Patrice Wendling

CHICAGO – Dr. Nassir Ghaemi is a bit of a maverick. The well-published author and director of the mood disorders and psychopharmacology programs at Tufts Medical Center in Boston likes to step off the well-worn CME lecture track and challenge his audience with the words of ancient philosophers, artists, and economists.

At the annual meeting of the American Academy of Clinical Psychiatrists, he pushed those in attendance even further, asking them to reconsider the widely held view that stimulant treatment is relatively safe in attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder.

Dr. Ghaemi contends that children and adults who are diagnosed with ADHD in the United States are automatically given amphetamines, and that there is a routine presumption that long-term treatment with these agents is warranted. He said he believes amphetamines should only be used as a last resort and primarily for short-term treatment in ADHD. In bipolar disorder, he takes the stance that amphetamines should be used even more sparingly–if at all.

The cornerstone of Dr. Ghaemi's arguments lies in emerging evidence that amphetamines might actually worsen ADHD and bipolar disorder.

Some of the first glimmers of this came nearly a decade ago from two retrospective pediatric studies showing a correlation between stimulants and mania. In 42 children with bipolar disorder and ADHD, the mean age of onset of ADHD was 5.5 years, mean length of stimulant use 6.9 years, and onset of manic symptoms 7.1 years (J. Am. Acad. Child Adolesc. Psychiatry 2000;39:713-20).

In 34 adolescents hospitalized with mania, patients with stimulant use before the onset of bipolar disorder had an earlier age at onset of the disease than those without prior stimulant exposure (10.7 vs. 13.9 years). Additionally, adolescents treated with at least two stimulants had a younger age at onset than those treated with one stimulant (Bipolar Disord. 2001;3:53-7).

“It's all association, correlational, observational; it's not definitive, it's not causative, but there's room for suspicion that amphetamines might be causing mania in these children,” said Dr. Ghaemi, also a professor of psychiatry at Tufts University who completed a research fellowship in psychopharmacology at Massachusetts General Hospital.

He went on to highlight additional data on treatment-emergent mania. In a brief open study in 14 depressed adults with a DSM-IV diagnosis of bipolar illness treated with methylphenidate added to a mood stabilizer regimen, 3 patients (21%) stopped methylphenidate because of anxiety, agitation, or hypomania (Bipolar Disord. 2000;2:56-9).

A case review of 82 children (mean age 10.6 years) with bipolar disorder not receiving mood stabilizers reported treatment-emergent mania in 20% of 40 children on stimulants–6 of 28 children on methylphenidate and 2 of 12 on amphetamines. The mean time to mania onset was 12.5 days from start of treatment (J. Affect. Disord. 2004:82:149-58).

By themselves, these data are not that alarming, given that antidepressants in the observational setting are associated with roughly a 20% mania switch rate, Dr. Ghaemi said. In the case review, however, long-term harmful effects were observed, including more mood episodes, suicidality, and hospitalization.

In his own study, co-led by former Emory University colleague Dr. Aliza Wingo, the rate of stimulant-associated mania or hypomania reached a staggering 40% in 137 adults with ADHD and bipolar disorder treated mostly with methyl phenidate for varying lengths of time (Psychopharmacol. Bull. 2008;41:37-47). “This is the largest study of adult ADHD bipolar comorbidity, and we're finding that stimulants are harmful in almost one-half of patients,” he said.

Routine and long-term amphetamine use in young children is particularly concerning, Dr. Ghaemi said, because animal studies have shown an association between early amphetamine use and adult neurobiologic effects, including decreased response to rewarding stimuli, increases in depressive and anxiety behaviors, and decreased dopaminergic neuronal activity. In rats given Ritalin at a dose of 2.0 mg/kg twice daily from days 20 to 35 after birth, researchers observed a significant decrease in long-term survival of newborn cells, particularly in the temporal hippocampus (Biol. Psychiatry 2006;60:1121-30).

The way in which this plays out in bipolar disorder is even more remarkable, as the illness itself can reduce cortical thickness, Dr. Ghaemi said. Brain MRIs identified significant decreased cortical thickening in multiple prefrontal cortices in 25 patients with bipolar disorder, relative to 21 healthy controls (Bipolar Disord. 2006;8:65-74). In addition, a correlation was found between illness duration and cortical thinning.

“Amphetamines, if they were newly coming to the market today, I believe they wouldn't make it through [Food and Drug Administration] screening because of this issue,” he said. (The agency has looked recently at the use of stimulants in children and adolescents with ADHD. See article below.)

Dr. Ghaemi's thinking is not so radical, according to Dr. Boghos Yerevanian, clinical professor of psychiatry, University of California, Los Angeles, and director of the mood disorders program at Greater Los Angeles VA Healthcare/Sepulveda.

“I agree with Dr. Ghaemi's observations; they are wise words,” Dr. Yerevanian said in an interview. “There are some data, not as well studied as [they] should be, that long-term stimulant treatment is associated with brain microvascular disease. This further complicates the problem with bipolars whose brain integrity is already compromised due to various factors, some of it known and most unknown. Stroke, of course, is associated with cocaine use in young people and cocaine in many respects mimics amphetamines.”

The next step is for the biologic data to be taken into monkey and human studies, and for the current evidence to be more widely disseminated, Dr. Ghaemi said. “I'm not saying you should stop using amphetamines, but you should think about these data when you're using amphetamines.”

Dr. Ghaemi reported that in the past year he has received research support from Pfizer Inc. and honoraria from Bristol-Myers Squibb. He was on the speakers bureau for Pfizer and Astra-Zeneca but is not currently.

To watch a video interview of Dr. Ghaemi, go to www.youtube.com/watch?v=aWuxgMtZxZY

CHICAGO – Dr. Nassir Ghaemi is a bit of a maverick. The well-published author and director of the mood disorders and psychopharmacology programs at Tufts Medical Center in Boston likes to step off the well-worn CME lecture track and challenge his audience with the words of ancient philosophers, artists, and economists.

At the annual meeting of the American Academy of Clinical Psychiatrists, he pushed those in attendance even further, asking them to reconsider the widely held view that stimulant treatment is relatively safe in attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder.

Dr. Ghaemi contends that children and adults who are diagnosed with ADHD in the United States are automatically given amphetamines, and that there is a routine presumption that long-term treatment with these agents is warranted. He said he believes amphetamines should only be used as a last resort and primarily for short-term treatment in ADHD. In bipolar disorder, he takes the stance that amphetamines should be used even more sparingly–if at all.

The cornerstone of Dr. Ghaemi's arguments lies in emerging evidence that amphetamines might actually worsen ADHD and bipolar disorder.

Some of the first glimmers of this came nearly a decade ago from two retrospective pediatric studies showing a correlation between stimulants and mania. In 42 children with bipolar disorder and ADHD, the mean age of onset of ADHD was 5.5 years, mean length of stimulant use 6.9 years, and onset of manic symptoms 7.1 years (J. Am. Acad. Child Adolesc. Psychiatry 2000;39:713-20).

In 34 adolescents hospitalized with mania, patients with stimulant use before the onset of bipolar disorder had an earlier age at onset of the disease than those without prior stimulant exposure (10.7 vs. 13.9 years). Additionally, adolescents treated with at least two stimulants had a younger age at onset than those treated with one stimulant (Bipolar Disord. 2001;3:53-7).

“It's all association, correlational, observational; it's not definitive, it's not causative, but there's room for suspicion that amphetamines might be causing mania in these children,” said Dr. Ghaemi, also a professor of psychiatry at Tufts University who completed a research fellowship in psychopharmacology at Massachusetts General Hospital.

He went on to highlight additional data on treatment-emergent mania. In a brief open study in 14 depressed adults with a DSM-IV diagnosis of bipolar illness treated with methylphenidate added to a mood stabilizer regimen, 3 patients (21%) stopped methylphenidate because of anxiety, agitation, or hypomania (Bipolar Disord. 2000;2:56-9).

A case review of 82 children (mean age 10.6 years) with bipolar disorder not receiving mood stabilizers reported treatment-emergent mania in 20% of 40 children on stimulants–6 of 28 children on methylphenidate and 2 of 12 on amphetamines. The mean time to mania onset was 12.5 days from start of treatment (J. Affect. Disord. 2004:82:149-58).

By themselves, these data are not that alarming, given that antidepressants in the observational setting are associated with roughly a 20% mania switch rate, Dr. Ghaemi said. In the case review, however, long-term harmful effects were observed, including more mood episodes, suicidality, and hospitalization.

In his own study, co-led by former Emory University colleague Dr. Aliza Wingo, the rate of stimulant-associated mania or hypomania reached a staggering 40% in 137 adults with ADHD and bipolar disorder treated mostly with methyl phenidate for varying lengths of time (Psychopharmacol. Bull. 2008;41:37-47). “This is the largest study of adult ADHD bipolar comorbidity, and we're finding that stimulants are harmful in almost one-half of patients,” he said.

Routine and long-term amphetamine use in young children is particularly concerning, Dr. Ghaemi said, because animal studies have shown an association between early amphetamine use and adult neurobiologic effects, including decreased response to rewarding stimuli, increases in depressive and anxiety behaviors, and decreased dopaminergic neuronal activity. In rats given Ritalin at a dose of 2.0 mg/kg twice daily from days 20 to 35 after birth, researchers observed a significant decrease in long-term survival of newborn cells, particularly in the temporal hippocampus (Biol. Psychiatry 2006;60:1121-30).

The way in which this plays out in bipolar disorder is even more remarkable, as the illness itself can reduce cortical thickness, Dr. Ghaemi said. Brain MRIs identified significant decreased cortical thickening in multiple prefrontal cortices in 25 patients with bipolar disorder, relative to 21 healthy controls (Bipolar Disord. 2006;8:65-74). In addition, a correlation was found between illness duration and cortical thinning.

“Amphetamines, if they were newly coming to the market today, I believe they wouldn't make it through [Food and Drug Administration] screening because of this issue,” he said. (The agency has looked recently at the use of stimulants in children and adolescents with ADHD. See article below.)

Dr. Ghaemi's thinking is not so radical, according to Dr. Boghos Yerevanian, clinical professor of psychiatry, University of California, Los Angeles, and director of the mood disorders program at Greater Los Angeles VA Healthcare/Sepulveda.

“I agree with Dr. Ghaemi's observations; they are wise words,” Dr. Yerevanian said in an interview. “There are some data, not as well studied as [they] should be, that long-term stimulant treatment is associated with brain microvascular disease. This further complicates the problem with bipolars whose brain integrity is already compromised due to various factors, some of it known and most unknown. Stroke, of course, is associated with cocaine use in young people and cocaine in many respects mimics amphetamines.”

The next step is for the biologic data to be taken into monkey and human studies, and for the current evidence to be more widely disseminated, Dr. Ghaemi said. “I'm not saying you should stop using amphetamines, but you should think about these data when you're using amphetamines.”

Dr. Ghaemi reported that in the past year he has received research support from Pfizer Inc. and honoraria from Bristol-Myers Squibb. He was on the speakers bureau for Pfizer and Astra-Zeneca but is not currently.

To watch a video interview of Dr. Ghaemi, go to www.youtube.com/watch?v=aWuxgMtZxZY

CHICAGO – Dr. Nassir Ghaemi is a bit of a maverick. The well-published author and director of the mood disorders and psychopharmacology programs at Tufts Medical Center in Boston likes to step off the well-worn CME lecture track and challenge his audience with the words of ancient philosophers, artists, and economists.

At the annual meeting of the American Academy of Clinical Psychiatrists, he pushed those in attendance even further, asking them to reconsider the widely held view that stimulant treatment is relatively safe in attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder.

Dr. Ghaemi contends that children and adults who are diagnosed with ADHD in the United States are automatically given amphetamines, and that there is a routine presumption that long-term treatment with these agents is warranted. He said he believes amphetamines should only be used as a last resort and primarily for short-term treatment in ADHD. In bipolar disorder, he takes the stance that amphetamines should be used even more sparingly–if at all.

The cornerstone of Dr. Ghaemi's arguments lies in emerging evidence that amphetamines might actually worsen ADHD and bipolar disorder.

Some of the first glimmers of this came nearly a decade ago from two retrospective pediatric studies showing a correlation between stimulants and mania. In 42 children with bipolar disorder and ADHD, the mean age of onset of ADHD was 5.5 years, mean length of stimulant use 6.9 years, and onset of manic symptoms 7.1 years (J. Am. Acad. Child Adolesc. Psychiatry 2000;39:713-20).

In 34 adolescents hospitalized with mania, patients with stimulant use before the onset of bipolar disorder had an earlier age at onset of the disease than those without prior stimulant exposure (10.7 vs. 13.9 years). Additionally, adolescents treated with at least two stimulants had a younger age at onset than those treated with one stimulant (Bipolar Disord. 2001;3:53-7).

“It's all association, correlational, observational; it's not definitive, it's not causative, but there's room for suspicion that amphetamines might be causing mania in these children,” said Dr. Ghaemi, also a professor of psychiatry at Tufts University who completed a research fellowship in psychopharmacology at Massachusetts General Hospital.

He went on to highlight additional data on treatment-emergent mania. In a brief open study in 14 depressed adults with a DSM-IV diagnosis of bipolar illness treated with methylphenidate added to a mood stabilizer regimen, 3 patients (21%) stopped methylphenidate because of anxiety, agitation, or hypomania (Bipolar Disord. 2000;2:56-9).

A case review of 82 children (mean age 10.6 years) with bipolar disorder not receiving mood stabilizers reported treatment-emergent mania in 20% of 40 children on stimulants–6 of 28 children on methylphenidate and 2 of 12 on amphetamines. The mean time to mania onset was 12.5 days from start of treatment (J. Affect. Disord. 2004:82:149-58).

By themselves, these data are not that alarming, given that antidepressants in the observational setting are associated with roughly a 20% mania switch rate, Dr. Ghaemi said. In the case review, however, long-term harmful effects were observed, including more mood episodes, suicidality, and hospitalization.

In his own study, co-led by former Emory University colleague Dr. Aliza Wingo, the rate of stimulant-associated mania or hypomania reached a staggering 40% in 137 adults with ADHD and bipolar disorder treated mostly with methyl phenidate for varying lengths of time (Psychopharmacol. Bull. 2008;41:37-47). “This is the largest study of adult ADHD bipolar comorbidity, and we're finding that stimulants are harmful in almost one-half of patients,” he said.

Routine and long-term amphetamine use in young children is particularly concerning, Dr. Ghaemi said, because animal studies have shown an association between early amphetamine use and adult neurobiologic effects, including decreased response to rewarding stimuli, increases in depressive and anxiety behaviors, and decreased dopaminergic neuronal activity. In rats given Ritalin at a dose of 2.0 mg/kg twice daily from days 20 to 35 after birth, researchers observed a significant decrease in long-term survival of newborn cells, particularly in the temporal hippocampus (Biol. Psychiatry 2006;60:1121-30).

The way in which this plays out in bipolar disorder is even more remarkable, as the illness itself can reduce cortical thickness, Dr. Ghaemi said. Brain MRIs identified significant decreased cortical thickening in multiple prefrontal cortices in 25 patients with bipolar disorder, relative to 21 healthy controls (Bipolar Disord. 2006;8:65-74). In addition, a correlation was found between illness duration and cortical thinning.

“Amphetamines, if they were newly coming to the market today, I believe they wouldn't make it through [Food and Drug Administration] screening because of this issue,” he said. (The agency has looked recently at the use of stimulants in children and adolescents with ADHD. See article below.)

Dr. Ghaemi's thinking is not so radical, according to Dr. Boghos Yerevanian, clinical professor of psychiatry, University of California, Los Angeles, and director of the mood disorders program at Greater Los Angeles VA Healthcare/Sepulveda.

“I agree with Dr. Ghaemi's observations; they are wise words,” Dr. Yerevanian said in an interview. “There are some data, not as well studied as [they] should be, that long-term stimulant treatment is associated with brain microvascular disease. This further complicates the problem with bipolars whose brain integrity is already compromised due to various factors, some of it known and most unknown. Stroke, of course, is associated with cocaine use in young people and cocaine in many respects mimics amphetamines.”

The next step is for the biologic data to be taken into monkey and human studies, and for the current evidence to be more widely disseminated, Dr. Ghaemi said. “I'm not saying you should stop using amphetamines, but you should think about these data when you're using amphetamines.”

Dr. Ghaemi reported that in the past year he has received research support from Pfizer Inc. and honoraria from Bristol-Myers Squibb. He was on the speakers bureau for Pfizer and Astra-Zeneca but is not currently.

To watch a video interview of Dr. Ghaemi, go to www.youtube.com/watch?v=aWuxgMtZxZY

CHICAGO — Hospitalists could do more to improve communication with their patients, a survey of 420 hospitalized patients suggests.

The proportion of “excellent” ratings for 21 individual hospitalists evaluated using the Communication Assessment Tool (CAT) ranged from 38.5% to 73.5%, with an average of 58.8%, Darlene Ferranti and her associates reported in a poster at the annual meeting of the Society of Hospital Medicine.

For individual items included in the previously validated CAT, the highest ratings for the group as a whole were for treating the patient with respect (68%), talking in terms the patient could understand (65%), and letting the patient talk without interruption (65%). The lowest ratings were for involving the patient in decisions as much as he or she wanted (53%) and encouraging the patient to ask questions (50%).

“A significant proportion of hospitalists in this sample may benefit from targeted training to improve communication with patients, particularly in the areas of encouraging patients to ask questions and involving patients in decision making,” they wrote.

The patients, who were hospitalized on general medicine inpatient units of an urban, academic hospital, were eligible to participate in the study after they had been assigned to a hospitalist for 2–3 days. Overall, 26% of patients were aged 44 years or younger, 39% were 45–64 years, and 35% were 65 years or older.

The survey included 20 patients for each of the 21 hospitalists. The hospitalists ranged in age from 30 to 36 years, and 57% were women. They had an average of 2.8 years of experience practicing as a hospitalist (range 1–8 years).

Differences between hospitalists' scores may be partly explained by specialization in a particular service, according to Ms. Ferranti, research study programs coordinator at Northwestern University Feinberg School of Medicine in Chicago, and her associates. These effects were minimized by capturing patients from different services and on different units, when possible.

The 15 items on the CAT describe performance in key aspects of effective communication, but do not reflect the particular skills and content used in successful patient-physician interactions.

“Future work could identify specific techniques used in medical interviews by highly rated physicians, with the goal of developing tools for targeted improvement,” they wrote.

CHICAGO — Hospitalists could do more to improve communication with their patients, a survey of 420 hospitalized patients suggests.

The proportion of “excellent” ratings for 21 individual hospitalists evaluated using the Communication Assessment Tool (CAT) ranged from 38.5% to 73.5%, with an average of 58.8%, Darlene Ferranti and her associates reported in a poster at the annual meeting of the Society of Hospital Medicine.

For individual items included in the previously validated CAT, the highest ratings for the group as a whole were for treating the patient with respect (68%), talking in terms the patient could understand (65%), and letting the patient talk without interruption (65%). The lowest ratings were for involving the patient in decisions as much as he or she wanted (53%) and encouraging the patient to ask questions (50%).

“A significant proportion of hospitalists in this sample may benefit from targeted training to improve communication with patients, particularly in the areas of encouraging patients to ask questions and involving patients in decision making,” they wrote.

The patients, who were hospitalized on general medicine inpatient units of an urban, academic hospital, were eligible to participate in the study after they had been assigned to a hospitalist for 2–3 days. Overall, 26% of patients were aged 44 years or younger, 39% were 45–64 years, and 35% were 65 years or older.

The survey included 20 patients for each of the 21 hospitalists. The hospitalists ranged in age from 30 to 36 years, and 57% were women. They had an average of 2.8 years of experience practicing as a hospitalist (range 1–8 years).

Differences between hospitalists' scores may be partly explained by specialization in a particular service, according to Ms. Ferranti, research study programs coordinator at Northwestern University Feinberg School of Medicine in Chicago, and her associates. These effects were minimized by capturing patients from different services and on different units, when possible.

The 15 items on the CAT describe performance in key aspects of effective communication, but do not reflect the particular skills and content used in successful patient-physician interactions.

“Future work could identify specific techniques used in medical interviews by highly rated physicians, with the goal of developing tools for targeted improvement,” they wrote.

CHICAGO — Hospitalists could do more to improve communication with their patients, a survey of 420 hospitalized patients suggests.

The proportion of “excellent” ratings for 21 individual hospitalists evaluated using the Communication Assessment Tool (CAT) ranged from 38.5% to 73.5%, with an average of 58.8%, Darlene Ferranti and her associates reported in a poster at the annual meeting of the Society of Hospital Medicine.

For individual items included in the previously validated CAT, the highest ratings for the group as a whole were for treating the patient with respect (68%), talking in terms the patient could understand (65%), and letting the patient talk without interruption (65%). The lowest ratings were for involving the patient in decisions as much as he or she wanted (53%) and encouraging the patient to ask questions (50%).

“A significant proportion of hospitalists in this sample may benefit from targeted training to improve communication with patients, particularly in the areas of encouraging patients to ask questions and involving patients in decision making,” they wrote.

The patients, who were hospitalized on general medicine inpatient units of an urban, academic hospital, were eligible to participate in the study after they had been assigned to a hospitalist for 2–3 days. Overall, 26% of patients were aged 44 years or younger, 39% were 45–64 years, and 35% were 65 years or older.

The survey included 20 patients for each of the 21 hospitalists. The hospitalists ranged in age from 30 to 36 years, and 57% were women. They had an average of 2.8 years of experience practicing as a hospitalist (range 1–8 years).

Differences between hospitalists' scores may be partly explained by specialization in a particular service, according to Ms. Ferranti, research study programs coordinator at Northwestern University Feinberg School of Medicine in Chicago, and her associates. These effects were minimized by capturing patients from different services and on different units, when possible.

The 15 items on the CAT describe performance in key aspects of effective communication, but do not reflect the particular skills and content used in successful patient-physician interactions.

“Future work could identify specific techniques used in medical interviews by highly rated physicians, with the goal of developing tools for targeted improvement,” they wrote.

CHICAGO — The effect of rapid response teams on hard clinical outcomes remains unclear, but such teams do seem to have an important role at many hospitals, experts said at the annual meeting of the Society of Hospital Medicine.

At the University of California at San Francisco, the rapid response team (RRT) was hospitalist-led from 2005 to 2007, but it struggled with low utilization and had little effect, said Dr. Sumant Ranji, of the university's division of hospital medicine. The RRT was disbanded, but it came back in late 2007, this time staffed by critical care nurses and respiratory therapists. Today, the RRT is popular among nurses, serves as an important liaison between floors and the ICU, and has a major role in educating new nurses.

Available 24/7, 365 days a year, the RRT responds to emergencies, follows up on ICU discharges, and proactively rounds on the wards. In about 20% of cases, the patient is transferred to the ICU.

“What we've found is that the rapid response team acts as a safety valve” and provides a way to identify system problems such as inadequate bedside staffing, poor communication between staff, and staff with inadequate training or experience, Dr. Ranji said.

An RRT should not be used as a replacement for Code Blue, said copresenter Dr. Winthrop Whitcomb, a hospitalist at Mercy Medical Center in Springfield, Mass., and cofounder of the Society of Hospital Medicine. Led by critical care nurses, Mercy's RRT is called when there is an acute change in heart rate, respiratory rate, or oxygen saturation; an acute or symptomatic change in systolic blood pressure; significant bleeding; new or prolonged seizures; unresolved chest pain; or other concerns.

After educating staff in early 2005, Mercy rolled out the RRT to all inpatient units and expanded the team to cover the entire hospital after just 7 months. The RRT includes nurses, ICU nurses, respiratory therapists, nursing supervisors, a hospitalist at night, and an intensivist during the day.

Despite receiving written educational materials about seeking assistance, after 12 months, not a single patient or family had called a rapid response at Mercy, he said.

Two other obstacles are criticism of staff members for calling the RRT and failure to have a plan for post-RRT care. A hospitalist involved in an RRT encounter must hand off care to the attending physician of record, Dr. Whitcomb said.

Billing for an RRT encounter can include critical care codes, if the encounter qualifies, or subsequent care codes, if the bill denotes a new diagnosis or an exacerbation of an existing one.

Mercy handles about a dozen rapid response calls per month, with two-thirds originating outside the ICU. A review of 449 RRT encounters showed that 45% of patients remained in their room, while 18% were transferred to the ICU. Unadjusted mortality rates for 2004–2008 were “pretty flat” at about 2.5%–3%, Dr. Whitcomb said.

In a systematic review of 13 RRT studies, Dr. Ranji and his associates reported reductions in inpatient mortality and cardiac arrest rates in 11 before-and-after studies. In the lone randomized controlled trial, however, mortality declined in the control group to a similar extent as in the observational studies (J. Hosp. Med. 2007;2:422–32).

The authors had no conflicts of interest.

CHICAGO — The effect of rapid response teams on hard clinical outcomes remains unclear, but such teams do seem to have an important role at many hospitals, experts said at the annual meeting of the Society of Hospital Medicine.

At the University of California at San Francisco, the rapid response team (RRT) was hospitalist-led from 2005 to 2007, but it struggled with low utilization and had little effect, said Dr. Sumant Ranji, of the university's division of hospital medicine. The RRT was disbanded, but it came back in late 2007, this time staffed by critical care nurses and respiratory therapists. Today, the RRT is popular among nurses, serves as an important liaison between floors and the ICU, and has a major role in educating new nurses.

Available 24/7, 365 days a year, the RRT responds to emergencies, follows up on ICU discharges, and proactively rounds on the wards. In about 20% of cases, the patient is transferred to the ICU.

“What we've found is that the rapid response team acts as a safety valve” and provides a way to identify system problems such as inadequate bedside staffing, poor communication between staff, and staff with inadequate training or experience, Dr. Ranji said.

An RRT should not be used as a replacement for Code Blue, said copresenter Dr. Winthrop Whitcomb, a hospitalist at Mercy Medical Center in Springfield, Mass., and cofounder of the Society of Hospital Medicine. Led by critical care nurses, Mercy's RRT is called when there is an acute change in heart rate, respiratory rate, or oxygen saturation; an acute or symptomatic change in systolic blood pressure; significant bleeding; new or prolonged seizures; unresolved chest pain; or other concerns.

After educating staff in early 2005, Mercy rolled out the RRT to all inpatient units and expanded the team to cover the entire hospital after just 7 months. The RRT includes nurses, ICU nurses, respiratory therapists, nursing supervisors, a hospitalist at night, and an intensivist during the day.

Despite receiving written educational materials about seeking assistance, after 12 months, not a single patient or family had called a rapid response at Mercy, he said.

Two other obstacles are criticism of staff members for calling the RRT and failure to have a plan for post-RRT care. A hospitalist involved in an RRT encounter must hand off care to the attending physician of record, Dr. Whitcomb said.

Billing for an RRT encounter can include critical care codes, if the encounter qualifies, or subsequent care codes, if the bill denotes a new diagnosis or an exacerbation of an existing one.

Mercy handles about a dozen rapid response calls per month, with two-thirds originating outside the ICU. A review of 449 RRT encounters showed that 45% of patients remained in their room, while 18% were transferred to the ICU. Unadjusted mortality rates for 2004–2008 were “pretty flat” at about 2.5%–3%, Dr. Whitcomb said.

In a systematic review of 13 RRT studies, Dr. Ranji and his associates reported reductions in inpatient mortality and cardiac arrest rates in 11 before-and-after studies. In the lone randomized controlled trial, however, mortality declined in the control group to a similar extent as in the observational studies (J. Hosp. Med. 2007;2:422–32).

The authors had no conflicts of interest.

CHICAGO — The effect of rapid response teams on hard clinical outcomes remains unclear, but such teams do seem to have an important role at many hospitals, experts said at the annual meeting of the Society of Hospital Medicine.

At the University of California at San Francisco, the rapid response team (RRT) was hospitalist-led from 2005 to 2007, but it struggled with low utilization and had little effect, said Dr. Sumant Ranji, of the university's division of hospital medicine. The RRT was disbanded, but it came back in late 2007, this time staffed by critical care nurses and respiratory therapists. Today, the RRT is popular among nurses, serves as an important liaison between floors and the ICU, and has a major role in educating new nurses.

Available 24/7, 365 days a year, the RRT responds to emergencies, follows up on ICU discharges, and proactively rounds on the wards. In about 20% of cases, the patient is transferred to the ICU.

“What we've found is that the rapid response team acts as a safety valve” and provides a way to identify system problems such as inadequate bedside staffing, poor communication between staff, and staff with inadequate training or experience, Dr. Ranji said.

An RRT should not be used as a replacement for Code Blue, said copresenter Dr. Winthrop Whitcomb, a hospitalist at Mercy Medical Center in Springfield, Mass., and cofounder of the Society of Hospital Medicine. Led by critical care nurses, Mercy's RRT is called when there is an acute change in heart rate, respiratory rate, or oxygen saturation; an acute or symptomatic change in systolic blood pressure; significant bleeding; new or prolonged seizures; unresolved chest pain; or other concerns.

After educating staff in early 2005, Mercy rolled out the RRT to all inpatient units and expanded the team to cover the entire hospital after just 7 months. The RRT includes nurses, ICU nurses, respiratory therapists, nursing supervisors, a hospitalist at night, and an intensivist during the day.

Despite receiving written educational materials about seeking assistance, after 12 months, not a single patient or family had called a rapid response at Mercy, he said.

Two other obstacles are criticism of staff members for calling the RRT and failure to have a plan for post-RRT care. A hospitalist involved in an RRT encounter must hand off care to the attending physician of record, Dr. Whitcomb said.

Billing for an RRT encounter can include critical care codes, if the encounter qualifies, or subsequent care codes, if the bill denotes a new diagnosis or an exacerbation of an existing one.

Mercy handles about a dozen rapid response calls per month, with two-thirds originating outside the ICU. A review of 449 RRT encounters showed that 45% of patients remained in their room, while 18% were transferred to the ICU. Unadjusted mortality rates for 2004–2008 were “pretty flat” at about 2.5%–3%, Dr. Whitcomb said.

In a systematic review of 13 RRT studies, Dr. Ranji and his associates reported reductions in inpatient mortality and cardiac arrest rates in 11 before-and-after studies. In the lone randomized controlled trial, however, mortality declined in the control group to a similar extent as in the observational studies (J. Hosp. Med. 2007;2:422–32).

The authors had no conflicts of interest.

CHICAGO — A multimodal, multidisciplinary quality improvement process substantially improved the overall quality of discharge documents across five acute care hospitals, according to a new study by Partners HealthCare of Boston.

After the quality improvement initiative, 96% of discharge packets contained all 12 data elements required for discharge, compared with 65% at baseline.

The largest improvement was seen in documentation of preadmission medication, which rose 19% from 81% to 100%, Dr. Esteban Gandara said at the annual meeting of the Society of Hospital Medicine. Documentation also significantly increased from 91% to 97% for follow-up information and from 92% to 96% for warfarin information. The increases were particularly large for these three items because they had the most room for improvement, he said.

The retrospective analysis included 3,101 discharge documentation packets for patients discharged to subacute facilities from January 2006 through September 2008. Discharge documents included discharge summaries, discharge orders, and nursing instructions and were reviewed for 50 randomly selected patients per hospital per quarter.

Improvements were achieved at all five hospitals in the Partners HealthCare system without financial incentives to the hospitals or physicians, said Dr. Gandara, of the division of internal medicine and primary care at Brigham and Women's Hospital in Boston. The biggest motivator was that the data were reported to the chief medical officer every quarter.

The quality improvement initiative was prompted by two recent studies at his hospital that found only 70% of discharge summaries had all of the information required by the Joint Commission. Important deficits were found regarding medication reconciliation, pending test results, and anticoagulation. There was also no formal quality assurance process in place to review discharge documentation, he said.

Interventions used during the 3-year initiative included technological improvements to hospitals' discharge ordering systems to actively solicit and/or automatically import required information into discharge documents, creation of discharge templates, feedback to clinicians and their service chiefs, staff education, and documentation reviews by nurse care coordinators prior to discharge.

Some of the hospitals did not utilize all of the interventions. They were also allowed to customize their discharge template, as long as it included all necessary data, Dr. Gandara said. The 12 required elements were treatment rendered, treatment response, allergies, preadmission medications, follow-up information, physician contact information, procedures performed, discharge medications, target international normalized ratio, and warfarin indication, duration, and dose.

The smallest quality improvement was observed at a community hospital that did not use technological improvements, while the largest improvements were seen at two academic medical centers with the greatest use of information technology, he said. Community hospitals discharged 53% of the sample, and 74% of patients were from medical units.

“Multiple interventions can improve discharge documentation,” Dr. Gandara said. “Different hospitals might choose different approaches.

“Education, feedback, and publicity are necessary, but you also need some high-reliability components such as IT or case manager sweeps,” he added.

Dr. Gandara acknowledged that some, but not all, of the observed improvement was likely due to changes in measurement methodology and that the study design is subject to confounding. Also, the study failed to analyze the effect of the intervention on patient outcomes.

The investigators disclosed no relevant conflicts of interest.

CHICAGO — A multimodal, multidisciplinary quality improvement process substantially improved the overall quality of discharge documents across five acute care hospitals, according to a new study by Partners HealthCare of Boston.

After the quality improvement initiative, 96% of discharge packets contained all 12 data elements required for discharge, compared with 65% at baseline.

The largest improvement was seen in documentation of preadmission medication, which rose 19% from 81% to 100%, Dr. Esteban Gandara said at the annual meeting of the Society of Hospital Medicine. Documentation also significantly increased from 91% to 97% for follow-up information and from 92% to 96% for warfarin information. The increases were particularly large for these three items because they had the most room for improvement, he said.

The retrospective analysis included 3,101 discharge documentation packets for patients discharged to subacute facilities from January 2006 through September 2008. Discharge documents included discharge summaries, discharge orders, and nursing instructions and were reviewed for 50 randomly selected patients per hospital per quarter.

Improvements were achieved at all five hospitals in the Partners HealthCare system without financial incentives to the hospitals or physicians, said Dr. Gandara, of the division of internal medicine and primary care at Brigham and Women's Hospital in Boston. The biggest motivator was that the data were reported to the chief medical officer every quarter.

The quality improvement initiative was prompted by two recent studies at his hospital that found only 70% of discharge summaries had all of the information required by the Joint Commission. Important deficits were found regarding medication reconciliation, pending test results, and anticoagulation. There was also no formal quality assurance process in place to review discharge documentation, he said.

Interventions used during the 3-year initiative included technological improvements to hospitals' discharge ordering systems to actively solicit and/or automatically import required information into discharge documents, creation of discharge templates, feedback to clinicians and their service chiefs, staff education, and documentation reviews by nurse care coordinators prior to discharge.

Some of the hospitals did not utilize all of the interventions. They were also allowed to customize their discharge template, as long as it included all necessary data, Dr. Gandara said. The 12 required elements were treatment rendered, treatment response, allergies, preadmission medications, follow-up information, physician contact information, procedures performed, discharge medications, target international normalized ratio, and warfarin indication, duration, and dose.

The smallest quality improvement was observed at a community hospital that did not use technological improvements, while the largest improvements were seen at two academic medical centers with the greatest use of information technology, he said. Community hospitals discharged 53% of the sample, and 74% of patients were from medical units.

“Multiple interventions can improve discharge documentation,” Dr. Gandara said. “Different hospitals might choose different approaches.

“Education, feedback, and publicity are necessary, but you also need some high-reliability components such as IT or case manager sweeps,” he added.

Dr. Gandara acknowledged that some, but not all, of the observed improvement was likely due to changes in measurement methodology and that the study design is subject to confounding. Also, the study failed to analyze the effect of the intervention on patient outcomes.

The investigators disclosed no relevant conflicts of interest.

CHICAGO — A multimodal, multidisciplinary quality improvement process substantially improved the overall quality of discharge documents across five acute care hospitals, according to a new study by Partners HealthCare of Boston.

After the quality improvement initiative, 96% of discharge packets contained all 12 data elements required for discharge, compared with 65% at baseline.

The largest improvement was seen in documentation of preadmission medication, which rose 19% from 81% to 100%, Dr. Esteban Gandara said at the annual meeting of the Society of Hospital Medicine. Documentation also significantly increased from 91% to 97% for follow-up information and from 92% to 96% for warfarin information. The increases were particularly large for these three items because they had the most room for improvement, he said.

The retrospective analysis included 3,101 discharge documentation packets for patients discharged to subacute facilities from January 2006 through September 2008. Discharge documents included discharge summaries, discharge orders, and nursing instructions and were reviewed for 50 randomly selected patients per hospital per quarter.

Improvements were achieved at all five hospitals in the Partners HealthCare system without financial incentives to the hospitals or physicians, said Dr. Gandara, of the division of internal medicine and primary care at Brigham and Women's Hospital in Boston. The biggest motivator was that the data were reported to the chief medical officer every quarter.

The quality improvement initiative was prompted by two recent studies at his hospital that found only 70% of discharge summaries had all of the information required by the Joint Commission. Important deficits were found regarding medication reconciliation, pending test results, and anticoagulation. There was also no formal quality assurance process in place to review discharge documentation, he said.

Interventions used during the 3-year initiative included technological improvements to hospitals' discharge ordering systems to actively solicit and/or automatically import required information into discharge documents, creation of discharge templates, feedback to clinicians and their service chiefs, staff education, and documentation reviews by nurse care coordinators prior to discharge.

Some of the hospitals did not utilize all of the interventions. They were also allowed to customize their discharge template, as long as it included all necessary data, Dr. Gandara said. The 12 required elements were treatment rendered, treatment response, allergies, preadmission medications, follow-up information, physician contact information, procedures performed, discharge medications, target international normalized ratio, and warfarin indication, duration, and dose.

The smallest quality improvement was observed at a community hospital that did not use technological improvements, while the largest improvements were seen at two academic medical centers with the greatest use of information technology, he said. Community hospitals discharged 53% of the sample, and 74% of patients were from medical units.

“Multiple interventions can improve discharge documentation,” Dr. Gandara said. “Different hospitals might choose different approaches.

“Education, feedback, and publicity are necessary, but you also need some high-reliability components such as IT or case manager sweeps,” he added.

Dr. Gandara acknowledged that some, but not all, of the observed improvement was likely due to changes in measurement methodology and that the study design is subject to confounding. Also, the study failed to analyze the effect of the intervention on patient outcomes.

The investigators disclosed no relevant conflicts of interest.

CHICAGO — Hospitalists are increasingly being asked to comanage patients with their surgical colleagues, but experts contend that this role should be carefully developed.

Some hospitalists may start comanaging patients as a collegial enterprise or because they've received “an offer they can't refuse” from their hospital CEO or department chair, Dr. Jeffrey Glasheen, director of hospital medicine at the University of Colorado, Denver, said at the annual meeting of the Society of Hospital Medicine.

For other hospitalists, comanagement evolves gradually. For example, if an increasing number of hip fracture patients are admitted to the hospitalist service via the emergency department, hospitalists eventually may find themselves comanaging almost every orthopedic patient.

Before getting into comanagement arrangements, hospitalists should consider what they're trying to accomplish and pay close attention to the potential for intended and unintended consequences, said copresenter Dr. Eric Siegal, of the University of Wisconsin, Madison.

“We should use some selection criteria to determine when to comanage,” Dr. Siegal said. “'Just do it' is a great slogan—if you're a shoe company.”

Comanagement can improve patient care, but it isn't a panacea. Potentially, comanagement can delay appropriate care, bypass established protocols, and disengage subspecialists. Conflicting orders and reports given by hospitalists and other physicians can confuse patients and the care team about who is doing what, ultimately increasing the risk of medical error.

The presenters agreed that the first step is to nail down the goal of comanaging a patient population. Ideally, hospitalists should focus on patients who will benefit the most from their involvement, such as those with significant medical comorbidities, Dr. Siegal said. Hospitalists should ask what problems they're expected to fix, whether their involvement is the best solution, what their involvement might jeopardize, and how to determine if comanagement has been successful.

There is no standard used to define the role of the hospitalist, Dr. Siegal acknowledged. Comanagement varies within institutions and even between groups of physicians, ranging from traditional medical consultation to a model in which hospitalists admit and assume primary responsibility for patients requiring surgical or subspecialty care.

Hospitalists should make it clear at the outset that their relationship with surgeons or subspecialists is one of equals, and should avoid becoming the hospital “admitologist” or “dischargologist.” Attempts should be made to decide who owns what aspects of care, agree when subspecialists must come in to see a patient, and define which patients should go to which service, Dr. Siegal said.

Audience members noted that financial considerations often drive the decision to expand hospitalist comanagement services, thereby freeing up higher-revenue providers. Some hospital leaders may view comanagement as a way to protect overstretched surgeons and subspecialists. This can result in overextended hospitalists who make mistakes, deliver poor care, and burn out professionally, Dr. Glasheen said.

Defining the scope of hospitalist practice is another challenge. The Core Competencies developed by the Society of Hospital Medicine define in broad terms what hospitalists do, but not what they can't do, Dr. Siegal said. Hospitalists should be wary if they find that comanagement evolves into a substitute for subspecialist care; if they are doing things on nights, weekends, or holidays that they wouldn't do on weekdays; or if the emergency department sends inappropriate patients to them because it's easier than calling the surgeon or subspecialist.

After rules of engagement are clearly defined and mutually agreed upon, they must be applied consistently. Problems can arise if hospitalists have different skill sets and apply them inconsistently. For example, one hospitalist on the team manages vents, but the next day another team member won't. If asked to comanage patients outside the scope of their training, hospitalists should negotiate for additional skills training, support, or equipment to allow them to do so competently and safely, Dr. Siegal said.

Hospitalists often ask if it matters if they are the attending physician of record for a patient. Theoretically, hospitalists are not legally responsible for a surgeon's decisions or problems that may arise during surgery, but they will inevitably be named in a lawsuit if their name is on the chart, Dr. Glasheen said. He advised hospitalists to document carefully if they disagree with the management of a patient.

Ultimately, Dr. Siegal said, comanagement may be best defined by a simple rule. If it “matters” who the attending physician of record is, then one service is by definition subordinate. As far as he is concerned, that is not comanagement.

Whether listed on a chart as an attending, a consultant, or a comanager, a hospitalist remains ethically and morally responsible for the patient, Dr. Glasheen added.

Dr. Siegal and Dr. Glasheen disclosed no relevant conflicts of interest.

CHICAGO — Hospitalists are increasingly being asked to comanage patients with their surgical colleagues, but experts contend that this role should be carefully developed.

Some hospitalists may start comanaging patients as a collegial enterprise or because they've received “an offer they can't refuse” from their hospital CEO or department chair, Dr. Jeffrey Glasheen, director of hospital medicine at the University of Colorado, Denver, said at the annual meeting of the Society of Hospital Medicine.

For other hospitalists, comanagement evolves gradually. For example, if an increasing number of hip fracture patients are admitted to the hospitalist service via the emergency department, hospitalists eventually may find themselves comanaging almost every orthopedic patient.

Before getting into comanagement arrangements, hospitalists should consider what they're trying to accomplish and pay close attention to the potential for intended and unintended consequences, said copresenter Dr. Eric Siegal, of the University of Wisconsin, Madison.

“We should use some selection criteria to determine when to comanage,” Dr. Siegal said. “'Just do it' is a great slogan—if you're a shoe company.”

Comanagement can improve patient care, but it isn't a panacea. Potentially, comanagement can delay appropriate care, bypass established protocols, and disengage subspecialists. Conflicting orders and reports given by hospitalists and other physicians can confuse patients and the care team about who is doing what, ultimately increasing the risk of medical error.

The presenters agreed that the first step is to nail down the goal of comanaging a patient population. Ideally, hospitalists should focus on patients who will benefit the most from their involvement, such as those with significant medical comorbidities, Dr. Siegal said. Hospitalists should ask what problems they're expected to fix, whether their involvement is the best solution, what their involvement might jeopardize, and how to determine if comanagement has been successful.

There is no standard used to define the role of the hospitalist, Dr. Siegal acknowledged. Comanagement varies within institutions and even between groups of physicians, ranging from traditional medical consultation to a model in which hospitalists admit and assume primary responsibility for patients requiring surgical or subspecialty care.

Hospitalists should make it clear at the outset that their relationship with surgeons or subspecialists is one of equals, and should avoid becoming the hospital “admitologist” or “dischargologist.” Attempts should be made to decide who owns what aspects of care, agree when subspecialists must come in to see a patient, and define which patients should go to which service, Dr. Siegal said.

Audience members noted that financial considerations often drive the decision to expand hospitalist comanagement services, thereby freeing up higher-revenue providers. Some hospital leaders may view comanagement as a way to protect overstretched surgeons and subspecialists. This can result in overextended hospitalists who make mistakes, deliver poor care, and burn out professionally, Dr. Glasheen said.

Defining the scope of hospitalist practice is another challenge. The Core Competencies developed by the Society of Hospital Medicine define in broad terms what hospitalists do, but not what they can't do, Dr. Siegal said. Hospitalists should be wary if they find that comanagement evolves into a substitute for subspecialist care; if they are doing things on nights, weekends, or holidays that they wouldn't do on weekdays; or if the emergency department sends inappropriate patients to them because it's easier than calling the surgeon or subspecialist.

After rules of engagement are clearly defined and mutually agreed upon, they must be applied consistently. Problems can arise if hospitalists have different skill sets and apply them inconsistently. For example, one hospitalist on the team manages vents, but the next day another team member won't. If asked to comanage patients outside the scope of their training, hospitalists should negotiate for additional skills training, support, or equipment to allow them to do so competently and safely, Dr. Siegal said.

Hospitalists often ask if it matters if they are the attending physician of record for a patient. Theoretically, hospitalists are not legally responsible for a surgeon's decisions or problems that may arise during surgery, but they will inevitably be named in a lawsuit if their name is on the chart, Dr. Glasheen said. He advised hospitalists to document carefully if they disagree with the management of a patient.

Ultimately, Dr. Siegal said, comanagement may be best defined by a simple rule. If it “matters” who the attending physician of record is, then one service is by definition subordinate. As far as he is concerned, that is not comanagement.

Whether listed on a chart as an attending, a consultant, or a comanager, a hospitalist remains ethically and morally responsible for the patient, Dr. Glasheen added.

Dr. Siegal and Dr. Glasheen disclosed no relevant conflicts of interest.

CHICAGO — Hospitalists are increasingly being asked to comanage patients with their surgical colleagues, but experts contend that this role should be carefully developed.

Some hospitalists may start comanaging patients as a collegial enterprise or because they've received “an offer they can't refuse” from their hospital CEO or department chair, Dr. Jeffrey Glasheen, director of hospital medicine at the University of Colorado, Denver, said at the annual meeting of the Society of Hospital Medicine.

For other hospitalists, comanagement evolves gradually. For example, if an increasing number of hip fracture patients are admitted to the hospitalist service via the emergency department, hospitalists eventually may find themselves comanaging almost every orthopedic patient.

Before getting into comanagement arrangements, hospitalists should consider what they're trying to accomplish and pay close attention to the potential for intended and unintended consequences, said copresenter Dr. Eric Siegal, of the University of Wisconsin, Madison.

“We should use some selection criteria to determine when to comanage,” Dr. Siegal said. “'Just do it' is a great slogan—if you're a shoe company.”

Comanagement can improve patient care, but it isn't a panacea. Potentially, comanagement can delay appropriate care, bypass established protocols, and disengage subspecialists. Conflicting orders and reports given by hospitalists and other physicians can confuse patients and the care team about who is doing what, ultimately increasing the risk of medical error.

The presenters agreed that the first step is to nail down the goal of comanaging a patient population. Ideally, hospitalists should focus on patients who will benefit the most from their involvement, such as those with significant medical comorbidities, Dr. Siegal said. Hospitalists should ask what problems they're expected to fix, whether their involvement is the best solution, what their involvement might jeopardize, and how to determine if comanagement has been successful.

There is no standard used to define the role of the hospitalist, Dr. Siegal acknowledged. Comanagement varies within institutions and even between groups of physicians, ranging from traditional medical consultation to a model in which hospitalists admit and assume primary responsibility for patients requiring surgical or subspecialty care.

Hospitalists should make it clear at the outset that their relationship with surgeons or subspecialists is one of equals, and should avoid becoming the hospital “admitologist” or “dischargologist.” Attempts should be made to decide who owns what aspects of care, agree when subspecialists must come in to see a patient, and define which patients should go to which service, Dr. Siegal said.

Audience members noted that financial considerations often drive the decision to expand hospitalist comanagement services, thereby freeing up higher-revenue providers. Some hospital leaders may view comanagement as a way to protect overstretched surgeons and subspecialists. This can result in overextended hospitalists who make mistakes, deliver poor care, and burn out professionally, Dr. Glasheen said.

Defining the scope of hospitalist practice is another challenge. The Core Competencies developed by the Society of Hospital Medicine define in broad terms what hospitalists do, but not what they can't do, Dr. Siegal said. Hospitalists should be wary if they find that comanagement evolves into a substitute for subspecialist care; if they are doing things on nights, weekends, or holidays that they wouldn't do on weekdays; or if the emergency department sends inappropriate patients to them because it's easier than calling the surgeon or subspecialist.

After rules of engagement are clearly defined and mutually agreed upon, they must be applied consistently. Problems can arise if hospitalists have different skill sets and apply them inconsistently. For example, one hospitalist on the team manages vents, but the next day another team member won't. If asked to comanage patients outside the scope of their training, hospitalists should negotiate for additional skills training, support, or equipment to allow them to do so competently and safely, Dr. Siegal said.

Hospitalists often ask if it matters if they are the attending physician of record for a patient. Theoretically, hospitalists are not legally responsible for a surgeon's decisions or problems that may arise during surgery, but they will inevitably be named in a lawsuit if their name is on the chart, Dr. Glasheen said. He advised hospitalists to document carefully if they disagree with the management of a patient.

Ultimately, Dr. Siegal said, comanagement may be best defined by a simple rule. If it “matters” who the attending physician of record is, then one service is by definition subordinate. As far as he is concerned, that is not comanagement.

Whether listed on a chart as an attending, a consultant, or a comanager, a hospitalist remains ethically and morally responsible for the patient, Dr. Glasheen added.

Dr. Siegal and Dr. Glasheen disclosed no relevant conflicts of interest.

ORLANDO — The concept of targeted therapies in melanoma took a step closer to reality with two early trials reporting positive responses to agents that specifically target BRAF or KIT mutations.

In a phase I study of 55 patients with a variety of cancers, 21 metastatic melanoma patients were treated twice daily with at least 240 mg PLX4032, an investigational oral, small-molecule inhibitor that selectively targets the BRAF V600E kinase mutation occurring in most melanomas.

Partial responses by RECIST (Response Evaluation Criteria in Solid Tumors) were confirmed in 9 of 16 BRAF V600E mutation-positive patients. Five of the nine responders had M1c disease, the highest "M" stage, Dr. Keith Flaherty and his associates reported at the annual meeting of the American Society of Clinical Oncology.

Seven patients developed disease progression at 3-14 months while still on therapy. A preliminary analysis suggests a progression-free survival of about 6 months, but the data are very immature and that estimate is likely to change with longer follow-up, said Dr. Flaherty of the University of Pennsylvania, Philadelphia.

In contrast, no tumor regression was observed in the five melanoma patients lacking the BRAF mutation, and all developed progressive disease within the first 3 months.

Interim results from a second phase II study of imatinib in inoperable melanoma showed that a KIT mutation or amplification was present in 21% (31 of 146 tumors) screened. Thus far, 15 of the 31 patients, median age 71 years, have been treated with 400 mg imatinib twice daily on a continuous basis.

Of the 12 patients evaluable for response, the overall rate was 33% by RECIST and included two complete responses and two partial responses, said Dr. Richard Carvajal, an oncologist with Memorial Sloan-Kettering Cancer Center in New York. Stable disease was reported in six patients and disease progression in two. The responses have been durable, lasting 40 weeks in some patients.

Dr. Carvajal noted that only one response by RECIST was reported in three prior phase II studies of imatinib in a total of 62 nonselected patients with advanced melanoma.

The findings are proof of concept that targeted therapies work in melanoma, a heterogenous group of diseases, said Dr. Boris Bastian of the University of California, San Francisco, who was invited to discuss the studies. He acknowledged that it is obviously early and few patients were treated, but that "it's a decisive step toward personalized medicine for our melanoma patients."

In the dose-escalation PLX4032 trial, sponsored by Plexxikon Inc. and Hoffman-La Roche Inc., dose-limiting toxicities developed in four of six patients who received 1,120 mg twice daily, the highest dose evaluated. A 960-mg twice-daily dosage is being evaluated as the maximum tolerated dose in an expanded cohort of mutation-positive melanoma patients, Dr. Flaherty said.

Adverse events with PLX4032 were clearly dose related, but even at higher doses, they tended to be mild, he said. Of note, 11% (six patients) were diagnosed while on study with cutaneous squamous cell carcinoma. Grade 3 or higher rash, fatigue, and pruritus were each reported in 2% of patients.

The PLX4032 study investigators disclosed financial ties with Plexxikon and Hoffman-La Roche. Dr. Carvajal and associates disclosed no personal conflicts of interest, but the study was supported by a Food and Drug Administration grant, an ASCO Young Investigator Award, and the Live4Life Foundation. Dr. Bastian disclosed consulting for Novartis and Exelixis Inc.

Partial responses were confirmed in 9 of 16 BRAF V600E mutation-positive patients treated with PLX4032.

Source DR. FLAHERTY

ORLANDO — The concept of targeted therapies in melanoma took a step closer to reality with two early trials reporting positive responses to agents that specifically target BRAF or KIT mutations.

In a phase I study of 55 patients with a variety of cancers, 21 metastatic melanoma patients were treated twice daily with at least 240 mg PLX4032, an investigational oral, small-molecule inhibitor that selectively targets the BRAF V600E kinase mutation occurring in most melanomas.

Partial responses by RECIST (Response Evaluation Criteria in Solid Tumors) were confirmed in 9 of 16 BRAF V600E mutation-positive patients. Five of the nine responders had M1c disease, the highest "M" stage, Dr. Keith Flaherty and his associates reported at the annual meeting of the American Society of Clinical Oncology.

Seven patients developed disease progression at 3-14 months while still on therapy. A preliminary analysis suggests a progression-free survival of about 6 months, but the data are very immature and that estimate is likely to change with longer follow-up, said Dr. Flaherty of the University of Pennsylvania, Philadelphia.

In contrast, no tumor regression was observed in the five melanoma patients lacking the BRAF mutation, and all developed progressive disease within the first 3 months.

Interim results from a second phase II study of imatinib in inoperable melanoma showed that a KIT mutation or amplification was present in 21% (31 of 146 tumors) screened. Thus far, 15 of the 31 patients, median age 71 years, have been treated with 400 mg imatinib twice daily on a continuous basis.

Of the 12 patients evaluable for response, the overall rate was 33% by RECIST and included two complete responses and two partial responses, said Dr. Richard Carvajal, an oncologist with Memorial Sloan-Kettering Cancer Center in New York. Stable disease was reported in six patients and disease progression in two. The responses have been durable, lasting 40 weeks in some patients.

Dr. Carvajal noted that only one response by RECIST was reported in three prior phase II studies of imatinib in a total of 62 nonselected patients with advanced melanoma.

The findings are proof of concept that targeted therapies work in melanoma, a heterogenous group of diseases, said Dr. Boris Bastian of the University of California, San Francisco, who was invited to discuss the studies. He acknowledged that it is obviously early and few patients were treated, but that "it's a decisive step toward personalized medicine for our melanoma patients."

In the dose-escalation PLX4032 trial, sponsored by Plexxikon Inc. and Hoffman-La Roche Inc., dose-limiting toxicities developed in four of six patients who received 1,120 mg twice daily, the highest dose evaluated. A 960-mg twice-daily dosage is being evaluated as the maximum tolerated dose in an expanded cohort of mutation-positive melanoma patients, Dr. Flaherty said.

Adverse events with PLX4032 were clearly dose related, but even at higher doses, they tended to be mild, he said. Of note, 11% (six patients) were diagnosed while on study with cutaneous squamous cell carcinoma. Grade 3 or higher rash, fatigue, and pruritus were each reported in 2% of patients.

The PLX4032 study investigators disclosed financial ties with Plexxikon and Hoffman-La Roche. Dr. Carvajal and associates disclosed no personal conflicts of interest, but the study was supported by a Food and Drug Administration grant, an ASCO Young Investigator Award, and the Live4Life Foundation. Dr. Bastian disclosed consulting for Novartis and Exelixis Inc.

Partial responses were confirmed in 9 of 16 BRAF V600E mutation-positive patients treated with PLX4032.

Source DR. FLAHERTY

ORLANDO — The concept of targeted therapies in melanoma took a step closer to reality with two early trials reporting positive responses to agents that specifically target BRAF or KIT mutations.

In a phase I study of 55 patients with a variety of cancers, 21 metastatic melanoma patients were treated twice daily with at least 240 mg PLX4032, an investigational oral, small-molecule inhibitor that selectively targets the BRAF V600E kinase mutation occurring in most melanomas.

Partial responses by RECIST (Response Evaluation Criteria in Solid Tumors) were confirmed in 9 of 16 BRAF V600E mutation-positive patients. Five of the nine responders had M1c disease, the highest "M" stage, Dr. Keith Flaherty and his associates reported at the annual meeting of the American Society of Clinical Oncology.

Seven patients developed disease progression at 3-14 months while still on therapy. A preliminary analysis suggests a progression-free survival of about 6 months, but the data are very immature and that estimate is likely to change with longer follow-up, said Dr. Flaherty of the University of Pennsylvania, Philadelphia.

In contrast, no tumor regression was observed in the five melanoma patients lacking the BRAF mutation, and all developed progressive disease within the first 3 months.

Interim results from a second phase II study of imatinib in inoperable melanoma showed that a KIT mutation or amplification was present in 21% (31 of 146 tumors) screened. Thus far, 15 of the 31 patients, median age 71 years, have been treated with 400 mg imatinib twice daily on a continuous basis.

Of the 12 patients evaluable for response, the overall rate was 33% by RECIST and included two complete responses and two partial responses, said Dr. Richard Carvajal, an oncologist with Memorial Sloan-Kettering Cancer Center in New York. Stable disease was reported in six patients and disease progression in two. The responses have been durable, lasting 40 weeks in some patients.

Dr. Carvajal noted that only one response by RECIST was reported in three prior phase II studies of imatinib in a total of 62 nonselected patients with advanced melanoma.

The findings are proof of concept that targeted therapies work in melanoma, a heterogenous group of diseases, said Dr. Boris Bastian of the University of California, San Francisco, who was invited to discuss the studies. He acknowledged that it is obviously early and few patients were treated, but that "it's a decisive step toward personalized medicine for our melanoma patients."

In the dose-escalation PLX4032 trial, sponsored by Plexxikon Inc. and Hoffman-La Roche Inc., dose-limiting toxicities developed in four of six patients who received 1,120 mg twice daily, the highest dose evaluated. A 960-mg twice-daily dosage is being evaluated as the maximum tolerated dose in an expanded cohort of mutation-positive melanoma patients, Dr. Flaherty said.

Adverse events with PLX4032 were clearly dose related, but even at higher doses, they tended to be mild, he said. Of note, 11% (six patients) were diagnosed while on study with cutaneous squamous cell carcinoma. Grade 3 or higher rash, fatigue, and pruritus were each reported in 2% of patients.

The PLX4032 study investigators disclosed financial ties with Plexxikon and Hoffman-La Roche. Dr. Carvajal and associates disclosed no personal conflicts of interest, but the study was supported by a Food and Drug Administration grant, an ASCO Young Investigator Award, and the Live4Life Foundation. Dr. Bastian disclosed consulting for Novartis and Exelixis Inc.

Partial responses were confirmed in 9 of 16 BRAF V600E mutation-positive patients treated with PLX4032.

Source DR. FLAHERTY

ORLANDO — Whole-breast irradiation resulted in no overall survival benefit over partial-breast irradiation in women with early breast cancer in a meta-analysis of three randomized clinical trials.

There were no statistically significant differences between the two therapies with regard to death (odds ratio, 0.91; P = .550), distant metastasis (OR, 0.74; P = .120), or supraclavicular recurrences (OR, 1.41; P = .560), according to a late-breaking abstract at the annual meeting of the American Society of Clinical Oncology.

Women treated with partial-breast irradiation were twice as likely to have local recurrence (OR, 2.15; P = .001), however, and three times more likely to have axillary recurrence (OR, 3.43; P less than .0001).

“Partial-breast irradiation may be safe and feasible for women with early-stage breast cancer because it does not jeopardize patient survival or the risk of metastasis,” coauthor Dr. Davide Mauri of the General Hospital of Lamia (Greece) told reporters at a press briefing. “Locoregional issues need to be further addressed.”

The findings are reassuring in terms of equivalent overall survival and reduction in risk of metastasis, but are not enough to change practice, said Dr. Jennifer Obel, who moderated the briefing. “Before we say from a meta-analysis that this should be the next standard of care for treating women with early-stage breast cancer, there are many randomized studies sponsored by major cooperative groups … that are forthcoming in the next couple of years and we should await those before we make our decision,” said Dr. Obel of NorthShore University HealthSystem in Chicago's Northern suburbs.

Two trials that could provide additional insights are the TARGIT (Targeted Intraoperative Radiation Therapy) trial in Europe and the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 trial in the United States, Dr. Obel said in an interview.

The U.S. phase III trial will compare the effectiveness of the two irradiation strategies in 4,300 women after lumpectomy for early-stage breast cancer. It will use three technologies: high-dose-rate multicatheter brachytherapy, high-dose-rate single-catheter balloon brachytherapy (Mammosite), and three-dimensional conformal external beam radiation therapy.

“It's one of the largest trials of its size that will be looking at whole-breast irradiation compared to various techniques of partial-breast irradiation,” she said. “These are the some of the most patient-friendly techniques.” She acknowledged that partial-breast irradiation improves patient compliance because it is typically given over 5 days, compared with 5 weeks or more for whole-breast radiation.

Dr. Mauri agreed that ongoing trials will further clarify whether partial-breast irradiation offers high efficacy with better cosmetic outcomes.

He suggested that technique may have played a role in biasing the locoregional recurrence results in the meta-analysis. Two of the three studies used a standardized field of radiation, irrespective of tumor size, which could have led to areas of disease being missed and increasing local recurrence. In addition, one of the studies included women with extremely large tumors as well as node-positive patients. “I think that this explanation makes this finding of increased local recurrence less concerning.”

The meta-analysis included a total of 1,140 women (575 randomized to whole-breast radiation therapy and 565 to partial-breast irradiation). Median survival follow-up ranged from 5 to 8 years. The investigators, led by Dr. Antonis Valachis of the University Hospital of Heraklion in Crete (Greece), disclosed no conflicts of interest.

The findings are reassuring in terms of survival and risk of metastasis, but not enough to change practice. DR. OBEL

ORLANDO — Whole-breast irradiation resulted in no overall survival benefit over partial-breast irradiation in women with early breast cancer in a meta-analysis of three randomized clinical trials.

There were no statistically significant differences between the two therapies with regard to death (odds ratio, 0.91; P = .550), distant metastasis (OR, 0.74; P = .120), or supraclavicular recurrences (OR, 1.41; P = .560), according to a late-breaking abstract at the annual meeting of the American Society of Clinical Oncology.

Women treated with partial-breast irradiation were twice as likely to have local recurrence (OR, 2.15; P = .001), however, and three times more likely to have axillary recurrence (OR, 3.43; P less than .0001).

“Partial-breast irradiation may be safe and feasible for women with early-stage breast cancer because it does not jeopardize patient survival or the risk of metastasis,” coauthor Dr. Davide Mauri of the General Hospital of Lamia (Greece) told reporters at a press briefing. “Locoregional issues need to be further addressed.”

The findings are reassuring in terms of equivalent overall survival and reduction in risk of metastasis, but are not enough to change practice, said Dr. Jennifer Obel, who moderated the briefing. “Before we say from a meta-analysis that this should be the next standard of care for treating women with early-stage breast cancer, there are many randomized studies sponsored by major cooperative groups … that are forthcoming in the next couple of years and we should await those before we make our decision,” said Dr. Obel of NorthShore University HealthSystem in Chicago's Northern suburbs.

Two trials that could provide additional insights are the TARGIT (Targeted Intraoperative Radiation Therapy) trial in Europe and the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 trial in the United States, Dr. Obel said in an interview.

The U.S. phase III trial will compare the effectiveness of the two irradiation strategies in 4,300 women after lumpectomy for early-stage breast cancer. It will use three technologies: high-dose-rate multicatheter brachytherapy, high-dose-rate single-catheter balloon brachytherapy (Mammosite), and three-dimensional conformal external beam radiation therapy.

“It's one of the largest trials of its size that will be looking at whole-breast irradiation compared to various techniques of partial-breast irradiation,” she said. “These are the some of the most patient-friendly techniques.” She acknowledged that partial-breast irradiation improves patient compliance because it is typically given over 5 days, compared with 5 weeks or more for whole-breast radiation.

Dr. Mauri agreed that ongoing trials will further clarify whether partial-breast irradiation offers high efficacy with better cosmetic outcomes.

He suggested that technique may have played a role in biasing the locoregional recurrence results in the meta-analysis. Two of the three studies used a standardized field of radiation, irrespective of tumor size, which could have led to areas of disease being missed and increasing local recurrence. In addition, one of the studies included women with extremely large tumors as well as node-positive patients. “I think that this explanation makes this finding of increased local recurrence less concerning.”

The meta-analysis included a total of 1,140 women (575 randomized to whole-breast radiation therapy and 565 to partial-breast irradiation). Median survival follow-up ranged from 5 to 8 years. The investigators, led by Dr. Antonis Valachis of the University Hospital of Heraklion in Crete (Greece), disclosed no conflicts of interest.

The findings are reassuring in terms of survival and risk of metastasis, but not enough to change practice. DR. OBEL

ORLANDO — Whole-breast irradiation resulted in no overall survival benefit over partial-breast irradiation in women with early breast cancer in a meta-analysis of three randomized clinical trials.

There were no statistically significant differences between the two therapies with regard to death (odds ratio, 0.91; P = .550), distant metastasis (OR, 0.74; P = .120), or supraclavicular recurrences (OR, 1.41; P = .560), according to a late-breaking abstract at the annual meeting of the American Society of Clinical Oncology.

Women treated with partial-breast irradiation were twice as likely to have local recurrence (OR, 2.15; P = .001), however, and three times more likely to have axillary recurrence (OR, 3.43; P less than .0001).

“Partial-breast irradiation may be safe and feasible for women with early-stage breast cancer because it does not jeopardize patient survival or the risk of metastasis,” coauthor Dr. Davide Mauri of the General Hospital of Lamia (Greece) told reporters at a press briefing. “Locoregional issues need to be further addressed.”

The findings are reassuring in terms of equivalent overall survival and reduction in risk of metastasis, but are not enough to change practice, said Dr. Jennifer Obel, who moderated the briefing. “Before we say from a meta-analysis that this should be the next standard of care for treating women with early-stage breast cancer, there are many randomized studies sponsored by major cooperative groups … that are forthcoming in the next couple of years and we should await those before we make our decision,” said Dr. Obel of NorthShore University HealthSystem in Chicago's Northern suburbs.

Two trials that could provide additional insights are the TARGIT (Targeted Intraoperative Radiation Therapy) trial in Europe and the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 trial in the United States, Dr. Obel said in an interview.

The U.S. phase III trial will compare the effectiveness of the two irradiation strategies in 4,300 women after lumpectomy for early-stage breast cancer. It will use three technologies: high-dose-rate multicatheter brachytherapy, high-dose-rate single-catheter balloon brachytherapy (Mammosite), and three-dimensional conformal external beam radiation therapy.

“It's one of the largest trials of its size that will be looking at whole-breast irradiation compared to various techniques of partial-breast irradiation,” she said. “These are the some of the most patient-friendly techniques.” She acknowledged that partial-breast irradiation improves patient compliance because it is typically given over 5 days, compared with 5 weeks or more for whole-breast radiation.

Dr. Mauri agreed that ongoing trials will further clarify whether partial-breast irradiation offers high efficacy with better cosmetic outcomes.

He suggested that technique may have played a role in biasing the locoregional recurrence results in the meta-analysis. Two of the three studies used a standardized field of radiation, irrespective of tumor size, which could have led to areas of disease being missed and increasing local recurrence. In addition, one of the studies included women with extremely large tumors as well as node-positive patients. “I think that this explanation makes this finding of increased local recurrence less concerning.”

The meta-analysis included a total of 1,140 women (575 randomized to whole-breast radiation therapy and 565 to partial-breast irradiation). Median survival follow-up ranged from 5 to 8 years. The investigators, led by Dr. Antonis Valachis of the University Hospital of Heraklion in Crete (Greece), disclosed no conflicts of interest.

The findings are reassuring in terms of survival and risk of metastasis, but not enough to change practice. DR. OBEL

CHICAGO — With hospitals under pressure to improve efficiency by reducing patient length of stay, findings from a new study suggest that this effort does not necessarily lead to increased readmission rates.

That's what Dr. Jorge Go and his colleagues at the Iowa City Veterans Affairs Medical Center found in an analysis of all 3,709,103 medical admissions to 129 VA hospitals from 1997 to 2007. Approximately 18% of patients (692,599) were excluded for reasons such as death, terminal cancer, or transfer to other facilities, leaving 3,016,504 patients for the final analysis.

Among patients in the analysis, 97% were male and 72% were white; the mean age was 65 years, and 46% had three to five comorbidities. Patients were stratified by five common conditions: heart failure, chronic obstructive pulmonary disease (COPD), acute myocardial infarction, community acquired pneumonia, and gastrointestinal hemorrhage.

During the 10-year interval, there was a 25% reduction in average length of stay (LOS) and a 7% reduction in hospital readmissions, Dr. Go reported at the annual meeting of the Society of Hospital Medicine.

The unadjusted mean LOS decreased significantly for all diagnoses, from 6 days in 1997 to 4.5 days in 2006-2007. The biggest reduction was in MI and pneumonia cases, with LOS dropping by 2 full days.

The unadjusted readmission rate also declined significantly for all diagnoses, from 13.9% in 1997 to 12.7% in 2007. The biggest decrease was in COPD patients (17.3% to 14.3%), while readmissions remained constant among those with GI hemorrhage.

“Decreasing LOS and readmissions seem to reflect secular trends—that we're providing more efficient and better care,” Dr. Go said. “It's reassuring to show that increasing patient efficiency has not resulted in increased hospital readmission.”

A multivariate analysis that adjusted for age, sex, income level, comorbidities, admission source, and VA facility showed that the decrease in readmission risk occurred earlier for chronic conditions than for acute conditions.

Compared with 1997, the readmission rate began to decrease significantly among heart failure patients from 2002-2003 (odds ratio 0.93) to 2006-2007 (OR 0.90), and among COPD patients from 1998-1999 (OR 0.91) to 2006-2007 (OR 0.79).

In contrast, significant declines in readmission rates occurred only in 2006-2007 for the acute conditions of MI (OR 0.88) and GI hemorrhage (OR 0.87), with no improvement for pneumonia during the study period, Dr. Go reported.

Possible explanations for this finding are that medical advances and improvements in delivery of care have been greater for chronic conditions than for acute conditions, or that care for acute conditions was already very good and thus more difficult to improve, Dr. Go said in an interview.

The observed pattern of changes in readmission rates for chronic and acute diseases could be useful to policymakers using readmission rates as a quality improvement measure. The National Quality Forum already endorses using 30-day all-cause heart failure readmissions as a quality measure and plans to use it for other conditions as well, he said.

The researchers disclosed no relevant conflicts of interest.

It's reassuring that increasing patient efficiency has not resulted in increased hospital readmission. DR. GO

CHICAGO — With hospitals under pressure to improve efficiency by reducing patient length of stay, findings from a new study suggest that this effort does not necessarily lead to increased readmission rates.

That's what Dr. Jorge Go and his colleagues at the Iowa City Veterans Affairs Medical Center found in an analysis of all 3,709,103 medical admissions to 129 VA hospitals from 1997 to 2007. Approximately 18% of patients (692,599) were excluded for reasons such as death, terminal cancer, or transfer to other facilities, leaving 3,016,504 patients for the final analysis.

Among patients in the analysis, 97% were male and 72% were white; the mean age was 65 years, and 46% had three to five comorbidities. Patients were stratified by five common conditions: heart failure, chronic obstructive pulmonary disease (COPD), acute myocardial infarction, community acquired pneumonia, and gastrointestinal hemorrhage.

During the 10-year interval, there was a 25% reduction in average length of stay (LOS) and a 7% reduction in hospital readmissions, Dr. Go reported at the annual meeting of the Society of Hospital Medicine.

The unadjusted mean LOS decreased significantly for all diagnoses, from 6 days in 1997 to 4.5 days in 2006-2007. The biggest reduction was in MI and pneumonia cases, with LOS dropping by 2 full days.

The unadjusted readmission rate also declined significantly for all diagnoses, from 13.9% in 1997 to 12.7% in 2007. The biggest decrease was in COPD patients (17.3% to 14.3%), while readmissions remained constant among those with GI hemorrhage.

“Decreasing LOS and readmissions seem to reflect secular trends—that we're providing more efficient and better care,” Dr. Go said. “It's reassuring to show that increasing patient efficiency has not resulted in increased hospital readmission.”

A multivariate analysis that adjusted for age, sex, income level, comorbidities, admission source, and VA facility showed that the decrease in readmission risk occurred earlier for chronic conditions than for acute conditions.

Compared with 1997, the readmission rate began to decrease significantly among heart failure patients from 2002-2003 (odds ratio 0.93) to 2006-2007 (OR 0.90), and among COPD patients from 1998-1999 (OR 0.91) to 2006-2007 (OR 0.79).

In contrast, significant declines in readmission rates occurred only in 2006-2007 for the acute conditions of MI (OR 0.88) and GI hemorrhage (OR 0.87), with no improvement for pneumonia during the study period, Dr. Go reported.

Possible explanations for this finding are that medical advances and improvements in delivery of care have been greater for chronic conditions than for acute conditions, or that care for acute conditions was already very good and thus more difficult to improve, Dr. Go said in an interview.

The observed pattern of changes in readmission rates for chronic and acute diseases could be useful to policymakers using readmission rates as a quality improvement measure. The National Quality Forum already endorses using 30-day all-cause heart failure readmissions as a quality measure and plans to use it for other conditions as well, he said.

The researchers disclosed no relevant conflicts of interest.

It's reassuring that increasing patient efficiency has not resulted in increased hospital readmission. DR. GO

CHICAGO — With hospitals under pressure to improve efficiency by reducing patient length of stay, findings from a new study suggest that this effort does not necessarily lead to increased readmission rates.

That's what Dr. Jorge Go and his colleagues at the Iowa City Veterans Affairs Medical Center found in an analysis of all 3,709,103 medical admissions to 129 VA hospitals from 1997 to 2007. Approximately 18% of patients (692,599) were excluded for reasons such as death, terminal cancer, or transfer to other facilities, leaving 3,016,504 patients for the final analysis.

Among patients in the analysis, 97% were male and 72% were white; the mean age was 65 years, and 46% had three to five comorbidities. Patients were stratified by five common conditions: heart failure, chronic obstructive pulmonary disease (COPD), acute myocardial infarction, community acquired pneumonia, and gastrointestinal hemorrhage.

During the 10-year interval, there was a 25% reduction in average length of stay (LOS) and a 7% reduction in hospital readmissions, Dr. Go reported at the annual meeting of the Society of Hospital Medicine.

The unadjusted mean LOS decreased significantly for all diagnoses, from 6 days in 1997 to 4.5 days in 2006-2007. The biggest reduction was in MI and pneumonia cases, with LOS dropping by 2 full days.

The unadjusted readmission rate also declined significantly for all diagnoses, from 13.9% in 1997 to 12.7% in 2007. The biggest decrease was in COPD patients (17.3% to 14.3%), while readmissions remained constant among those with GI hemorrhage.

“Decreasing LOS and readmissions seem to reflect secular trends—that we're providing more efficient and better care,” Dr. Go said. “It's reassuring to show that increasing patient efficiency has not resulted in increased hospital readmission.”

A multivariate analysis that adjusted for age, sex, income level, comorbidities, admission source, and VA facility showed that the decrease in readmission risk occurred earlier for chronic conditions than for acute conditions.

Compared with 1997, the readmission rate began to decrease significantly among heart failure patients from 2002-2003 (odds ratio 0.93) to 2006-2007 (OR 0.90), and among COPD patients from 1998-1999 (OR 0.91) to 2006-2007 (OR 0.79).

In contrast, significant declines in readmission rates occurred only in 2006-2007 for the acute conditions of MI (OR 0.88) and GI hemorrhage (OR 0.87), with no improvement for pneumonia during the study period, Dr. Go reported.

Possible explanations for this finding are that medical advances and improvements in delivery of care have been greater for chronic conditions than for acute conditions, or that care for acute conditions was already very good and thus more difficult to improve, Dr. Go said in an interview.

The observed pattern of changes in readmission rates for chronic and acute diseases could be useful to policymakers using readmission rates as a quality improvement measure. The National Quality Forum already endorses using 30-day all-cause heart failure readmissions as a quality measure and plans to use it for other conditions as well, he said.

The researchers disclosed no relevant conflicts of interest.

It's reassuring that increasing patient efficiency has not resulted in increased hospital readmission. DR. GO

CHICAGO – An updated guideline addressing persistent pain in older people takes a tough stance on the use of nonsteroidal anti-inflammatory drugs.

The American Geriatrics Society (AGS) guideline recommends that acetaminophen be considered for initial and ongoing treatment of persistent pain, particularly musculoskeletal pain. But in a significant departure from its 2002 guideline, the AGS recommends that nonselective NSAIDs and cyclooxygenase-2 (COX-2) selective inhibitors “be considered rarely, and with extreme caution, in highly selected individuals.”

The AGS had recommended that seniors use over-the-counter or prescription NSAIDs, such as aspirin or ibuprofen, or COX-2 inhibitors before being prescribed an opioid. The current recommendation reflects recent good evidence that this is a risky strategy in older people, panel member Dr. James Katz said at the society's annual meeting, where the guidelines (“Pharmacological Management of Persistent Pain in Older Persons”) were released.

Traditional NSAIDs are associated with adverse gastrointestinal events in 20% of patients, with 107,000 hospitalizations and 16,500 deaths yearly attributed to NSAID-related GI complications.

COX-2 inhibitors seem to produce fewer upper GI events than do other NSAIDs, but “all nonsteroidals, whether they are [COX-2 inhibitors] or not, have a significant portfolio of adverse effects that is noteworthy for the elderly population,” said Dr. Katz, director of rheumatology at George Washington University in Washington. “They can aggravate hypertension, they can cause renal impairment by a variety of mechanisms, [they can cause] edema [and] gastrointestinal problems, and now we know cardiovascular and cerebrovascular disease can be attributed to nonsteroidal interaction.”

Last year's study of 336,906 community-dwelling Medicaid beneficiaries by the Veterans Affairs Tennessee Valley Healthcare System extended concerns about COX-2 selective inhibitors to cerebrovascular disease, said Dr. Katz. The study suggested an increased risk of stroke with rofecoxib (Vioxx) and valdecoxib (Bextra), compared with the effects of nonselective agents (Stroke 2008;39:2037-45). The finding was not statistically significant, but both drugs have been withdrawn from the market.

Recent evidence also showed that combining a traditional NSAID with low-dose aspirin therapy increases the risk of GI bleeding beyond that of the traditional NSAID alone (Curr. Opin. Rheumatol. 2008;20:239-45). In 2006, the Food and Drug Administration warned against taking aspirin and ibuprofen together.

More research is needed to determine whether other NSAIDs interfere with the cardioprotective benefits of low-dose aspirin, said Dr. Katz, who was part of a panel unveiling the guidelines at the meeting. Panel members also said that more data are needed on the safety of topical preparations of NSAIDs.

The revised guideline recommends the eradication of Helicobacter pylori prior to initiating NSAIDs for pain, and the use of a proton pump inhibitor or misoprostol for gastrointestinal protection in older persons taking nonselective NSAIDs or in patients taking a COX-2 selective inhibitor with aspirin.

The guideline recommends that physicians consider opioid therapy for patients with moderate to severe pain, pain-related functional impairment, or diminished quality of life because of pain. People with continual or frequent daily pain may be treated with around-the-clock, time-contingent dosing aimed at achieving steady-state opioid therapy, said Dr. Perry Fine of the pain management center at the University of Utah, Salt Lake City.

He noted the guideline's caution concerning methadone, and recommended that only clinicians who are well versed in its use and risks initiate and titrate the drug. “That doesn't mean you don't do it,” said Dr. Fine, “but hook yourself up to someone who has a lot of experience in this when you believe this drug is indicated, if you don't have the experience.”

Methadone-related deaths during pain treatment have risen up to eightfold in recent years, largely because methadone is attractive as a relatively inexpensive drug, but it has an unpredictable and long half-life. That the drug stays active is a blessing, but is also a problem because it accumulates in the body, Dr. Fine said.

Earlier this year, the American Pain Society and the American Academy of Pain Medicine released clinical guidance on the management of opioid therapy for chronic noncancer pain (J. Pain 2009; 10:113-30). Like the AGS guidelines, that document stressed the need for clinicians to regularly assess patients for pain intensity, functional status, side effects, and safe and responsible medication use.

The updated AGS guideline also provides new references and discussions of the use of newer adjuvant, topical, and other drugs for recalcitrant pain. “Persistent pain isn't a normal part of aging and should not be ignored,” Dr. Cheryl Phillips, AGS president, said in a statement. “As seniors become susceptible to more complex health ailments, the need for a clear and precise pain management plan is key.”

The AGS published its first pain guideline in 1998. For the 2009 recommendations, a panel of experts conducted a systematic review of 2,400 abstracts and 240 data-based, full-text articles. It focused on pharmacotherapy because it is the most common strategy used for pain management among elderly people, as well as the area of greatest risk, said panel chair Dr. Bruce Ferrell of the University of California, Los Angeles. The 2009 update is to be published in an upcoming issue of the Journal of the American Geriatrics Society.

Dr. Katz disclosed that he has served as a paid consultant for the American Academy of CME Inc. and for UCB Pharma Inc. Dr. Fine said he is as a paid consultant or speaker for numerous pharmaceutical companies and has commercial interests in Johnson & Johnson and Cephalon Inc. Dr. Ferrell disclosed no relevant conflict of interest.

CHICAGO – An updated guideline addressing persistent pain in older people takes a tough stance on the use of nonsteroidal anti-inflammatory drugs.

The American Geriatrics Society (AGS) guideline recommends that acetaminophen be considered for initial and ongoing treatment of persistent pain, particularly musculoskeletal pain. But in a significant departure from its 2002 guideline, the AGS recommends that nonselective NSAIDs and cyclooxygenase-2 (COX-2) selective inhibitors “be considered rarely, and with extreme caution, in highly selected individuals.”

The AGS had recommended that seniors use over-the-counter or prescription NSAIDs, such as aspirin or ibuprofen, or COX-2 inhibitors before being prescribed an opioid. The current recommendation reflects recent good evidence that this is a risky strategy in older people, panel member Dr. James Katz said at the society's annual meeting, where the guidelines (“Pharmacological Management of Persistent Pain in Older Persons”) were released.

Traditional NSAIDs are associated with adverse gastrointestinal events in 20% of patients, with 107,000 hospitalizations and 16,500 deaths yearly attributed to NSAID-related GI complications.

COX-2 inhibitors seem to produce fewer upper GI events than do other NSAIDs, but “all nonsteroidals, whether they are [COX-2 inhibitors] or not, have a significant portfolio of adverse effects that is noteworthy for the elderly population,” said Dr. Katz, director of rheumatology at George Washington University in Washington. “They can aggravate hypertension, they can cause renal impairment by a variety of mechanisms, [they can cause] edema [and] gastrointestinal problems, and now we know cardiovascular and cerebrovascular disease can be attributed to nonsteroidal interaction.”

Last year's study of 336,906 community-dwelling Medicaid beneficiaries by the Veterans Affairs Tennessee Valley Healthcare System extended concerns about COX-2 selective inhibitors to cerebrovascular disease, said Dr. Katz. The study suggested an increased risk of stroke with rofecoxib (Vioxx) and valdecoxib (Bextra), compared with the effects of nonselective agents (Stroke 2008;39:2037-45). The finding was not statistically significant, but both drugs have been withdrawn from the market.

Recent evidence also showed that combining a traditional NSAID with low-dose aspirin therapy increases the risk of GI bleeding beyond that of the traditional NSAID alone (Curr. Opin. Rheumatol. 2008;20:239-45). In 2006, the Food and Drug Administration warned against taking aspirin and ibuprofen together.

More research is needed to determine whether other NSAIDs interfere with the cardioprotective benefits of low-dose aspirin, said Dr. Katz, who was part of a panel unveiling the guidelines at the meeting. Panel members also said that more data are needed on the safety of topical preparations of NSAIDs.

The revised guideline recommends the eradication of Helicobacter pylori prior to initiating NSAIDs for pain, and the use of a proton pump inhibitor or misoprostol for gastrointestinal protection in older persons taking nonselective NSAIDs or in patients taking a COX-2 selective inhibitor with aspirin.

The guideline recommends that physicians consider opioid therapy for patients with moderate to severe pain, pain-related functional impairment, or diminished quality of life because of pain. People with continual or frequent daily pain may be treated with around-the-clock, time-contingent dosing aimed at achieving steady-state opioid therapy, said Dr. Perry Fine of the pain management center at the University of Utah, Salt Lake City.

He noted the guideline's caution concerning methadone, and recommended that only clinicians who are well versed in its use and risks initiate and titrate the drug. “That doesn't mean you don't do it,” said Dr. Fine, “but hook yourself up to someone who has a lot of experience in this when you believe this drug is indicated, if you don't have the experience.”

Methadone-related deaths during pain treatment have risen up to eightfold in recent years, largely because methadone is attractive as a relatively inexpensive drug, but it has an unpredictable and long half-life. That the drug stays active is a blessing, but is also a problem because it accumulates in the body, Dr. Fine said.

Earlier this year, the American Pain Society and the American Academy of Pain Medicine released clinical guidance on the management of opioid therapy for chronic noncancer pain (J. Pain 2009; 10:113-30). Like the AGS guidelines, that document stressed the need for clinicians to regularly assess patients for pain intensity, functional status, side effects, and safe and responsible medication use.

The updated AGS guideline also provides new references and discussions of the use of newer adjuvant, topical, and other drugs for recalcitrant pain. “Persistent pain isn't a normal part of aging and should not be ignored,” Dr. Cheryl Phillips, AGS president, said in a statement. “As seniors become susceptible to more complex health ailments, the need for a clear and precise pain management plan is key.”

The AGS published its first pain guideline in 1998. For the 2009 recommendations, a panel of experts conducted a systematic review of 2,400 abstracts and 240 data-based, full-text articles. It focused on pharmacotherapy because it is the most common strategy used for pain management among elderly people, as well as the area of greatest risk, said panel chair Dr. Bruce Ferrell of the University of California, Los Angeles. The 2009 update is to be published in an upcoming issue of the Journal of the American Geriatrics Society.

Dr. Katz disclosed that he has served as a paid consultant for the American Academy of CME Inc. and for UCB Pharma Inc. Dr. Fine said he is as a paid consultant or speaker for numerous pharmaceutical companies and has commercial interests in Johnson & Johnson and Cephalon Inc. Dr. Ferrell disclosed no relevant conflict of interest.

CHICAGO – An updated guideline addressing persistent pain in older people takes a tough stance on the use of nonsteroidal anti-inflammatory drugs.

The American Geriatrics Society (AGS) guideline recommends that acetaminophen be considered for initial and ongoing treatment of persistent pain, particularly musculoskeletal pain. But in a significant departure from its 2002 guideline, the AGS recommends that nonselective NSAIDs and cyclooxygenase-2 (COX-2) selective inhibitors “be considered rarely, and with extreme caution, in highly selected individuals.”

The AGS had recommended that seniors use over-the-counter or prescription NSAIDs, such as aspirin or ibuprofen, or COX-2 inhibitors before being prescribed an opioid. The current recommendation reflects recent good evidence that this is a risky strategy in older people, panel member Dr. James Katz said at the society's annual meeting, where the guidelines (“Pharmacological Management of Persistent Pain in Older Persons”) were released.

Traditional NSAIDs are associated with adverse gastrointestinal events in 20% of patients, with 107,000 hospitalizations and 16,500 deaths yearly attributed to NSAID-related GI complications.

COX-2 inhibitors seem to produce fewer upper GI events than do other NSAIDs, but “all nonsteroidals, whether they are [COX-2 inhibitors] or not, have a significant portfolio of adverse effects that is noteworthy for the elderly population,” said Dr. Katz, director of rheumatology at George Washington University in Washington. “They can aggravate hypertension, they can cause renal impairment by a variety of mechanisms, [they can cause] edema [and] gastrointestinal problems, and now we know cardiovascular and cerebrovascular disease can be attributed to nonsteroidal interaction.”

Last year's study of 336,906 community-dwelling Medicaid beneficiaries by the Veterans Affairs Tennessee Valley Healthcare System extended concerns about COX-2 selective inhibitors to cerebrovascular disease, said Dr. Katz. The study suggested an increased risk of stroke with rofecoxib (Vioxx) and valdecoxib (Bextra), compared with the effects of nonselective agents (Stroke 2008;39:2037-45). The finding was not statistically significant, but both drugs have been withdrawn from the market.

Recent evidence also showed that combining a traditional NSAID with low-dose aspirin therapy increases the risk of GI bleeding beyond that of the traditional NSAID alone (Curr. Opin. Rheumatol. 2008;20:239-45). In 2006, the Food and Drug Administration warned against taking aspirin and ibuprofen together.

More research is needed to determine whether other NSAIDs interfere with the cardioprotective benefits of low-dose aspirin, said Dr. Katz, who was part of a panel unveiling the guidelines at the meeting. Panel members also said that more data are needed on the safety of topical preparations of NSAIDs.

The revised guideline recommends the eradication of Helicobacter pylori prior to initiating NSAIDs for pain, and the use of a proton pump inhibitor or misoprostol for gastrointestinal protection in older persons taking nonselective NSAIDs or in patients taking a COX-2 selective inhibitor with aspirin.

The guideline recommends that physicians consider opioid therapy for patients with moderate to severe pain, pain-related functional impairment, or diminished quality of life because of pain. People with continual or frequent daily pain may be treated with around-the-clock, time-contingent dosing aimed at achieving steady-state opioid therapy, said Dr. Perry Fine of the pain management center at the University of Utah, Salt Lake City.

He noted the guideline's caution concerning methadone, and recommended that only clinicians who are well versed in its use and risks initiate and titrate the drug. “That doesn't mean you don't do it,” said Dr. Fine, “but hook yourself up to someone who has a lot of experience in this when you believe this drug is indicated, if you don't have the experience.”

Methadone-related deaths during pain treatment have risen up to eightfold in recent years, largely because methadone is attractive as a relatively inexpensive drug, but it has an unpredictable and long half-life. That the drug stays active is a blessing, but is also a problem because it accumulates in the body, Dr. Fine said.

Earlier this year, the American Pain Society and the American Academy of Pain Medicine released clinical guidance on the management of opioid therapy for chronic noncancer pain (J. Pain 2009; 10:113-30). Like the AGS guidelines, that document stressed the need for clinicians to regularly assess patients for pain intensity, functional status, side effects, and safe and responsible medication use.

The updated AGS guideline also provides new references and discussions of the use of newer adjuvant, topical, and other drugs for recalcitrant pain. “Persistent pain isn't a normal part of aging and should not be ignored,” Dr. Cheryl Phillips, AGS president, said in a statement. “As seniors become susceptible to more complex health ailments, the need for a clear and precise pain management plan is key.”

The AGS published its first pain guideline in 1998. For the 2009 recommendations, a panel of experts conducted a systematic review of 2,400 abstracts and 240 data-based, full-text articles. It focused on pharmacotherapy because it is the most common strategy used for pain management among elderly people, as well as the area of greatest risk, said panel chair Dr. Bruce Ferrell of the University of California, Los Angeles. The 2009 update is to be published in an upcoming issue of the Journal of the American Geriatrics Society.

Dr. Katz disclosed that he has served as a paid consultant for the American Academy of CME Inc. and for UCB Pharma Inc. Dr. Fine said he is as a paid consultant or speaker for numerous pharmaceutical companies and has commercial interests in Johnson & Johnson and Cephalon Inc. Dr. Ferrell disclosed no relevant conflict of interest.

CHICAGO – Elderly persons shown a video depiction of advanced Alzheimer's are less likely to opt for life-prolonging care, compared with those who listen to a verbal description.

A multicenter, prospective trial randomized 200 community-dwelling adults aged at least 65 years (mean 75 years) to one of two interventions and then compared their preferences for advanced care if they were in a state of dementia. In all, 106 participants listened to a standardized verbal description of stage 7 Alzheimer's, which is the final stage of the disease when individuals lose the ability to speak or respond to their environment, and ultimately their ability to control movement. The other 94 participants listened to the verbal description and viewed a 2-minute video of a real patient with features of stage 7 Alzheimer's and her family. (Video can be viewed online at www.ACPdecisions.com

Among those hearing only the verbal description, 68% preferred comfort care, 17% chose limited care, 13% wanted care that would prolong their life, and 2% were uncertain.

Among those receiving both the verbal narrative and the video, 87% preferred comfort care, 8% chose limited care, 4% desired life-prolonging care, and 1% were undecided, Dr. Angelo E. Volandes said at the annual meeting of the American Geriatrics Society.

“Most patients don't have experience with advanced disease,” he said. “Video may promote preferences for comfort care by providing more realistic expectations of dementia.”

Preferences also appear more stable when made with the assistance of video. After 6 weeks, 27 (29%) of 94 participants interviewed in the verbal group changed their preferences, compared with only 5 (6%) of 84 participants in the video group. The difference between groups was statistically significant, said Dr. Volandes, an internal medicine physician with Massachusetts General Hospital and Harvard University Medical School, both in Boston. Comfort care was significantly more likely to be selected as the new preference (86%) in the verbal group, whereas the percentage choosing this option remained constant in the video group.

“The use of innovative videos in end-of-life decision-making and advance care planning discussions is relatively new,” Dr. Volandes said in an interview. “Further work and studies are needed to examine the implementation of these videos in clinical practice before they can become the standard of care for advance care planning.”

Dr. Volandes acknowledged that the study did not use real patients with a dementia diagnosis, and did not include Hispanics or Asians, although he said that similar findings have been observed in his previous research with Hispanics.

The convenience sample, selected from two primary care and two geriatric clinics, was 58% female, 29.5% African American, and had a score of 7 or higher on the Short Portable Mental Status Questionnaire. Overall, 68% of the verbal group and 73% in the video group had a 9th-grade or higher level of health literacy on the Rapid Estimate of Adult Literacy in Medicine test.

One audience member remarked that advanced care directives are the most important thing he does as a geriatrician, and another acknowledged the struggle that often arises over goals of care with family members and health care power of attorney documents. The use of video in advance care planning has been evaluated in surrogate decision makers with similar results, Dr. Volandes said.

Dr. Volandes, who received a new investigator award for his work by the American Geriatrics Society, disclosed no conflicts of interest for himself or his associates. The study was sponsored by the Alzheimer's Association, the John A. Hartford Foundation, and the Foundation for Informed Medical Decision Making.

Care preferences remained stable when viewers watched a video of a patient with stage 7 Alzheimer's, shown here. COURTESY DR. ANGELO E. VOLANDES

CHICAGO – Elderly persons shown a video depiction of advanced Alzheimer's are less likely to opt for life-prolonging care, compared with those who listen to a verbal description.

A multicenter, prospective trial randomized 200 community-dwelling adults aged at least 65 years (mean 75 years) to one of two interventions and then compared their preferences for advanced care if they were in a state of dementia. In all, 106 participants listened to a standardized verbal description of stage 7 Alzheimer's, which is the final stage of the disease when individuals lose the ability to speak or respond to their environment, and ultimately their ability to control movement. The other 94 participants listened to the verbal description and viewed a 2-minute video of a real patient with features of stage 7 Alzheimer's and her family. (Video can be viewed online at www.ACPdecisions.com

Among those hearing only the verbal description, 68% preferred comfort care, 17% chose limited care, 13% wanted care that would prolong their life, and 2% were uncertain.

Among those receiving both the verbal narrative and the video, 87% preferred comfort care, 8% chose limited care, 4% desired life-prolonging care, and 1% were undecided, Dr. Angelo E. Volandes said at the annual meeting of the American Geriatrics Society.

“Most patients don't have experience with advanced disease,” he said. “Video may promote preferences for comfort care by providing more realistic expectations of dementia.”

Preferences also appear more stable when made with the assistance of video. After 6 weeks, 27 (29%) of 94 participants interviewed in the verbal group changed their preferences, compared with only 5 (6%) of 84 participants in the video group. The difference between groups was statistically significant, said Dr. Volandes, an internal medicine physician with Massachusetts General Hospital and Harvard University Medical School, both in Boston. Comfort care was significantly more likely to be selected as the new preference (86%) in the verbal group, whereas the percentage choosing this option remained constant in the video group.

“The use of innovative videos in end-of-life decision-making and advance care planning discussions is relatively new,” Dr. Volandes said in an interview. “Further work and studies are needed to examine the implementation of these videos in clinical practice before they can become the standard of care for advance care planning.”

Dr. Volandes acknowledged that the study did not use real patients with a dementia diagnosis, and did not include Hispanics or Asians, although he said that similar findings have been observed in his previous research with Hispanics.

The convenience sample, selected from two primary care and two geriatric clinics, was 58% female, 29.5% African American, and had a score of 7 or higher on the Short Portable Mental Status Questionnaire. Overall, 68% of the verbal group and 73% in the video group had a 9th-grade or higher level of health literacy on the Rapid Estimate of Adult Literacy in Medicine test.

One audience member remarked that advanced care directives are the most important thing he does as a geriatrician, and another acknowledged the struggle that often arises over goals of care with family members and health care power of attorney documents. The use of video in advance care planning has been evaluated in surrogate decision makers with similar results, Dr. Volandes said.

Dr. Volandes, who received a new investigator award for his work by the American Geriatrics Society, disclosed no conflicts of interest for himself or his associates. The study was sponsored by the Alzheimer's Association, the John A. Hartford Foundation, and the Foundation for Informed Medical Decision Making.

Care preferences remained stable when viewers watched a video of a patient with stage 7 Alzheimer's, shown here. COURTESY DR. ANGELO E. VOLANDES

CHICAGO – Elderly persons shown a video depiction of advanced Alzheimer's are less likely to opt for life-prolonging care, compared with those who listen to a verbal description.

A multicenter, prospective trial randomized 200 community-dwelling adults aged at least 65 years (mean 75 years) to one of two interventions and then compared their preferences for advanced care if they were in a state of dementia. In all, 106 participants listened to a standardized verbal description of stage 7 Alzheimer's, which is the final stage of the disease when individuals lose the ability to speak or respond to their environment, and ultimately their ability to control movement. The other 94 participants listened to the verbal description and viewed a 2-minute video of a real patient with features of stage 7 Alzheimer's and her family. (Video can be viewed online at www.ACPdecisions.com

Among those hearing only the verbal description, 68% preferred comfort care, 17% chose limited care, 13% wanted care that would prolong their life, and 2% were uncertain.

Among those receiving both the verbal narrative and the video, 87% preferred comfort care, 8% chose limited care, 4% desired life-prolonging care, and 1% were undecided, Dr. Angelo E. Volandes said at the annual meeting of the American Geriatrics Society.

“Most patients don't have experience with advanced disease,” he said. “Video may promote preferences for comfort care by providing more realistic expectations of dementia.”

Preferences also appear more stable when made with the assistance of video. After 6 weeks, 27 (29%) of 94 participants interviewed in the verbal group changed their preferences, compared with only 5 (6%) of 84 participants in the video group. The difference between groups was statistically significant, said Dr. Volandes, an internal medicine physician with Massachusetts General Hospital and Harvard University Medical School, both in Boston. Comfort care was significantly more likely to be selected as the new preference (86%) in the verbal group, whereas the percentage choosing this option remained constant in the video group.

“The use of innovative videos in end-of-life decision-making and advance care planning discussions is relatively new,” Dr. Volandes said in an interview. “Further work and studies are needed to examine the implementation of these videos in clinical practice before they can become the standard of care for advance care planning.”

Dr. Volandes acknowledged that the study did not use real patients with a dementia diagnosis, and did not include Hispanics or Asians, although he said that similar findings have been observed in his previous research with Hispanics.

The convenience sample, selected from two primary care and two geriatric clinics, was 58% female, 29.5% African American, and had a score of 7 or higher on the Short Portable Mental Status Questionnaire. Overall, 68% of the verbal group and 73% in the video group had a 9th-grade or higher level of health literacy on the Rapid Estimate of Adult Literacy in Medicine test.

One audience member remarked that advanced care directives are the most important thing he does as a geriatrician, and another acknowledged the struggle that often arises over goals of care with family members and health care power of attorney documents. The use of video in advance care planning has been evaluated in surrogate decision makers with similar results, Dr. Volandes said.

Dr. Volandes, who received a new investigator award for his work by the American Geriatrics Society, disclosed no conflicts of interest for himself or his associates. The study was sponsored by the Alzheimer's Association, the John A. Hartford Foundation, and the Foundation for Informed Medical Decision Making.

Care preferences remained stable when viewers watched a video of a patient with stage 7 Alzheimer's, shown here. COURTESY DR. ANGELO E. VOLANDES