Richard Quinn

A new Archives of Internal Medicine study that shows the use of multiple anti-thrombotics increases the risk of bleeding in atrial fibrillation (AF) patients compared with warfarin monotherapy shouldn't change hospitalists' prescribing patterns, according to one physician.

Kurt Pfeifer, MD, FACP, program director of the Internal Medicine Residency program at Medical College in Milwaukee, says the research is important, as it adds to the knowledge base on the potential dangers of combining aspirin, warfarin, and clopidogrel. But even in cases where bleeding risks can be tripled, Dr. Pfeifer suggests hospitalists keep an eye on the risk-reward curve.

"It comes back to: Ask yourself, Do [patients] have a reason to be on it?" says Dr. Pfeifer, an associate professor who stays current on bleeding-risk research. "If they do, you better have a real reason for not putting them on it."

The study concluded that all combinations of the three medications in AF patients are associated with increased risk of both fatal and nonfatal bleeding (Arch Intern Med. 2010;170(16):1433-1441). The cohort study noted that "dual warfarin and clopidogrel therapy and triple therapy carried a more than 3-fold higher risk than did warfarin monotherapy."

Dr. Pfeifer doesn't discount the information, but notes that he would likely only discourage the use in patients with a particularly high risk for bleeding. However, he thinks the study is also a good reminder that HM practitioners should communicate the risks and therapies to both patients and their PCPs.

"It's important to know what the risks are, but it doesn't take away from what the indicators are," he says. "In most of these situations, I think you can feel better that you’ve academically addressed it."

A new Archives of Internal Medicine study that shows the use of multiple anti-thrombotics increases the risk of bleeding in atrial fibrillation (AF) patients compared with warfarin monotherapy shouldn't change hospitalists' prescribing patterns, according to one physician.

Kurt Pfeifer, MD, FACP, program director of the Internal Medicine Residency program at Medical College in Milwaukee, says the research is important, as it adds to the knowledge base on the potential dangers of combining aspirin, warfarin, and clopidogrel. But even in cases where bleeding risks can be tripled, Dr. Pfeifer suggests hospitalists keep an eye on the risk-reward curve.

"It comes back to: Ask yourself, Do [patients] have a reason to be on it?" says Dr. Pfeifer, an associate professor who stays current on bleeding-risk research. "If they do, you better have a real reason for not putting them on it."

The study concluded that all combinations of the three medications in AF patients are associated with increased risk of both fatal and nonfatal bleeding (Arch Intern Med. 2010;170(16):1433-1441). The cohort study noted that "dual warfarin and clopidogrel therapy and triple therapy carried a more than 3-fold higher risk than did warfarin monotherapy."

Dr. Pfeifer doesn't discount the information, but notes that he would likely only discourage the use in patients with a particularly high risk for bleeding. However, he thinks the study is also a good reminder that HM practitioners should communicate the risks and therapies to both patients and their PCPs.

"It's important to know what the risks are, but it doesn't take away from what the indicators are," he says. "In most of these situations, I think you can feel better that you’ve academically addressed it."

A new Archives of Internal Medicine study that shows the use of multiple anti-thrombotics increases the risk of bleeding in atrial fibrillation (AF) patients compared with warfarin monotherapy shouldn't change hospitalists' prescribing patterns, according to one physician.

Kurt Pfeifer, MD, FACP, program director of the Internal Medicine Residency program at Medical College in Milwaukee, says the research is important, as it adds to the knowledge base on the potential dangers of combining aspirin, warfarin, and clopidogrel. But even in cases where bleeding risks can be tripled, Dr. Pfeifer suggests hospitalists keep an eye on the risk-reward curve.

"It comes back to: Ask yourself, Do [patients] have a reason to be on it?" says Dr. Pfeifer, an associate professor who stays current on bleeding-risk research. "If they do, you better have a real reason for not putting them on it."

The study concluded that all combinations of the three medications in AF patients are associated with increased risk of both fatal and nonfatal bleeding (Arch Intern Med. 2010;170(16):1433-1441). The cohort study noted that "dual warfarin and clopidogrel therapy and triple therapy carried a more than 3-fold higher risk than did warfarin monotherapy."

Dr. Pfeifer doesn't discount the information, but notes that he would likely only discourage the use in patients with a particularly high risk for bleeding. However, he thinks the study is also a good reminder that HM practitioners should communicate the risks and therapies to both patients and their PCPs.

"It's important to know what the risks are, but it doesn't take away from what the indicators are," he says. "In most of these situations, I think you can feel better that you’ve academically addressed it."

In This Edition

Literature at a Glance

A guide to this month’s studies

• Effect of early follow-up on readmission rates
• Heart rate control and outcomes in atrial fibrillation
• Pneumococcal vaccine to prevent stroke and MI
• Long-term outcomes of endovascular repair of AAA
• Insurance and outcomes in myocardial infarction
• Risk of gastrointestinal bleeding and cardiovascular outcomes with concurrent PPI and clopidogrel use
• CT in patients with suspected coronary artery disease

Reduced 30-Day Readmission Rate for Patients Discharged from Hospitals with Higher Rates of Early Follow-Up

Clinical question: Is early follow-up after discharge for heart failure associated with a reduction in readmission rates?

Background: Readmission for heart failure is very frequent and often unplanned. Early follow-up visits after discharge have been hypothesized to reduce readmissions but have been undefined.

Study design: Retrospective cohort study.

Setting: Patients with Medicare inpatient claims data linked to the OPTIMIZE-HF and GWTG-HF registries.

Synopsis: The study included 30,136 patients >65 years old with the principal discharge diagnosis of heart failure from 2003 to 2006. Hospitals were stratified into quartiles based upon the median arrival rate to “early” (within one week after discharge) follow-up appointments. Ranges of arrival rates to these appointments ranged from Quartile 1 (Q1) (<32.4% of patients) to Q4 (>44.5%). Readmission rates were highest in the lowest quartile of “early” follow-up (Q1: 23.3%; Q2: 20.5%; Q3: 20.5%; Q4: 20.5%, P<0.001). No mortality difference was seen.

The study also examined whether the physician following the patient after discharge impacted the readmission rate for these same quartiles, comparing cardiologists to generalists and comparing the same physician at discharge and follow-up (defined as “continuity”) versus different physicians. Follow-up with continuity or a cardiologist did not reduce readmissions.

Interestingly, nearly all markers of quality were best in Q1 and Q2 hospitals, which had the lowest arrival rates to appointments, which might reflect patient-centered rather than hospital-centered issues.

Bottom line: Hospitals with low “early” follow-up appointment rates after discharge have a higher readmission rate, although causality is not established.

Citation: Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303 (17):1716-1722.

Strict Heart Rate Control Is Not Necessary in Management of Chronic Atrial Fibrillation

Clinical question: Is lenient heart rate control inferior to strict heart rate control in preventing cardiovascular events in patients with chronic atrial fibrillation?

Background: Guidelines generally call for the use of medications to achieve strict heart rate control in the management of chronic atrial fibrillation, but the optimal level of heart rate control necessary to avoid cardiovascular events remains uncertain.

Study design: Prospectively randomized, noninferiority trial.

Setting: Thirty-three medical centers in the Netherlands.

Synopsis: The study looked at 614 patients with permanent atrial fibrillation; 311 patients were randomized to lenient control and 303 to strict control. Calcium channel blockers, beta-blockers, or digoxin were dose-adjusted to control heart rate below 110 beats per minute (bpm) in the lenient control group versus 80 bpm in the strict control group.

Thirty-eight patients (12.9%) in the lenient control group and 43 (14.9%) in the strict control group reached the primary composite outcome of significant cardiovascular events (death, heart failure, stroke, embolism, major bleeding, major arrhythmia, need for pacemaker, or severe drug adverse event). Although no statistical difference in the frequency of these events between groups was detected, the study was dramatically underpowered due to unanticipated low event rates.

Bottom line: Although the lenient control group had far fewer outpatient visits and a trend toward improved outcomes, no definite conclusion regarding the management of permanent atrial fibrillation can be drawn from this underpowered noninferiority trial.

Citation: Van Gelder IC, Groenveld HF, Crijns HJ, et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010;362(15):1363-1373.

Pneumococcal Vaccine Does Not Reduce the Risk of Stroke or Myocardial Infarction

Clinical question: Does pneumococcal vaccination reduce the risk of acute myocardial infarction (MI) and stroke?

Background: Studies have demonstrated that influenza vaccination reduces the risk of cardiac and cerebrovascular events. A single study has shown similar outcomes for the pneumococcal vaccination, although the study was limited by confounders and selection bias.

Study design: Retrospective cohort.

Setting: Large HMO in California.

Synopsis: More than 84,000 men participating in the California Men’s Health Study (CMHS) and enrolled in the Kaiser Permanente health plan were categorized as unvaccinated or vaccinated with the pneumococcal vaccine. Vaccinated patients had 10.73 first MIs and 5.30 strokes per 1,000 person-years, compared with unvaccinated patients who incurred 6.07 MIs and 1.90 strokes per 1,000 unvaccinated person-years based on ICD-9 codes.

Even with propensity scoring to minimize selection bias, no clear evidence of benefit was observed. One significant limitation is that 80% of the unvaccinated patients were younger than 60 years old, whereas 74% of the vaccinated patients were 60 or older; this might represent selection bias that cannot be overcome with propensity scoring.

Bottom line: In a population of men older than age 45, pneumococcal vaccination does not appear to reduce the risk of acute MI or stroke.

Citation: Tseng HF, Slezak JM, Quinn VP, et al. Pneumococcal vaccination and risk of acute myocardial infarction and stroke in men. JAMA. 2010;303(17):1699-1706.

No Durable Mortality Benefit from Endovascular Repair of Enlarged Abdominal Aortic Aneurysm

Clinical question: What is the cost and mortality benefit of endovascular versus open repair of abdominal aneurysms?

Background: Previous studies demonstrated a 30-day mortality benefit using endovascular repair over open surgical repair of large abdominal aortic aneurysms. Limited longer-term data are available assessing the durability of these findings.

Study design: Randomized controlled trial.

Setting: Thirty-seven hospitals in the United Kingdom.

Synopsis: Researchers looked at 1,252 patients who were at least 60 years old with a large abdominal aortic aneurysm (>5.5 cm) on CT scan. The patients were randomized to open versus endovascular repair and followed for a median of six years postoperatively. An early, postoperative, all-cause mortality benefit was observed for endovascular repair (1.8%) compared with open repair (4.3%), but no benefit was seen after six months of follow-up, driven by secondary aneurysm ruptures with endovascular grafts. Graft-related complications in all time periods were higher in the endovascular repair group, highest from 0 to 6 months (nearly 50% of patients), and were associated with an increased cost.

Bottom line: Immediate postoperative mortality benefit of endovascular repair is not sustained for abdominal aortic aneurysm beyond six months postoperatively.

Citation: The United Kingdom EVAR trial investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010:362(20):1863-1870.

Financial Constraints Delay Presentation in Patients Suffering from Acute Myocardial Infarction

Clinical question: Does being underinsured or uninsured delay individuals from seeking treatment for emergency medical care?

Background: The number of underinsured or uninsured Americans is growing. Studies have shown that patients with financial concerns avoid routine preventive and chronic medical care; however, similar avoidance has not been defined clearly for patients seeking emergent care.

Study design: Prospective cohort study.

Setting: Twenty-four urban hospitals in the U.S. included in a multisite, acute myocardial infarction (AMI) registry.

Synopsis: Of the 3,721 patients enrolled in the AMI registry, 61.7% of the cohort was insured and without financial concerns that prevented them from seeking care. These patients were less likely to have delays in care related to AMI compared with patients who were insured with financial concerns (18.5% of the cohort; OR 1.22; 95% confidence interval [CI], 1.06-1.40) or uninsured (19.8%; OR 1.30; 95% CI, 1.12-1.51) in all time frames after symptom onset. Patients were less likely to undergo PCI or thrombolysis if the delay to presentation was more than six hours.

After adjustment for confounding factors, the authors concluded that uninsured and underinsured patients were likely to delay presentation to the hospital. Despite these findings, alternative etiologies for delays in care are likely to be more significant, as insurance considerations only account for an 8% difference between the well-insured group (39.3% delayed seeking care >6 hours) and the uninsured group (48.6%). These etiologies are ill-defined.

Bottom line: Underinsured or uninsured patients have a small but significant delay in seeking treatment for AMI due to financial concerns.

Citation: Smolderen KG, Spertus JA, Nallamothu BK, et al. Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. JAMA. 2010;303 (14):1392-1400.

Concurrent Use of PPIs and Clopidogrel Decrease Hospitalizations for Gastroduodenal Bleeding without Significant Increase in Adverse Cardiovascular Events

Clinical question: Does concomitant use of proton-pump inhibitors (PPIs) and clopidogrel affect the risks of hospitalizations for gastroduodenal bleeding and serious cardiovascular events?

Background: PPIs commonly are prescribed with clopidogrel to reduce the risk of serious gastroduodenal bleeding. Recent observational studies suggest that concurrent PPI and clopidogrel administration might increase the risk of cardiovascular events compared with clopidogrel alone.

Study design: Retrospective cohort.

Setting: Tennessee Medicaid program.

Synopsis: Researchers identified 20,596 patients hospitalized for acute MI, revascularization, or unstable angina, and prescribed clopidogrel. Of this cohort, 7,593 were initial concurrent PPI users—62% used pantoprazole and 9% used omeprazole. Hospitalizations for gastroduodenal bleeding were reduced by 50% (HR 0.50 [95% CI, 0.39-0.65]) in concurrent users of PPIs and clopidogrel, compared with nonusers of PPIs.

Concurrent use was not associated with a statistically significant increase in serious cardiovascular diseases (HR, 0.99 [95% CI, 0.82-1.19]), defined as acute MI, sudden cardiac death, nonfatal or fatal stroke, or other cardiovascular deaths.

Subgroup analyses of individual PPIs and patients undergoing percutaneous coronary interventions also showed no increased risk of serious cardiovascular events. This study could differ from previous observational studies because far fewer patients were on omeprazole, the most potent inhibitor of clopidogrel.

Bottom line: In patients treated with clopidogrel, PPI users had 50% fewer hospitalizations for gastroduodenal bleeding compared with nonusers. Concurrent use of clopidogrel and PPIs, most of which was pantoprazole, was not associated with a significant increase in serious cardiovascular events.

Citation: Ray WA, Murray KT, Griffin MR, et al. Outcomes with concurrent use of clopidogrel and proton-pump inhibitors. Ann Intern Med. 2010;152(6):337-345.

CTCA a Promising, Noninvasive Option in Evaluating Patients with Suspected Coronary Artery Disease

Clinical question: How does computed tomography coronary angiography (CTCA) compare to noninvasive stress testing for diagnosing coronary artery disease (CAD)?

Background: CTCA is a newer, noninvasive test that has a high diagnostic accuracy for CAD, but its clinical role in the evaluation of patients with chest symptoms is unclear.

Study design: Observational study.

Setting: Single academic center in the Netherlands.

Synopsis: Five hundred seventeen eligible patients were evaluated with stress testing and CTCA. The patients were classified as having a low (<20%), intermediate (20%-80%), or high (>80%) pretest probability of CAD based on the Duke clinical score. Using coronary angiography as the gold standard, stress-testing was found to be less accurate than CTCA in all of the patient groups. In patients with low and intermediate pretest probabilities, a negative CTCA had a post-test probability of 0% and 1%, respectively. On the other hand, patients with an intermediate pretest probability and a positive CTCA had a post-test probability of 94% (CI, 89%-97%). In patients with an initial high pretest probability, stress-testing and CTCA confirmed disease in most cases.

The results of this study suggest that CTCA is particularly useful in evaluating patients with an intermediate pretest probability.

Patients were ineligible in this study if they had acute coronary syndromes, previous coronary stent placement, coronary artery bypass surgery, or myocardial infarction. It is important to note that because anatomic lesions seen on imaging (CTCA and coronary angiography) are not always functionally significant, CTCA might have seemed more accurate and clinically useful than it actually is. The investigators also acknowledge that further studies are necessary before CTCA can be accepted as a first-line diagnostic test.

Bottom line: In patients with an intermediate pretest probability of CAD, a negative CTCA is valuable in excluding coronary artery disease, thereby reducing the need for invasive coronary angiography in this group.

Citation: Weustink AC, Mollet NR, Neefjes LA, et al. Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease. Ann Intern Med. 2010;152(10):630-639. TH

PEDIATRIC HM LITerature

Neonatal Nonhemolytic Hyperbilirubinemia Not Associated with Long-Term Cognitive or Neuropsychiatric Disability

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is exposure to neonatal nonhemolytic hyperbilirubinemia associated with negative long-term cognitive effects?

Background: Guidelines for the treatment of neonatal hyperbilirubinemia focus on the prevention of rare but potentially devastating consequences: bilirubin encephalopathy and subsequent kernicterus. Small studies have raised concerns regarding the potential for long-term cognitive disability in infants exposed to severe hyperbilirubinemia without kernicterus. This association primarily has been noted in patients with severe hemolytic hyperbilirubinemia; the relationship in nonhemolytic cases is less clear.

Study design: Retrospective, population-based cohort study.

Setting: Fifth Military Conscription District of Denmark.

Synopsis: All 18-year-old male conscripts born from 1977 to 1983 had data extracted from a national discharge registry with respect to maximum total serum bilirubin (TSB-max) and other clinical details. Infants born <35 weeks or of multiple gestation, age >14 days at TSB-max, or with hemolytic disease were excluded. TSB-max was analyzed as a categorical and dichotomous variable. Data were then compared to a validated Danish intelligence test administered at military draft conscription and the presence of neuropsychiatric diagnoses.

Of those examined, 463 men exceeded the cutoff for TSB-max, compared with 12,718 controls. There were no significant differences between groups with respect to the presence of neuropsychiatric diagnoses or cognitive performance.

This study benefits from its population-based design and use of an inclusive national database. However, cognitive performance is notoriously difficult to study, owing to the numerous potential confounders, many of which could not be ascertained retrospectively from the registry. Additional limitations were that the Danish thresholds for phototherapy and exchange transfusion were 240 μmol/L and 340 μmol/L (or approximately 14 mg/dL and 20 mg/dL), respectively, and only 25 newborns were exposed to levels greater than 340 μmol/L.

Although no dose response association was noted between 240 μmol/L and 340 μmol/L, no conclusions may be drawn regarding significantly higher levels.

Bottom line: Neonatal nonhemolytic hyperbilirubinemia requiring phototherapy is unlikely to be associated with long-term cognitive or neuropsychiatric disability.

Citation: Ebbesen F, Ehrenstein V, Traeger M, Nielsen GL. Neonatal non-hemolytic hyperbilirubinemia: a prevalence study of adult neuropsychiatric disability and cognitive function in 463 male Danish conscripts. Arch Dis Child. 2010;95(8):583-587.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Effect of early follow-up on readmission rates
• Heart rate control and outcomes in atrial fibrillation
• Pneumococcal vaccine to prevent stroke and MI
• Long-term outcomes of endovascular repair of AAA
• Insurance and outcomes in myocardial infarction
• Risk of gastrointestinal bleeding and cardiovascular outcomes with concurrent PPI and clopidogrel use
• CT in patients with suspected coronary artery disease

Reduced 30-Day Readmission Rate for Patients Discharged from Hospitals with Higher Rates of Early Follow-Up

Clinical question: Is early follow-up after discharge for heart failure associated with a reduction in readmission rates?

Background: Readmission for heart failure is very frequent and often unplanned. Early follow-up visits after discharge have been hypothesized to reduce readmissions but have been undefined.

Study design: Retrospective cohort study.

Setting: Patients with Medicare inpatient claims data linked to the OPTIMIZE-HF and GWTG-HF registries.

Synopsis: The study included 30,136 patients >65 years old with the principal discharge diagnosis of heart failure from 2003 to 2006. Hospitals were stratified into quartiles based upon the median arrival rate to “early” (within one week after discharge) follow-up appointments. Ranges of arrival rates to these appointments ranged from Quartile 1 (Q1) (<32.4% of patients) to Q4 (>44.5%). Readmission rates were highest in the lowest quartile of “early” follow-up (Q1: 23.3%; Q2: 20.5%; Q3: 20.5%; Q4: 20.5%, P<0.001). No mortality difference was seen.

The study also examined whether the physician following the patient after discharge impacted the readmission rate for these same quartiles, comparing cardiologists to generalists and comparing the same physician at discharge and follow-up (defined as “continuity”) versus different physicians. Follow-up with continuity or a cardiologist did not reduce readmissions.

Interestingly, nearly all markers of quality were best in Q1 and Q2 hospitals, which had the lowest arrival rates to appointments, which might reflect patient-centered rather than hospital-centered issues.

Bottom line: Hospitals with low “early” follow-up appointment rates after discharge have a higher readmission rate, although causality is not established.

Citation: Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303 (17):1716-1722.

Strict Heart Rate Control Is Not Necessary in Management of Chronic Atrial Fibrillation

Clinical question: Is lenient heart rate control inferior to strict heart rate control in preventing cardiovascular events in patients with chronic atrial fibrillation?

Background: Guidelines generally call for the use of medications to achieve strict heart rate control in the management of chronic atrial fibrillation, but the optimal level of heart rate control necessary to avoid cardiovascular events remains uncertain.

Study design: Prospectively randomized, noninferiority trial.

Setting: Thirty-three medical centers in the Netherlands.

Synopsis: The study looked at 614 patients with permanent atrial fibrillation; 311 patients were randomized to lenient control and 303 to strict control. Calcium channel blockers, beta-blockers, or digoxin were dose-adjusted to control heart rate below 110 beats per minute (bpm) in the lenient control group versus 80 bpm in the strict control group.

Thirty-eight patients (12.9%) in the lenient control group and 43 (14.9%) in the strict control group reached the primary composite outcome of significant cardiovascular events (death, heart failure, stroke, embolism, major bleeding, major arrhythmia, need for pacemaker, or severe drug adverse event). Although no statistical difference in the frequency of these events between groups was detected, the study was dramatically underpowered due to unanticipated low event rates.

Bottom line: Although the lenient control group had far fewer outpatient visits and a trend toward improved outcomes, no definite conclusion regarding the management of permanent atrial fibrillation can be drawn from this underpowered noninferiority trial.

Citation: Van Gelder IC, Groenveld HF, Crijns HJ, et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010;362(15):1363-1373.

Pneumococcal Vaccine Does Not Reduce the Risk of Stroke or Myocardial Infarction

Clinical question: Does pneumococcal vaccination reduce the risk of acute myocardial infarction (MI) and stroke?

Background: Studies have demonstrated that influenza vaccination reduces the risk of cardiac and cerebrovascular events. A single study has shown similar outcomes for the pneumococcal vaccination, although the study was limited by confounders and selection bias.

Study design: Retrospective cohort.

Setting: Large HMO in California.

Synopsis: More than 84,000 men participating in the California Men’s Health Study (CMHS) and enrolled in the Kaiser Permanente health plan were categorized as unvaccinated or vaccinated with the pneumococcal vaccine. Vaccinated patients had 10.73 first MIs and 5.30 strokes per 1,000 person-years, compared with unvaccinated patients who incurred 6.07 MIs and 1.90 strokes per 1,000 unvaccinated person-years based on ICD-9 codes.

Even with propensity scoring to minimize selection bias, no clear evidence of benefit was observed. One significant limitation is that 80% of the unvaccinated patients were younger than 60 years old, whereas 74% of the vaccinated patients were 60 or older; this might represent selection bias that cannot be overcome with propensity scoring.

Bottom line: In a population of men older than age 45, pneumococcal vaccination does not appear to reduce the risk of acute MI or stroke.

Citation: Tseng HF, Slezak JM, Quinn VP, et al. Pneumococcal vaccination and risk of acute myocardial infarction and stroke in men. JAMA. 2010;303(17):1699-1706.

No Durable Mortality Benefit from Endovascular Repair of Enlarged Abdominal Aortic Aneurysm

Clinical question: What is the cost and mortality benefit of endovascular versus open repair of abdominal aneurysms?

Background: Previous studies demonstrated a 30-day mortality benefit using endovascular repair over open surgical repair of large abdominal aortic aneurysms. Limited longer-term data are available assessing the durability of these findings.

Study design: Randomized controlled trial.

Setting: Thirty-seven hospitals in the United Kingdom.

Synopsis: Researchers looked at 1,252 patients who were at least 60 years old with a large abdominal aortic aneurysm (>5.5 cm) on CT scan. The patients were randomized to open versus endovascular repair and followed for a median of six years postoperatively. An early, postoperative, all-cause mortality benefit was observed for endovascular repair (1.8%) compared with open repair (4.3%), but no benefit was seen after six months of follow-up, driven by secondary aneurysm ruptures with endovascular grafts. Graft-related complications in all time periods were higher in the endovascular repair group, highest from 0 to 6 months (nearly 50% of patients), and were associated with an increased cost.

Bottom line: Immediate postoperative mortality benefit of endovascular repair is not sustained for abdominal aortic aneurysm beyond six months postoperatively.

Citation: The United Kingdom EVAR trial investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010:362(20):1863-1870.

Financial Constraints Delay Presentation in Patients Suffering from Acute Myocardial Infarction

Clinical question: Does being underinsured or uninsured delay individuals from seeking treatment for emergency medical care?

Background: The number of underinsured or uninsured Americans is growing. Studies have shown that patients with financial concerns avoid routine preventive and chronic medical care; however, similar avoidance has not been defined clearly for patients seeking emergent care.

Study design: Prospective cohort study.

Setting: Twenty-four urban hospitals in the U.S. included in a multisite, acute myocardial infarction (AMI) registry.

Synopsis: Of the 3,721 patients enrolled in the AMI registry, 61.7% of the cohort was insured and without financial concerns that prevented them from seeking care. These patients were less likely to have delays in care related to AMI compared with patients who were insured with financial concerns (18.5% of the cohort; OR 1.22; 95% confidence interval [CI], 1.06-1.40) or uninsured (19.8%; OR 1.30; 95% CI, 1.12-1.51) in all time frames after symptom onset. Patients were less likely to undergo PCI or thrombolysis if the delay to presentation was more than six hours.

After adjustment for confounding factors, the authors concluded that uninsured and underinsured patients were likely to delay presentation to the hospital. Despite these findings, alternative etiologies for delays in care are likely to be more significant, as insurance considerations only account for an 8% difference between the well-insured group (39.3% delayed seeking care >6 hours) and the uninsured group (48.6%). These etiologies are ill-defined.

Bottom line: Underinsured or uninsured patients have a small but significant delay in seeking treatment for AMI due to financial concerns.

Citation: Smolderen KG, Spertus JA, Nallamothu BK, et al. Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. JAMA. 2010;303 (14):1392-1400.

Concurrent Use of PPIs and Clopidogrel Decrease Hospitalizations for Gastroduodenal Bleeding without Significant Increase in Adverse Cardiovascular Events

Clinical question: Does concomitant use of proton-pump inhibitors (PPIs) and clopidogrel affect the risks of hospitalizations for gastroduodenal bleeding and serious cardiovascular events?

Background: PPIs commonly are prescribed with clopidogrel to reduce the risk of serious gastroduodenal bleeding. Recent observational studies suggest that concurrent PPI and clopidogrel administration might increase the risk of cardiovascular events compared with clopidogrel alone.

Study design: Retrospective cohort.

Setting: Tennessee Medicaid program.

Synopsis: Researchers identified 20,596 patients hospitalized for acute MI, revascularization, or unstable angina, and prescribed clopidogrel. Of this cohort, 7,593 were initial concurrent PPI users—62% used pantoprazole and 9% used omeprazole. Hospitalizations for gastroduodenal bleeding were reduced by 50% (HR 0.50 [95% CI, 0.39-0.65]) in concurrent users of PPIs and clopidogrel, compared with nonusers of PPIs.

Concurrent use was not associated with a statistically significant increase in serious cardiovascular diseases (HR, 0.99 [95% CI, 0.82-1.19]), defined as acute MI, sudden cardiac death, nonfatal or fatal stroke, or other cardiovascular deaths.

Subgroup analyses of individual PPIs and patients undergoing percutaneous coronary interventions also showed no increased risk of serious cardiovascular events. This study could differ from previous observational studies because far fewer patients were on omeprazole, the most potent inhibitor of clopidogrel.

Bottom line: In patients treated with clopidogrel, PPI users had 50% fewer hospitalizations for gastroduodenal bleeding compared with nonusers. Concurrent use of clopidogrel and PPIs, most of which was pantoprazole, was not associated with a significant increase in serious cardiovascular events.

Citation: Ray WA, Murray KT, Griffin MR, et al. Outcomes with concurrent use of clopidogrel and proton-pump inhibitors. Ann Intern Med. 2010;152(6):337-345.

CTCA a Promising, Noninvasive Option in Evaluating Patients with Suspected Coronary Artery Disease

Clinical question: How does computed tomography coronary angiography (CTCA) compare to noninvasive stress testing for diagnosing coronary artery disease (CAD)?

Background: CTCA is a newer, noninvasive test that has a high diagnostic accuracy for CAD, but its clinical role in the evaluation of patients with chest symptoms is unclear.

Study design: Observational study.

Setting: Single academic center in the Netherlands.

Synopsis: Five hundred seventeen eligible patients were evaluated with stress testing and CTCA. The patients were classified as having a low (<20%), intermediate (20%-80%), or high (>80%) pretest probability of CAD based on the Duke clinical score. Using coronary angiography as the gold standard, stress-testing was found to be less accurate than CTCA in all of the patient groups. In patients with low and intermediate pretest probabilities, a negative CTCA had a post-test probability of 0% and 1%, respectively. On the other hand, patients with an intermediate pretest probability and a positive CTCA had a post-test probability of 94% (CI, 89%-97%). In patients with an initial high pretest probability, stress-testing and CTCA confirmed disease in most cases.

The results of this study suggest that CTCA is particularly useful in evaluating patients with an intermediate pretest probability.

Patients were ineligible in this study if they had acute coronary syndromes, previous coronary stent placement, coronary artery bypass surgery, or myocardial infarction. It is important to note that because anatomic lesions seen on imaging (CTCA and coronary angiography) are not always functionally significant, CTCA might have seemed more accurate and clinically useful than it actually is. The investigators also acknowledge that further studies are necessary before CTCA can be accepted as a first-line diagnostic test.

Bottom line: In patients with an intermediate pretest probability of CAD, a negative CTCA is valuable in excluding coronary artery disease, thereby reducing the need for invasive coronary angiography in this group.

Citation: Weustink AC, Mollet NR, Neefjes LA, et al. Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease. Ann Intern Med. 2010;152(10):630-639. TH

PEDIATRIC HM LITerature

Neonatal Nonhemolytic Hyperbilirubinemia Not Associated with Long-Term Cognitive or Neuropsychiatric Disability

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is exposure to neonatal nonhemolytic hyperbilirubinemia associated with negative long-term cognitive effects?

Background: Guidelines for the treatment of neonatal hyperbilirubinemia focus on the prevention of rare but potentially devastating consequences: bilirubin encephalopathy and subsequent kernicterus. Small studies have raised concerns regarding the potential for long-term cognitive disability in infants exposed to severe hyperbilirubinemia without kernicterus. This association primarily has been noted in patients with severe hemolytic hyperbilirubinemia; the relationship in nonhemolytic cases is less clear.

Study design: Retrospective, population-based cohort study.

Setting: Fifth Military Conscription District of Denmark.

Synopsis: All 18-year-old male conscripts born from 1977 to 1983 had data extracted from a national discharge registry with respect to maximum total serum bilirubin (TSB-max) and other clinical details. Infants born <35 weeks or of multiple gestation, age >14 days at TSB-max, or with hemolytic disease were excluded. TSB-max was analyzed as a categorical and dichotomous variable. Data were then compared to a validated Danish intelligence test administered at military draft conscription and the presence of neuropsychiatric diagnoses.

Of those examined, 463 men exceeded the cutoff for TSB-max, compared with 12,718 controls. There were no significant differences between groups with respect to the presence of neuropsychiatric diagnoses or cognitive performance.

This study benefits from its population-based design and use of an inclusive national database. However, cognitive performance is notoriously difficult to study, owing to the numerous potential confounders, many of which could not be ascertained retrospectively from the registry. Additional limitations were that the Danish thresholds for phototherapy and exchange transfusion were 240 μmol/L and 340 μmol/L (or approximately 14 mg/dL and 20 mg/dL), respectively, and only 25 newborns were exposed to levels greater than 340 μmol/L.

Although no dose response association was noted between 240 μmol/L and 340 μmol/L, no conclusions may be drawn regarding significantly higher levels.

Bottom line: Neonatal nonhemolytic hyperbilirubinemia requiring phototherapy is unlikely to be associated with long-term cognitive or neuropsychiatric disability.

Citation: Ebbesen F, Ehrenstein V, Traeger M, Nielsen GL. Neonatal non-hemolytic hyperbilirubinemia: a prevalence study of adult neuropsychiatric disability and cognitive function in 463 male Danish conscripts. Arch Dis Child. 2010;95(8):583-587.

In This Edition

Literature at a Glance

A guide to this month’s studies

• Effect of early follow-up on readmission rates
• Heart rate control and outcomes in atrial fibrillation
• Pneumococcal vaccine to prevent stroke and MI
• Long-term outcomes of endovascular repair of AAA
• Insurance and outcomes in myocardial infarction
• Risk of gastrointestinal bleeding and cardiovascular outcomes with concurrent PPI and clopidogrel use
• CT in patients with suspected coronary artery disease

Reduced 30-Day Readmission Rate for Patients Discharged from Hospitals with Higher Rates of Early Follow-Up

Clinical question: Is early follow-up after discharge for heart failure associated with a reduction in readmission rates?

Background: Readmission for heart failure is very frequent and often unplanned. Early follow-up visits after discharge have been hypothesized to reduce readmissions but have been undefined.

Study design: Retrospective cohort study.

Setting: Patients with Medicare inpatient claims data linked to the OPTIMIZE-HF and GWTG-HF registries.

Synopsis: The study included 30,136 patients >65 years old with the principal discharge diagnosis of heart failure from 2003 to 2006. Hospitals were stratified into quartiles based upon the median arrival rate to “early” (within one week after discharge) follow-up appointments. Ranges of arrival rates to these appointments ranged from Quartile 1 (Q1) (<32.4% of patients) to Q4 (>44.5%). Readmission rates were highest in the lowest quartile of “early” follow-up (Q1: 23.3%; Q2: 20.5%; Q3: 20.5%; Q4: 20.5%, P<0.001). No mortality difference was seen.

The study also examined whether the physician following the patient after discharge impacted the readmission rate for these same quartiles, comparing cardiologists to generalists and comparing the same physician at discharge and follow-up (defined as “continuity”) versus different physicians. Follow-up with continuity or a cardiologist did not reduce readmissions.

Interestingly, nearly all markers of quality were best in Q1 and Q2 hospitals, which had the lowest arrival rates to appointments, which might reflect patient-centered rather than hospital-centered issues.

Bottom line: Hospitals with low “early” follow-up appointment rates after discharge have a higher readmission rate, although causality is not established.

Citation: Hernandez AF, Greiner MA, Fonarow GC, et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303 (17):1716-1722.

Strict Heart Rate Control Is Not Necessary in Management of Chronic Atrial Fibrillation

Clinical question: Is lenient heart rate control inferior to strict heart rate control in preventing cardiovascular events in patients with chronic atrial fibrillation?

Background: Guidelines generally call for the use of medications to achieve strict heart rate control in the management of chronic atrial fibrillation, but the optimal level of heart rate control necessary to avoid cardiovascular events remains uncertain.

Study design: Prospectively randomized, noninferiority trial.

Setting: Thirty-three medical centers in the Netherlands.

Synopsis: The study looked at 614 patients with permanent atrial fibrillation; 311 patients were randomized to lenient control and 303 to strict control. Calcium channel blockers, beta-blockers, or digoxin were dose-adjusted to control heart rate below 110 beats per minute (bpm) in the lenient control group versus 80 bpm in the strict control group.

Thirty-eight patients (12.9%) in the lenient control group and 43 (14.9%) in the strict control group reached the primary composite outcome of significant cardiovascular events (death, heart failure, stroke, embolism, major bleeding, major arrhythmia, need for pacemaker, or severe drug adverse event). Although no statistical difference in the frequency of these events between groups was detected, the study was dramatically underpowered due to unanticipated low event rates.

Bottom line: Although the lenient control group had far fewer outpatient visits and a trend toward improved outcomes, no definite conclusion regarding the management of permanent atrial fibrillation can be drawn from this underpowered noninferiority trial.

Citation: Van Gelder IC, Groenveld HF, Crijns HJ, et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010;362(15):1363-1373.

Pneumococcal Vaccine Does Not Reduce the Risk of Stroke or Myocardial Infarction

Clinical question: Does pneumococcal vaccination reduce the risk of acute myocardial infarction (MI) and stroke?

Background: Studies have demonstrated that influenza vaccination reduces the risk of cardiac and cerebrovascular events. A single study has shown similar outcomes for the pneumococcal vaccination, although the study was limited by confounders and selection bias.

Study design: Retrospective cohort.

Setting: Large HMO in California.

Synopsis: More than 84,000 men participating in the California Men’s Health Study (CMHS) and enrolled in the Kaiser Permanente health plan were categorized as unvaccinated or vaccinated with the pneumococcal vaccine. Vaccinated patients had 10.73 first MIs and 5.30 strokes per 1,000 person-years, compared with unvaccinated patients who incurred 6.07 MIs and 1.90 strokes per 1,000 unvaccinated person-years based on ICD-9 codes.

Even with propensity scoring to minimize selection bias, no clear evidence of benefit was observed. One significant limitation is that 80% of the unvaccinated patients were younger than 60 years old, whereas 74% of the vaccinated patients were 60 or older; this might represent selection bias that cannot be overcome with propensity scoring.

Bottom line: In a population of men older than age 45, pneumococcal vaccination does not appear to reduce the risk of acute MI or stroke.

Citation: Tseng HF, Slezak JM, Quinn VP, et al. Pneumococcal vaccination and risk of acute myocardial infarction and stroke in men. JAMA. 2010;303(17):1699-1706.

No Durable Mortality Benefit from Endovascular Repair of Enlarged Abdominal Aortic Aneurysm

Clinical question: What is the cost and mortality benefit of endovascular versus open repair of abdominal aneurysms?

Background: Previous studies demonstrated a 30-day mortality benefit using endovascular repair over open surgical repair of large abdominal aortic aneurysms. Limited longer-term data are available assessing the durability of these findings.

Study design: Randomized controlled trial.

Setting: Thirty-seven hospitals in the United Kingdom.

Synopsis: Researchers looked at 1,252 patients who were at least 60 years old with a large abdominal aortic aneurysm (>5.5 cm) on CT scan. The patients were randomized to open versus endovascular repair and followed for a median of six years postoperatively. An early, postoperative, all-cause mortality benefit was observed for endovascular repair (1.8%) compared with open repair (4.3%), but no benefit was seen after six months of follow-up, driven by secondary aneurysm ruptures with endovascular grafts. Graft-related complications in all time periods were higher in the endovascular repair group, highest from 0 to 6 months (nearly 50% of patients), and were associated with an increased cost.

Bottom line: Immediate postoperative mortality benefit of endovascular repair is not sustained for abdominal aortic aneurysm beyond six months postoperatively.

Citation: The United Kingdom EVAR trial investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010:362(20):1863-1870.

Financial Constraints Delay Presentation in Patients Suffering from Acute Myocardial Infarction

Clinical question: Does being underinsured or uninsured delay individuals from seeking treatment for emergency medical care?

Background: The number of underinsured or uninsured Americans is growing. Studies have shown that patients with financial concerns avoid routine preventive and chronic medical care; however, similar avoidance has not been defined clearly for patients seeking emergent care.

Study design: Prospective cohort study.

Setting: Twenty-four urban hospitals in the U.S. included in a multisite, acute myocardial infarction (AMI) registry.

Synopsis: Of the 3,721 patients enrolled in the AMI registry, 61.7% of the cohort was insured and without financial concerns that prevented them from seeking care. These patients were less likely to have delays in care related to AMI compared with patients who were insured with financial concerns (18.5% of the cohort; OR 1.22; 95% confidence interval [CI], 1.06-1.40) or uninsured (19.8%; OR 1.30; 95% CI, 1.12-1.51) in all time frames after symptom onset. Patients were less likely to undergo PCI or thrombolysis if the delay to presentation was more than six hours.

After adjustment for confounding factors, the authors concluded that uninsured and underinsured patients were likely to delay presentation to the hospital. Despite these findings, alternative etiologies for delays in care are likely to be more significant, as insurance considerations only account for an 8% difference between the well-insured group (39.3% delayed seeking care >6 hours) and the uninsured group (48.6%). These etiologies are ill-defined.

Bottom line: Underinsured or uninsured patients have a small but significant delay in seeking treatment for AMI due to financial concerns.

Citation: Smolderen KG, Spertus JA, Nallamothu BK, et al. Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. JAMA. 2010;303 (14):1392-1400.

Concurrent Use of PPIs and Clopidogrel Decrease Hospitalizations for Gastroduodenal Bleeding without Significant Increase in Adverse Cardiovascular Events

Clinical question: Does concomitant use of proton-pump inhibitors (PPIs) and clopidogrel affect the risks of hospitalizations for gastroduodenal bleeding and serious cardiovascular events?

Background: PPIs commonly are prescribed with clopidogrel to reduce the risk of serious gastroduodenal bleeding. Recent observational studies suggest that concurrent PPI and clopidogrel administration might increase the risk of cardiovascular events compared with clopidogrel alone.

Study design: Retrospective cohort.

Setting: Tennessee Medicaid program.

Synopsis: Researchers identified 20,596 patients hospitalized for acute MI, revascularization, or unstable angina, and prescribed clopidogrel. Of this cohort, 7,593 were initial concurrent PPI users—62% used pantoprazole and 9% used omeprazole. Hospitalizations for gastroduodenal bleeding were reduced by 50% (HR 0.50 [95% CI, 0.39-0.65]) in concurrent users of PPIs and clopidogrel, compared with nonusers of PPIs.

Concurrent use was not associated with a statistically significant increase in serious cardiovascular diseases (HR, 0.99 [95% CI, 0.82-1.19]), defined as acute MI, sudden cardiac death, nonfatal or fatal stroke, or other cardiovascular deaths.

Subgroup analyses of individual PPIs and patients undergoing percutaneous coronary interventions also showed no increased risk of serious cardiovascular events. This study could differ from previous observational studies because far fewer patients were on omeprazole, the most potent inhibitor of clopidogrel.

Bottom line: In patients treated with clopidogrel, PPI users had 50% fewer hospitalizations for gastroduodenal bleeding compared with nonusers. Concurrent use of clopidogrel and PPIs, most of which was pantoprazole, was not associated with a significant increase in serious cardiovascular events.

Citation: Ray WA, Murray KT, Griffin MR, et al. Outcomes with concurrent use of clopidogrel and proton-pump inhibitors. Ann Intern Med. 2010;152(6):337-345.

CTCA a Promising, Noninvasive Option in Evaluating Patients with Suspected Coronary Artery Disease

Clinical question: How does computed tomography coronary angiography (CTCA) compare to noninvasive stress testing for diagnosing coronary artery disease (CAD)?

Background: CTCA is a newer, noninvasive test that has a high diagnostic accuracy for CAD, but its clinical role in the evaluation of patients with chest symptoms is unclear.

Study design: Observational study.

Setting: Single academic center in the Netherlands.

Synopsis: Five hundred seventeen eligible patients were evaluated with stress testing and CTCA. The patients were classified as having a low (<20%), intermediate (20%-80%), or high (>80%) pretest probability of CAD based on the Duke clinical score. Using coronary angiography as the gold standard, stress-testing was found to be less accurate than CTCA in all of the patient groups. In patients with low and intermediate pretest probabilities, a negative CTCA had a post-test probability of 0% and 1%, respectively. On the other hand, patients with an intermediate pretest probability and a positive CTCA had a post-test probability of 94% (CI, 89%-97%). In patients with an initial high pretest probability, stress-testing and CTCA confirmed disease in most cases.

The results of this study suggest that CTCA is particularly useful in evaluating patients with an intermediate pretest probability.

Patients were ineligible in this study if they had acute coronary syndromes, previous coronary stent placement, coronary artery bypass surgery, or myocardial infarction. It is important to note that because anatomic lesions seen on imaging (CTCA and coronary angiography) are not always functionally significant, CTCA might have seemed more accurate and clinically useful than it actually is. The investigators also acknowledge that further studies are necessary before CTCA can be accepted as a first-line diagnostic test.

Bottom line: In patients with an intermediate pretest probability of CAD, a negative CTCA is valuable in excluding coronary artery disease, thereby reducing the need for invasive coronary angiography in this group.

Citation: Weustink AC, Mollet NR, Neefjes LA, et al. Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease. Ann Intern Med. 2010;152(10):630-639. TH

PEDIATRIC HM LITerature

Neonatal Nonhemolytic Hyperbilirubinemia Not Associated with Long-Term Cognitive or Neuropsychiatric Disability

Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: Is exposure to neonatal nonhemolytic hyperbilirubinemia associated with negative long-term cognitive effects?

Background: Guidelines for the treatment of neonatal hyperbilirubinemia focus on the prevention of rare but potentially devastating consequences: bilirubin encephalopathy and subsequent kernicterus. Small studies have raised concerns regarding the potential for long-term cognitive disability in infants exposed to severe hyperbilirubinemia without kernicterus. This association primarily has been noted in patients with severe hemolytic hyperbilirubinemia; the relationship in nonhemolytic cases is less clear.

Study design: Retrospective, population-based cohort study.

Setting: Fifth Military Conscription District of Denmark.

Synopsis: All 18-year-old male conscripts born from 1977 to 1983 had data extracted from a national discharge registry with respect to maximum total serum bilirubin (TSB-max) and other clinical details. Infants born <35 weeks or of multiple gestation, age >14 days at TSB-max, or with hemolytic disease were excluded. TSB-max was analyzed as a categorical and dichotomous variable. Data were then compared to a validated Danish intelligence test administered at military draft conscription and the presence of neuropsychiatric diagnoses.

Of those examined, 463 men exceeded the cutoff for TSB-max, compared with 12,718 controls. There were no significant differences between groups with respect to the presence of neuropsychiatric diagnoses or cognitive performance.

This study benefits from its population-based design and use of an inclusive national database. However, cognitive performance is notoriously difficult to study, owing to the numerous potential confounders, many of which could not be ascertained retrospectively from the registry. Additional limitations were that the Danish thresholds for phototherapy and exchange transfusion were 240 μmol/L and 340 μmol/L (or approximately 14 mg/dL and 20 mg/dL), respectively, and only 25 newborns were exposed to levels greater than 340 μmol/L.

Although no dose response association was noted between 240 μmol/L and 340 μmol/L, no conclusions may be drawn regarding significantly higher levels.

Bottom line: Neonatal nonhemolytic hyperbilirubinemia requiring phototherapy is unlikely to be associated with long-term cognitive or neuropsychiatric disability.

Citation: Ebbesen F, Ehrenstein V, Traeger M, Nielsen GL. Neonatal non-hemolytic hyperbilirubinemia: a prevalence study of adult neuropsychiatric disability and cognitive function in 463 male Danish conscripts. Arch Dis Child. 2010;95(8):583-587.

Hospitalists should take care to remember the potentially violent offenders and situations that surround them daily at work, says a member of SHM's Practice Management Committee.

Michael Radzienda, MD, SFHM, vice president of hospital medicine and clinical effectiveness at Vanguard Health System in Southborough, Mass., says the recent shooting of a doctor at Johns Hopkins Hospital in Baltimore serves as a stark reminder that violence in the hospital is a concern for providers more than ever. To Dr. Radzienda's mind, that includes patients attacking doctors or patients attacking other patients.

"It's a newer issue for hospitalists, but one that they need to pay attention to," Dr. Radzienda says. "The volume of high-risk interactions that a hospitalist might have is significant compared to what that volume might have looked like 10 years ago before the hospitalist (model) took off."

And while one might think the incident at Johns Hopkins is enough to shine a lasting spotlight on the issue, a report from The Joint Commission this summer on hospital violence faded relatively quickly after its issuance. The commission's Sentinel Event Database, in fact, includes a category of assault, rape, and homicide (combined) with 256 reports since 1995, a number the organization suggests is under-reported. The commission's latest report, published in June, found that since 2004, hospitals have reported "significant increases in reports of assault, rape, and homicide, with the greater number of reports in the last three years."

The report recommends physicians learn techniques to identify potentially violent patients, implement violence de-escalation approaches, and even conduct violence audits to help determine an institution’s safety protocols.

Dr. Radzienda understands that training time and resources are stretched thin, but he says more focus on violence would be helpful to institutions and individual physicians. "The problem is someone needs to recognize this type of thing," he says. "But how do you prioritize that?"

Hospitalists should take care to remember the potentially violent offenders and situations that surround them daily at work, says a member of SHM's Practice Management Committee.

Michael Radzienda, MD, SFHM, vice president of hospital medicine and clinical effectiveness at Vanguard Health System in Southborough, Mass., says the recent shooting of a doctor at Johns Hopkins Hospital in Baltimore serves as a stark reminder that violence in the hospital is a concern for providers more than ever. To Dr. Radzienda's mind, that includes patients attacking doctors or patients attacking other patients.

"It's a newer issue for hospitalists, but one that they need to pay attention to," Dr. Radzienda says. "The volume of high-risk interactions that a hospitalist might have is significant compared to what that volume might have looked like 10 years ago before the hospitalist (model) took off."

And while one might think the incident at Johns Hopkins is enough to shine a lasting spotlight on the issue, a report from The Joint Commission this summer on hospital violence faded relatively quickly after its issuance. The commission's Sentinel Event Database, in fact, includes a category of assault, rape, and homicide (combined) with 256 reports since 1995, a number the organization suggests is under-reported. The commission's latest report, published in June, found that since 2004, hospitals have reported "significant increases in reports of assault, rape, and homicide, with the greater number of reports in the last three years."

The report recommends physicians learn techniques to identify potentially violent patients, implement violence de-escalation approaches, and even conduct violence audits to help determine an institution’s safety protocols.

Dr. Radzienda understands that training time and resources are stretched thin, but he says more focus on violence would be helpful to institutions and individual physicians. "The problem is someone needs to recognize this type of thing," he says. "But how do you prioritize that?"

Hospitalists should take care to remember the potentially violent offenders and situations that surround them daily at work, says a member of SHM's Practice Management Committee.

Michael Radzienda, MD, SFHM, vice president of hospital medicine and clinical effectiveness at Vanguard Health System in Southborough, Mass., says the recent shooting of a doctor at Johns Hopkins Hospital in Baltimore serves as a stark reminder that violence in the hospital is a concern for providers more than ever. To Dr. Radzienda's mind, that includes patients attacking doctors or patients attacking other patients.

"It's a newer issue for hospitalists, but one that they need to pay attention to," Dr. Radzienda says. "The volume of high-risk interactions that a hospitalist might have is significant compared to what that volume might have looked like 10 years ago before the hospitalist (model) took off."

And while one might think the incident at Johns Hopkins is enough to shine a lasting spotlight on the issue, a report from The Joint Commission this summer on hospital violence faded relatively quickly after its issuance. The commission's Sentinel Event Database, in fact, includes a category of assault, rape, and homicide (combined) with 256 reports since 1995, a number the organization suggests is under-reported. The commission's latest report, published in June, found that since 2004, hospitals have reported "significant increases in reports of assault, rape, and homicide, with the greater number of reports in the last three years."

The report recommends physicians learn techniques to identify potentially violent patients, implement violence de-escalation approaches, and even conduct violence audits to help determine an institution’s safety protocols.

Dr. Radzienda understands that training time and resources are stretched thin, but he says more focus on violence would be helpful to institutions and individual physicians. "The problem is someone needs to recognize this type of thing," he says. "But how do you prioritize that?"

Hospitalists might be able to help reduce their institutions' readmission rate by adding in targeted screenings for depressive symptoms, according to the author of a study in this month’s Journal of Hospital Medicine.

The report found that patients surveyed with said symptoms had a higher rate of readmission at 30 days after discharge (0.563 vs. 0.296) (DOI: 10.1002/jhm.673). Similar data were found at both 60 and 90 days after discharge.

Suzanne Mitchell, MD, MS, an instructor at Boston University School of Medicine/Boston Medical Center and one of the authors of the study, thinks the work should be a first step toward creating transitional-care programs that target depressive symptoms. “If we just screen and have nothing to offer, we’re not really helping patients out,” Dr. Mitchell says. “It’s an important piece to have some kind of program available to help bridge the transition process.”

Dr. Mitchell says that as more research associates depression with readmission rates, HM leaders will begin to see the value in creating programs to better communicate with patients about it. Ideas include follow-up phone calls with a PCP to discuss mental-health support options.

She adds that while hospitalists taking patient histories might glean information about depressive symptoms, HM groups can consider more targeted questions to determine a patient’s risk.

“Being able to open that conversation and having it on your radar is very important,” Dr. Mitchell says. “I find that if I don’t open the conversation, it doesn’t happen. But once I do, the patient is open to disclosing.”

Hospitalists might be able to help reduce their institutions' readmission rate by adding in targeted screenings for depressive symptoms, according to the author of a study in this month’s Journal of Hospital Medicine.

The report found that patients surveyed with said symptoms had a higher rate of readmission at 30 days after discharge (0.563 vs. 0.296) (DOI: 10.1002/jhm.673). Similar data were found at both 60 and 90 days after discharge.

Suzanne Mitchell, MD, MS, an instructor at Boston University School of Medicine/Boston Medical Center and one of the authors of the study, thinks the work should be a first step toward creating transitional-care programs that target depressive symptoms. “If we just screen and have nothing to offer, we’re not really helping patients out,” Dr. Mitchell says. “It’s an important piece to have some kind of program available to help bridge the transition process.”

Dr. Mitchell says that as more research associates depression with readmission rates, HM leaders will begin to see the value in creating programs to better communicate with patients about it. Ideas include follow-up phone calls with a PCP to discuss mental-health support options.

She adds that while hospitalists taking patient histories might glean information about depressive symptoms, HM groups can consider more targeted questions to determine a patient’s risk.

“Being able to open that conversation and having it on your radar is very important,” Dr. Mitchell says. “I find that if I don’t open the conversation, it doesn’t happen. But once I do, the patient is open to disclosing.”

Hospitalists might be able to help reduce their institutions' readmission rate by adding in targeted screenings for depressive symptoms, according to the author of a study in this month’s Journal of Hospital Medicine.

The report found that patients surveyed with said symptoms had a higher rate of readmission at 30 days after discharge (0.563 vs. 0.296) (DOI: 10.1002/jhm.673). Similar data were found at both 60 and 90 days after discharge.

Suzanne Mitchell, MD, MS, an instructor at Boston University School of Medicine/Boston Medical Center and one of the authors of the study, thinks the work should be a first step toward creating transitional-care programs that target depressive symptoms. “If we just screen and have nothing to offer, we’re not really helping patients out,” Dr. Mitchell says. “It’s an important piece to have some kind of program available to help bridge the transition process.”

Dr. Mitchell says that as more research associates depression with readmission rates, HM leaders will begin to see the value in creating programs to better communicate with patients about it. Ideas include follow-up phone calls with a PCP to discuss mental-health support options.

She adds that while hospitalists taking patient histories might glean information about depressive symptoms, HM groups can consider more targeted questions to determine a patient’s risk.

“Being able to open that conversation and having it on your radar is very important,” Dr. Mitchell says. “I find that if I don’t open the conversation, it doesn’t happen. But once I do, the patient is open to disclosing.”

An Archives of Internal Medicine report and a U.S. Food and Drug Administration (FDA) advisory that question the long-term safety of inferior vena cava (IVC) filters should give hospitalists pause, one HM leader says.

The Aug. 9 report (PDF) found that the Bard Recovery and Bard G2 filters “had high prevalences of fracture and embolization, with potentially life-threatening sequelae." An FDA advisory issued the same day as the study cautioned that retrievable filters are not always removed from patients once the risk of pulmonary embolism (PE) has subsided, further increasing the risks.

“We’re going to be thinking more than twice before we recommend when these filters are placed in and then thinking twice about when we get them out,” says Shaker Eid, MD, an instructor of medicine at Johns Hopkins University School of Medicine in Baltimore.

Dr. Eid, however, cautions HM leaders about being too fearful of the data. The Archives report, he notes, was a single-center study. And while the FDA reports that the use of filters grew exponentially from 1979 to 2007, new American College of Chest Physicians guidelines from 2008 have limited their use mostly to patients who cannot receive anticoagulation treatments, Dr. Eid notes.

In cases in which they are necessary to implant, or in instances in which a patient already has a permanent IVC filter implanted, Dr. Eid recommends hospitalists be diligent in working with the filter.

An Archives of Internal Medicine report and a U.S. Food and Drug Administration (FDA) advisory that question the long-term safety of inferior vena cava (IVC) filters should give hospitalists pause, one HM leader says.

The Aug. 9 report (PDF) found that the Bard Recovery and Bard G2 filters “had high prevalences of fracture and embolization, with potentially life-threatening sequelae." An FDA advisory issued the same day as the study cautioned that retrievable filters are not always removed from patients once the risk of pulmonary embolism (PE) has subsided, further increasing the risks.

“We’re going to be thinking more than twice before we recommend when these filters are placed in and then thinking twice about when we get them out,” says Shaker Eid, MD, an instructor of medicine at Johns Hopkins University School of Medicine in Baltimore.

Dr. Eid, however, cautions HM leaders about being too fearful of the data. The Archives report, he notes, was a single-center study. And while the FDA reports that the use of filters grew exponentially from 1979 to 2007, new American College of Chest Physicians guidelines from 2008 have limited their use mostly to patients who cannot receive anticoagulation treatments, Dr. Eid notes.

In cases in which they are necessary to implant, or in instances in which a patient already has a permanent IVC filter implanted, Dr. Eid recommends hospitalists be diligent in working with the filter.

An Archives of Internal Medicine report and a U.S. Food and Drug Administration (FDA) advisory that question the long-term safety of inferior vena cava (IVC) filters should give hospitalists pause, one HM leader says.

The Aug. 9 report (PDF) found that the Bard Recovery and Bard G2 filters “had high prevalences of fracture and embolization, with potentially life-threatening sequelae." An FDA advisory issued the same day as the study cautioned that retrievable filters are not always removed from patients once the risk of pulmonary embolism (PE) has subsided, further increasing the risks.

“We’re going to be thinking more than twice before we recommend when these filters are placed in and then thinking twice about when we get them out,” says Shaker Eid, MD, an instructor of medicine at Johns Hopkins University School of Medicine in Baltimore.

Dr. Eid, however, cautions HM leaders about being too fearful of the data. The Archives report, he notes, was a single-center study. And while the FDA reports that the use of filters grew exponentially from 1979 to 2007, new American College of Chest Physicians guidelines from 2008 have limited their use mostly to patients who cannot receive anticoagulation treatments, Dr. Eid notes.

In cases in which they are necessary to implant, or in instances in which a patient already has a permanent IVC filter implanted, Dr. Eid recommends hospitalists be diligent in working with the filter.

Hospitalists might want to incorporate questions about how much time a patient spends sitting into their diagnostic interview—then consider the same question for themselves.

A study published this spring in Medicine & Science in Sports & Exercise reports that time spent watching TV or riding in a car “were significant cardiovascular disease (CVD) mortality predictors” (Med Sci Sports Exerc. 2010;42(5):879-885). The research gained traction in medical publications and was highlighted in The New York Times. But for one of the researchers at the University of South Carolina, more work is needed.

“This is sort of a new way of looking at the equation,” says Steven Hooker, PhD, director of the university's Prevention Research Center. “We really don’t have any formal guidelines or recommendations on limiting sedentary behavior, although I think at some point in time we’ll get to that stage.”

Until then, hospitalists are in a prime position to determine a patient’s lifestyle—sedentary or active—via routine checklist questions they ask upon admission. Although some HM groups already ask questions about how often a patient exercises, Dr. Hooker suspects only a few groups ask how often a patient breaks up long periods of sitting.

Further, he suggests that while there are no standard recommendations, hospitalists would serve their patients well by incorporating helpful hints in discharge instructions or admission interviews.

“Encourage a person to build in standing or slight walking breaks in a daily routine, recommend they stand periodically while attending long meetings or during long periods of travel,” Dr. Hooker says. “Common sense reigns here.”

On the flip side, hospitalists would do well to remember that while their workday might include a high level of light-intensity activity, they face the same pitfalls as their patients: commuting, sitting in meetings, long periods of time in front of the computer, TV, or PlayStation.

“We have to get the public looking at physical activity and physical inactivity as two completely separate things,” says study first author Tatiana Warren, MS, a doctoral student in the department of exercise science at the University of South Carolina's Arnold School of Public Health. “We have to continue to do more research and get the word out.”

Hospitalists might want to incorporate questions about how much time a patient spends sitting into their diagnostic interview—then consider the same question for themselves.

A study published this spring in Medicine & Science in Sports & Exercise reports that time spent watching TV or riding in a car “were significant cardiovascular disease (CVD) mortality predictors” (Med Sci Sports Exerc. 2010;42(5):879-885). The research gained traction in medical publications and was highlighted in The New York Times. But for one of the researchers at the University of South Carolina, more work is needed.

“This is sort of a new way of looking at the equation,” says Steven Hooker, PhD, director of the university's Prevention Research Center. “We really don’t have any formal guidelines or recommendations on limiting sedentary behavior, although I think at some point in time we’ll get to that stage.”

Until then, hospitalists are in a prime position to determine a patient’s lifestyle—sedentary or active—via routine checklist questions they ask upon admission. Although some HM groups already ask questions about how often a patient exercises, Dr. Hooker suspects only a few groups ask how often a patient breaks up long periods of sitting.

Further, he suggests that while there are no standard recommendations, hospitalists would serve their patients well by incorporating helpful hints in discharge instructions or admission interviews.

“Encourage a person to build in standing or slight walking breaks in a daily routine, recommend they stand periodically while attending long meetings or during long periods of travel,” Dr. Hooker says. “Common sense reigns here.”

On the flip side, hospitalists would do well to remember that while their workday might include a high level of light-intensity activity, they face the same pitfalls as their patients: commuting, sitting in meetings, long periods of time in front of the computer, TV, or PlayStation.

“We have to get the public looking at physical activity and physical inactivity as two completely separate things,” says study first author Tatiana Warren, MS, a doctoral student in the department of exercise science at the University of South Carolina's Arnold School of Public Health. “We have to continue to do more research and get the word out.”

Hospitalists might want to incorporate questions about how much time a patient spends sitting into their diagnostic interview—then consider the same question for themselves.

A study published this spring in Medicine & Science in Sports & Exercise reports that time spent watching TV or riding in a car “were significant cardiovascular disease (CVD) mortality predictors” (Med Sci Sports Exerc. 2010;42(5):879-885). The research gained traction in medical publications and was highlighted in The New York Times. But for one of the researchers at the University of South Carolina, more work is needed.

“This is sort of a new way of looking at the equation,” says Steven Hooker, PhD, director of the university's Prevention Research Center. “We really don’t have any formal guidelines or recommendations on limiting sedentary behavior, although I think at some point in time we’ll get to that stage.”

Until then, hospitalists are in a prime position to determine a patient’s lifestyle—sedentary or active—via routine checklist questions they ask upon admission. Although some HM groups already ask questions about how often a patient exercises, Dr. Hooker suspects only a few groups ask how often a patient breaks up long periods of sitting.

Further, he suggests that while there are no standard recommendations, hospitalists would serve their patients well by incorporating helpful hints in discharge instructions or admission interviews.

“Encourage a person to build in standing or slight walking breaks in a daily routine, recommend they stand periodically while attending long meetings or during long periods of travel,” Dr. Hooker says. “Common sense reigns here.”

On the flip side, hospitalists would do well to remember that while their workday might include a high level of light-intensity activity, they face the same pitfalls as their patients: commuting, sitting in meetings, long periods of time in front of the computer, TV, or PlayStation.

“We have to get the public looking at physical activity and physical inactivity as two completely separate things,” says study first author Tatiana Warren, MS, a doctoral student in the department of exercise science at the University of South Carolina's Arnold School of Public Health. “We have to continue to do more research and get the word out.”

Hospitalists are in position to take a leading role in the prevention of catheter-related bloodstream infections (CRBSIs), according to a spokeswoman for the Association for Professionals in Infection Control and Epidemiology (APIC).

The APIC perspective is timely, as the group released a survey this summer that found hospitals continue to struggle with preventable hospital-associated infections (HAIs). Half the survey respondents said their institutions struggle with CRBSIs and blame lack of time, resources, and a lack of administrative initiative as “hindering their ability to combat these infections more aggressively.”

The push also comes as a new Centers for Medicare and Medicaid Services rule means that, beginning next year, central-line-associated bloodstream infections (CLABSIs) will be reported and posted on a CDC website. The public disclosure of such preventable infections should motivate physicians to more aggressively address the problem, according to the APIC.

“Hospitalists need to be the champions,” says Sharon Jacobs, RN, MS, CIC, manager of infection prevention and control at St. Clair Hospital in Pittsburgh.

To that end, Jacobs offers some tips on how hospitalists and others can help stem the tide of the estimated 80,000 patients a year who develop CRBSIs. They include:

• Hand hygiene: The use of gloves during procedures does not mean physicians should forgo washing their hands.
• Large drapes: Most vendors now include drapes in their line kits, but for those that might not, consider using the largest drape available to cover and protect as much of the patient as possible. Consider creating a cart to store all applicable equipment.
• Focus on care continuum: Insertion of a line is the first step. Make sure the line is properly maintained as long as it remains in the patient. Consider replacing lines hastily inserted in the ED or other departments. Remove all lines as quickly as clinically efficient.

  

Another key, Jacobs says, is to create a collaborative environment where hospitalists, intensivists, nurses, and others will feel encouraged to point out improvements instead of feeling chastised for pointing out potential errors.

“The mindset is changing,” she adds. “It doesn’t take any longer to follow these procedures than it does to put a line in without them.”

Hospitalists are in position to take a leading role in the prevention of catheter-related bloodstream infections (CRBSIs), according to a spokeswoman for the Association for Professionals in Infection Control and Epidemiology (APIC).

The APIC perspective is timely, as the group released a survey this summer that found hospitals continue to struggle with preventable hospital-associated infections (HAIs). Half the survey respondents said their institutions struggle with CRBSIs and blame lack of time, resources, and a lack of administrative initiative as “hindering their ability to combat these infections more aggressively.”

The push also comes as a new Centers for Medicare and Medicaid Services rule means that, beginning next year, central-line-associated bloodstream infections (CLABSIs) will be reported and posted on a CDC website. The public disclosure of such preventable infections should motivate physicians to more aggressively address the problem, according to the APIC.

“Hospitalists need to be the champions,” says Sharon Jacobs, RN, MS, CIC, manager of infection prevention and control at St. Clair Hospital in Pittsburgh.

To that end, Jacobs offers some tips on how hospitalists and others can help stem the tide of the estimated 80,000 patients a year who develop CRBSIs. They include:

• Hand hygiene: The use of gloves during procedures does not mean physicians should forgo washing their hands.
• Large drapes: Most vendors now include drapes in their line kits, but for those that might not, consider using the largest drape available to cover and protect as much of the patient as possible. Consider creating a cart to store all applicable equipment.
• Focus on care continuum: Insertion of a line is the first step. Make sure the line is properly maintained as long as it remains in the patient. Consider replacing lines hastily inserted in the ED or other departments. Remove all lines as quickly as clinically efficient.

  

Another key, Jacobs says, is to create a collaborative environment where hospitalists, intensivists, nurses, and others will feel encouraged to point out improvements instead of feeling chastised for pointing out potential errors.

“The mindset is changing,” she adds. “It doesn’t take any longer to follow these procedures than it does to put a line in without them.”

Hospitalists are in position to take a leading role in the prevention of catheter-related bloodstream infections (CRBSIs), according to a spokeswoman for the Association for Professionals in Infection Control and Epidemiology (APIC).

The APIC perspective is timely, as the group released a survey this summer that found hospitals continue to struggle with preventable hospital-associated infections (HAIs). Half the survey respondents said their institutions struggle with CRBSIs and blame lack of time, resources, and a lack of administrative initiative as “hindering their ability to combat these infections more aggressively.”

The push also comes as a new Centers for Medicare and Medicaid Services rule means that, beginning next year, central-line-associated bloodstream infections (CLABSIs) will be reported and posted on a CDC website. The public disclosure of such preventable infections should motivate physicians to more aggressively address the problem, according to the APIC.

“Hospitalists need to be the champions,” says Sharon Jacobs, RN, MS, CIC, manager of infection prevention and control at St. Clair Hospital in Pittsburgh.

To that end, Jacobs offers some tips on how hospitalists and others can help stem the tide of the estimated 80,000 patients a year who develop CRBSIs. They include:

• Hand hygiene: The use of gloves during procedures does not mean physicians should forgo washing their hands.
• Large drapes: Most vendors now include drapes in their line kits, but for those that might not, consider using the largest drape available to cover and protect as much of the patient as possible. Consider creating a cart to store all applicable equipment.
• Focus on care continuum: Insertion of a line is the first step. Make sure the line is properly maintained as long as it remains in the patient. Consider replacing lines hastily inserted in the ED or other departments. Remove all lines as quickly as clinically efficient.

  

Another key, Jacobs says, is to create a collaborative environment where hospitalists, intensivists, nurses, and others will feel encouraged to point out improvements instead of feeling chastised for pointing out potential errors.

“The mindset is changing,” she adds. “It doesn’t take any longer to follow these procedures than it does to put a line in without them.”

Now that the Centers for Medicare and Medicaid Services (CMS) has defined "meaningful use" of electronic health records (EHR), hospitalists know what's expected of them in order to grab a piece of the $20 billion set aside for doctors and hospitals that adopt new technologies.

CMS’ final rule (PDF) is less restrictive than the proposed rule put forth in January, but it still challenges HM groups and their respective institutions to meet new guidelines to make digital record-keeping routine. Stage-one rules, which take effect next year, require eligible physicians (EPs) and eligible hospitals to meet goals in 15 and 14 categories, respectively. Up to five goals can be deferred, according to CMS. The CMS timeline includes second and third stages, each of which will require goals that are even more advanced.

Some hospitalists feared the rules in stage one would be punitively strict, says Robert Lineberger MD FHM, medical information officer at Durham (N.C.) Regional Hospital, part of the Duke University Health System. “What it means is the government is serious about helping people instead of being as strict as it appeared they were going to be,” says Dr. Lineberger, who serves on SHM's IT Core Committee. “I think people are overall pretty pleased there was a relaxation.”

The road to full adoption of EHR is far from complete, and hospitals that have yet to put in place even the most basic electronic infrastructure might struggle to meet even the lowest thresholds.

And while specific standards for future stages have not been codified, “like everything else that goes on in the hospital, [HM] should be in the middle of that,” Dr. Lineberger says.

Now that the Centers for Medicare and Medicaid Services (CMS) has defined "meaningful use" of electronic health records (EHR), hospitalists know what's expected of them in order to grab a piece of the $20 billion set aside for doctors and hospitals that adopt new technologies.

CMS’ final rule (PDF) is less restrictive than the proposed rule put forth in January, but it still challenges HM groups and their respective institutions to meet new guidelines to make digital record-keeping routine. Stage-one rules, which take effect next year, require eligible physicians (EPs) and eligible hospitals to meet goals in 15 and 14 categories, respectively. Up to five goals can be deferred, according to CMS. The CMS timeline includes second and third stages, each of which will require goals that are even more advanced.

Some hospitalists feared the rules in stage one would be punitively strict, says Robert Lineberger MD FHM, medical information officer at Durham (N.C.) Regional Hospital, part of the Duke University Health System. “What it means is the government is serious about helping people instead of being as strict as it appeared they were going to be,” says Dr. Lineberger, who serves on SHM's IT Core Committee. “I think people are overall pretty pleased there was a relaxation.”

The road to full adoption of EHR is far from complete, and hospitals that have yet to put in place even the most basic electronic infrastructure might struggle to meet even the lowest thresholds.

And while specific standards for future stages have not been codified, “like everything else that goes on in the hospital, [HM] should be in the middle of that,” Dr. Lineberger says.

Now that the Centers for Medicare and Medicaid Services (CMS) has defined "meaningful use" of electronic health records (EHR), hospitalists know what's expected of them in order to grab a piece of the $20 billion set aside for doctors and hospitals that adopt new technologies.

CMS’ final rule (PDF) is less restrictive than the proposed rule put forth in January, but it still challenges HM groups and their respective institutions to meet new guidelines to make digital record-keeping routine. Stage-one rules, which take effect next year, require eligible physicians (EPs) and eligible hospitals to meet goals in 15 and 14 categories, respectively. Up to five goals can be deferred, according to CMS. The CMS timeline includes second and third stages, each of which will require goals that are even more advanced.

Some hospitalists feared the rules in stage one would be punitively strict, says Robert Lineberger MD FHM, medical information officer at Durham (N.C.) Regional Hospital, part of the Duke University Health System. “What it means is the government is serious about helping people instead of being as strict as it appeared they were going to be,” says Dr. Lineberger, who serves on SHM's IT Core Committee. “I think people are overall pretty pleased there was a relaxation.”

The road to full adoption of EHR is far from complete, and hospitals that have yet to put in place even the most basic electronic infrastructure might struggle to meet even the lowest thresholds.

And while specific standards for future stages have not been codified, “like everything else that goes on in the hospital, [HM] should be in the middle of that,” Dr. Lineberger says.

A new study in this month's Journal of Hospital Medicine that catalogues the daily routine of HM practitioners is a first step in helping streamline the hospitalist’s workflow for efficiency, say several people associated with the report.

The report, “Where Did the Day Go? A Time-Motion Study of Hospitalists,” attempted to capture the amount of time hospitalists spent on various activities, including interacting with electronic health records (EHR) (34.1%), communication with colleagues (25.9%), and direct care (7.4%) (J Hosp Med. 2010;5(6):323-328). But one of the report’s senior authors, as well as the co-author of an accompanying editorial, anticipate that the study will serve as a springboard for future research on how hospitalists can best use their time.

Hospitalists need to “lay the foundation to figure how not to just observe what the doctors are doing, but how, in the future, to what they should be doing,” says Mark Williams, MD, FHM, professor and chief of hospital medicine at Northwestern University's Feinberg School of Medicine in Chicago. “We’ve got to have a good understanding of what we’re doing every day to move forward.”

The research, which furthered a similar Northwestern study completed in 2006 found that 16% of all activities occurred simultaneously, meaning that the surveyed hospitalists spent about 9% of their average 10.3-hour shift multitasking.

“Sadly, we documented that the vast majority [of time] is away from the patient, not with the patient,” Dr. Williams says.

Dr. Williams and Amit Prachand, an administrator in the HM department at Northwestern, hope to see more research done to define the best workflow for a hospitalist. Both agree, though, that dedicated funding will have to be set aside, either by federal agencies or research institutions, to make that happen.

“We need to convince people the money is well spent in focusing on this,” says Prachand, co-author of the editorial “Hospitalists: Lean Leaders for Hospitals.” “I think the hospital is going to be the one with the most to gain by supporting these opportunities.”

A new study in this month's Journal of Hospital Medicine that catalogues the daily routine of HM practitioners is a first step in helping streamline the hospitalist’s workflow for efficiency, say several people associated with the report.

The report, “Where Did the Day Go? A Time-Motion Study of Hospitalists,” attempted to capture the amount of time hospitalists spent on various activities, including interacting with electronic health records (EHR) (34.1%), communication with colleagues (25.9%), and direct care (7.4%) (J Hosp Med. 2010;5(6):323-328). But one of the report’s senior authors, as well as the co-author of an accompanying editorial, anticipate that the study will serve as a springboard for future research on how hospitalists can best use their time.

Hospitalists need to “lay the foundation to figure how not to just observe what the doctors are doing, but how, in the future, to what they should be doing,” says Mark Williams, MD, FHM, professor and chief of hospital medicine at Northwestern University's Feinberg School of Medicine in Chicago. “We’ve got to have a good understanding of what we’re doing every day to move forward.”

The research, which furthered a similar Northwestern study completed in 2006 found that 16% of all activities occurred simultaneously, meaning that the surveyed hospitalists spent about 9% of their average 10.3-hour shift multitasking.

“Sadly, we documented that the vast majority [of time] is away from the patient, not with the patient,” Dr. Williams says.

Dr. Williams and Amit Prachand, an administrator in the HM department at Northwestern, hope to see more research done to define the best workflow for a hospitalist. Both agree, though, that dedicated funding will have to be set aside, either by federal agencies or research institutions, to make that happen.

“We need to convince people the money is well spent in focusing on this,” says Prachand, co-author of the editorial “Hospitalists: Lean Leaders for Hospitals.” “I think the hospital is going to be the one with the most to gain by supporting these opportunities.”

A new study in this month's Journal of Hospital Medicine that catalogues the daily routine of HM practitioners is a first step in helping streamline the hospitalist’s workflow for efficiency, say several people associated with the report.

The report, “Where Did the Day Go? A Time-Motion Study of Hospitalists,” attempted to capture the amount of time hospitalists spent on various activities, including interacting with electronic health records (EHR) (34.1%), communication with colleagues (25.9%), and direct care (7.4%) (J Hosp Med. 2010;5(6):323-328). But one of the report’s senior authors, as well as the co-author of an accompanying editorial, anticipate that the study will serve as a springboard for future research on how hospitalists can best use their time.

Hospitalists need to “lay the foundation to figure how not to just observe what the doctors are doing, but how, in the future, to what they should be doing,” says Mark Williams, MD, FHM, professor and chief of hospital medicine at Northwestern University's Feinberg School of Medicine in Chicago. “We’ve got to have a good understanding of what we’re doing every day to move forward.”

The research, which furthered a similar Northwestern study completed in 2006 found that 16% of all activities occurred simultaneously, meaning that the surveyed hospitalists spent about 9% of their average 10.3-hour shift multitasking.

“Sadly, we documented that the vast majority [of time] is away from the patient, not with the patient,” Dr. Williams says.

Dr. Williams and Amit Prachand, an administrator in the HM department at Northwestern, hope to see more research done to define the best workflow for a hospitalist. Both agree, though, that dedicated funding will have to be set aside, either by federal agencies or research institutions, to make that happen.

“We need to convince people the money is well spent in focusing on this,” says Prachand, co-author of the editorial “Hospitalists: Lean Leaders for Hospitals.” “I think the hospital is going to be the one with the most to gain by supporting these opportunities.”

New guidelines from the Centers for Disease Control and Prevention (CDC) that recommend interferon-gamma release assay (IGRA) blood tests over the century-old tuberculin skin test (TST) to detect Mycobacterium tuberculosis (TB) could help hospitalist groups save time and money, according to the head of a TB institute.

The guidelines, published in the CDC’s Morbidity & Mortality Weekly Report, recommend providers use IGRAs over TSTs for certain populations, including patients who historically are unlikely to return for a needed second visit to read the TST results and patients who have previously received Bacille Calmette-Guérin (BCG) as a vaccine or as a cancer therapy (MMWR Recomm Rep. 2010;59(RR-5):1-25).

TSTs remain the preferred test for children younger than 5 years old, although some research has suggested that using both tests in youngsters could increase diagnostic sensitivity for that population.

Lee B. Reichman, MD, MPH, FACP, FCCP, of New Jersey Medical School’s Global Tuberculosis Institute in Newark says the improved efficacy of IGRAs should help weed out the false positives associated with the TSTs. That should be a boon for hospitalists looking to boost cost efficiency by focusing care delivery on the most at-risk populations, he adds.

“The hospitalist is busy,” Dr. Reichman says. “So now he doesn’t have to worry about all those people who are turning out to be a false positive.”

Dr. Reichman hopes the new guidelines catch on quickly, particularly because IGRAs must be conducted in laboratory settings that help ensure better predictive results. He fears, however, that adherence to traditional methods like BCG vaccination, which is particularly popular in Europe, might stall widespread IGRA adoption.

“It will take time to get there,” he says. “The TB community is notoriously slow in adapting new technologies.”

New guidelines from the Centers for Disease Control and Prevention (CDC) that recommend interferon-gamma release assay (IGRA) blood tests over the century-old tuberculin skin test (TST) to detect Mycobacterium tuberculosis (TB) could help hospitalist groups save time and money, according to the head of a TB institute.

The guidelines, published in the CDC’s Morbidity & Mortality Weekly Report, recommend providers use IGRAs over TSTs for certain populations, including patients who historically are unlikely to return for a needed second visit to read the TST results and patients who have previously received Bacille Calmette-Guérin (BCG) as a vaccine or as a cancer therapy (MMWR Recomm Rep. 2010;59(RR-5):1-25).

TSTs remain the preferred test for children younger than 5 years old, although some research has suggested that using both tests in youngsters could increase diagnostic sensitivity for that population.

Lee B. Reichman, MD, MPH, FACP, FCCP, of New Jersey Medical School’s Global Tuberculosis Institute in Newark says the improved efficacy of IGRAs should help weed out the false positives associated with the TSTs. That should be a boon for hospitalists looking to boost cost efficiency by focusing care delivery on the most at-risk populations, he adds.

“The hospitalist is busy,” Dr. Reichman says. “So now he doesn’t have to worry about all those people who are turning out to be a false positive.”

Dr. Reichman hopes the new guidelines catch on quickly, particularly because IGRAs must be conducted in laboratory settings that help ensure better predictive results. He fears, however, that adherence to traditional methods like BCG vaccination, which is particularly popular in Europe, might stall widespread IGRA adoption.

“It will take time to get there,” he says. “The TB community is notoriously slow in adapting new technologies.”

New guidelines from the Centers for Disease Control and Prevention (CDC) that recommend interferon-gamma release assay (IGRA) blood tests over the century-old tuberculin skin test (TST) to detect Mycobacterium tuberculosis (TB) could help hospitalist groups save time and money, according to the head of a TB institute.

The guidelines, published in the CDC’s Morbidity & Mortality Weekly Report, recommend providers use IGRAs over TSTs for certain populations, including patients who historically are unlikely to return for a needed second visit to read the TST results and patients who have previously received Bacille Calmette-Guérin (BCG) as a vaccine or as a cancer therapy (MMWR Recomm Rep. 2010;59(RR-5):1-25).

TSTs remain the preferred test for children younger than 5 years old, although some research has suggested that using both tests in youngsters could increase diagnostic sensitivity for that population.

Lee B. Reichman, MD, MPH, FACP, FCCP, of New Jersey Medical School’s Global Tuberculosis Institute in Newark says the improved efficacy of IGRAs should help weed out the false positives associated with the TSTs. That should be a boon for hospitalists looking to boost cost efficiency by focusing care delivery on the most at-risk populations, he adds.

“The hospitalist is busy,” Dr. Reichman says. “So now he doesn’t have to worry about all those people who are turning out to be a false positive.”

Dr. Reichman hopes the new guidelines catch on quickly, particularly because IGRAs must be conducted in laboratory settings that help ensure better predictive results. He fears, however, that adherence to traditional methods like BCG vaccination, which is particularly popular in Europe, might stall widespread IGRA adoption.

“It will take time to get there,” he says. “The TB community is notoriously slow in adapting new technologies.”