption

A recent study published in Archives of Internal Medicine supports a quick resumption of anticoagulation following a GI bleed.2 Although previous studies on restarting anticoagulants were small and demonstrated mixed results, this retrospective cohort study examined more than 442 warfarin-associated GI bleeds. After adjusting for various clinical indicators (e.g. clinical seriousness of bleeding, requirement of transfusions), the investigators found that the decision not to resume warfarin within 90 days of an initial GI hemorrhage was associated with an increased risk of thrombosis and death. Of note, in those patients restarted on warfarin, the mean time to medication initiation was four days following the initial GI bleed. In those not restarted on warfarin, the earliest incidence of thrombosis was documented at eight days following cessation of anticoagulation.²

Though its clinical implications are limited by the retrospective design, this study is helpful in guiding management decisions. Randomized control trials and society recommendations on this topic are lacking, so the decision to resume anticoagulants rests on patient-specific estimates of the risk of recurrent bleeding and the benefits of resuming anticoagulants.

In identifying those patients most likely to benefit from restarting anticoagulation, the risk of thromboembolism should be determined using an established risk stratification framework, such as Antithrombotic Therapy and Prevention of Thrombosis, 9th edition (see Table 1).³ According to the guidelines, patients at highest risk of thromboembolism (in the absence of anticoagulation) are those with:

• mitral valve prostheses;
• atrial fibrillation with a CHADS2 score of five to six or cerebrovascular accidents (CVA) within the last three months; and/or
• venous thromboembolism (VTE) within the last three months or history of severe thrombophilia.

Patients at the lowest risk of thromboembolism are those with:

• mechanical aortic prostheses with no other stroke risk factors;
• atrial fibrillation with a CHADS2 score of zero to two; and/or
• a single VTE that occurred >12 months prior.

There are several approaches to identifying patients at greatest risk for bleeding. Location-specific modeling for upper GI bleeds (e.g. Rockall score) and lower GI bleeds (e.g. BLEED score) focus on the clinical presentation and/or endoscopic findings. General hemorrhage risk scores (e.g. HAS-BLED, ATRIA) focus on medical comorbidities. While easy to use, the predictive value of such scores as part of anticoagulation resumption after a GI hemorrhage remains uncertain.

Based on the above methods of risk stratification, patients at higher risk of thromboembolism and lower risk of bleeding will likely benefit from waiting only a short time interval before restarting anticoagulation. Based on the trial conducted by Witt and colleagues, anticoagulation typically can be reinitiated within four days of obtaining hemostatic and hemodynamic stability.² Conversely, those at highest risk of bleeding and lower risk of thromboembolism will benefit from a delayed resumption of anticoagulation. Involvement of a specialist, such as a gastroenterologist, could help further clarify the risk of rebleeding.

The ideal approach for patients with a high risk of both bleeding and thromboembolism remains uncertain. Such cases highlight the need for an informed discussion with the patient and any involved caregivers, as well as involvement of inpatient subspecialists and outpatient longitudinal providers.

There remains a lack of evidence on the best method to restart anticoagulation. Based on small and retrospective trials, we recommend restarting warfarin at the patient’s previous home dose. The duration of inpatient monitoring following warfarin initiation should be individualized, but warfarin is not expected to impair coagulation for four to six days after initiation.

Little data is available with respect to the role of novel oral anticoagulants after a GI bleed. Given the lack of reversing agents for these drugs, we recommend exercising caution in populations with a high risk of rebleeding. Theoretically, given that these agents reach peak effect faster than warfarin, waiting an additional four days after the time frame recommended for starting warfarin is a prudent resumption strategy for novel oral anticoagulants.

click for large version

Resumption of Antiplatelet Agents

The decision to resume antiplatelet therapy should also be highly individualized. In addition to weighing the risk of bleeding (as described in the previous section), the physician must also estimate the benefits of antiplatelet therapy in decreasing the risk of cardiovascular events.

In low-risk patients on antiplatelet therapy (i.e., for primary cardiovascular prevention) reinitiation after a bleeding episode can be reasonably delayed, because the risk of rebleeding likely outweighs the potential benefit of restarting therapy.

For patients who are at intermediate risk (i.e., those on antiplatelet agents for secondary prevention of cardiovascular disease), emerging evidence argues for early reinstitution after a GI bleed. In a trial published in Annals of Internal Medicine, Sung and colleagues randomized 156 patients to aspirin or placebo therapy immediately following endoscopically obtained hemostasis for peptic ulcer bleeding.⁴ All patients received PPIs. There was no significant difference in bleeding rates between the two groups, but delayed resumption of aspirin was associated with a significant increase in all-cause mortality.

Two recent meta-analyses provide further insight into the risks of withholding aspirin therapy. The first, which included 50,279 patients on aspirin for secondary prevention, found that aspirin non-adherence or withdrawal after a GI bleed was associated with a three-fold higher risk of major adverse cardiac events.⁵ Cardiac event rates were highest in the subgroup of patients with a history of prior percutaneous coronary stenting.

A second meta-analysis evaluated patients who had aspirin held perioperatively. In a population of patients on aspirin for secondary prevention, the mean time after withholding aspirin was 8.5 days to coronary events, 14.3 days to cerebrovascular events, and 25.8 days to peripheral arterial events.⁶ Events occurred as early as five days after withdrawal of aspirin.

Patients with recent intracoronary stenting are at highest risk of thrombosis. In patients with a bare metal stent placed within six weeks, or a drug-eluting stent placed within six months, every effort should be made to minimize interruptions of dual antiplatelet therapy.

Based on the data presented above, for patients at intermediate and/or high risk of adverse cardiac events, we recommend reinstitution of aspirin as soon as possible following a GI hemorrhage, preferably within five days. PPI co-therapy is a mainstay for secondary prevention of upper GI bleeding in patients on antiplatelet therapy. Current research and guidelines have not addressed specifically the role of withholding and reinitiating aspirin in lower GI bleeding, non-peptic ulcer, or upper-GI bleeding, however, a similar strategy is likely appropriate. As with the decision for restarting anticoagulants, discussion with relevant specialists is essential to best define the risk of re-bleeding.

Back to the Cases

Given her CHADS2 score of three, the patient with a diverticular bleed has a 9.6% annual risk of stroke if she does not resume anticoagulation. Using the HAS-BLED and ATRIA scores, this patient has 2.6% to 5.8% annual risk of hemorrhage. We recommend resuming warfarin anticoagulation therapy within four days of achieving hemostasis.

For the patient with coronary artery disease with remote drug-eluting stent placement and upper GI bleed, evidence supports early resumption of appropriate antiplatelet therapy following endoscopic therapy and hemostasis. We recommend resuming aspirin during the current hospitalization and concomitant treatment with a PPI indefinitely.

Bottom Line

Following a GI bleed, the risks and benefits of restarting anticoagulant and antiplatelet agents need to be carefully considered. In patients on oral anticoagulants at high risk for thromboembolism and low risk for rebleeding, consider restarting anticoagulation within four to five days. Patients on antiplatelet agents for secondary prevention should have the medication restarted during hospitalization after endoscopically obtained hemostasis of a peptic ulcer.

In all cases, hospitalists should engage the patient, gastroenterologist, and outpatient provider to best determine when resumption of anticoagulant and/or antiplatelet agents should occur.

Dr. Allen-Dicker is a hospitalist and clinical instructor at Mount Sinai Medical Center in New York City. Dr. Briones is director of perioperative services in the division of hospital medicine and an assistant professor; Dr. Berman is a hospitalist and a clinical instructor, and Dr. Dunn is a professor of medicine and chief of the division of hospital medicine, all at Mount Sinai Medical Center.

References

1. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101-113.
2. Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012;172(19):1484-1491.
3. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S-350S.
4. Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: A randomized trial. Ann Intern Med. 2010;152(1):1-9.
5. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27(22):2667-2674.
6. Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med. 2005;257(5):399-414.

click for large version

Two Cases

A 76-year-old female with a history of hypertension, diabetes, atrial fibrillation, and diverticulosis is admitted with acute onset of dizziness and several episodes of bright red blood per rectum. Her labs show a new anemia at hemoglobin level 6.9 g/dL and an international normalized ratio (INR) of 2.7. She is transfused several units of packed red blood cells and fresh frozen plasma without further bleeding. She undergoes an esophagogastroduodenoscopy (EGD) and colonoscopy, which are notable only for extensive diverticulosis. In preparing the discharge medication reconciliation, you are uncertain what to do with the patient’s anticoagulation.

An 85-year-old male with coronary artery disease status post-percutaneous coronary intervention, with placement of a drug-eluting stent several years prior, is admitted with multiple weeks of epigastric discomfort and acute onset of hematemesis. His laboratory tests are notable for a new anemia at hemoglobin level 6.5 g/dL. Urgent EGD demonstrates a bleeding ulcer, which is cauterized. He is started on a proton-pump inhibitor (PPI). He inquires as to when he can restart his home medications, including aspirin.

Overview

Gastrointestinal (GI) bleeding is a serious complication of anticoagulant and antiplatelet therapy. Risks for GI bleeding include older age, history of peptic ulcer disease, NSAID or steroid use, and the use of antiplatelet or anticoagulation therapy. The estimated incidence of GI bleeding in the general population is 48 to 160 cases (upper GI) and 21 cases (lower GI) per 1,000 adults per year, with a case-mortality rate between 5% and 14%.¹

Although there is consensus on ceasing anticoagulant and antiplatelet agents during an acute GI bleed, debate remains over the appropriate approach to restarting these agents.

Anticoagulant Resumption

A recent study published in Archives of Internal Medicine supports a quick resumption of anticoagulation following a GI bleed.2 Although previous studies on restarting anticoagulants were small and demonstrated mixed results, this retrospective cohort study examined more than 442 warfarin-associated GI bleeds. After adjusting for various clinical indicators (e.g. clinical seriousness of bleeding, requirement of transfusions), the investigators found that the decision not to resume warfarin within 90 days of an initial GI hemorrhage was associated with an increased risk of thrombosis and death. Of note, in those patients restarted on warfarin, the mean time to medication initiation was four days following the initial GI bleed. In those not restarted on warfarin, the earliest incidence of thrombosis was documented at eight days following cessation of anticoagulation.²

Though its clinical implications are limited by the retrospective design, this study is helpful in guiding management decisions. Randomized control trials and society recommendations on this topic are lacking, so the decision to resume anticoagulants rests on patient-specific estimates of the risk of recurrent bleeding and the benefits of resuming anticoagulants.

In identifying those patients most likely to benefit from restarting anticoagulation, the risk of thromboembolism should be determined using an established risk stratification framework, such as Antithrombotic Therapy and Prevention of Thrombosis, 9th edition (see Table 1).³ According to the guidelines, patients at highest risk of thromboembolism (in the absence of anticoagulation) are those with:

• mitral valve prostheses;
• atrial fibrillation with a CHADS2 score of five to six or cerebrovascular accidents (CVA) within the last three months; and/or
• venous thromboembolism (VTE) within the last three months or history of severe thrombophilia.

Patients at the lowest risk of thromboembolism are those with:

• mechanical aortic prostheses with no other stroke risk factors;
• atrial fibrillation with a CHADS2 score of zero to two; and/or
• a single VTE that occurred >12 months prior.

There are several approaches to identifying patients at greatest risk for bleeding. Location-specific modeling for upper GI bleeds (e.g. Rockall score) and lower GI bleeds (e.g. BLEED score) focus on the clinical presentation and/or endoscopic findings. General hemorrhage risk scores (e.g. HAS-BLED, ATRIA) focus on medical comorbidities. While easy to use, the predictive value of such scores as part of anticoagulation resumption after a GI hemorrhage remains uncertain.

Based on the above methods of risk stratification, patients at higher risk of thromboembolism and lower risk of bleeding will likely benefit from waiting only a short time interval before restarting anticoagulation. Based on the trial conducted by Witt and colleagues, anticoagulation typically can be reinitiated within four days of obtaining hemostatic and hemodynamic stability.² Conversely, those at highest risk of bleeding and lower risk of thromboembolism will benefit from a delayed resumption of anticoagulation. Involvement of a specialist, such as a gastroenterologist, could help further clarify the risk of rebleeding.

The ideal approach for patients with a high risk of both bleeding and thromboembolism remains uncertain. Such cases highlight the need for an informed discussion with the patient and any involved caregivers, as well as involvement of inpatient subspecialists and outpatient longitudinal providers.

There remains a lack of evidence on the best method to restart anticoagulation. Based on small and retrospective trials, we recommend restarting warfarin at the patient’s previous home dose. The duration of inpatient monitoring following warfarin initiation should be individualized, but warfarin is not expected to impair coagulation for four to six days after initiation.

Little data is available with respect to the role of novel oral anticoagulants after a GI bleed. Given the lack of reversing agents for these drugs, we recommend exercising caution in populations with a high risk of rebleeding. Theoretically, given that these agents reach peak effect faster than warfarin, waiting an additional four days after the time frame recommended for starting warfarin is a prudent resumption strategy for novel oral anticoagulants.

click for large version

Resumption of Antiplatelet Agents

The decision to resume antiplatelet therapy should also be highly individualized. In addition to weighing the risk of bleeding (as described in the previous section), the physician must also estimate the benefits of antiplatelet therapy in decreasing the risk of cardiovascular events.

In low-risk patients on antiplatelet therapy (i.e., for primary cardiovascular prevention) reinitiation after a bleeding episode can be reasonably delayed, because the risk of rebleeding likely outweighs the potential benefit of restarting therapy.

For patients who are at intermediate risk (i.e., those on antiplatelet agents for secondary prevention of cardiovascular disease), emerging evidence argues for early reinstitution after a GI bleed. In a trial published in Annals of Internal Medicine, Sung and colleagues randomized 156 patients to aspirin or placebo therapy immediately following endoscopically obtained hemostasis for peptic ulcer bleeding.⁴ All patients received PPIs. There was no significant difference in bleeding rates between the two groups, but delayed resumption of aspirin was associated with a significant increase in all-cause mortality.

Two recent meta-analyses provide further insight into the risks of withholding aspirin therapy. The first, which included 50,279 patients on aspirin for secondary prevention, found that aspirin non-adherence or withdrawal after a GI bleed was associated with a three-fold higher risk of major adverse cardiac events.⁵ Cardiac event rates were highest in the subgroup of patients with a history of prior percutaneous coronary stenting.

A second meta-analysis evaluated patients who had aspirin held perioperatively. In a population of patients on aspirin for secondary prevention, the mean time after withholding aspirin was 8.5 days to coronary events, 14.3 days to cerebrovascular events, and 25.8 days to peripheral arterial events.⁶ Events occurred as early as five days after withdrawal of aspirin.

Patients with recent intracoronary stenting are at highest risk of thrombosis. In patients with a bare metal stent placed within six weeks, or a drug-eluting stent placed within six months, every effort should be made to minimize interruptions of dual antiplatelet therapy.

Based on the data presented above, for patients at intermediate and/or high risk of adverse cardiac events, we recommend reinstitution of aspirin as soon as possible following a GI hemorrhage, preferably within five days. PPI co-therapy is a mainstay for secondary prevention of upper GI bleeding in patients on antiplatelet therapy. Current research and guidelines have not addressed specifically the role of withholding and reinitiating aspirin in lower GI bleeding, non-peptic ulcer, or upper-GI bleeding, however, a similar strategy is likely appropriate. As with the decision for restarting anticoagulants, discussion with relevant specialists is essential to best define the risk of re-bleeding.

Back to the Cases

Given her CHADS2 score of three, the patient with a diverticular bleed has a 9.6% annual risk of stroke if she does not resume anticoagulation. Using the HAS-BLED and ATRIA scores, this patient has 2.6% to 5.8% annual risk of hemorrhage. We recommend resuming warfarin anticoagulation therapy within four days of achieving hemostasis.

For the patient with coronary artery disease with remote drug-eluting stent placement and upper GI bleed, evidence supports early resumption of appropriate antiplatelet therapy following endoscopic therapy and hemostasis. We recommend resuming aspirin during the current hospitalization and concomitant treatment with a PPI indefinitely.

Bottom Line

Following a GI bleed, the risks and benefits of restarting anticoagulant and antiplatelet agents need to be carefully considered. In patients on oral anticoagulants at high risk for thromboembolism and low risk for rebleeding, consider restarting anticoagulation within four to five days. Patients on antiplatelet agents for secondary prevention should have the medication restarted during hospitalization after endoscopically obtained hemostasis of a peptic ulcer.

In all cases, hospitalists should engage the patient, gastroenterologist, and outpatient provider to best determine when resumption of anticoagulant and/or antiplatelet agents should occur.

Dr. Allen-Dicker is a hospitalist and clinical instructor at Mount Sinai Medical Center in New York City. Dr. Briones is director of perioperative services in the division of hospital medicine and an assistant professor; Dr. Berman is a hospitalist and a clinical instructor, and Dr. Dunn is a professor of medicine and chief of the division of hospital medicine, all at Mount Sinai Medical Center.

References

1. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101-113.
2. Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012;172(19):1484-1491.
3. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S-350S.
4. Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: A randomized trial. Ann Intern Med. 2010;152(1):1-9.
5. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27(22):2667-2674.
6. Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med. 2005;257(5):399-414.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

Brendon Shank is SHM’s associate vice president of communications.

SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

Brendon Shank is SHM’s associate vice president of communications.

SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

Brendon Shank is SHM’s associate vice president of communications.

One of hospital medicine’s premiere experts on urinary catheter use says that even though UTIs might be the main catheter issue with which hospitalists concern themselves, it’s just one of the issues to be thinking about when caring for patients with the devices.

“Non-infectious complications—trauma during time of insertion, pain, discomfort, hematuria after catheter removal—are also very important issues that a hospitalist needs to be aware of, even though we tend not to track those issues as closely as infections related to the catheter,” says Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor.

Often, there’s no easy way to know whether a patient might have sustained some injury at the time of insertion, because it’s not noted anywhere how many attempts at insertion there were. So it takes extra care to take that into account.

Simply having a catheter can lead to some problems that hospitalists usually try to prevent, he said.

“The catheter tethers the patient to the bed and acts as a one-point restraint,” says Dr. Saint, who many years ago co-wrote an article on the topic.4 “So it prevents them from getting up and out of bed, increasing the risk for venous thromboembolism [and] pressure sores, and the de-conditioning may lead to falls.”

A urinary catheter alone is not a recipe for bed rest.

“The patient could still get up and out of bed, but there needs to be close attention paid to the drainage bag and making sure that the drainage bag is kept below the bladder to prevent the reflux of urine into the bladder,” he says.

It’s similar to the recognition that ICU and hip-replacement patients benefit from early mobilization.

“We just have to be mindful of making sure that we do good catheter and drainage bag maintenance so that it minimizes the risk of infection,” Dr. Saint says.

Tom Collins is a freelance writer in South Florida.

One of hospital medicine’s premiere experts on urinary catheter use says that even though UTIs might be the main catheter issue with which hospitalists concern themselves, it’s just one of the issues to be thinking about when caring for patients with the devices.

“Non-infectious complications—trauma during time of insertion, pain, discomfort, hematuria after catheter removal—are also very important issues that a hospitalist needs to be aware of, even though we tend not to track those issues as closely as infections related to the catheter,” says Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor.

Often, there’s no easy way to know whether a patient might have sustained some injury at the time of insertion, because it’s not noted anywhere how many attempts at insertion there were. So it takes extra care to take that into account.

Simply having a catheter can lead to some problems that hospitalists usually try to prevent, he said.

“The catheter tethers the patient to the bed and acts as a one-point restraint,” says Dr. Saint, who many years ago co-wrote an article on the topic.4 “So it prevents them from getting up and out of bed, increasing the risk for venous thromboembolism [and] pressure sores, and the de-conditioning may lead to falls.”

A urinary catheter alone is not a recipe for bed rest.

“The patient could still get up and out of bed, but there needs to be close attention paid to the drainage bag and making sure that the drainage bag is kept below the bladder to prevent the reflux of urine into the bladder,” he says.

It’s similar to the recognition that ICU and hip-replacement patients benefit from early mobilization.

“We just have to be mindful of making sure that we do good catheter and drainage bag maintenance so that it minimizes the risk of infection,” Dr. Saint says.

Tom Collins is a freelance writer in South Florida.

One of hospital medicine’s premiere experts on urinary catheter use says that even though UTIs might be the main catheter issue with which hospitalists concern themselves, it’s just one of the issues to be thinking about when caring for patients with the devices.

“Non-infectious complications—trauma during time of insertion, pain, discomfort, hematuria after catheter removal—are also very important issues that a hospitalist needs to be aware of, even though we tend not to track those issues as closely as infections related to the catheter,” says Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor.

Often, there’s no easy way to know whether a patient might have sustained some injury at the time of insertion, because it’s not noted anywhere how many attempts at insertion there were. So it takes extra care to take that into account.

Simply having a catheter can lead to some problems that hospitalists usually try to prevent, he said.

“The catheter tethers the patient to the bed and acts as a one-point restraint,” says Dr. Saint, who many years ago co-wrote an article on the topic.4 “So it prevents them from getting up and out of bed, increasing the risk for venous thromboembolism [and] pressure sores, and the de-conditioning may lead to falls.”

A urinary catheter alone is not a recipe for bed rest.

“The patient could still get up and out of bed, but there needs to be close attention paid to the drainage bag and making sure that the drainage bag is kept below the bladder to prevent the reflux of urine into the bladder,” he says.

It’s similar to the recognition that ICU and hip-replacement patients benefit from early mobilization.

“We just have to be mindful of making sure that we do good catheter and drainage bag maintenance so that it minimizes the risk of infection,” Dr. Saint says.

Tom Collins is a freelance writer in South Florida.