Patrice Wendling

CHICAGO — Trivalent inactivated influenza vaccine may not elicit a clinically adequate antibody response in elderly adults, pilot data suggest.

Based on blood assays taken before and 4 weeks after administration of the Fluarix 2007/2008 formula, 88% of 71 community-dwelling older adults, mean age 85 years, failed to mount a fourfold antibody response to any of the three virus strains present in the trivalent influenza vaccine (TIV).

Only two patients had a fourfold antibody response to both influenza A types, H1N1 and H3N2, and none had such a response to all three strains—H1NI, H3N2, and influenza B, Dr. Sean X. Leng said at the annual meeting of the American Geriatrics Society. A fourfold or higher vaccine antibody titer increase, also called positive seroconversion, is the criterion for a clinically adequate antibody response.

In contrast, he noted that the vaccine insert reports that 444 (60%) of 745 persons, aged 18–64 years, had a fourfold antibody response to the H1N1 strain, 461 (62%) had such a response to H3N2, and 575 (77%) did so to the influenza B strain.

“Obviously this is pilot data, but [it does] point out the importance of the need for comprehensive evaluation of this vaccine in older and frail populations,” said Dr. Leng of the division of geriatric medicine and gerontology at Johns Hopkins University in Baltimore.

The audience questioned whether immunity would be a more accurate measure of vaccine protection than antibody response in the elderly since they are more likely than the young to have been vaccinated before and thus would have higher baseline antibody levels. Of note, researchers at Stanford University recently reported that even the type of vaccine—TIV or live attenuated influenza vaccine—received in prior years affects both serum antibody and B-cell responses to subsequent vaccination (PLoS ONE 2008;8:e2975).

Most patients in the current study had high baseline titer levels, which would make it more difficult to achieve positive seroconversion, acknowledged Dr. Leng. Patients had received flu vaccine for an average of 7 years prior to study entry, although this was based on self-report and subject to memory bias.

Still, 25 (3.4%) participants reported signs and symptoms of flu-like illness during the 2007–2008 flu season, although laboratory confirmation of a diagnosis of influenza was not performed. No influenza-related deaths were reported.

Influenza is the fourth leading cause of death in older Americans, with the elderly bearing more than 90% of influenza-related mortality.

Dr. Leng noted that those aged 75 years and older make up a small percentage of vaccine trial cohorts, despite being the fastest growing segment of the population. In one vaccine trial, only 11% of patients were at least 75 years old (JAMA 1994;272:1661–5). The one-size-fits-all approach to influenza vaccine needs to be re-examined, as is being done with cancer screening in elderly and other high-risk groups, he suggested.

Patients in the study ranged in age from 72 to 95 years, 79% were women, and 93% were white. The average number of diagnoses was 3.7 and they included hypertension (67%), osteoarthritis (45%), and dyslipidemia (38%).

Dr. Leng and associates reported no conflicts of interest. The study was sponsored by the National Institute on Aging and the American Federation for Aging Research.

CHICAGO — Trivalent inactivated influenza vaccine may not elicit a clinically adequate antibody response in elderly adults, pilot data suggest.

Based on blood assays taken before and 4 weeks after administration of the Fluarix 2007/2008 formula, 88% of 71 community-dwelling older adults, mean age 85 years, failed to mount a fourfold antibody response to any of the three virus strains present in the trivalent influenza vaccine (TIV).

Only two patients had a fourfold antibody response to both influenza A types, H1N1 and H3N2, and none had such a response to all three strains—H1NI, H3N2, and influenza B, Dr. Sean X. Leng said at the annual meeting of the American Geriatrics Society. A fourfold or higher vaccine antibody titer increase, also called positive seroconversion, is the criterion for a clinically adequate antibody response.

In contrast, he noted that the vaccine insert reports that 444 (60%) of 745 persons, aged 18–64 years, had a fourfold antibody response to the H1N1 strain, 461 (62%) had such a response to H3N2, and 575 (77%) did so to the influenza B strain.

“Obviously this is pilot data, but [it does] point out the importance of the need for comprehensive evaluation of this vaccine in older and frail populations,” said Dr. Leng of the division of geriatric medicine and gerontology at Johns Hopkins University in Baltimore.

The audience questioned whether immunity would be a more accurate measure of vaccine protection than antibody response in the elderly since they are more likely than the young to have been vaccinated before and thus would have higher baseline antibody levels. Of note, researchers at Stanford University recently reported that even the type of vaccine—TIV or live attenuated influenza vaccine—received in prior years affects both serum antibody and B-cell responses to subsequent vaccination (PLoS ONE 2008;8:e2975).

Most patients in the current study had high baseline titer levels, which would make it more difficult to achieve positive seroconversion, acknowledged Dr. Leng. Patients had received flu vaccine for an average of 7 years prior to study entry, although this was based on self-report and subject to memory bias.

Still, 25 (3.4%) participants reported signs and symptoms of flu-like illness during the 2007–2008 flu season, although laboratory confirmation of a diagnosis of influenza was not performed. No influenza-related deaths were reported.

Influenza is the fourth leading cause of death in older Americans, with the elderly bearing more than 90% of influenza-related mortality.

Dr. Leng noted that those aged 75 years and older make up a small percentage of vaccine trial cohorts, despite being the fastest growing segment of the population. In one vaccine trial, only 11% of patients were at least 75 years old (JAMA 1994;272:1661–5). The one-size-fits-all approach to influenza vaccine needs to be re-examined, as is being done with cancer screening in elderly and other high-risk groups, he suggested.

Patients in the study ranged in age from 72 to 95 years, 79% were women, and 93% were white. The average number of diagnoses was 3.7 and they included hypertension (67%), osteoarthritis (45%), and dyslipidemia (38%).

Dr. Leng and associates reported no conflicts of interest. The study was sponsored by the National Institute on Aging and the American Federation for Aging Research.

CHICAGO — Trivalent inactivated influenza vaccine may not elicit a clinically adequate antibody response in elderly adults, pilot data suggest.

Based on blood assays taken before and 4 weeks after administration of the Fluarix 2007/2008 formula, 88% of 71 community-dwelling older adults, mean age 85 years, failed to mount a fourfold antibody response to any of the three virus strains present in the trivalent influenza vaccine (TIV).

Only two patients had a fourfold antibody response to both influenza A types, H1N1 and H3N2, and none had such a response to all three strains—H1NI, H3N2, and influenza B, Dr. Sean X. Leng said at the annual meeting of the American Geriatrics Society. A fourfold or higher vaccine antibody titer increase, also called positive seroconversion, is the criterion for a clinically adequate antibody response.

In contrast, he noted that the vaccine insert reports that 444 (60%) of 745 persons, aged 18–64 years, had a fourfold antibody response to the H1N1 strain, 461 (62%) had such a response to H3N2, and 575 (77%) did so to the influenza B strain.

“Obviously this is pilot data, but [it does] point out the importance of the need for comprehensive evaluation of this vaccine in older and frail populations,” said Dr. Leng of the division of geriatric medicine and gerontology at Johns Hopkins University in Baltimore.

The audience questioned whether immunity would be a more accurate measure of vaccine protection than antibody response in the elderly since they are more likely than the young to have been vaccinated before and thus would have higher baseline antibody levels. Of note, researchers at Stanford University recently reported that even the type of vaccine—TIV or live attenuated influenza vaccine—received in prior years affects both serum antibody and B-cell responses to subsequent vaccination (PLoS ONE 2008;8:e2975).

Most patients in the current study had high baseline titer levels, which would make it more difficult to achieve positive seroconversion, acknowledged Dr. Leng. Patients had received flu vaccine for an average of 7 years prior to study entry, although this was based on self-report and subject to memory bias.

Still, 25 (3.4%) participants reported signs and symptoms of flu-like illness during the 2007–2008 flu season, although laboratory confirmation of a diagnosis of influenza was not performed. No influenza-related deaths were reported.

Influenza is the fourth leading cause of death in older Americans, with the elderly bearing more than 90% of influenza-related mortality.

Dr. Leng noted that those aged 75 years and older make up a small percentage of vaccine trial cohorts, despite being the fastest growing segment of the population. In one vaccine trial, only 11% of patients were at least 75 years old (JAMA 1994;272:1661–5). The one-size-fits-all approach to influenza vaccine needs to be re-examined, as is being done with cancer screening in elderly and other high-risk groups, he suggested.

Patients in the study ranged in age from 72 to 95 years, 79% were women, and 93% were white. The average number of diagnoses was 3.7 and they included hypertension (67%), osteoarthritis (45%), and dyslipidemia (38%).

Dr. Leng and associates reported no conflicts of interest. The study was sponsored by the National Institute on Aging and the American Federation for Aging Research.

CHICAGO – Israeli investigators have developed a visual analog scale to measure the intensity of acute stress reaction symptoms in the emergency department.

The scale is similar in design to the widely used Wong-Baker Faces Pain Rating Scale, and accurately predicted the level of emotional reactions weeks after a traumatic event in two studies.

The new scale is the first to measure acute stress reaction symptoms occurring right after a traumatic event, Dr. Ilan Kutz explained at the annual meeting of the International Society for Traumatic Stress Studies. Instruments are available to measure acute stress disorder, but the disorder is typically diagnosed after the first 4 weeks. It's likely that no scale has been developed to measure acute stress reaction symptoms because “it's considered a normative response and so fleeting that people never bothered to attach much attention to it,” he said.

Dr. Kutz and his associates developed more than a dozen questionnaires in an attempt to tackle such assessment issues as how to weight various symptoms (for example, hyperarousal vs. disassociation), how to categorize symptom intensity, and who should conduct the assessment and when. In the end, none of the measures were brief or simple to interpret.

“So we designed, out of a bit of despair, another kind of scale taken from the pain visual analog scale that says distress is something the patient and the clinician can point to,” said Dr. Kutz, Meir Hospital, Tel-Aviv, Israel.

The 10-point acute stress reaction visual analog scale (ASR-VAS) includes five faces, ranging from a frowning and tearful face representing “extreme distress” to a smiling face for “no distress.” The scale was tested by more than 1,000 Israeli clinicians with no training in acute stress reaction and found to be a simple and intuitive measurement for what the patient was experiencing, with a high interrater reliability, he said.

Dr. Kutz and Rachel Dekel, Ph.D., of Bar Ilan University in Ramat-Gan, Israel, then asked 23 victims of a terrorist attack and their clinicians to use the ASR-VAS to rate the intensity of distress within 30 minutes of arrival in the ED and 3-6 hours later after a clinical intervention.

As expected, patients rated their level of distress somewhat higher on arrival than did clinicians (7.4 points vs. 6 points), and the rating given by both groups had significantly decreased upon the patients' release (6.4 vs. 5), she said at the meeting.

Telephone interviews were conducted by a social worker 4 weeks after the event using the Stanford Acute Stress Reaction Questionnaire and again 4-5 months later using the Post-Traumatic Stress Disorder (PTSD) Inventory.

A high positive correlation was observed between the ASR-VAS level of distress upon arrival and the level of distress at the two follow-up interviews, Dr. Dekel said.

In an effort to replicate their findings, a second study with the same protocol was conducted in 62 patients, aged 18-70 years, who experienced a motor vehicle accident but did not require surgery. The patients were subdivided into three groups based on their ASR-VAS scores: 18 “resilient” patients arrived and left the hospital with a score below 5; 23 “adaptive” patients arrived with a score above 5, but experienced a 30% drop or more at release; and 21 “nonadaptive” patients whose score was above 5 at arrival and failed to decrease by 30% or more at discharge.

The nonadaptive group had significantly higher levels of distress on the 4-point Stanford questionnaire 4 weeks after the accident (2.11 points), compared with the adaptive (1.15 points) and resilient (0.69 points) groups, Dr. Dekel reported. The difference was not significant between nonadaptive and adaptive groups.

At 4 months, PTSD symptom levels were also significantly higher in the nonadaptive group than in the resilient group, and trended higher in the adaptive group, compared with the resilient group.

Because of the small size of the subgroups, it was not statistically possible to determine if the scale could predict who will develop long-term distress after a trauma, but it can be used with 90% confidence to predict those who are unlikely to develop distress, she said.

Dr. Dekel acknowledged that the studies were limited by their small size, the use of telephone interviews, and the potential for car accident victims to be seeking secondary gains through insurance compensation.

Although these early findings should be interpreted with care, Dr. Kutz and Dr. Dekel concluded that the scale would be a useful tool in mass casualty events.

The investigators reported no conflicts of interest or funding support for the studies.

CHICAGO – Israeli investigators have developed a visual analog scale to measure the intensity of acute stress reaction symptoms in the emergency department.

The scale is similar in design to the widely used Wong-Baker Faces Pain Rating Scale, and accurately predicted the level of emotional reactions weeks after a traumatic event in two studies.

The new scale is the first to measure acute stress reaction symptoms occurring right after a traumatic event, Dr. Ilan Kutz explained at the annual meeting of the International Society for Traumatic Stress Studies. Instruments are available to measure acute stress disorder, but the disorder is typically diagnosed after the first 4 weeks. It's likely that no scale has been developed to measure acute stress reaction symptoms because “it's considered a normative response and so fleeting that people never bothered to attach much attention to it,” he said.

Dr. Kutz and his associates developed more than a dozen questionnaires in an attempt to tackle such assessment issues as how to weight various symptoms (for example, hyperarousal vs. disassociation), how to categorize symptom intensity, and who should conduct the assessment and when. In the end, none of the measures were brief or simple to interpret.

“So we designed, out of a bit of despair, another kind of scale taken from the pain visual analog scale that says distress is something the patient and the clinician can point to,” said Dr. Kutz, Meir Hospital, Tel-Aviv, Israel.

The 10-point acute stress reaction visual analog scale (ASR-VAS) includes five faces, ranging from a frowning and tearful face representing “extreme distress” to a smiling face for “no distress.” The scale was tested by more than 1,000 Israeli clinicians with no training in acute stress reaction and found to be a simple and intuitive measurement for what the patient was experiencing, with a high interrater reliability, he said.

Dr. Kutz and Rachel Dekel, Ph.D., of Bar Ilan University in Ramat-Gan, Israel, then asked 23 victims of a terrorist attack and their clinicians to use the ASR-VAS to rate the intensity of distress within 30 minutes of arrival in the ED and 3-6 hours later after a clinical intervention.

As expected, patients rated their level of distress somewhat higher on arrival than did clinicians (7.4 points vs. 6 points), and the rating given by both groups had significantly decreased upon the patients' release (6.4 vs. 5), she said at the meeting.

Telephone interviews were conducted by a social worker 4 weeks after the event using the Stanford Acute Stress Reaction Questionnaire and again 4-5 months later using the Post-Traumatic Stress Disorder (PTSD) Inventory.

A high positive correlation was observed between the ASR-VAS level of distress upon arrival and the level of distress at the two follow-up interviews, Dr. Dekel said.

In an effort to replicate their findings, a second study with the same protocol was conducted in 62 patients, aged 18-70 years, who experienced a motor vehicle accident but did not require surgery. The patients were subdivided into three groups based on their ASR-VAS scores: 18 “resilient” patients arrived and left the hospital with a score below 5; 23 “adaptive” patients arrived with a score above 5, but experienced a 30% drop or more at release; and 21 “nonadaptive” patients whose score was above 5 at arrival and failed to decrease by 30% or more at discharge.

The nonadaptive group had significantly higher levels of distress on the 4-point Stanford questionnaire 4 weeks after the accident (2.11 points), compared with the adaptive (1.15 points) and resilient (0.69 points) groups, Dr. Dekel reported. The difference was not significant between nonadaptive and adaptive groups.

At 4 months, PTSD symptom levels were also significantly higher in the nonadaptive group than in the resilient group, and trended higher in the adaptive group, compared with the resilient group.

Because of the small size of the subgroups, it was not statistically possible to determine if the scale could predict who will develop long-term distress after a trauma, but it can be used with 90% confidence to predict those who are unlikely to develop distress, she said.

Dr. Dekel acknowledged that the studies were limited by their small size, the use of telephone interviews, and the potential for car accident victims to be seeking secondary gains through insurance compensation.

Although these early findings should be interpreted with care, Dr. Kutz and Dr. Dekel concluded that the scale would be a useful tool in mass casualty events.

The investigators reported no conflicts of interest or funding support for the studies.

CHICAGO – Israeli investigators have developed a visual analog scale to measure the intensity of acute stress reaction symptoms in the emergency department.

The scale is similar in design to the widely used Wong-Baker Faces Pain Rating Scale, and accurately predicted the level of emotional reactions weeks after a traumatic event in two studies.

The new scale is the first to measure acute stress reaction symptoms occurring right after a traumatic event, Dr. Ilan Kutz explained at the annual meeting of the International Society for Traumatic Stress Studies. Instruments are available to measure acute stress disorder, but the disorder is typically diagnosed after the first 4 weeks. It's likely that no scale has been developed to measure acute stress reaction symptoms because “it's considered a normative response and so fleeting that people never bothered to attach much attention to it,” he said.

Dr. Kutz and his associates developed more than a dozen questionnaires in an attempt to tackle such assessment issues as how to weight various symptoms (for example, hyperarousal vs. disassociation), how to categorize symptom intensity, and who should conduct the assessment and when. In the end, none of the measures were brief or simple to interpret.

“So we designed, out of a bit of despair, another kind of scale taken from the pain visual analog scale that says distress is something the patient and the clinician can point to,” said Dr. Kutz, Meir Hospital, Tel-Aviv, Israel.

The 10-point acute stress reaction visual analog scale (ASR-VAS) includes five faces, ranging from a frowning and tearful face representing “extreme distress” to a smiling face for “no distress.” The scale was tested by more than 1,000 Israeli clinicians with no training in acute stress reaction and found to be a simple and intuitive measurement for what the patient was experiencing, with a high interrater reliability, he said.

Dr. Kutz and Rachel Dekel, Ph.D., of Bar Ilan University in Ramat-Gan, Israel, then asked 23 victims of a terrorist attack and their clinicians to use the ASR-VAS to rate the intensity of distress within 30 minutes of arrival in the ED and 3-6 hours later after a clinical intervention.

As expected, patients rated their level of distress somewhat higher on arrival than did clinicians (7.4 points vs. 6 points), and the rating given by both groups had significantly decreased upon the patients' release (6.4 vs. 5), she said at the meeting.

Telephone interviews were conducted by a social worker 4 weeks after the event using the Stanford Acute Stress Reaction Questionnaire and again 4-5 months later using the Post-Traumatic Stress Disorder (PTSD) Inventory.

A high positive correlation was observed between the ASR-VAS level of distress upon arrival and the level of distress at the two follow-up interviews, Dr. Dekel said.

In an effort to replicate their findings, a second study with the same protocol was conducted in 62 patients, aged 18-70 years, who experienced a motor vehicle accident but did not require surgery. The patients were subdivided into three groups based on their ASR-VAS scores: 18 “resilient” patients arrived and left the hospital with a score below 5; 23 “adaptive” patients arrived with a score above 5, but experienced a 30% drop or more at release; and 21 “nonadaptive” patients whose score was above 5 at arrival and failed to decrease by 30% or more at discharge.

The nonadaptive group had significantly higher levels of distress on the 4-point Stanford questionnaire 4 weeks after the accident (2.11 points), compared with the adaptive (1.15 points) and resilient (0.69 points) groups, Dr. Dekel reported. The difference was not significant between nonadaptive and adaptive groups.

At 4 months, PTSD symptom levels were also significantly higher in the nonadaptive group than in the resilient group, and trended higher in the adaptive group, compared with the resilient group.

Because of the small size of the subgroups, it was not statistically possible to determine if the scale could predict who will develop long-term distress after a trauma, but it can be used with 90% confidence to predict those who are unlikely to develop distress, she said.

Dr. Dekel acknowledged that the studies were limited by their small size, the use of telephone interviews, and the potential for car accident victims to be seeking secondary gains through insurance compensation.

Although these early findings should be interpreted with care, Dr. Kutz and Dr. Dekel concluded that the scale would be a useful tool in mass casualty events.

The investigators reported no conflicts of interest or funding support for the studies.

AUSTIN, TEX. – A survey of nurses suggests that they might have a knowledge gap regarding the use of opioids at the end of their patients' lives.

Among 181 nurses surveyed at three urban Midwestern medical centers, 65% reported being confident in their ability to titrate a continuous opioid infusion to manage a dying patient's symptoms. Despite that, many nurses incorrectly answered three of four questions designed to test their knowledge of specific opioid practices, researcher Margaret Barnett reported at the annual meeting of the American Academy of Hospice and Palliative Medicine. Most respondents knew the appropriate starting dose for a continuous morphine infusion in a patient admitted with severe pain that was uncontrolled with Percocet (oxycodone with acetaminophen). But they struggled to identify the correct morphine dose for a patient whose pain scores remained unchanged after receiving an intravenous morphine bolus, said Ms. Barnett, an advanced clinical nurse palliative care specialist at University of Kansas Medical Center, Kansas City. Most nurses also failed to identify how many hours it would take a patient to reach a steady state after the continuous infusion of morphine was increased or how long to wait between giving intravenous boluses.

The respondents had an average of 13 years of registered nursing experience, 61% had a bachelor of science in nursing or a higher degree, and 58% had cared for a patient requiring opioid titration in the past year.

The author disclosed no conflicts. The Nursing Honor Society, Sigma Theta Tau International, supported the study.

AUSTIN, TEX. – A survey of nurses suggests that they might have a knowledge gap regarding the use of opioids at the end of their patients' lives.

Among 181 nurses surveyed at three urban Midwestern medical centers, 65% reported being confident in their ability to titrate a continuous opioid infusion to manage a dying patient's symptoms. Despite that, many nurses incorrectly answered three of four questions designed to test their knowledge of specific opioid practices, researcher Margaret Barnett reported at the annual meeting of the American Academy of Hospice and Palliative Medicine. Most respondents knew the appropriate starting dose for a continuous morphine infusion in a patient admitted with severe pain that was uncontrolled with Percocet (oxycodone with acetaminophen). But they struggled to identify the correct morphine dose for a patient whose pain scores remained unchanged after receiving an intravenous morphine bolus, said Ms. Barnett, an advanced clinical nurse palliative care specialist at University of Kansas Medical Center, Kansas City. Most nurses also failed to identify how many hours it would take a patient to reach a steady state after the continuous infusion of morphine was increased or how long to wait between giving intravenous boluses.

The respondents had an average of 13 years of registered nursing experience, 61% had a bachelor of science in nursing or a higher degree, and 58% had cared for a patient requiring opioid titration in the past year.

The author disclosed no conflicts. The Nursing Honor Society, Sigma Theta Tau International, supported the study.

AUSTIN, TEX. – A survey of nurses suggests that they might have a knowledge gap regarding the use of opioids at the end of their patients' lives.

Among 181 nurses surveyed at three urban Midwestern medical centers, 65% reported being confident in their ability to titrate a continuous opioid infusion to manage a dying patient's symptoms. Despite that, many nurses incorrectly answered three of four questions designed to test their knowledge of specific opioid practices, researcher Margaret Barnett reported at the annual meeting of the American Academy of Hospice and Palliative Medicine. Most respondents knew the appropriate starting dose for a continuous morphine infusion in a patient admitted with severe pain that was uncontrolled with Percocet (oxycodone with acetaminophen). But they struggled to identify the correct morphine dose for a patient whose pain scores remained unchanged after receiving an intravenous morphine bolus, said Ms. Barnett, an advanced clinical nurse palliative care specialist at University of Kansas Medical Center, Kansas City. Most nurses also failed to identify how many hours it would take a patient to reach a steady state after the continuous infusion of morphine was increased or how long to wait between giving intravenous boluses.

The respondents had an average of 13 years of registered nursing experience, 61% had a bachelor of science in nursing or a higher degree, and 58% had cared for a patient requiring opioid titration in the past year.

The author disclosed no conflicts. The Nursing Honor Society, Sigma Theta Tau International, supported the study.

AUSTIN, TEX. — A program designed to address unmet palliative care needs among frail, elderly patients who repeatedly sought acute care at Beth Israel Medical Center's emergency department led to a steady increase in palliative care consultations.

The BriefPal Program at the New York City-based hospital identified elderly patients who had a Karnofsky Performance Status score below 80 (0–100 scale, with 100 being healthy), at least a moderate decline in functional status, and a specific life-limiting condition: advanced dementia, severe congestive heart failure or chronic obstructive pulmonary disease, advanced malignancy, or AIDS.

Stage 2 of the screening protocol identified subgroups of patients with a recent loss of activities of daily living, high symptom burden, extremely poor functional status, and high levels of caregiver burden.

During the 3-month pilot phase, 864 patients older than 65 years were screened; 131 patients met the initial criteria, and 62 met stage 2 criteria. Although 35% of the 62 patients died within 60 days of their index visit, none was receiving palliative care services, coinvestigator Myra Glajchen, D.S.W., reported at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The team, also led by Dr. Knox Todd, identified multiple barriers to providing palliative care services in the ED. In almost half of cases (49%), the primary care physicians admitting the patients did not want to make the referral, because they felt they were more familiar with the patients or were unfamiliar with palliative care services, Dr. Glajchen said.

In 25% of cases, the patient or family said no. In another 25% of cases, the ED physician balked at making the referral because of concerns about more paperwork or phone calls, time constraints, or a failure to realize the value of palliative care.

Lessons learned by the team included the need for specifically targeted palliative care education in the ED, the crucial role of champions in project implementation, and the importance of rapid quality indicator initiatives to demonstrate tangible results, Dr. Glajchen said.

Ultimately, the team provided brief training in palliative care and quality indicators to 41 emergency physicians, exceeding its goal of 21, and to four of eight physician assistants, 31 of 45 nurses, and three of five social workers. Classes were offered at all hours to accommodate various shifts, and were repeated to address staff turnover.

The team also implemented standardized screening based on the two-stage protocol, and began offering palliative care interventions and referrals for appropriate patients.

Palliative care consultations originating in the ED increased steadily over the course of the project, and by the first quarter of 2008, accounted for fully one-half of all palliative care consultations in the hospital, Dr. Glajchen reported. The team screened 2,451 patients and provided 94 palliative care consultations and 168 ED palliative care interventions in 245 patients identified as having unmet needs. Interviews with 264 caregivers revealed particularly high rates of caregiver burden.

“Caregiver burden is often a driving force of why people come to the ED in the first place,” she said.

Beth Israel uses the National Consensus Project (NCP) for Quality Palliative Care as a framework for its palliative care and will be exploring a range of quality indicator approaches for implementing best practices, said copresenter Dr. Russell Portenoy, chair of pain medicine and palliative care at Beth Israel. Because the NCP model was designed as an inpatient consultative model of specialist care, it is not an exact fit in the ED, he said. However, it can be adapted to fit the ED.

The NCP calls for comprehensive interdisciplinary assessment of patients with advanced illness, goal setting based on patient/family preferences, and an environment that provides privacy. That may require a shift from current ED care, Dr. Portenoy said, in which triage often is done by a registered nurse, care is problem focused and standardized, and treatment is delivered by a continually rotating group of physicians.

In addition, social workers and psychiatrists may not be a core part of the team—and privacy often means pulling a thin curtain around the patient to have very difficult discussions frequently conducted through the help of an interpreter or family member.

Finally, misaligned financial incentives are one of the biggest challenges. Optimal ED-based palliative care will mean getting patients home rather than admitting them, Dr. Portenoy said—and that may make it less attractive to the hospital.

He suggested that palliative medicine specialists focused on the ED will need to refine systems to increase reimbursement for palliative care services delivered by physicians, physician assistants, or nurse practitioners. They also will need to negotiate with hospitals based on the overall quality and potential for cost savings that palliative care can provide on the inpatient side.

“If the only way that EDs around the country are going to be able to implement best practices for palliative care is through volunteerism and grants, then it's not going to work,” he said.

AUSTIN, TEX. — A program designed to address unmet palliative care needs among frail, elderly patients who repeatedly sought acute care at Beth Israel Medical Center's emergency department led to a steady increase in palliative care consultations.

The BriefPal Program at the New York City-based hospital identified elderly patients who had a Karnofsky Performance Status score below 80 (0–100 scale, with 100 being healthy), at least a moderate decline in functional status, and a specific life-limiting condition: advanced dementia, severe congestive heart failure or chronic obstructive pulmonary disease, advanced malignancy, or AIDS.

Stage 2 of the screening protocol identified subgroups of patients with a recent loss of activities of daily living, high symptom burden, extremely poor functional status, and high levels of caregiver burden.

During the 3-month pilot phase, 864 patients older than 65 years were screened; 131 patients met the initial criteria, and 62 met stage 2 criteria. Although 35% of the 62 patients died within 60 days of their index visit, none was receiving palliative care services, coinvestigator Myra Glajchen, D.S.W., reported at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The team, also led by Dr. Knox Todd, identified multiple barriers to providing palliative care services in the ED. In almost half of cases (49%), the primary care physicians admitting the patients did not want to make the referral, because they felt they were more familiar with the patients or were unfamiliar with palliative care services, Dr. Glajchen said.

In 25% of cases, the patient or family said no. In another 25% of cases, the ED physician balked at making the referral because of concerns about more paperwork or phone calls, time constraints, or a failure to realize the value of palliative care.

Lessons learned by the team included the need for specifically targeted palliative care education in the ED, the crucial role of champions in project implementation, and the importance of rapid quality indicator initiatives to demonstrate tangible results, Dr. Glajchen said.

Ultimately, the team provided brief training in palliative care and quality indicators to 41 emergency physicians, exceeding its goal of 21, and to four of eight physician assistants, 31 of 45 nurses, and three of five social workers. Classes were offered at all hours to accommodate various shifts, and were repeated to address staff turnover.

The team also implemented standardized screening based on the two-stage protocol, and began offering palliative care interventions and referrals for appropriate patients.

Palliative care consultations originating in the ED increased steadily over the course of the project, and by the first quarter of 2008, accounted for fully one-half of all palliative care consultations in the hospital, Dr. Glajchen reported. The team screened 2,451 patients and provided 94 palliative care consultations and 168 ED palliative care interventions in 245 patients identified as having unmet needs. Interviews with 264 caregivers revealed particularly high rates of caregiver burden.

“Caregiver burden is often a driving force of why people come to the ED in the first place,” she said.

Beth Israel uses the National Consensus Project (NCP) for Quality Palliative Care as a framework for its palliative care and will be exploring a range of quality indicator approaches for implementing best practices, said copresenter Dr. Russell Portenoy, chair of pain medicine and palliative care at Beth Israel. Because the NCP model was designed as an inpatient consultative model of specialist care, it is not an exact fit in the ED, he said. However, it can be adapted to fit the ED.

The NCP calls for comprehensive interdisciplinary assessment of patients with advanced illness, goal setting based on patient/family preferences, and an environment that provides privacy. That may require a shift from current ED care, Dr. Portenoy said, in which triage often is done by a registered nurse, care is problem focused and standardized, and treatment is delivered by a continually rotating group of physicians.

In addition, social workers and psychiatrists may not be a core part of the team—and privacy often means pulling a thin curtain around the patient to have very difficult discussions frequently conducted through the help of an interpreter or family member.

Finally, misaligned financial incentives are one of the biggest challenges. Optimal ED-based palliative care will mean getting patients home rather than admitting them, Dr. Portenoy said—and that may make it less attractive to the hospital.

He suggested that palliative medicine specialists focused on the ED will need to refine systems to increase reimbursement for palliative care services delivered by physicians, physician assistants, or nurse practitioners. They also will need to negotiate with hospitals based on the overall quality and potential for cost savings that palliative care can provide on the inpatient side.

“If the only way that EDs around the country are going to be able to implement best practices for palliative care is through volunteerism and grants, then it's not going to work,” he said.

AUSTIN, TEX. — A program designed to address unmet palliative care needs among frail, elderly patients who repeatedly sought acute care at Beth Israel Medical Center's emergency department led to a steady increase in palliative care consultations.

The BriefPal Program at the New York City-based hospital identified elderly patients who had a Karnofsky Performance Status score below 80 (0–100 scale, with 100 being healthy), at least a moderate decline in functional status, and a specific life-limiting condition: advanced dementia, severe congestive heart failure or chronic obstructive pulmonary disease, advanced malignancy, or AIDS.

Stage 2 of the screening protocol identified subgroups of patients with a recent loss of activities of daily living, high symptom burden, extremely poor functional status, and high levels of caregiver burden.

During the 3-month pilot phase, 864 patients older than 65 years were screened; 131 patients met the initial criteria, and 62 met stage 2 criteria. Although 35% of the 62 patients died within 60 days of their index visit, none was receiving palliative care services, coinvestigator Myra Glajchen, D.S.W., reported at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The team, also led by Dr. Knox Todd, identified multiple barriers to providing palliative care services in the ED. In almost half of cases (49%), the primary care physicians admitting the patients did not want to make the referral, because they felt they were more familiar with the patients or were unfamiliar with palliative care services, Dr. Glajchen said.

In 25% of cases, the patient or family said no. In another 25% of cases, the ED physician balked at making the referral because of concerns about more paperwork or phone calls, time constraints, or a failure to realize the value of palliative care.

Lessons learned by the team included the need for specifically targeted palliative care education in the ED, the crucial role of champions in project implementation, and the importance of rapid quality indicator initiatives to demonstrate tangible results, Dr. Glajchen said.

Ultimately, the team provided brief training in palliative care and quality indicators to 41 emergency physicians, exceeding its goal of 21, and to four of eight physician assistants, 31 of 45 nurses, and three of five social workers. Classes were offered at all hours to accommodate various shifts, and were repeated to address staff turnover.

The team also implemented standardized screening based on the two-stage protocol, and began offering palliative care interventions and referrals for appropriate patients.

Palliative care consultations originating in the ED increased steadily over the course of the project, and by the first quarter of 2008, accounted for fully one-half of all palliative care consultations in the hospital, Dr. Glajchen reported. The team screened 2,451 patients and provided 94 palliative care consultations and 168 ED palliative care interventions in 245 patients identified as having unmet needs. Interviews with 264 caregivers revealed particularly high rates of caregiver burden.

“Caregiver burden is often a driving force of why people come to the ED in the first place,” she said.

Beth Israel uses the National Consensus Project (NCP) for Quality Palliative Care as a framework for its palliative care and will be exploring a range of quality indicator approaches for implementing best practices, said copresenter Dr. Russell Portenoy, chair of pain medicine and palliative care at Beth Israel. Because the NCP model was designed as an inpatient consultative model of specialist care, it is not an exact fit in the ED, he said. However, it can be adapted to fit the ED.

The NCP calls for comprehensive interdisciplinary assessment of patients with advanced illness, goal setting based on patient/family preferences, and an environment that provides privacy. That may require a shift from current ED care, Dr. Portenoy said, in which triage often is done by a registered nurse, care is problem focused and standardized, and treatment is delivered by a continually rotating group of physicians.

In addition, social workers and psychiatrists may not be a core part of the team—and privacy often means pulling a thin curtain around the patient to have very difficult discussions frequently conducted through the help of an interpreter or family member.

Finally, misaligned financial incentives are one of the biggest challenges. Optimal ED-based palliative care will mean getting patients home rather than admitting them, Dr. Portenoy said—and that may make it less attractive to the hospital.

He suggested that palliative medicine specialists focused on the ED will need to refine systems to increase reimbursement for palliative care services delivered by physicians, physician assistants, or nurse practitioners. They also will need to negotiate with hospitals based on the overall quality and potential for cost savings that palliative care can provide on the inpatient side.

“If the only way that EDs around the country are going to be able to implement best practices for palliative care is through volunteerism and grants, then it's not going to work,” he said.

CHICAGO — A new Web site and iPhone application could render hospital paging systems as obsolete as eight-track tapes.

Designed around existing wireless technology, the MComm communication system allows for task-oriented and priority-based messaging in real-time fashion, hospitalist Vineet Chopra and his colleagues at the University of Michigan Health System in Ann Arbor reported at the annual meeting of the Society of Hospital Medicine.

Hospitalists or other members of a medical team can create patient-specific tasks using either a wireless device or a Web-based portal. Tasks are assigned to individuals or to multiple members of the team and labeled as either urgent (requiring action within 30 minutes) or nonurgent.

Caregivers receive either an audible or silent vibratory alert based on task priority. This sets MComm apart from traditional paging systems that cannot distinguish between urgent and mundane messages, Dr. Chopra said. MComm also signals the original creator of a task that a message has been received and lets users note when they've completed a task, thereby closing the loop on the one-way flow of information that is a significant limitation of paging systems.

“We believe that MComm represents a technological breakthrough in medical communication via work flow process improvements,” Dr. Chopra said. “The use of mobile devices that organize tasks by patients and priority using a team-based approach is unprecedented.”

Tasks can be filtered across patients according to priority, assignee, creator, and/or status, allowing for immediate work flow prioritization. MComm, which is in beta testing, is expected to be launched for use by the university's hospitalist group and its medicine-pediatrics residency program within the next few months, once testing is complete, Dr. Chopra said in an interview.

The university's medical school has a keen interest in using the technology at its newly acquired Pfizer campus where most of the animal and basic science labs will be placed. “Task delegation and defined roles are key features to all of these settings,” he said.

In light of the movement toward patient- and family-centered care, session moderators asked if the researchers could imagine a day when patients or their advocates could be tied into the MComm system in real time.

“Absolutely,” Dr. Chopra said. “We've looked at even giving patients iPhones so that they could look at their progress” and keep tabs on scheduled tests or other details. “I think that kind of patient empowerment is coming. We are certainly hopeful that this will actually enhance that movement.”

The moderators cautioned that increased access to patient information has a flip side: the need to protect patient privacy. MComm will use secure technology, and all activities will be archived for HIPAA compliance, Dr. Chopra said. Management of individual patient information is shared by the team, along with individual devices and user accounts, which can be passed on at the end of each workday to night coverage teams.

Future upgrades under development include capabilities for voice communication via both cellular and WiFi technology, and for sending laboratory reports to providers. Integration of MComm into the existing electronic medical record system will happen almost immediately, Dr. Chopra said.

“We designed this to be a new version of the pager for many years to come,” he said.

More information about the MComm system is available at www.synaptin.com

Tasks can be organized by patients and team priorities. PHOTO COURTESY DR. VINEET CHOPRA

Users report back when delegated tasks are done. PHOTO COURTESY DR. VINEET CHOPRA

CHICAGO — A new Web site and iPhone application could render hospital paging systems as obsolete as eight-track tapes.

Designed around existing wireless technology, the MComm communication system allows for task-oriented and priority-based messaging in real-time fashion, hospitalist Vineet Chopra and his colleagues at the University of Michigan Health System in Ann Arbor reported at the annual meeting of the Society of Hospital Medicine.

Hospitalists or other members of a medical team can create patient-specific tasks using either a wireless device or a Web-based portal. Tasks are assigned to individuals or to multiple members of the team and labeled as either urgent (requiring action within 30 minutes) or nonurgent.

Caregivers receive either an audible or silent vibratory alert based on task priority. This sets MComm apart from traditional paging systems that cannot distinguish between urgent and mundane messages, Dr. Chopra said. MComm also signals the original creator of a task that a message has been received and lets users note when they've completed a task, thereby closing the loop on the one-way flow of information that is a significant limitation of paging systems.

“We believe that MComm represents a technological breakthrough in medical communication via work flow process improvements,” Dr. Chopra said. “The use of mobile devices that organize tasks by patients and priority using a team-based approach is unprecedented.”

Tasks can be filtered across patients according to priority, assignee, creator, and/or status, allowing for immediate work flow prioritization. MComm, which is in beta testing, is expected to be launched for use by the university's hospitalist group and its medicine-pediatrics residency program within the next few months, once testing is complete, Dr. Chopra said in an interview.

The university's medical school has a keen interest in using the technology at its newly acquired Pfizer campus where most of the animal and basic science labs will be placed. “Task delegation and defined roles are key features to all of these settings,” he said.

In light of the movement toward patient- and family-centered care, session moderators asked if the researchers could imagine a day when patients or their advocates could be tied into the MComm system in real time.

“Absolutely,” Dr. Chopra said. “We've looked at even giving patients iPhones so that they could look at their progress” and keep tabs on scheduled tests or other details. “I think that kind of patient empowerment is coming. We are certainly hopeful that this will actually enhance that movement.”

The moderators cautioned that increased access to patient information has a flip side: the need to protect patient privacy. MComm will use secure technology, and all activities will be archived for HIPAA compliance, Dr. Chopra said. Management of individual patient information is shared by the team, along with individual devices and user accounts, which can be passed on at the end of each workday to night coverage teams.

Future upgrades under development include capabilities for voice communication via both cellular and WiFi technology, and for sending laboratory reports to providers. Integration of MComm into the existing electronic medical record system will happen almost immediately, Dr. Chopra said.

“We designed this to be a new version of the pager for many years to come,” he said.

More information about the MComm system is available at www.synaptin.com

Tasks can be organized by patients and team priorities. PHOTO COURTESY DR. VINEET CHOPRA

Users report back when delegated tasks are done. PHOTO COURTESY DR. VINEET CHOPRA

CHICAGO — A new Web site and iPhone application could render hospital paging systems as obsolete as eight-track tapes.

Designed around existing wireless technology, the MComm communication system allows for task-oriented and priority-based messaging in real-time fashion, hospitalist Vineet Chopra and his colleagues at the University of Michigan Health System in Ann Arbor reported at the annual meeting of the Society of Hospital Medicine.

Hospitalists or other members of a medical team can create patient-specific tasks using either a wireless device or a Web-based portal. Tasks are assigned to individuals or to multiple members of the team and labeled as either urgent (requiring action within 30 minutes) or nonurgent.

Caregivers receive either an audible or silent vibratory alert based on task priority. This sets MComm apart from traditional paging systems that cannot distinguish between urgent and mundane messages, Dr. Chopra said. MComm also signals the original creator of a task that a message has been received and lets users note when they've completed a task, thereby closing the loop on the one-way flow of information that is a significant limitation of paging systems.

“We believe that MComm represents a technological breakthrough in medical communication via work flow process improvements,” Dr. Chopra said. “The use of mobile devices that organize tasks by patients and priority using a team-based approach is unprecedented.”

Tasks can be filtered across patients according to priority, assignee, creator, and/or status, allowing for immediate work flow prioritization. MComm, which is in beta testing, is expected to be launched for use by the university's hospitalist group and its medicine-pediatrics residency program within the next few months, once testing is complete, Dr. Chopra said in an interview.

The university's medical school has a keen interest in using the technology at its newly acquired Pfizer campus where most of the animal and basic science labs will be placed. “Task delegation and defined roles are key features to all of these settings,” he said.

In light of the movement toward patient- and family-centered care, session moderators asked if the researchers could imagine a day when patients or their advocates could be tied into the MComm system in real time.

“Absolutely,” Dr. Chopra said. “We've looked at even giving patients iPhones so that they could look at their progress” and keep tabs on scheduled tests or other details. “I think that kind of patient empowerment is coming. We are certainly hopeful that this will actually enhance that movement.”

The moderators cautioned that increased access to patient information has a flip side: the need to protect patient privacy. MComm will use secure technology, and all activities will be archived for HIPAA compliance, Dr. Chopra said. Management of individual patient information is shared by the team, along with individual devices and user accounts, which can be passed on at the end of each workday to night coverage teams.

Future upgrades under development include capabilities for voice communication via both cellular and WiFi technology, and for sending laboratory reports to providers. Integration of MComm into the existing electronic medical record system will happen almost immediately, Dr. Chopra said.

“We designed this to be a new version of the pager for many years to come,” he said.

More information about the MComm system is available at www.synaptin.com

Tasks can be organized by patients and team priorities. PHOTO COURTESY DR. VINEET CHOPRA

Users report back when delegated tasks are done. PHOTO COURTESY DR. VINEET CHOPRA

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 (OR 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.

Although the sample size was large, Dr. Go acknowledged that the study could not account for severity of illness, differentiate planned from unplanned readmissions, or capture readmissions by VA patients to private or university hospitals.

The researchers disclosed no relevant conflicts of interest.

The findings suggest that 'we're providing more efficient and better care. It's reassuring to show 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 (OR 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.

Although the sample size was large, Dr. Go acknowledged that the study could not account for severity of illness, differentiate planned from unplanned readmissions, or capture readmissions by VA patients to private or university hospitals.

The researchers disclosed no relevant conflicts of interest.

The findings suggest that 'we're providing more efficient and better care. It's reassuring to show 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 (OR 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.

Although the sample size was large, Dr. Go acknowledged that the study could not account for severity of illness, differentiate planned from unplanned readmissions, or capture readmissions by VA patients to private or university hospitals.

The researchers disclosed no relevant conflicts of interest.

The findings suggest that 'we're providing more efficient and better care. It's reassuring to show that increasing patient efficiency has not resulted in increased hospital readmission.' DR. GO

CHICAGO — Real-time relay of the venous thromboembolism prophylaxis order status of all patients at a 550-bed tertiary care teaching hospital increased prophylaxis usage in the ICU and in medical and surgical units.

For at least 5 months after the intervention, 15 nursing units averaged a greater than 90% prevalence of venous thromboembolism (VTE) prophylaxis, a level reached by just 5 units prior to the intervention, Dr. Jason Stein and his colleagues at Emory University, Atlanta, reported in a poster at the annual meeting of the Society of Hospital Medicine.

Pulmonary embolism resulting from VTE is the leading preventable cause of hospital death. Yet a large U.S. registry study showed that most hospitalized patients with risk factors for deep-vein thrombosis did not receive prophylaxis (Am. J. Cardiol. 2004;93:259–62).

In the current study, pharmacologic VTE prophylaxis in the surgical ICU significantly increased from 78% at baseline to 94% after the intervention. That occurred without a significant rise in lone mechanical prophylaxis, which increased from 17.3% to 19.6%.

In a medical nursing unit, the intervention led to a significant increase in overall VTE prophylaxis (from 85% to 91%) that was almost entirely attributable to an increase in lone mechanical prophylaxis (from 14.6% to 20.2%).

Frontline processes, such as rounding format or timing of capture of new orders, may modulate the effect of the program, and thus explain the different outcomes between the two units, Dr. Stein and his colleagues said.

In the surgical ICU, simultaneous physical rounding on every patient is conducted every morning by all members of the frontline clinical team, including the responsible physician. A clinical pharmacist views the real-time relay-and-display program prior to rounds to call attention to appropriateness of VTE prophylaxis during rounds. New VTE prophylaxis orders are discussed and captured via new physician orders during rounds.

In contrast, the rounding format in the medical unit is asynchronous physical rounding on patients by clinical team members. A multidisciplinary team meets on weekday mornings to discuss patients. The charge nurse views the relay-and-display program to call attention to patients, with no order for VTE prophylaxis during the team meeting. New orders are discussed but not captured during the meeting, and the nurse follows up ad hoc.

“More research is needed to examine sustainability and to clarify features of the most effective implementations of relay-and-display strategies in hospitals,” they said.

Dr. Stein disclosed stock holdings with Ingenious Med Inc. as well as honoraria from Sanofi.

CHICAGO — Real-time relay of the venous thromboembolism prophylaxis order status of all patients at a 550-bed tertiary care teaching hospital increased prophylaxis usage in the ICU and in medical and surgical units.

For at least 5 months after the intervention, 15 nursing units averaged a greater than 90% prevalence of venous thromboembolism (VTE) prophylaxis, a level reached by just 5 units prior to the intervention, Dr. Jason Stein and his colleagues at Emory University, Atlanta, reported in a poster at the annual meeting of the Society of Hospital Medicine.

Pulmonary embolism resulting from VTE is the leading preventable cause of hospital death. Yet a large U.S. registry study showed that most hospitalized patients with risk factors for deep-vein thrombosis did not receive prophylaxis (Am. J. Cardiol. 2004;93:259–62).

In the current study, pharmacologic VTE prophylaxis in the surgical ICU significantly increased from 78% at baseline to 94% after the intervention. That occurred without a significant rise in lone mechanical prophylaxis, which increased from 17.3% to 19.6%.

In a medical nursing unit, the intervention led to a significant increase in overall VTE prophylaxis (from 85% to 91%) that was almost entirely attributable to an increase in lone mechanical prophylaxis (from 14.6% to 20.2%).

Frontline processes, such as rounding format or timing of capture of new orders, may modulate the effect of the program, and thus explain the different outcomes between the two units, Dr. Stein and his colleagues said.

In the surgical ICU, simultaneous physical rounding on every patient is conducted every morning by all members of the frontline clinical team, including the responsible physician. A clinical pharmacist views the real-time relay-and-display program prior to rounds to call attention to appropriateness of VTE prophylaxis during rounds. New VTE prophylaxis orders are discussed and captured via new physician orders during rounds.

In contrast, the rounding format in the medical unit is asynchronous physical rounding on patients by clinical team members. A multidisciplinary team meets on weekday mornings to discuss patients. The charge nurse views the relay-and-display program to call attention to patients, with no order for VTE prophylaxis during the team meeting. New orders are discussed but not captured during the meeting, and the nurse follows up ad hoc.

“More research is needed to examine sustainability and to clarify features of the most effective implementations of relay-and-display strategies in hospitals,” they said.

Dr. Stein disclosed stock holdings with Ingenious Med Inc. as well as honoraria from Sanofi.

CHICAGO — Real-time relay of the venous thromboembolism prophylaxis order status of all patients at a 550-bed tertiary care teaching hospital increased prophylaxis usage in the ICU and in medical and surgical units.

For at least 5 months after the intervention, 15 nursing units averaged a greater than 90% prevalence of venous thromboembolism (VTE) prophylaxis, a level reached by just 5 units prior to the intervention, Dr. Jason Stein and his colleagues at Emory University, Atlanta, reported in a poster at the annual meeting of the Society of Hospital Medicine.

Pulmonary embolism resulting from VTE is the leading preventable cause of hospital death. Yet a large U.S. registry study showed that most hospitalized patients with risk factors for deep-vein thrombosis did not receive prophylaxis (Am. J. Cardiol. 2004;93:259–62).

In the current study, pharmacologic VTE prophylaxis in the surgical ICU significantly increased from 78% at baseline to 94% after the intervention. That occurred without a significant rise in lone mechanical prophylaxis, which increased from 17.3% to 19.6%.

In a medical nursing unit, the intervention led to a significant increase in overall VTE prophylaxis (from 85% to 91%) that was almost entirely attributable to an increase in lone mechanical prophylaxis (from 14.6% to 20.2%).

Frontline processes, such as rounding format or timing of capture of new orders, may modulate the effect of the program, and thus explain the different outcomes between the two units, Dr. Stein and his colleagues said.

In the surgical ICU, simultaneous physical rounding on every patient is conducted every morning by all members of the frontline clinical team, including the responsible physician. A clinical pharmacist views the real-time relay-and-display program prior to rounds to call attention to appropriateness of VTE prophylaxis during rounds. New VTE prophylaxis orders are discussed and captured via new physician orders during rounds.

In contrast, the rounding format in the medical unit is asynchronous physical rounding on patients by clinical team members. A multidisciplinary team meets on weekday mornings to discuss patients. The charge nurse views the relay-and-display program to call attention to patients, with no order for VTE prophylaxis during the team meeting. New orders are discussed but not captured during the meeting, and the nurse follows up ad hoc.

“More research is needed to examine sustainability and to clarify features of the most effective implementations of relay-and-display strategies in hospitals,” they said.

Dr. Stein disclosed stock holdings with Ingenious Med Inc. as well as honoraria from Sanofi.

CHICAGO — The 2009-H1N1 influenza epidemic has mostly affected young people so far, but health professionals should take care to protect the vulnerable elderly from infection, Dr. Stefan Gravenstein said during an influenza symposium at the annual meeting of the American Geriatrics Society.

Dr. Gravenstein and other speakers said that the outbreak highlights the need for new drugs and vaccines to fight influenza in the elderly.

“You should do general infection control: hand hygiene, cough etiquette, and social distancing,” he said. “The general party line is 6 feet for social distancing, but the farther the better to avoid transmission.”

Transmission between generations within families has been reported in several countries. Two audience members noted that residents of their New Jersey nursing home had influenza A just 1 week before the epidemic came to light, and they speculated that they might have witnessed early cases in the swine-origin 2009-H1N1 outbreak.

Nursing homes and other long-term care facilities with active cases of influenza should halt group dining and instead deliver meals to individuals' rooms, cancel group programs, and restrict staff movement between wards. To protect incoming residents, facilities should delay new admissions to a ward for 7 days after a case of influenza has been confirmed there, suggested Dr. Gravenstein, a professor of medicine at Brown University and clinical director of the company Quality Partners of Rhode Island, both in Providence.

“If you have someone who is sick, keep them in their room,” Dr. Gravenstein said. “If a facility has no influenza cases, it can continue to operate as usual, except for the usual seasonal influenza precautions.”

The triad of cough, a temperature higher than 38°C, and illness lasting 7 days or less is a reasonably sensitive indicator of contagious influenza, but the gold standard is a viral culture, Dr. Ann Falsey said during the symposium. Viral culture allows for strain typing and resistance testing, both of which are important in the current outbreak. The disadvantage of waiting for an infection to be confirmed by culture is that it can take 3–7 days. That delay can impede infection control and lapse beyond when antiviral treatment should begin, Dr. Falsey said.

Real-time polymerase chain reaction testing is good but expensive and not yet widely available, she said. Immunofluorescence or enzyme immunoassay can give results within 15–30 minutes, but should be followed with viral culture, if possible.

No matter which test for 2009-H1N1 is used, it's only as good as the specimen taken, emphasized Dr. Falsey, a professor of medicine, infectious disease, at the University of Rochester (N.Y.) School of Medicine and Dentistry. Samples should be taken using a nasal swab in both nostrils and a separate throat swab, preferably with plastic rather than wooden swabs.

Viral isolation is important because different influenza viruses are susceptible and resistant to different drugs, she said. “Information on antiviral sensitivities of the recently circulating H1N1 influenza is preliminary, but this virus appears to be sensitive to oseltamivir and zanamivir but resistant to the adamantanes, unlike seasonal H1N1 influenza,” Dr. Falsey said in an interview.

Oseltamivir (Tamiflu) resistance has been a growing concern worldwide. The Centers for Disease Control and Prevention reported oseltamivir resistance in 0.7% of 588 influenza A H1N1 isolates during the 2006–2007 flu season. That number jumped to 12% of 1,026 isolates during the 2007–2008 flu season. And as of Jan. 24, 2009, 98% of H1N1 isolates tested in the United States were resistant to oseltamivir, Dr. Falsey said.

Resistance is 16% worldwide. However, oseltamivir resistance does not seem to be associated with previous use of the drug. The prevalence of resistant isolates is low in Japan, where the agent is widely used, and resistance is present in Denmark, where oseltamivir is not used. The most likely explanations for the resistance occurring are point mutations and drift in the virus, Dr. Falsey said.

Zanamivir would be the preferred medication for any H1N1 virus, but a combination of oseltamivir and rimantadine could be prescribed, Dr. Falsey said. “There has been a little bit of data that combination therapy makes some sense and may reduce resistance.”

Clinicians might also want to use antiviral therapy beyond the 48-hour window after symptom onset, as recommended by the Advisory Committee on Immunization Practices. In one study, antiviral therapy was associated with a significant reduction in mortality even though only 29% of patients were treated within 48 hours (Clin. Infect. Dis. 2007;45:1568–75).

Influenza vaccines in the elderly are associated with substantial benefits in terms of reduced illness, hospitalization, and death, although there is some controversy about the magnitude of the mortality benefit, said Dr. Kristin Nichol, a professor of medicine at the University of Minnesota and the Minneapolis VA Medical Center. The controversy derives from concerns about the methodology in observational studies, possible bias in studies of healthy vaccines, and the fact that influenza mortality rates have not declined overall, despite increases in vaccination rates.

Sanofi Pasteur Inc. sponsored the conference session. Dr. Gravenstein disclosed that he is a consultant for GlaxoSmithKline and Sanofi Aventis. Dr. Falsey disclosed that she receives research support from GlaxoSmithKline and Sanofi Pasteur Inc. Dr. Nichol has received research funding from Sanofi and GlaxoSmithKline and has served as a consultant and member of the companies' medical advisory boards, as she has for MedImmune, Novartis, and CLS.

CHICAGO — The 2009-H1N1 influenza epidemic has mostly affected young people so far, but health professionals should take care to protect the vulnerable elderly from infection, Dr. Stefan Gravenstein said during an influenza symposium at the annual meeting of the American Geriatrics Society.

Dr. Gravenstein and other speakers said that the outbreak highlights the need for new drugs and vaccines to fight influenza in the elderly.

“You should do general infection control: hand hygiene, cough etiquette, and social distancing,” he said. “The general party line is 6 feet for social distancing, but the farther the better to avoid transmission.”

Transmission between generations within families has been reported in several countries. Two audience members noted that residents of their New Jersey nursing home had influenza A just 1 week before the epidemic came to light, and they speculated that they might have witnessed early cases in the swine-origin 2009-H1N1 outbreak.

Nursing homes and other long-term care facilities with active cases of influenza should halt group dining and instead deliver meals to individuals' rooms, cancel group programs, and restrict staff movement between wards. To protect incoming residents, facilities should delay new admissions to a ward for 7 days after a case of influenza has been confirmed there, suggested Dr. Gravenstein, a professor of medicine at Brown University and clinical director of the company Quality Partners of Rhode Island, both in Providence.

“If you have someone who is sick, keep them in their room,” Dr. Gravenstein said. “If a facility has no influenza cases, it can continue to operate as usual, except for the usual seasonal influenza precautions.”

The triad of cough, a temperature higher than 38°C, and illness lasting 7 days or less is a reasonably sensitive indicator of contagious influenza, but the gold standard is a viral culture, Dr. Ann Falsey said during the symposium. Viral culture allows for strain typing and resistance testing, both of which are important in the current outbreak. The disadvantage of waiting for an infection to be confirmed by culture is that it can take 3–7 days. That delay can impede infection control and lapse beyond when antiviral treatment should begin, Dr. Falsey said.

Real-time polymerase chain reaction testing is good but expensive and not yet widely available, she said. Immunofluorescence or enzyme immunoassay can give results within 15–30 minutes, but should be followed with viral culture, if possible.

No matter which test for 2009-H1N1 is used, it's only as good as the specimen taken, emphasized Dr. Falsey, a professor of medicine, infectious disease, at the University of Rochester (N.Y.) School of Medicine and Dentistry. Samples should be taken using a nasal swab in both nostrils and a separate throat swab, preferably with plastic rather than wooden swabs.

Viral isolation is important because different influenza viruses are susceptible and resistant to different drugs, she said. “Information on antiviral sensitivities of the recently circulating H1N1 influenza is preliminary, but this virus appears to be sensitive to oseltamivir and zanamivir but resistant to the adamantanes, unlike seasonal H1N1 influenza,” Dr. Falsey said in an interview.

Oseltamivir (Tamiflu) resistance has been a growing concern worldwide. The Centers for Disease Control and Prevention reported oseltamivir resistance in 0.7% of 588 influenza A H1N1 isolates during the 2006–2007 flu season. That number jumped to 12% of 1,026 isolates during the 2007–2008 flu season. And as of Jan. 24, 2009, 98% of H1N1 isolates tested in the United States were resistant to oseltamivir, Dr. Falsey said.

Resistance is 16% worldwide. However, oseltamivir resistance does not seem to be associated with previous use of the drug. The prevalence of resistant isolates is low in Japan, where the agent is widely used, and resistance is present in Denmark, where oseltamivir is not used. The most likely explanations for the resistance occurring are point mutations and drift in the virus, Dr. Falsey said.

Zanamivir would be the preferred medication for any H1N1 virus, but a combination of oseltamivir and rimantadine could be prescribed, Dr. Falsey said. “There has been a little bit of data that combination therapy makes some sense and may reduce resistance.”

Clinicians might also want to use antiviral therapy beyond the 48-hour window after symptom onset, as recommended by the Advisory Committee on Immunization Practices. In one study, antiviral therapy was associated with a significant reduction in mortality even though only 29% of patients were treated within 48 hours (Clin. Infect. Dis. 2007;45:1568–75).

Influenza vaccines in the elderly are associated with substantial benefits in terms of reduced illness, hospitalization, and death, although there is some controversy about the magnitude of the mortality benefit, said Dr. Kristin Nichol, a professor of medicine at the University of Minnesota and the Minneapolis VA Medical Center. The controversy derives from concerns about the methodology in observational studies, possible bias in studies of healthy vaccines, and the fact that influenza mortality rates have not declined overall, despite increases in vaccination rates.

Sanofi Pasteur Inc. sponsored the conference session. Dr. Gravenstein disclosed that he is a consultant for GlaxoSmithKline and Sanofi Aventis. Dr. Falsey disclosed that she receives research support from GlaxoSmithKline and Sanofi Pasteur Inc. Dr. Nichol has received research funding from Sanofi and GlaxoSmithKline and has served as a consultant and member of the companies' medical advisory boards, as she has for MedImmune, Novartis, and CLS.

CHICAGO — The 2009-H1N1 influenza epidemic has mostly affected young people so far, but health professionals should take care to protect the vulnerable elderly from infection, Dr. Stefan Gravenstein said during an influenza symposium at the annual meeting of the American Geriatrics Society.

Dr. Gravenstein and other speakers said that the outbreak highlights the need for new drugs and vaccines to fight influenza in the elderly.

“You should do general infection control: hand hygiene, cough etiquette, and social distancing,” he said. “The general party line is 6 feet for social distancing, but the farther the better to avoid transmission.”

Transmission between generations within families has been reported in several countries. Two audience members noted that residents of their New Jersey nursing home had influenza A just 1 week before the epidemic came to light, and they speculated that they might have witnessed early cases in the swine-origin 2009-H1N1 outbreak.

Nursing homes and other long-term care facilities with active cases of influenza should halt group dining and instead deliver meals to individuals' rooms, cancel group programs, and restrict staff movement between wards. To protect incoming residents, facilities should delay new admissions to a ward for 7 days after a case of influenza has been confirmed there, suggested Dr. Gravenstein, a professor of medicine at Brown University and clinical director of the company Quality Partners of Rhode Island, both in Providence.

“If you have someone who is sick, keep them in their room,” Dr. Gravenstein said. “If a facility has no influenza cases, it can continue to operate as usual, except for the usual seasonal influenza precautions.”

The triad of cough, a temperature higher than 38°C, and illness lasting 7 days or less is a reasonably sensitive indicator of contagious influenza, but the gold standard is a viral culture, Dr. Ann Falsey said during the symposium. Viral culture allows for strain typing and resistance testing, both of which are important in the current outbreak. The disadvantage of waiting for an infection to be confirmed by culture is that it can take 3–7 days. That delay can impede infection control and lapse beyond when antiviral treatment should begin, Dr. Falsey said.

Real-time polymerase chain reaction testing is good but expensive and not yet widely available, she said. Immunofluorescence or enzyme immunoassay can give results within 15–30 minutes, but should be followed with viral culture, if possible.

No matter which test for 2009-H1N1 is used, it's only as good as the specimen taken, emphasized Dr. Falsey, a professor of medicine, infectious disease, at the University of Rochester (N.Y.) School of Medicine and Dentistry. Samples should be taken using a nasal swab in both nostrils and a separate throat swab, preferably with plastic rather than wooden swabs.

Viral isolation is important because different influenza viruses are susceptible and resistant to different drugs, she said. “Information on antiviral sensitivities of the recently circulating H1N1 influenza is preliminary, but this virus appears to be sensitive to oseltamivir and zanamivir but resistant to the adamantanes, unlike seasonal H1N1 influenza,” Dr. Falsey said in an interview.

Oseltamivir (Tamiflu) resistance has been a growing concern worldwide. The Centers for Disease Control and Prevention reported oseltamivir resistance in 0.7% of 588 influenza A H1N1 isolates during the 2006–2007 flu season. That number jumped to 12% of 1,026 isolates during the 2007–2008 flu season. And as of Jan. 24, 2009, 98% of H1N1 isolates tested in the United States were resistant to oseltamivir, Dr. Falsey said.

Resistance is 16% worldwide. However, oseltamivir resistance does not seem to be associated with previous use of the drug. The prevalence of resistant isolates is low in Japan, where the agent is widely used, and resistance is present in Denmark, where oseltamivir is not used. The most likely explanations for the resistance occurring are point mutations and drift in the virus, Dr. Falsey said.

Zanamivir would be the preferred medication for any H1N1 virus, but a combination of oseltamivir and rimantadine could be prescribed, Dr. Falsey said. “There has been a little bit of data that combination therapy makes some sense and may reduce resistance.”

Clinicians might also want to use antiviral therapy beyond the 48-hour window after symptom onset, as recommended by the Advisory Committee on Immunization Practices. In one study, antiviral therapy was associated with a significant reduction in mortality even though only 29% of patients were treated within 48 hours (Clin. Infect. Dis. 2007;45:1568–75).

Influenza vaccines in the elderly are associated with substantial benefits in terms of reduced illness, hospitalization, and death, although there is some controversy about the magnitude of the mortality benefit, said Dr. Kristin Nichol, a professor of medicine at the University of Minnesota and the Minneapolis VA Medical Center. The controversy derives from concerns about the methodology in observational studies, possible bias in studies of healthy vaccines, and the fact that influenza mortality rates have not declined overall, despite increases in vaccination rates.

Sanofi Pasteur Inc. sponsored the conference session. Dr. Gravenstein disclosed that he is a consultant for GlaxoSmithKline and Sanofi Aventis. Dr. Falsey disclosed that she receives research support from GlaxoSmithKline and Sanofi Pasteur Inc. Dr. Nichol has received research funding from Sanofi and GlaxoSmithKline and has served as a consultant and member of the companies' medical advisory boards, as she has for MedImmune, Novartis, and CLS.

CHICAGO — Even if history records the 2009-H1N1 influenza epidemic as mild, its appearance highlights the need to improve seasonal-flu vaccination rates among the elderly and the health care workers who take care of them, said speakers during an influenza symposium.

Vaccination rates among people aged 65 years and older have remained stagnant since the late 1990s, at about two-thirds of that population, despite Medicare coverage of the influenza vaccine, said geriatric nurse practitioner Lynn Chilton, D.N.S.C., during the annual meeting of the American Society of Geriatrics. For 2007–2008, 71.2% of people aged 65 years or older were vaccinated (Vaccine 2009;27:815–8). The National Center for Health Statistics Healthy People 2010 has a target of 90% for flu vaccinations.

Dr. Chilton said that her own study of 393 ambulatory patients aged 65 years and older at three rural clinics in Mississippi found that 9.5% of the patients had never received an influenza vaccine and 4% had not had one for more than 10 years. Nearly all of the study participants reported their health as fair or good.

The reasons cited most frequently for not receiving a flu shot during the past year were the belief that there was no need (45%), having had a reaction to a previous injection (22%), or thinking that immunization caused the flu (15%), said Dr. Chilton, a nursing professor at the University of South Alabama in Mobile. None of the patients cited concerns about cost or undisclosed vaccine ingredients, although the latter concern has been recorded among low-income urban residents (Am. J. Prev. Med. 2001;20:21–5).

The overall immunization rate in the study was 73.5%, but the number was significantly higher among patients who received postcard reminders and whose nurse practitioner had received and shared a fact sheet on influenza than among patients who were not exposed to either intervention.

Giving reminders and information “is a simple, very cost-effective strategy,” Dr. Chilton observed. “I receive reminders from my gynecologist when it's time for me to get a mammogram, postcard reminders from my dentist for my annual check-up, and reminders from my veterinarian for my dog to be immunized, but I've never received a reminder from any primary care provider telling me it's time for me to have an annual immunization, particularly influenza.”

Health care provider recommendations go a long way toward improving vaccination behaviors, Dr. Chilton said. In one study, a provider's recommendation was one of the strongest independent predictors of whether a patient at high risk would be vaccinated (J. Gen. Intern. Med. 1996;11:673–7).

Symposium moderator Dr. Stefan Gravenstein took aim at the other side of the equation, stressing the need for all health care workers and volunteers with patient contact to be vaccinated each fall and during a community outbreak. Increased vaccination rates reduce lost work days and errors made by workers filling in for absent colleagues.

Currently, fewer than half of all health care workers are vaccinated, said Dr. Gravenstein, medical director of Tockwotton Home, Providence, R.I., and clinical director of Quality Partners of Rhode Island. In 2007–2008, 41.8% of health care workers were vaccinated, well below the Healthy People 2010 goal of 60% for this group, he said.

Health care workers may come to work with influenza because they are asymptomatic, disregard symptoms because of a misdirected work ethic, or be unaware that they pose a danger to their patients.

This last point may be surprising, said Dr. Gravenstein, but he recalled a recent conversation with a nurse whose son was feverish after returning from Mexico. She wasn't sure it was necessary for him to see a doctor.

“We believe that often in nursing homes where we have outbreaks that the original vector is a health care worker,” he said.

Dr. Gravenstein reported that he is a consultant for GlaxoSmithKline and for the Sanofi Aventis Group.

Sanofi Pasteur Inc. sponsored the symposium.

Better flu shot coverage would help prevent epidemics (above, 2009-H1N1). ©CDC

CHICAGO — Even if history records the 2009-H1N1 influenza epidemic as mild, its appearance highlights the need to improve seasonal-flu vaccination rates among the elderly and the health care workers who take care of them, said speakers during an influenza symposium.

Vaccination rates among people aged 65 years and older have remained stagnant since the late 1990s, at about two-thirds of that population, despite Medicare coverage of the influenza vaccine, said geriatric nurse practitioner Lynn Chilton, D.N.S.C., during the annual meeting of the American Society of Geriatrics. For 2007–2008, 71.2% of people aged 65 years or older were vaccinated (Vaccine 2009;27:815–8). The National Center for Health Statistics Healthy People 2010 has a target of 90% for flu vaccinations.

Dr. Chilton said that her own study of 393 ambulatory patients aged 65 years and older at three rural clinics in Mississippi found that 9.5% of the patients had never received an influenza vaccine and 4% had not had one for more than 10 years. Nearly all of the study participants reported their health as fair or good.

The reasons cited most frequently for not receiving a flu shot during the past year were the belief that there was no need (45%), having had a reaction to a previous injection (22%), or thinking that immunization caused the flu (15%), said Dr. Chilton, a nursing professor at the University of South Alabama in Mobile. None of the patients cited concerns about cost or undisclosed vaccine ingredients, although the latter concern has been recorded among low-income urban residents (Am. J. Prev. Med. 2001;20:21–5).

The overall immunization rate in the study was 73.5%, but the number was significantly higher among patients who received postcard reminders and whose nurse practitioner had received and shared a fact sheet on influenza than among patients who were not exposed to either intervention.

Giving reminders and information “is a simple, very cost-effective strategy,” Dr. Chilton observed. “I receive reminders from my gynecologist when it's time for me to get a mammogram, postcard reminders from my dentist for my annual check-up, and reminders from my veterinarian for my dog to be immunized, but I've never received a reminder from any primary care provider telling me it's time for me to have an annual immunization, particularly influenza.”

Health care provider recommendations go a long way toward improving vaccination behaviors, Dr. Chilton said. In one study, a provider's recommendation was one of the strongest independent predictors of whether a patient at high risk would be vaccinated (J. Gen. Intern. Med. 1996;11:673–7).

Symposium moderator Dr. Stefan Gravenstein took aim at the other side of the equation, stressing the need for all health care workers and volunteers with patient contact to be vaccinated each fall and during a community outbreak. Increased vaccination rates reduce lost work days and errors made by workers filling in for absent colleagues.

Currently, fewer than half of all health care workers are vaccinated, said Dr. Gravenstein, medical director of Tockwotton Home, Providence, R.I., and clinical director of Quality Partners of Rhode Island. In 2007–2008, 41.8% of health care workers were vaccinated, well below the Healthy People 2010 goal of 60% for this group, he said.

Health care workers may come to work with influenza because they are asymptomatic, disregard symptoms because of a misdirected work ethic, or be unaware that they pose a danger to their patients.

This last point may be surprising, said Dr. Gravenstein, but he recalled a recent conversation with a nurse whose son was feverish after returning from Mexico. She wasn't sure it was necessary for him to see a doctor.

“We believe that often in nursing homes where we have outbreaks that the original vector is a health care worker,” he said.

Dr. Gravenstein reported that he is a consultant for GlaxoSmithKline and for the Sanofi Aventis Group.

Sanofi Pasteur Inc. sponsored the symposium.

Better flu shot coverage would help prevent epidemics (above, 2009-H1N1). ©CDC

CHICAGO — Even if history records the 2009-H1N1 influenza epidemic as mild, its appearance highlights the need to improve seasonal-flu vaccination rates among the elderly and the health care workers who take care of them, said speakers during an influenza symposium.

Vaccination rates among people aged 65 years and older have remained stagnant since the late 1990s, at about two-thirds of that population, despite Medicare coverage of the influenza vaccine, said geriatric nurse practitioner Lynn Chilton, D.N.S.C., during the annual meeting of the American Society of Geriatrics. For 2007–2008, 71.2% of people aged 65 years or older were vaccinated (Vaccine 2009;27:815–8). The National Center for Health Statistics Healthy People 2010 has a target of 90% for flu vaccinations.

Dr. Chilton said that her own study of 393 ambulatory patients aged 65 years and older at three rural clinics in Mississippi found that 9.5% of the patients had never received an influenza vaccine and 4% had not had one for more than 10 years. Nearly all of the study participants reported their health as fair or good.

The reasons cited most frequently for not receiving a flu shot during the past year were the belief that there was no need (45%), having had a reaction to a previous injection (22%), or thinking that immunization caused the flu (15%), said Dr. Chilton, a nursing professor at the University of South Alabama in Mobile. None of the patients cited concerns about cost or undisclosed vaccine ingredients, although the latter concern has been recorded among low-income urban residents (Am. J. Prev. Med. 2001;20:21–5).

The overall immunization rate in the study was 73.5%, but the number was significantly higher among patients who received postcard reminders and whose nurse practitioner had received and shared a fact sheet on influenza than among patients who were not exposed to either intervention.

Giving reminders and information “is a simple, very cost-effective strategy,” Dr. Chilton observed. “I receive reminders from my gynecologist when it's time for me to get a mammogram, postcard reminders from my dentist for my annual check-up, and reminders from my veterinarian for my dog to be immunized, but I've never received a reminder from any primary care provider telling me it's time for me to have an annual immunization, particularly influenza.”

Health care provider recommendations go a long way toward improving vaccination behaviors, Dr. Chilton said. In one study, a provider's recommendation was one of the strongest independent predictors of whether a patient at high risk would be vaccinated (J. Gen. Intern. Med. 1996;11:673–7).

Symposium moderator Dr. Stefan Gravenstein took aim at the other side of the equation, stressing the need for all health care workers and volunteers with patient contact to be vaccinated each fall and during a community outbreak. Increased vaccination rates reduce lost work days and errors made by workers filling in for absent colleagues.

Currently, fewer than half of all health care workers are vaccinated, said Dr. Gravenstein, medical director of Tockwotton Home, Providence, R.I., and clinical director of Quality Partners of Rhode Island. In 2007–2008, 41.8% of health care workers were vaccinated, well below the Healthy People 2010 goal of 60% for this group, he said.

Health care workers may come to work with influenza because they are asymptomatic, disregard symptoms because of a misdirected work ethic, or be unaware that they pose a danger to their patients.

This last point may be surprising, said Dr. Gravenstein, but he recalled a recent conversation with a nurse whose son was feverish after returning from Mexico. She wasn't sure it was necessary for him to see a doctor.

“We believe that often in nursing homes where we have outbreaks that the original vector is a health care worker,” he said.

Dr. Gravenstein reported that he is a consultant for GlaxoSmithKline and for the Sanofi Aventis Group.

Sanofi Pasteur Inc. sponsored the symposium.

Better flu shot coverage would help prevent epidemics (above, 2009-H1N1). ©CDC

CHICAGO — Fracture risk increases in arthritis patients within about 3 months of starting corticosteroids and remains high, according to Dr. Nelson Watts.

“How much of this is steroids and how much of this is the underlying disease is unanswered,” said Dr. Watts, an endocrinologist and director of the bone health and osteoporosis center at the University of Cincinnati.

Glucocorticoid-induced osteoporosis results from a variety of systemic effects of corticosteroids, but it's the combination of reduced bone formation and increased bone resorption that causes a “double whammy” for patients—a troubling aspect for rheumatologists, who regularly dispense corticosteroids for their patients, Dr. Watts said at a symposium sponsored by the American College of Rheumatology.

The exact dose at which corticosteroids increase fracture risk is also difficult to tease out because of the underlying disease. One study observed that fracture risk was dose dependent and significantly higher with 2.5 mg/day or more of oral prednisone, with increases of 61% in hip and 160% in vertebral fractures (J. Bone Miner. Res. 2000;15:993-1000).

“It may well be that people who need 2.5 [mg]/day of prednisone are at increased risk for fracture not because of prednisone, but because of their rheumatoid arthritis; … clearly, as the dose goes up, the risk increases,” he said.

The American College of Rheumatology's current guidelines on glucocorticoid-induced osteoporosis highlight lifestyle modifications, such as calcium and vitamin D supplementation, weight-bearing exercise, and minimization of alcohol intake.

The value of calcium and vitamin D supplementation is unclear, Dr. Watts said. In a relatively small trial in 96 RA patients on prednisone, daily supplementation with 500 IU of vitamin D and 1,000 mg of calcium carbonate per day significantly improved bone mineral density, at a rate of 0.72% in the lumbar spine and 0.85% in the trochanter per year, compared with losses of 2% and 0.9%, respectively, among patients on placebo (Ann. Intern. Med. 1996;125:961-8).

In four prospective studies in 173 patients who recently started corticosteroid therapy, however, bone loss occurred at a rate of 3%–5% per year, despite daily supplementation with 500-800 mg of calcium. Two other studies that Dr. Watts highlighted reported no bone loss in patients who were given up to 1,000 mg per day of calcium and up to 500 IU per day of vitamin D.

Pooled data show a significant 70% decrease in vertebral fractures with risedronate vs. placebo, Dr. Watts said. New prescribing information also shows that bone mineral density changes were significantly better with zoledronic acid than alendronate.

Dr. Watts disclosed relationships with Amgen Inc., Eli Lilly & Co., Procter & Gamble Co., Sanofi-Aventis, Novo Nordisk Inc., and Novartis Pharmaceuticals Corp., which manufactures Reclast.

The combination of reduced bone formation and increased bone resorption causes a 'double whammy.' DR. WATTS

CHICAGO — Fracture risk increases in arthritis patients within about 3 months of starting corticosteroids and remains high, according to Dr. Nelson Watts.

“How much of this is steroids and how much of this is the underlying disease is unanswered,” said Dr. Watts, an endocrinologist and director of the bone health and osteoporosis center at the University of Cincinnati.

Glucocorticoid-induced osteoporosis results from a variety of systemic effects of corticosteroids, but it's the combination of reduced bone formation and increased bone resorption that causes a “double whammy” for patients—a troubling aspect for rheumatologists, who regularly dispense corticosteroids for their patients, Dr. Watts said at a symposium sponsored by the American College of Rheumatology.

The exact dose at which corticosteroids increase fracture risk is also difficult to tease out because of the underlying disease. One study observed that fracture risk was dose dependent and significantly higher with 2.5 mg/day or more of oral prednisone, with increases of 61% in hip and 160% in vertebral fractures (J. Bone Miner. Res. 2000;15:993-1000).

“It may well be that people who need 2.5 [mg]/day of prednisone are at increased risk for fracture not because of prednisone, but because of their rheumatoid arthritis; … clearly, as the dose goes up, the risk increases,” he said.

The American College of Rheumatology's current guidelines on glucocorticoid-induced osteoporosis highlight lifestyle modifications, such as calcium and vitamin D supplementation, weight-bearing exercise, and minimization of alcohol intake.

The value of calcium and vitamin D supplementation is unclear, Dr. Watts said. In a relatively small trial in 96 RA patients on prednisone, daily supplementation with 500 IU of vitamin D and 1,000 mg of calcium carbonate per day significantly improved bone mineral density, at a rate of 0.72% in the lumbar spine and 0.85% in the trochanter per year, compared with losses of 2% and 0.9%, respectively, among patients on placebo (Ann. Intern. Med. 1996;125:961-8).

In four prospective studies in 173 patients who recently started corticosteroid therapy, however, bone loss occurred at a rate of 3%–5% per year, despite daily supplementation with 500-800 mg of calcium. Two other studies that Dr. Watts highlighted reported no bone loss in patients who were given up to 1,000 mg per day of calcium and up to 500 IU per day of vitamin D.

Pooled data show a significant 70% decrease in vertebral fractures with risedronate vs. placebo, Dr. Watts said. New prescribing information also shows that bone mineral density changes were significantly better with zoledronic acid than alendronate.

Dr. Watts disclosed relationships with Amgen Inc., Eli Lilly & Co., Procter & Gamble Co., Sanofi-Aventis, Novo Nordisk Inc., and Novartis Pharmaceuticals Corp., which manufactures Reclast.

The combination of reduced bone formation and increased bone resorption causes a 'double whammy.' DR. WATTS

CHICAGO — Fracture risk increases in arthritis patients within about 3 months of starting corticosteroids and remains high, according to Dr. Nelson Watts.

“How much of this is steroids and how much of this is the underlying disease is unanswered,” said Dr. Watts, an endocrinologist and director of the bone health and osteoporosis center at the University of Cincinnati.

Glucocorticoid-induced osteoporosis results from a variety of systemic effects of corticosteroids, but it's the combination of reduced bone formation and increased bone resorption that causes a “double whammy” for patients—a troubling aspect for rheumatologists, who regularly dispense corticosteroids for their patients, Dr. Watts said at a symposium sponsored by the American College of Rheumatology.

The exact dose at which corticosteroids increase fracture risk is also difficult to tease out because of the underlying disease. One study observed that fracture risk was dose dependent and significantly higher with 2.5 mg/day or more of oral prednisone, with increases of 61% in hip and 160% in vertebral fractures (J. Bone Miner. Res. 2000;15:993-1000).

“It may well be that people who need 2.5 [mg]/day of prednisone are at increased risk for fracture not because of prednisone, but because of their rheumatoid arthritis; … clearly, as the dose goes up, the risk increases,” he said.

The American College of Rheumatology's current guidelines on glucocorticoid-induced osteoporosis highlight lifestyle modifications, such as calcium and vitamin D supplementation, weight-bearing exercise, and minimization of alcohol intake.

The value of calcium and vitamin D supplementation is unclear, Dr. Watts said. In a relatively small trial in 96 RA patients on prednisone, daily supplementation with 500 IU of vitamin D and 1,000 mg of calcium carbonate per day significantly improved bone mineral density, at a rate of 0.72% in the lumbar spine and 0.85% in the trochanter per year, compared with losses of 2% and 0.9%, respectively, among patients on placebo (Ann. Intern. Med. 1996;125:961-8).

In four prospective studies in 173 patients who recently started corticosteroid therapy, however, bone loss occurred at a rate of 3%–5% per year, despite daily supplementation with 500-800 mg of calcium. Two other studies that Dr. Watts highlighted reported no bone loss in patients who were given up to 1,000 mg per day of calcium and up to 500 IU per day of vitamin D.

Pooled data show a significant 70% decrease in vertebral fractures with risedronate vs. placebo, Dr. Watts said. New prescribing information also shows that bone mineral density changes were significantly better with zoledronic acid than alendronate.

Dr. Watts disclosed relationships with Amgen Inc., Eli Lilly & Co., Procter & Gamble Co., Sanofi-Aventis, Novo Nordisk Inc., and Novartis Pharmaceuticals Corp., which manufactures Reclast.

The combination of reduced bone formation and increased bone resorption causes a 'double whammy.' DR. WATTS