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NEW YORK (Reuters Health) - Rates of kidney stones have increased substantially over the past 20 years, particularly among children, adolescents, females, and blacks, according to a population-based study in South Carolina.

Historically, the highest rates of kidney stone disease have been in middle-aged white men, but the new findings underscore emerging changes in this pattern. Prior studies have found that prevalent kidney stone disease has nearly doubled in the United States over the past two decades. The extent to which specific groups of patients have been affected has been less clear, although there have been reports of increasing frequency of kidney stones among youth.

"My colleagues and I wondered if kidney stones were increasing preferentially among adolescents more than in other age groups," lead researcher Dr. Gregory Tasian, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told Reuters Health by email.

To estimate the annual kidney stone incidence in South Carolina in their repeated cross-sectional study, the researchers used U.S. Census data and data from the South Carolina Medical Encounter Data and Financial Reports, which includes information on all surgeries, emergency department visits, and inpatient hospitalizations in the state from 1997 to 2012. Using linear mixed models, they also sought to identify the patient groups in whom the rate of stones has increased the most.

Nearly 153,000 adult and pediatric patients among a state population of about 4.6 million received care for kidney stones from 1997 to 2012, the researchers reported online January 14 in the Clinical Journal of the American Society of Nephrology.

The annual incidence increased 16% during that time, with the largest increases occurring in teens, blacks, and women.  Teens 15 to 19 years comprised the age group with the largest increase in incidence of kidney stones from 1997 (an age-specific rate of nearly 80 per 100,000) to 2012 (about 155 per 100,000).

Overall, teens 15 to 19 experienced a 26% increase per five years (incidence rate ratio, 1.26), after adjusting for sex and race. The increase was substantially greater among teen girls,

with an annual incidence 52% higher than for teen boys.

Increases in cumulative risk of kidney stones during childhood were similar for girls (87%) and boys (90%), although the risks in 2012 were "modest," at 0.9% (for girls) and 0.6% (for boys), the researchers say. They note that the "emergence of nephrolithiasis as a disease that begins in childhood is worrisome because there is limited evidence about how to best treat children" with the condition.

After adjusting for age and race, incidence of kidney stones  increased an estimated 15% per five years (IRR, 1.15) among females of all ages during the study period, but was stable among males (IRR, 0.99). The estimated lifetime risk for women increased from 10.5% in 1997 to 15.2% in 2012, but remained unchanged for men at about 23%. Incidence of kidney stones among blacks rose an estimated 15% per five years (IRR, 1.15) during the study period, compared with an estimated 3% among whites (IRR, 1.03).

"We were not surprised by the high occurrence of kidney  stones among adolescents and females (5% and 3% per year), which is consistent with other studies reported to date," Dr. Tasian

said. "We were, however, surprised by how much kidney stones were increasing in African-Americans, as previous studies have not really studied differences in kidney stone occurrence among different racial groups."

Although the study focused on kidney stone disease in South Carolina, it's likely that similar patterns exist across the nation, he said.

"Kidney stones have increased 70% over the last 30 years in adults in the U.S., and we are also seeing higher rates of kidney stones in children across the U.S.," Dr. Tasian said.

However, even though kidney stones are also increasing in many areas in the world, for many reasons, the results should not be generalized beyond the United States, he noted.

"This study is an important step forward in understanding the changing epidemiology of kidney stone disease," Dr. Charles D. Scales, of Duke University Medical Center in Durham, North Carolina, told Reuters Health by email. The underlying causes of the increase are unclear. "In adults, it may be related to the tidal wave of obesity and diabetes in the United States," said Dr. Scales, an expert in kidney stones who was not involved with the study.

These epidemiologic trends provide more support for the concept that "chronic and poorly understood metabolic derangements are likely causing all of these new stones in previously low-risk individuals," he said.

Increased consumption of high-sodium processed food and dehydration also may be contributing factors, he added. "Emerging evidence suggests that a kidney stone may foreshadow future medical problems, such as heart disease, bone density loss, and chronic kidney disease," Dr. Scales said. "So from the public-health perspective, the worst may be yet to come as these teenagers with stones become adults."

The study had no commercial funding and the authors reported no disclosures.

NEW YORK (Reuters Health) - Rates of kidney stones have increased substantially over the past 20 years, particularly among children, adolescents, females, and blacks, according to a population-based study in South Carolina.

Historically, the highest rates of kidney stone disease have been in middle-aged white men, but the new findings underscore emerging changes in this pattern. Prior studies have found that prevalent kidney stone disease has nearly doubled in the United States over the past two decades. The extent to which specific groups of patients have been affected has been less clear, although there have been reports of increasing frequency of kidney stones among youth.

"My colleagues and I wondered if kidney stones were increasing preferentially among adolescents more than in other age groups," lead researcher Dr. Gregory Tasian, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told Reuters Health by email.

To estimate the annual kidney stone incidence in South Carolina in their repeated cross-sectional study, the researchers used U.S. Census data and data from the South Carolina Medical Encounter Data and Financial Reports, which includes information on all surgeries, emergency department visits, and inpatient hospitalizations in the state from 1997 to 2012. Using linear mixed models, they also sought to identify the patient groups in whom the rate of stones has increased the most.

Nearly 153,000 adult and pediatric patients among a state population of about 4.6 million received care for kidney stones from 1997 to 2012, the researchers reported online January 14 in the Clinical Journal of the American Society of Nephrology.

The annual incidence increased 16% during that time, with the largest increases occurring in teens, blacks, and women.  Teens 15 to 19 years comprised the age group with the largest increase in incidence of kidney stones from 1997 (an age-specific rate of nearly 80 per 100,000) to 2012 (about 155 per 100,000).

Overall, teens 15 to 19 experienced a 26% increase per five years (incidence rate ratio, 1.26), after adjusting for sex and race. The increase was substantially greater among teen girls,

with an annual incidence 52% higher than for teen boys.

Increases in cumulative risk of kidney stones during childhood were similar for girls (87%) and boys (90%), although the risks in 2012 were "modest," at 0.9% (for girls) and 0.6% (for boys), the researchers say. They note that the "emergence of nephrolithiasis as a disease that begins in childhood is worrisome because there is limited evidence about how to best treat children" with the condition.

After adjusting for age and race, incidence of kidney stones  increased an estimated 15% per five years (IRR, 1.15) among females of all ages during the study period, but was stable among males (IRR, 0.99). The estimated lifetime risk for women increased from 10.5% in 1997 to 15.2% in 2012, but remained unchanged for men at about 23%. Incidence of kidney stones among blacks rose an estimated 15% per five years (IRR, 1.15) during the study period, compared with an estimated 3% among whites (IRR, 1.03).

"We were not surprised by the high occurrence of kidney  stones among adolescents and females (5% and 3% per year), which is consistent with other studies reported to date," Dr. Tasian

said. "We were, however, surprised by how much kidney stones were increasing in African-Americans, as previous studies have not really studied differences in kidney stone occurrence among different racial groups."

Although the study focused on kidney stone disease in South Carolina, it's likely that similar patterns exist across the nation, he said.

"Kidney stones have increased 70% over the last 30 years in adults in the U.S., and we are also seeing higher rates of kidney stones in children across the U.S.," Dr. Tasian said.

However, even though kidney stones are also increasing in many areas in the world, for many reasons, the results should not be generalized beyond the United States, he noted.

"This study is an important step forward in understanding the changing epidemiology of kidney stone disease," Dr. Charles D. Scales, of Duke University Medical Center in Durham, North Carolina, told Reuters Health by email. The underlying causes of the increase are unclear. "In adults, it may be related to the tidal wave of obesity and diabetes in the United States," said Dr. Scales, an expert in kidney stones who was not involved with the study.

These epidemiologic trends provide more support for the concept that "chronic and poorly understood metabolic derangements are likely causing all of these new stones in previously low-risk individuals," he said.

Increased consumption of high-sodium processed food and dehydration also may be contributing factors, he added. "Emerging evidence suggests that a kidney stone may foreshadow future medical problems, such as heart disease, bone density loss, and chronic kidney disease," Dr. Scales said. "So from the public-health perspective, the worst may be yet to come as these teenagers with stones become adults."

The study had no commercial funding and the authors reported no disclosures.

NEW YORK (Reuters Health) - Rates of kidney stones have increased substantially over the past 20 years, particularly among children, adolescents, females, and blacks, according to a population-based study in South Carolina.

Historically, the highest rates of kidney stone disease have been in middle-aged white men, but the new findings underscore emerging changes in this pattern. Prior studies have found that prevalent kidney stone disease has nearly doubled in the United States over the past two decades. The extent to which specific groups of patients have been affected has been less clear, although there have been reports of increasing frequency of kidney stones among youth.

"My colleagues and I wondered if kidney stones were increasing preferentially among adolescents more than in other age groups," lead researcher Dr. Gregory Tasian, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told Reuters Health by email.

To estimate the annual kidney stone incidence in South Carolina in their repeated cross-sectional study, the researchers used U.S. Census data and data from the South Carolina Medical Encounter Data and Financial Reports, which includes information on all surgeries, emergency department visits, and inpatient hospitalizations in the state from 1997 to 2012. Using linear mixed models, they also sought to identify the patient groups in whom the rate of stones has increased the most.

Nearly 153,000 adult and pediatric patients among a state population of about 4.6 million received care for kidney stones from 1997 to 2012, the researchers reported online January 14 in the Clinical Journal of the American Society of Nephrology.

The annual incidence increased 16% during that time, with the largest increases occurring in teens, blacks, and women.  Teens 15 to 19 years comprised the age group with the largest increase in incidence of kidney stones from 1997 (an age-specific rate of nearly 80 per 100,000) to 2012 (about 155 per 100,000).

Overall, teens 15 to 19 experienced a 26% increase per five years (incidence rate ratio, 1.26), after adjusting for sex and race. The increase was substantially greater among teen girls,

with an annual incidence 52% higher than for teen boys.

Increases in cumulative risk of kidney stones during childhood were similar for girls (87%) and boys (90%), although the risks in 2012 were "modest," at 0.9% (for girls) and 0.6% (for boys), the researchers say. They note that the "emergence of nephrolithiasis as a disease that begins in childhood is worrisome because there is limited evidence about how to best treat children" with the condition.

After adjusting for age and race, incidence of kidney stones  increased an estimated 15% per five years (IRR, 1.15) among females of all ages during the study period, but was stable among males (IRR, 0.99). The estimated lifetime risk for women increased from 10.5% in 1997 to 15.2% in 2012, but remained unchanged for men at about 23%. Incidence of kidney stones among blacks rose an estimated 15% per five years (IRR, 1.15) during the study period, compared with an estimated 3% among whites (IRR, 1.03).

"We were not surprised by the high occurrence of kidney  stones among adolescents and females (5% and 3% per year), which is consistent with other studies reported to date," Dr. Tasian

said. "We were, however, surprised by how much kidney stones were increasing in African-Americans, as previous studies have not really studied differences in kidney stone occurrence among different racial groups."

Although the study focused on kidney stone disease in South Carolina, it's likely that similar patterns exist across the nation, he said.

"Kidney stones have increased 70% over the last 30 years in adults in the U.S., and we are also seeing higher rates of kidney stones in children across the U.S.," Dr. Tasian said.

However, even though kidney stones are also increasing in many areas in the world, for many reasons, the results should not be generalized beyond the United States, he noted.

"This study is an important step forward in understanding the changing epidemiology of kidney stone disease," Dr. Charles D. Scales, of Duke University Medical Center in Durham, North Carolina, told Reuters Health by email. The underlying causes of the increase are unclear. "In adults, it may be related to the tidal wave of obesity and diabetes in the United States," said Dr. Scales, an expert in kidney stones who was not involved with the study.

These epidemiologic trends provide more support for the concept that "chronic and poorly understood metabolic derangements are likely causing all of these new stones in previously low-risk individuals," he said.

Increased consumption of high-sodium processed food and dehydration also may be contributing factors, he added. "Emerging evidence suggests that a kidney stone may foreshadow future medical problems, such as heart disease, bone density loss, and chronic kidney disease," Dr. Scales said. "So from the public-health perspective, the worst may be yet to come as these teenagers with stones become adults."

The study had no commercial funding and the authors reported no disclosures.

As the practice of medicine continues to transition to performance-based payment systems, the number of mergers of hospitalists and specialists has surged. Payment models that focus on clinical outcomes and best practices link payment to the ability of physicians to provide efficient, quality healthcare and improve patient outcomes. These payment systems are changing the way healthcare services are delivered by demanding better patient care at a lower cost. The result is increasing pressure on physicians to meet operational and quality goals, or receive less reimbursement for their services.

Studies have shown that the effective use of hospitalists can improve standardized patient care for surgical patients. Hospitalists also provide value to specialists by freeing up time so they can focus on their area of expertise. As a result, co-management arrangements between hospitalists and specialists have become a popular tool to define working relationships and improve the quality of care patients receive.

Hospitalist Evolution

When hospitalists first debuted, they were seen as a threat to primary care physicians and specialists. Over time, they were criticized for performing routine work for specialized physicians. To overcome these negative connotations and prove their worth, hospitalists began co-managing patients for surgical specialists, who soon realized the significant value hospitalist services provided. Not only do they share in the responsibility of care provided to patients, but they also reduce readmissions and costs associated with providing healthcare.

Now there are even specialty hospitalists who specialize in a particular field, such as orthopedics or obstetrics.

Why Co-Management?

Hospitalists add value by helping to alleviate the burden on specialists—providing ED coverage, assisting in the operating room, and rounding on patients. They evaluate surgical patients for medical issues, reconcile medications across the spectrum of a patient’s care, and standardize the patient discharge and communication processes.

Providing these services frees specialists from rounding and allows them to concentrate on their specialty. Hospitalists do not have office-based practices, which allows them to spend their time in the hospital caring for admitted, pre-operative, and post-operative patients.

It is in the pre-operative and post-operative environments where hospitalists have established their extreme value to specialists. Under co-management arrangements, hospitalists are able to ensure that all pre-operative tests are conducted, reports are dictated, and the patient’s medical history is available. Pre-operative evaluations allow the hospitalist to develop a post-operative plan of care and proactively address many medical concerns. Also, the hospitalist is available to see patients immediately after surgery, allowing immediate evaluation and treatment for high blood pressure, diabetic issues, or other medical issues.

In sum, the hospitalist is responsible for the medical care of the specialist’s patients, and the specialist is able to focus on the specialty services he or she provides. Providing these services gives hospitalists the opportunity to anticipate problems and overcome issues, which results in more efficient care, shorter lengths of stay in the hospital, and improved patient satisfaction. Such results make hospitalists critical to success in performance-based payment systems.

Successful Co-Management Arrangements

A key to success in establishing a co-management arrangement between a hospitalist and a specialist is setting forth the parameters of the relationship in a written agreement. It is particularly important that the relationship foster equality among the parties, regardless of who is the attending physician of record. The parties should be jointly responsible for patient care, with the hospitalist treating the patient’s general medical concerns and the specialist focusing on techniques within his specialty to improve the patient’s issues.

The agreement should clearly state the responsibilities of each party, including delineating the party responsible for decisions such as admission and discharge. It should address resources and set forth the standardized processes and protocols to be used when treating patients.

Specialists can vary in their treatment of patients, so it is best to document their expectations at the onset of the relationship. Also, successful co-management is contingent upon regular communication between the hospitalist and the specialist. It is important to establish those boundaries in advance to prevent miscommunication down the road.

In particular, the agreement should explicitly describe the lines of authority and how conflicts will be addressed.

Final Thoughts

Co-management is a growing trend that can provide an opportunity for hospitalists to expand their practice and reinforce their value to both specialists and the hospital. The improved quality of care and patient satisfaction that is associated with hospitalist services can be crucial to maximizing reimbursement under a value-based reimbursement system. TH

As the practice of medicine continues to transition to performance-based payment systems, the number of mergers of hospitalists and specialists has surged. Payment models that focus on clinical outcomes and best practices link payment to the ability of physicians to provide efficient, quality healthcare and improve patient outcomes. These payment systems are changing the way healthcare services are delivered by demanding better patient care at a lower cost. The result is increasing pressure on physicians to meet operational and quality goals, or receive less reimbursement for their services.

Studies have shown that the effective use of hospitalists can improve standardized patient care for surgical patients. Hospitalists also provide value to specialists by freeing up time so they can focus on their area of expertise. As a result, co-management arrangements between hospitalists and specialists have become a popular tool to define working relationships and improve the quality of care patients receive.

Hospitalist Evolution

When hospitalists first debuted, they were seen as a threat to primary care physicians and specialists. Over time, they were criticized for performing routine work for specialized physicians. To overcome these negative connotations and prove their worth, hospitalists began co-managing patients for surgical specialists, who soon realized the significant value hospitalist services provided. Not only do they share in the responsibility of care provided to patients, but they also reduce readmissions and costs associated with providing healthcare.

Now there are even specialty hospitalists who specialize in a particular field, such as orthopedics or obstetrics.

Why Co-Management?

Hospitalists add value by helping to alleviate the burden on specialists—providing ED coverage, assisting in the operating room, and rounding on patients. They evaluate surgical patients for medical issues, reconcile medications across the spectrum of a patient’s care, and standardize the patient discharge and communication processes.

Providing these services frees specialists from rounding and allows them to concentrate on their specialty. Hospitalists do not have office-based practices, which allows them to spend their time in the hospital caring for admitted, pre-operative, and post-operative patients.

It is in the pre-operative and post-operative environments where hospitalists have established their extreme value to specialists. Under co-management arrangements, hospitalists are able to ensure that all pre-operative tests are conducted, reports are dictated, and the patient’s medical history is available. Pre-operative evaluations allow the hospitalist to develop a post-operative plan of care and proactively address many medical concerns. Also, the hospitalist is available to see patients immediately after surgery, allowing immediate evaluation and treatment for high blood pressure, diabetic issues, or other medical issues.

In sum, the hospitalist is responsible for the medical care of the specialist’s patients, and the specialist is able to focus on the specialty services he or she provides. Providing these services gives hospitalists the opportunity to anticipate problems and overcome issues, which results in more efficient care, shorter lengths of stay in the hospital, and improved patient satisfaction. Such results make hospitalists critical to success in performance-based payment systems.

Successful Co-Management Arrangements

A key to success in establishing a co-management arrangement between a hospitalist and a specialist is setting forth the parameters of the relationship in a written agreement. It is particularly important that the relationship foster equality among the parties, regardless of who is the attending physician of record. The parties should be jointly responsible for patient care, with the hospitalist treating the patient’s general medical concerns and the specialist focusing on techniques within his specialty to improve the patient’s issues.

The agreement should clearly state the responsibilities of each party, including delineating the party responsible for decisions such as admission and discharge. It should address resources and set forth the standardized processes and protocols to be used when treating patients.

Specialists can vary in their treatment of patients, so it is best to document their expectations at the onset of the relationship. Also, successful co-management is contingent upon regular communication between the hospitalist and the specialist. It is important to establish those boundaries in advance to prevent miscommunication down the road.

In particular, the agreement should explicitly describe the lines of authority and how conflicts will be addressed.

Final Thoughts

Co-management is a growing trend that can provide an opportunity for hospitalists to expand their practice and reinforce their value to both specialists and the hospital. The improved quality of care and patient satisfaction that is associated with hospitalist services can be crucial to maximizing reimbursement under a value-based reimbursement system. TH

As the practice of medicine continues to transition to performance-based payment systems, the number of mergers of hospitalists and specialists has surged. Payment models that focus on clinical outcomes and best practices link payment to the ability of physicians to provide efficient, quality healthcare and improve patient outcomes. These payment systems are changing the way healthcare services are delivered by demanding better patient care at a lower cost. The result is increasing pressure on physicians to meet operational and quality goals, or receive less reimbursement for their services.

Studies have shown that the effective use of hospitalists can improve standardized patient care for surgical patients. Hospitalists also provide value to specialists by freeing up time so they can focus on their area of expertise. As a result, co-management arrangements between hospitalists and specialists have become a popular tool to define working relationships and improve the quality of care patients receive.

Hospitalist Evolution

When hospitalists first debuted, they were seen as a threat to primary care physicians and specialists. Over time, they were criticized for performing routine work for specialized physicians. To overcome these negative connotations and prove their worth, hospitalists began co-managing patients for surgical specialists, who soon realized the significant value hospitalist services provided. Not only do they share in the responsibility of care provided to patients, but they also reduce readmissions and costs associated with providing healthcare.

Now there are even specialty hospitalists who specialize in a particular field, such as orthopedics or obstetrics.

Why Co-Management?

Hospitalists add value by helping to alleviate the burden on specialists—providing ED coverage, assisting in the operating room, and rounding on patients. They evaluate surgical patients for medical issues, reconcile medications across the spectrum of a patient’s care, and standardize the patient discharge and communication processes.

Providing these services frees specialists from rounding and allows them to concentrate on their specialty. Hospitalists do not have office-based practices, which allows them to spend their time in the hospital caring for admitted, pre-operative, and post-operative patients.

It is in the pre-operative and post-operative environments where hospitalists have established their extreme value to specialists. Under co-management arrangements, hospitalists are able to ensure that all pre-operative tests are conducted, reports are dictated, and the patient’s medical history is available. Pre-operative evaluations allow the hospitalist to develop a post-operative plan of care and proactively address many medical concerns. Also, the hospitalist is available to see patients immediately after surgery, allowing immediate evaluation and treatment for high blood pressure, diabetic issues, or other medical issues.

In sum, the hospitalist is responsible for the medical care of the specialist’s patients, and the specialist is able to focus on the specialty services he or she provides. Providing these services gives hospitalists the opportunity to anticipate problems and overcome issues, which results in more efficient care, shorter lengths of stay in the hospital, and improved patient satisfaction. Such results make hospitalists critical to success in performance-based payment systems.

Successful Co-Management Arrangements

A key to success in establishing a co-management arrangement between a hospitalist and a specialist is setting forth the parameters of the relationship in a written agreement. It is particularly important that the relationship foster equality among the parties, regardless of who is the attending physician of record. The parties should be jointly responsible for patient care, with the hospitalist treating the patient’s general medical concerns and the specialist focusing on techniques within his specialty to improve the patient’s issues.

The agreement should clearly state the responsibilities of each party, including delineating the party responsible for decisions such as admission and discharge. It should address resources and set forth the standardized processes and protocols to be used when treating patients.

Specialists can vary in their treatment of patients, so it is best to document their expectations at the onset of the relationship. Also, successful co-management is contingent upon regular communication between the hospitalist and the specialist. It is important to establish those boundaries in advance to prevent miscommunication down the road.

In particular, the agreement should explicitly describe the lines of authority and how conflicts will be addressed.

Final Thoughts

Co-management is a growing trend that can provide an opportunity for hospitalists to expand their practice and reinforce their value to both specialists and the hospital. The improved quality of care and patient satisfaction that is associated with hospitalist services can be crucial to maximizing reimbursement under a value-based reimbursement system. TH

NEW YORK (Reuters Health)—Women with heart failure (HF) derive as much benefit from implantable cardiac defibrillators (ICDs) for primary prevention as men, according to a comparative effectiveness study.

"Randomized clinical trials demonstrated that the ICD confers survival benefit to many patients with heart failure; however, data on ICDs in women were inadequate due to the relatively small number of women enrolled in those trials," study investigator Dr. Sana Al-Khatib, heart rhythm specialist from Duke Clinical Research Institute in Durham, North Carolina, told Reuters Health by email.

This analysis, online January 12 in Circulation: Heart Failure, showed that women with heart failure and an ICD had "significantly better survival than women with no ICD," Dr. Al-Khatib said.

"Our findings support the gender-neutral guideline recommendations regarding the use of primary prevention ICDs in eligible patients. As a result, women with heart failure should be equally considered for a primary prevention ICD as men," she added.

For the analysis, researchers linked data from 264 hospitals participating in the Get With The Guidelines Heart Failure registry with data from the Centers for Medicare and Medicaid

Services.

Using propensity score matching, they created a cohort of 430 women with heart failure and a preventive ICD and 430 similar women with heart failure but no ICD. For comparison, they propensity score matched 859 men with heart failure and an ICD to 859 men without an ICD.

After three years, 40.2% of women with an ICD had died, compared with 48.7% of women without an ICD. The corresponding mortality rates in men were 42.9% and 52.9%.

In the matched cohorts, an ICD was associated with "similarly better survival" in women and men (hazard ratios, 0.78 and 0.76, respectively). There was no interaction between sex and presence of an ICD with regard to survival (p=0.79).

"Despite the survival benefits of primary prevention ICDs in patients with HF demonstrated in randomized clinical trials, benefit in the subgroup of women from these trials has not been

definitively proved. This uncertainty on survival benefit may be one of several contributing factors to the lower rates of ICD referral and implantation in eligible women," the investigators note in their article.

The current data, they conclude, "support current guideline recommendations" for the implantation of a primary prevention ICD in eligible women and men with HF and reduced left ventricular ejection fraction.

The Agency for Healthcare Research and Quality funded the study. One author reported consulting for Medtronic.

NEW YORK (Reuters Health)—Women with heart failure (HF) derive as much benefit from implantable cardiac defibrillators (ICDs) for primary prevention as men, according to a comparative effectiveness study.

"Randomized clinical trials demonstrated that the ICD confers survival benefit to many patients with heart failure; however, data on ICDs in women were inadequate due to the relatively small number of women enrolled in those trials," study investigator Dr. Sana Al-Khatib, heart rhythm specialist from Duke Clinical Research Institute in Durham, North Carolina, told Reuters Health by email.

This analysis, online January 12 in Circulation: Heart Failure, showed that women with heart failure and an ICD had "significantly better survival than women with no ICD," Dr. Al-Khatib said.

"Our findings support the gender-neutral guideline recommendations regarding the use of primary prevention ICDs in eligible patients. As a result, women with heart failure should be equally considered for a primary prevention ICD as men," she added.

For the analysis, researchers linked data from 264 hospitals participating in the Get With The Guidelines Heart Failure registry with data from the Centers for Medicare and Medicaid

Services.

Using propensity score matching, they created a cohort of 430 women with heart failure and a preventive ICD and 430 similar women with heart failure but no ICD. For comparison, they propensity score matched 859 men with heart failure and an ICD to 859 men without an ICD.

After three years, 40.2% of women with an ICD had died, compared with 48.7% of women without an ICD. The corresponding mortality rates in men were 42.9% and 52.9%.

In the matched cohorts, an ICD was associated with "similarly better survival" in women and men (hazard ratios, 0.78 and 0.76, respectively). There was no interaction between sex and presence of an ICD with regard to survival (p=0.79).

"Despite the survival benefits of primary prevention ICDs in patients with HF demonstrated in randomized clinical trials, benefit in the subgroup of women from these trials has not been

definitively proved. This uncertainty on survival benefit may be one of several contributing factors to the lower rates of ICD referral and implantation in eligible women," the investigators note in their article.

The current data, they conclude, "support current guideline recommendations" for the implantation of a primary prevention ICD in eligible women and men with HF and reduced left ventricular ejection fraction.

The Agency for Healthcare Research and Quality funded the study. One author reported consulting for Medtronic.

NEW YORK (Reuters Health)—Women with heart failure (HF) derive as much benefit from implantable cardiac defibrillators (ICDs) for primary prevention as men, according to a comparative effectiveness study.

"Randomized clinical trials demonstrated that the ICD confers survival benefit to many patients with heart failure; however, data on ICDs in women were inadequate due to the relatively small number of women enrolled in those trials," study investigator Dr. Sana Al-Khatib, heart rhythm specialist from Duke Clinical Research Institute in Durham, North Carolina, told Reuters Health by email.

This analysis, online January 12 in Circulation: Heart Failure, showed that women with heart failure and an ICD had "significantly better survival than women with no ICD," Dr. Al-Khatib said.

"Our findings support the gender-neutral guideline recommendations regarding the use of primary prevention ICDs in eligible patients. As a result, women with heart failure should be equally considered for a primary prevention ICD as men," she added.

For the analysis, researchers linked data from 264 hospitals participating in the Get With The Guidelines Heart Failure registry with data from the Centers for Medicare and Medicaid

Services.

Using propensity score matching, they created a cohort of 430 women with heart failure and a preventive ICD and 430 similar women with heart failure but no ICD. For comparison, they propensity score matched 859 men with heart failure and an ICD to 859 men without an ICD.

After three years, 40.2% of women with an ICD had died, compared with 48.7% of women without an ICD. The corresponding mortality rates in men were 42.9% and 52.9%.

In the matched cohorts, an ICD was associated with "similarly better survival" in women and men (hazard ratios, 0.78 and 0.76, respectively). There was no interaction between sex and presence of an ICD with regard to survival (p=0.79).

"Despite the survival benefits of primary prevention ICDs in patients with HF demonstrated in randomized clinical trials, benefit in the subgroup of women from these trials has not been

definitively proved. This uncertainty on survival benefit may be one of several contributing factors to the lower rates of ICD referral and implantation in eligible women," the investigators note in their article.

The current data, they conclude, "support current guideline recommendations" for the implantation of a primary prevention ICD in eligible women and men with HF and reduced left ventricular ejection fraction.

The Agency for Healthcare Research and Quality funded the study. One author reported consulting for Medtronic.

Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die as a result of these infections. To promote improved antibiotic-prescribing behaviors among the nation’s hospitalists, SHM launched its “Fight the Resistance” campaign in November 2015. Cynthia Cheung, MD, a hospitalist in the Triton Hospitalists group at Houston Methodist Willowbrook Hospital and assistant professor of clinical medicine at Houston Methodist, recently shared efforts by a team at her hospital that are closely aligned with SHM’s campaign.

Question: What led you to a career in hospital medicine?

Answer: I was very fortunate to train in a program that had excellent hospitalists at the University of California at Los Angeles. Our general wards were staffed by very talented attending physicians, many of whom were hospitalists, and I quickly fell in love with the fast pace of hospital medicine. My UCLA experience confirmed that hospital medicine was the path for me. I finished my residency in 2010 and began my current role at Houston Methodist early in 2014. Almost two years later, I still love what I do.

Q: How did you get involved in antibiotic stewardship at your hospital?

A: One of my colleagues, an infectious disease specialist and chair of our antimicrobial stewardship committee, invited me to join her team. In retrospect, I had never really thought very much about antibiotic stewardship aside from trying to prescribe the proper antibiotics and the appropriate dosages to my patients. I had not fully considered the quality perspective under such a focused lens; being a part of this committee really opened my eyes, especially since the committee’s goals are completely focused on optimizing clinical outcomes and minimizing unintended consequences of antibiotic use.

Q: What most excites you about SHM’s “Fight the Resistance” campaign?

A: I joined SHM a year ago, and I think it’s really exciting that SHM is drawing attention to hospitalists’ roles in promoting antibiotic stewardship in addition to its other quality improvement initiatives. Previously, antibiotic stewardship appeared to be mostly the province of infectious disease physicians, but that isn’t the case anymore. As frontline providers, we are poised to make a difference in appropriate antibiotic use if armed with the proper knowledge and tools.

Q: As part of “Fight the Resistance,” SHM developed recommendations for promoting antibiotic stewardship in hospitals. How do your team efforts align with SHM’s campaign?

A: One of SHM’s recommendations is to engage with a team of hospital-based clinicians to improve stewardship, and our committee oversees a pharmacist-driven real-time audit and feedback intervention to optimize antibiotic use. Often, after a provider places an antibiotic order, additional culture results and clinical information become available. Our pharmacists evaluate this information and contact the provider if they feel the antibiotic dose prescribed is not the most effective or if there is a culture-antibiotic mismatch.

Or the pharmacist might notice that a patient has been taking an antibiotic for an extended duration and may discuss with the provider whether an appropriate duration can be defined. They will call and consult with providers to help them consider discontinuation or de-escalation if necessary. This is in line with SHM’s recommendation to rethink antibiotic treatment time course. Our clinician acceptance rate has been 90 percent in favor of interventions proposed by the pharmacists.

Any time a provider declines pharmacist intervention, our committee reviews these cases to determine whether or not the decision was in the best interest of the patient given the information available. The reviewers include an interdisciplinary team of hospitalists, infectious disease physicians, critical care physicians, and emergency physicians. If one particular clinician has a record of prescribing suboptimally, the team would review that particular provider’s prescribing habits with more detail.

Our committee is also aligned with SHM’s recommendation to identify mechanisms to educate providers on appropriate prescribing by creating guidelines for different classes of bacterial infections and communicating them to our clinical staff. For gram-negative infections, we recommend avoiding the use of carbapenems and antipseudomonal agents in known pathogens that are not pseudonomous. For gram-positive infections, we advise against use of MRSA/VRE-active antibiotics in known pathogens that are not resistant and the use of double coverage in non-synergistic settings. In the case of anaerobic infections, our guidelines suggest clinicians not use double coverage when susceptibilities are known. These guidelines form the backbone of our reviews and assist the pharmacists in their feedback and audit.

Moving forward, one of our committee’s primary action items is to develop a method of communicating our resistance patterns effectively to our clinical staff to make them more widely known. The information is currently sitting in a silo and is not as easily accessible to assist clinicians in their decision-making process when prescribing antibiotics. We also hope to address appropriate usage of daptomycin and ceftaroline, reduce rates of inappropriate treatment of asymptomatic bacteriuria, and seek additional ways to reduce rates of Clostridium difficile infection.

Q: What do you think is most important for hospitalists to know about their roles in antibiotic stewardship?

A: It is extremely important to remember that antibiotics are one of the few classes of drugs that can harm a patient through promotion of resistance—even if the medication was not given to the patient directly. A lot of clinicians may have been taught a certain way to prescribe antibiotics in training or have become rooted in habit. Hospitalists need to proactively stay abreast of antibiotic stewardship developments, share with fellow providers, and not be afraid to alter the way they prescribe.

While this personal education process might seem daunting at first, medicine is a lifelong learning experience. As physicians, we see new things and learn new things every day. I encourage all hospitalists—and all hospital-based staff—to try to take a greater role in stewardship. You do not have to be a specialist to make a difference, and it doesn’t matter at which point in your career you are. Antibiotic resistance affects everyone. Now is the time to step up and fight it. TH

Brett Radler is SHM’s communications coordinator.

Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die as a result of these infections. To promote improved antibiotic-prescribing behaviors among the nation’s hospitalists, SHM launched its “Fight the Resistance” campaign in November 2015. Cynthia Cheung, MD, a hospitalist in the Triton Hospitalists group at Houston Methodist Willowbrook Hospital and assistant professor of clinical medicine at Houston Methodist, recently shared efforts by a team at her hospital that are closely aligned with SHM’s campaign.

Question: What led you to a career in hospital medicine?

Answer: I was very fortunate to train in a program that had excellent hospitalists at the University of California at Los Angeles. Our general wards were staffed by very talented attending physicians, many of whom were hospitalists, and I quickly fell in love with the fast pace of hospital medicine. My UCLA experience confirmed that hospital medicine was the path for me. I finished my residency in 2010 and began my current role at Houston Methodist early in 2014. Almost two years later, I still love what I do.

Q: How did you get involved in antibiotic stewardship at your hospital?

A: One of my colleagues, an infectious disease specialist and chair of our antimicrobial stewardship committee, invited me to join her team. In retrospect, I had never really thought very much about antibiotic stewardship aside from trying to prescribe the proper antibiotics and the appropriate dosages to my patients. I had not fully considered the quality perspective under such a focused lens; being a part of this committee really opened my eyes, especially since the committee’s goals are completely focused on optimizing clinical outcomes and minimizing unintended consequences of antibiotic use.

Q: What most excites you about SHM’s “Fight the Resistance” campaign?

A: I joined SHM a year ago, and I think it’s really exciting that SHM is drawing attention to hospitalists’ roles in promoting antibiotic stewardship in addition to its other quality improvement initiatives. Previously, antibiotic stewardship appeared to be mostly the province of infectious disease physicians, but that isn’t the case anymore. As frontline providers, we are poised to make a difference in appropriate antibiotic use if armed with the proper knowledge and tools.

Q: As part of “Fight the Resistance,” SHM developed recommendations for promoting antibiotic stewardship in hospitals. How do your team efforts align with SHM’s campaign?

A: One of SHM’s recommendations is to engage with a team of hospital-based clinicians to improve stewardship, and our committee oversees a pharmacist-driven real-time audit and feedback intervention to optimize antibiotic use. Often, after a provider places an antibiotic order, additional culture results and clinical information become available. Our pharmacists evaluate this information and contact the provider if they feel the antibiotic dose prescribed is not the most effective or if there is a culture-antibiotic mismatch.

Or the pharmacist might notice that a patient has been taking an antibiotic for an extended duration and may discuss with the provider whether an appropriate duration can be defined. They will call and consult with providers to help them consider discontinuation or de-escalation if necessary. This is in line with SHM’s recommendation to rethink antibiotic treatment time course. Our clinician acceptance rate has been 90 percent in favor of interventions proposed by the pharmacists.

Any time a provider declines pharmacist intervention, our committee reviews these cases to determine whether or not the decision was in the best interest of the patient given the information available. The reviewers include an interdisciplinary team of hospitalists, infectious disease physicians, critical care physicians, and emergency physicians. If one particular clinician has a record of prescribing suboptimally, the team would review that particular provider’s prescribing habits with more detail.

Our committee is also aligned with SHM’s recommendation to identify mechanisms to educate providers on appropriate prescribing by creating guidelines for different classes of bacterial infections and communicating them to our clinical staff. For gram-negative infections, we recommend avoiding the use of carbapenems and antipseudomonal agents in known pathogens that are not pseudonomous. For gram-positive infections, we advise against use of MRSA/VRE-active antibiotics in known pathogens that are not resistant and the use of double coverage in non-synergistic settings. In the case of anaerobic infections, our guidelines suggest clinicians not use double coverage when susceptibilities are known. These guidelines form the backbone of our reviews and assist the pharmacists in their feedback and audit.

Moving forward, one of our committee’s primary action items is to develop a method of communicating our resistance patterns effectively to our clinical staff to make them more widely known. The information is currently sitting in a silo and is not as easily accessible to assist clinicians in their decision-making process when prescribing antibiotics. We also hope to address appropriate usage of daptomycin and ceftaroline, reduce rates of inappropriate treatment of asymptomatic bacteriuria, and seek additional ways to reduce rates of Clostridium difficile infection.

Q: What do you think is most important for hospitalists to know about their roles in antibiotic stewardship?

A: It is extremely important to remember that antibiotics are one of the few classes of drugs that can harm a patient through promotion of resistance—even if the medication was not given to the patient directly. A lot of clinicians may have been taught a certain way to prescribe antibiotics in training or have become rooted in habit. Hospitalists need to proactively stay abreast of antibiotic stewardship developments, share with fellow providers, and not be afraid to alter the way they prescribe.

While this personal education process might seem daunting at first, medicine is a lifelong learning experience. As physicians, we see new things and learn new things every day. I encourage all hospitalists—and all hospital-based staff—to try to take a greater role in stewardship. You do not have to be a specialist to make a difference, and it doesn’t matter at which point in your career you are. Antibiotic resistance affects everyone. Now is the time to step up and fight it. TH

Brett Radler is SHM’s communications coordinator.

Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die as a result of these infections. To promote improved antibiotic-prescribing behaviors among the nation’s hospitalists, SHM launched its “Fight the Resistance” campaign in November 2015. Cynthia Cheung, MD, a hospitalist in the Triton Hospitalists group at Houston Methodist Willowbrook Hospital and assistant professor of clinical medicine at Houston Methodist, recently shared efforts by a team at her hospital that are closely aligned with SHM’s campaign.

Question: What led you to a career in hospital medicine?

Answer: I was very fortunate to train in a program that had excellent hospitalists at the University of California at Los Angeles. Our general wards were staffed by very talented attending physicians, many of whom were hospitalists, and I quickly fell in love with the fast pace of hospital medicine. My UCLA experience confirmed that hospital medicine was the path for me. I finished my residency in 2010 and began my current role at Houston Methodist early in 2014. Almost two years later, I still love what I do.

Q: How did you get involved in antibiotic stewardship at your hospital?

A: One of my colleagues, an infectious disease specialist and chair of our antimicrobial stewardship committee, invited me to join her team. In retrospect, I had never really thought very much about antibiotic stewardship aside from trying to prescribe the proper antibiotics and the appropriate dosages to my patients. I had not fully considered the quality perspective under such a focused lens; being a part of this committee really opened my eyes, especially since the committee’s goals are completely focused on optimizing clinical outcomes and minimizing unintended consequences of antibiotic use.

Q: What most excites you about SHM’s “Fight the Resistance” campaign?

A: I joined SHM a year ago, and I think it’s really exciting that SHM is drawing attention to hospitalists’ roles in promoting antibiotic stewardship in addition to its other quality improvement initiatives. Previously, antibiotic stewardship appeared to be mostly the province of infectious disease physicians, but that isn’t the case anymore. As frontline providers, we are poised to make a difference in appropriate antibiotic use if armed with the proper knowledge and tools.

Q: As part of “Fight the Resistance,” SHM developed recommendations for promoting antibiotic stewardship in hospitals. How do your team efforts align with SHM’s campaign?

A: One of SHM’s recommendations is to engage with a team of hospital-based clinicians to improve stewardship, and our committee oversees a pharmacist-driven real-time audit and feedback intervention to optimize antibiotic use. Often, after a provider places an antibiotic order, additional culture results and clinical information become available. Our pharmacists evaluate this information and contact the provider if they feel the antibiotic dose prescribed is not the most effective or if there is a culture-antibiotic mismatch.

Or the pharmacist might notice that a patient has been taking an antibiotic for an extended duration and may discuss with the provider whether an appropriate duration can be defined. They will call and consult with providers to help them consider discontinuation or de-escalation if necessary. This is in line with SHM’s recommendation to rethink antibiotic treatment time course. Our clinician acceptance rate has been 90 percent in favor of interventions proposed by the pharmacists.

Any time a provider declines pharmacist intervention, our committee reviews these cases to determine whether or not the decision was in the best interest of the patient given the information available. The reviewers include an interdisciplinary team of hospitalists, infectious disease physicians, critical care physicians, and emergency physicians. If one particular clinician has a record of prescribing suboptimally, the team would review that particular provider’s prescribing habits with more detail.

Our committee is also aligned with SHM’s recommendation to identify mechanisms to educate providers on appropriate prescribing by creating guidelines for different classes of bacterial infections and communicating them to our clinical staff. For gram-negative infections, we recommend avoiding the use of carbapenems and antipseudomonal agents in known pathogens that are not pseudonomous. For gram-positive infections, we advise against use of MRSA/VRE-active antibiotics in known pathogens that are not resistant and the use of double coverage in non-synergistic settings. In the case of anaerobic infections, our guidelines suggest clinicians not use double coverage when susceptibilities are known. These guidelines form the backbone of our reviews and assist the pharmacists in their feedback and audit.

Moving forward, one of our committee’s primary action items is to develop a method of communicating our resistance patterns effectively to our clinical staff to make them more widely known. The information is currently sitting in a silo and is not as easily accessible to assist clinicians in their decision-making process when prescribing antibiotics. We also hope to address appropriate usage of daptomycin and ceftaroline, reduce rates of inappropriate treatment of asymptomatic bacteriuria, and seek additional ways to reduce rates of Clostridium difficile infection.

Q: What do you think is most important for hospitalists to know about their roles in antibiotic stewardship?

A: It is extremely important to remember that antibiotics are one of the few classes of drugs that can harm a patient through promotion of resistance—even if the medication was not given to the patient directly. A lot of clinicians may have been taught a certain way to prescribe antibiotics in training or have become rooted in habit. Hospitalists need to proactively stay abreast of antibiotic stewardship developments, share with fellow providers, and not be afraid to alter the way they prescribe.

While this personal education process might seem daunting at first, medicine is a lifelong learning experience. As physicians, we see new things and learn new things every day. I encourage all hospitalists—and all hospital-based staff—to try to take a greater role in stewardship. You do not have to be a specialist to make a difference, and it doesn’t matter at which point in your career you are. Antibiotic resistance affects everyone. Now is the time to step up and fight it. TH

Brett Radler is SHM’s communications coordinator.

Clinical question: Do peripherally inserted central catheters increase the risk for upper- and lower-extremity deep venous thromboses?

Bottom line: Although the association between peripherally inserted central catheters (PICCs) and upper-extremity deep venous thromboses (DVTs) was already known, this study shows that PICCs are also associated with a greater risk of lower-extremity DVTs, suggesting that PICC insertion in itself may be a trigger for thrombosis. (LOE = 2b)

Reference: Greene MT, Flander SA, Woller SC, Bernstein SJ, Chopra V. The association between PICC use and venous thromboembolism in upper and lower extremities. Am J Med 2015;128(9):986–993.

Study design: Cohort (retrospective)

Funding source: Industry

Setting: Inpatient (any location) with outpatient follow-up

Synopsis

Using a statewide registry as well as individual medical records, these investigators collected data for 76,242 hospitalized patients to examine the association between PICC placement and venous thromboembolism (VTE). Patients with a history of VTE, those undergoing surgery, those admitted to an intensive care unit, and those under observation were excluded. Patients were followed up for 90 days after index hospitalization to identify the development of symptomatic pulmonary emboli or upper- or lower-extremity proximal DVTs.

Overall, 5% of the cohort had PICCs present on admission or placed during the hospitalization. As compared with those without PICCs, patients with PICCs were more likely to be older than 70 years; have recent surgery or history of VTE; and have diabetes, inflammatory bowel disease, sepsis, or pneumonia. After adjusting for other risk factors for VTE, the presence of a PICC was not only associated with risk of upper-extremity DVT (hazard ratio [HR] = 10.49; 95% CI 7.79-14.11; P < .001), but also modestly associated with risk of lower-extremity DVT (HR = 1.48; 1.02-2.15; P = .038). The authors hypothesize that PICC line insertion may trigger a systemic thrombosis leading to DVTs in different locations, including the lower extremities. There was no significant association with pulmonary embolism.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Do peripherally inserted central catheters increase the risk for upper- and lower-extremity deep venous thromboses?

Bottom line: Although the association between peripherally inserted central catheters (PICCs) and upper-extremity deep venous thromboses (DVTs) was already known, this study shows that PICCs are also associated with a greater risk of lower-extremity DVTs, suggesting that PICC insertion in itself may be a trigger for thrombosis. (LOE = 2b)

Reference: Greene MT, Flander SA, Woller SC, Bernstein SJ, Chopra V. The association between PICC use and venous thromboembolism in upper and lower extremities. Am J Med 2015;128(9):986–993.

Study design: Cohort (retrospective)

Funding source: Industry

Setting: Inpatient (any location) with outpatient follow-up

Synopsis

Using a statewide registry as well as individual medical records, these investigators collected data for 76,242 hospitalized patients to examine the association between PICC placement and venous thromboembolism (VTE). Patients with a history of VTE, those undergoing surgery, those admitted to an intensive care unit, and those under observation were excluded. Patients were followed up for 90 days after index hospitalization to identify the development of symptomatic pulmonary emboli or upper- or lower-extremity proximal DVTs.

Overall, 5% of the cohort had PICCs present on admission or placed during the hospitalization. As compared with those without PICCs, patients with PICCs were more likely to be older than 70 years; have recent surgery or history of VTE; and have diabetes, inflammatory bowel disease, sepsis, or pneumonia. After adjusting for other risk factors for VTE, the presence of a PICC was not only associated with risk of upper-extremity DVT (hazard ratio [HR] = 10.49; 95% CI 7.79-14.11; P < .001), but also modestly associated with risk of lower-extremity DVT (HR = 1.48; 1.02-2.15; P = .038). The authors hypothesize that PICC line insertion may trigger a systemic thrombosis leading to DVTs in different locations, including the lower extremities. There was no significant association with pulmonary embolism.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: Do peripherally inserted central catheters increase the risk for upper- and lower-extremity deep venous thromboses?

Bottom line: Although the association between peripherally inserted central catheters (PICCs) and upper-extremity deep venous thromboses (DVTs) was already known, this study shows that PICCs are also associated with a greater risk of lower-extremity DVTs, suggesting that PICC insertion in itself may be a trigger for thrombosis. (LOE = 2b)

Reference: Greene MT, Flander SA, Woller SC, Bernstein SJ, Chopra V. The association between PICC use and venous thromboembolism in upper and lower extremities. Am J Med 2015;128(9):986–993.

Study design: Cohort (retrospective)

Funding source: Industry

Setting: Inpatient (any location) with outpatient follow-up

Synopsis

Using a statewide registry as well as individual medical records, these investigators collected data for 76,242 hospitalized patients to examine the association between PICC placement and venous thromboembolism (VTE). Patients with a history of VTE, those undergoing surgery, those admitted to an intensive care unit, and those under observation were excluded. Patients were followed up for 90 days after index hospitalization to identify the development of symptomatic pulmonary emboli or upper- or lower-extremity proximal DVTs.

Overall, 5% of the cohort had PICCs present on admission or placed during the hospitalization. As compared with those without PICCs, patients with PICCs were more likely to be older than 70 years; have recent surgery or history of VTE; and have diabetes, inflammatory bowel disease, sepsis, or pneumonia. After adjusting for other risk factors for VTE, the presence of a PICC was not only associated with risk of upper-extremity DVT (hazard ratio [HR] = 10.49; 95% CI 7.79-14.11; P < .001), but also modestly associated with risk of lower-extremity DVT (HR = 1.48; 1.02-2.15; P = .038). The authors hypothesize that PICC line insertion may trigger a systemic thrombosis leading to DVTs in different locations, including the lower extremities. There was no significant association with pulmonary embolism.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: For pleurodesis, do nonsteroidal anti-inflammatory drugs and smaller chest tubes, as compared with opioids and larger tubes, provide better pain relief while maintaining efficacy of the procedure?

Bottom line: Although nonsteroidal anti-inflammatory drugs (NSAIDs) are not necessarily more effective than opiates for pain relief after pleurodesis, they should be considered a safe and effective analgesic option for these patients. NSAIDs do not lead to higher rates of pleurodesis failure. Using a smaller chest tube, on the other hand, does not provide a clinically significant pain benefit and may ultimately lead to a higher rate of pleurodesis failure. (LOE = 1b)

Reference: Rahman NM, Pepperell J, Rehal S, et al. Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis efficacy among patients with malignant pleural effusion. JAMA 2015;314(24):2614–2653.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Synopsis

Using concealed allocation, these investigators randomized 320 patients requiring pleurodesis for malignant pleural effusions to receive either NSAIDs or opioids and small or large (12F vs 24F) chest tubes. Patients who underwent thoracoscopy, which necessitates a 24F tube postprocedure, were randomized to receive either NSAIDs or opiates but were not included in the chest tube size analysis. Those who did not undergo thoracoscopy were randomized into both arms of the trial, either NSAIDs or opiates and either 12F or 24F chest tubes.

The NSAID groups received 800 mg ibuprofen 3 times daily as needed; the opiate groups received 10 mg to 20 mg oral morphine up to 4 times daily. The patients were not masked to any of the interventions. All patients also received scheduled 1g acetaminophen 4 times daily and intravenous morphine as needed for breakthrough pain. Pain was measured using a 100-mm visual analog scale. Pleurodesis failure was defined as requiring another pleural intervention within 3 months after randomization. Patients had similar baseline characteristics in all treatment groups, except for more men in the larger chest tube group.

Overall, there was no significant difference detected in mean pain scores while the chest tube was in place in the NSAID group as compared with the opiate group, but the NSAID group required more breakthrough intravenous morphine than the opiate group (38% vs 26%; P = .003). Patients in the smaller chest tube group reported less pain than the larger tube group (mean visual analog scale score = 22 mm vs 27 mm; P = .04). Although this finding was statistically significant, the absolute difference in pain scores was small and not necessarily clinically meaningful. For pleurodesis failure, the NSAID group was noninferior to the opiate group; however, the smaller chest tube group had a higher rate of pleurodesis failure and did not meet noninferiority criteria. Pain scores at 1 or 3 months, adverse events, and mortality did not differ for either of the comparisons.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: For pleurodesis, do nonsteroidal anti-inflammatory drugs and smaller chest tubes, as compared with opioids and larger tubes, provide better pain relief while maintaining efficacy of the procedure?

Bottom line: Although nonsteroidal anti-inflammatory drugs (NSAIDs) are not necessarily more effective than opiates for pain relief after pleurodesis, they should be considered a safe and effective analgesic option for these patients. NSAIDs do not lead to higher rates of pleurodesis failure. Using a smaller chest tube, on the other hand, does not provide a clinically significant pain benefit and may ultimately lead to a higher rate of pleurodesis failure. (LOE = 1b)

Reference: Rahman NM, Pepperell J, Rehal S, et al. Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis efficacy among patients with malignant pleural effusion. JAMA 2015;314(24):2614–2653.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Synopsis

Using concealed allocation, these investigators randomized 320 patients requiring pleurodesis for malignant pleural effusions to receive either NSAIDs or opioids and small or large (12F vs 24F) chest tubes. Patients who underwent thoracoscopy, which necessitates a 24F tube postprocedure, were randomized to receive either NSAIDs or opiates but were not included in the chest tube size analysis. Those who did not undergo thoracoscopy were randomized into both arms of the trial, either NSAIDs or opiates and either 12F or 24F chest tubes.

The NSAID groups received 800 mg ibuprofen 3 times daily as needed; the opiate groups received 10 mg to 20 mg oral morphine up to 4 times daily. The patients were not masked to any of the interventions. All patients also received scheduled 1g acetaminophen 4 times daily and intravenous morphine as needed for breakthrough pain. Pain was measured using a 100-mm visual analog scale. Pleurodesis failure was defined as requiring another pleural intervention within 3 months after randomization. Patients had similar baseline characteristics in all treatment groups, except for more men in the larger chest tube group.

Overall, there was no significant difference detected in mean pain scores while the chest tube was in place in the NSAID group as compared with the opiate group, but the NSAID group required more breakthrough intravenous morphine than the opiate group (38% vs 26%; P = .003). Patients in the smaller chest tube group reported less pain than the larger tube group (mean visual analog scale score = 22 mm vs 27 mm; P = .04). Although this finding was statistically significant, the absolute difference in pain scores was small and not necessarily clinically meaningful. For pleurodesis failure, the NSAID group was noninferior to the opiate group; however, the smaller chest tube group had a higher rate of pleurodesis failure and did not meet noninferiority criteria. Pain scores at 1 or 3 months, adverse events, and mortality did not differ for either of the comparisons.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question: For pleurodesis, do nonsteroidal anti-inflammatory drugs and smaller chest tubes, as compared with opioids and larger tubes, provide better pain relief while maintaining efficacy of the procedure?

Bottom line: Although nonsteroidal anti-inflammatory drugs (NSAIDs) are not necessarily more effective than opiates for pain relief after pleurodesis, they should be considered a safe and effective analgesic option for these patients. NSAIDs do not lead to higher rates of pleurodesis failure. Using a smaller chest tube, on the other hand, does not provide a clinically significant pain benefit and may ultimately lead to a higher rate of pleurodesis failure. (LOE = 1b)

Reference: Rahman NM, Pepperell J, Rehal S, et al. Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis efficacy among patients with malignant pleural effusion. JAMA 2015;314(24):2614–2653.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Synopsis

Using concealed allocation, these investigators randomized 320 patients requiring pleurodesis for malignant pleural effusions to receive either NSAIDs or opioids and small or large (12F vs 24F) chest tubes. Patients who underwent thoracoscopy, which necessitates a 24F tube postprocedure, were randomized to receive either NSAIDs or opiates but were not included in the chest tube size analysis. Those who did not undergo thoracoscopy were randomized into both arms of the trial, either NSAIDs or opiates and either 12F or 24F chest tubes.

The NSAID groups received 800 mg ibuprofen 3 times daily as needed; the opiate groups received 10 mg to 20 mg oral morphine up to 4 times daily. The patients were not masked to any of the interventions. All patients also received scheduled 1g acetaminophen 4 times daily and intravenous morphine as needed for breakthrough pain. Pain was measured using a 100-mm visual analog scale. Pleurodesis failure was defined as requiring another pleural intervention within 3 months after randomization. Patients had similar baseline characteristics in all treatment groups, except for more men in the larger chest tube group.

Overall, there was no significant difference detected in mean pain scores while the chest tube was in place in the NSAID group as compared with the opiate group, but the NSAID group required more breakthrough intravenous morphine than the opiate group (38% vs 26%; P = .003). Patients in the smaller chest tube group reported less pain than the larger tube group (mean visual analog scale score = 22 mm vs 27 mm; P = .04). Although this finding was statistically significant, the absolute difference in pain scores was small and not necessarily clinically meaningful. For pleurodesis failure, the NSAID group was noninferior to the opiate group; however, the smaller chest tube group had a higher rate of pleurodesis failure and did not meet noninferiority criteria. Pain scores at 1 or 3 months, adverse events, and mortality did not differ for either of the comparisons.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Risk-based payment models are becoming increasingly common in healthcare. Programs and initiatives such as Medicare Advantage, accountable care organizations (ACOs), and bundled payments are tasking hospitals, physicians, post-acute, and other providers with better managing patient care to improve outcomes and lower costs.

According to the Kaiser Family Foundation, Medicare Advantage—through which providers accept full risk to treat patients for a fixed annual rate—grew by more than 1 million beneficiaries between March 2014 and March 2015. Today, 31%, or almost one in three Medicare beneficiaries, are enrolled in a Medicare Advantage plan.

The much newer ACO and bundled payment models are also growing quickly. And by the end of 2018, the Department of Health & Human Services would like to move more than 50% of Medicare payments into such models.

According to healthcare intelligence firm Leavitt Partners, in early 2015 there were 744 active ACOs in the U.S., up from just 64 at the same time in 2011. Those organizations, through which providers collaborate to manage the cost and quality of care for a patient population, grew by about 4.5 million covered lives between the beginning of 2014 and 2015, reaching 23.5 million participants.

The somewhat similar Bundled Payment for Care Improvement (BPCI) initiative had more than 2,100 participating providers as of August 2015, including acute-care hospitals, skilled nursing facilities (SNFs), physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies working together to assume financial risk for certain episodes of care based upon specific diagnosis-related groups (DRGs).

As this growth continues, hospitalists are uniquely positioned to drive success in risk-based payment models if they can become more “longitudinally” involved in patient care rather than focused solely on inpatient services. That means partnering with providers outside the hospital, extending their own practice beyond the hospital, and leveraging technology.

Partnering outside the Hospital

In a recent series of “On the Horizon” articles in The Hospitalist, Win Whitcomb, MD, MHM, argues that hospitalists hoping to capitalize on savings from the BPCI program must think “beyond the four walls” of the hospital to how they can impact the cost and quality of care in the post-acute setting as well as readmission rates. I couldn’t agree more.

The “buying power” hospitalists wield with their referral patterns puts them in a unique position to influence the quality of care at post-acute facilities, thereby benefiting hospitals and their patients.

Traditionally, a hospitalist discharging a patient to a SNF would not ordinarily recommend a particular facility. They likely would leave the mandated “patient choice” presentation to the case manager. And that presentation normally would consist of a list of facilities in the market, with little to no quality or cost information associated with any of the facilities. This process essentially becomes a roll of the dice as to whether the best facility is chosen for particular patients and their conditions.

Under risk-based payment models, hospitalists should consider working with SNFs to help them develop clinical protocols that reduce costly lengths of stay and hospital readmission rates. In return for improving their efficiency and care, the hospitalists can help increase referrals to those SNFs by designing a process (in partnership with the discharge-planning staff) that will provide information on cost and quality of post-discharge options for patients and families. Given the information, patients and families are much more likely to choose a facility that benefits them and, in turn, benefits the system.

Broaden Your Practice

In addition, hospitalists should consider hiring or designating personnel to help manage patients in a post-discharge environment.

In particular, HM groups are increasingly partnering with or hiring “SNFists” to manage the patients they discharge from hospitals. As the name suggests, SNFists are dedicated to treating patients in the SNF environment, just as hospitalists treat patients in the hospital. Nurse practitioners and physician assistants are playing an increasingly important role in this space.

By partnering with SNFists (internal or external to the hospital medicine practice), hospitalists can ensure better continuity of care after discharge and a higher level of care than patients typically receive in a post-acute setting. Often, SNFists are able to detect declines in a patient’s condition early enough to intervene and prevent a hospital readmission. Similarly, their supervision and communication with the hospitalist helps ensure the patient is following the discharge plan and more likely to achieve a prompt recovery.

Leveraging Technology

Though providers across healthcare settings are embracing technology systems such as electronic medical records, most continue to struggle with the lack of system interoperability for adequately sharing patient information.

On a local level, hospitalists can work with post-acute and other partnering providers to help identify what, if any, existing medical record technologies can be made to interface with one another—or if there are any adequate workarounds to facilitate the transfer of patient information and support the continuity of care post-discharge.

Other technology tools, such as telemedicine programs or remote patient monitoring, may also be options hospitalists may want to champion as a way to help manage episodes of care that extend beyond the acute-care hospital stay.

Looking Ahead

There’s no doubt risk-based payment models will continue to gain prevalence in the healthcare market. By thinking beyond the hospital, hospitalists can take a more active role in achieving success in these new models. TH

Risk-based payment models are becoming increasingly common in healthcare. Programs and initiatives such as Medicare Advantage, accountable care organizations (ACOs), and bundled payments are tasking hospitals, physicians, post-acute, and other providers with better managing patient care to improve outcomes and lower costs.

According to the Kaiser Family Foundation, Medicare Advantage—through which providers accept full risk to treat patients for a fixed annual rate—grew by more than 1 million beneficiaries between March 2014 and March 2015. Today, 31%, or almost one in three Medicare beneficiaries, are enrolled in a Medicare Advantage plan.

The much newer ACO and bundled payment models are also growing quickly. And by the end of 2018, the Department of Health & Human Services would like to move more than 50% of Medicare payments into such models.

According to healthcare intelligence firm Leavitt Partners, in early 2015 there were 744 active ACOs in the U.S., up from just 64 at the same time in 2011. Those organizations, through which providers collaborate to manage the cost and quality of care for a patient population, grew by about 4.5 million covered lives between the beginning of 2014 and 2015, reaching 23.5 million participants.

The somewhat similar Bundled Payment for Care Improvement (BPCI) initiative had more than 2,100 participating providers as of August 2015, including acute-care hospitals, skilled nursing facilities (SNFs), physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies working together to assume financial risk for certain episodes of care based upon specific diagnosis-related groups (DRGs).

As this growth continues, hospitalists are uniquely positioned to drive success in risk-based payment models if they can become more “longitudinally” involved in patient care rather than focused solely on inpatient services. That means partnering with providers outside the hospital, extending their own practice beyond the hospital, and leveraging technology.

Partnering outside the Hospital

In a recent series of “On the Horizon” articles in The Hospitalist, Win Whitcomb, MD, MHM, argues that hospitalists hoping to capitalize on savings from the BPCI program must think “beyond the four walls” of the hospital to how they can impact the cost and quality of care in the post-acute setting as well as readmission rates. I couldn’t agree more.

The “buying power” hospitalists wield with their referral patterns puts them in a unique position to influence the quality of care at post-acute facilities, thereby benefiting hospitals and their patients.

Traditionally, a hospitalist discharging a patient to a SNF would not ordinarily recommend a particular facility. They likely would leave the mandated “patient choice” presentation to the case manager. And that presentation normally would consist of a list of facilities in the market, with little to no quality or cost information associated with any of the facilities. This process essentially becomes a roll of the dice as to whether the best facility is chosen for particular patients and their conditions.

Under risk-based payment models, hospitalists should consider working with SNFs to help them develop clinical protocols that reduce costly lengths of stay and hospital readmission rates. In return for improving their efficiency and care, the hospitalists can help increase referrals to those SNFs by designing a process (in partnership with the discharge-planning staff) that will provide information on cost and quality of post-discharge options for patients and families. Given the information, patients and families are much more likely to choose a facility that benefits them and, in turn, benefits the system.

Broaden Your Practice

In addition, hospitalists should consider hiring or designating personnel to help manage patients in a post-discharge environment.

In particular, HM groups are increasingly partnering with or hiring “SNFists” to manage the patients they discharge from hospitals. As the name suggests, SNFists are dedicated to treating patients in the SNF environment, just as hospitalists treat patients in the hospital. Nurse practitioners and physician assistants are playing an increasingly important role in this space.

By partnering with SNFists (internal or external to the hospital medicine practice), hospitalists can ensure better continuity of care after discharge and a higher level of care than patients typically receive in a post-acute setting. Often, SNFists are able to detect declines in a patient’s condition early enough to intervene and prevent a hospital readmission. Similarly, their supervision and communication with the hospitalist helps ensure the patient is following the discharge plan and more likely to achieve a prompt recovery.

Leveraging Technology

Though providers across healthcare settings are embracing technology systems such as electronic medical records, most continue to struggle with the lack of system interoperability for adequately sharing patient information.

On a local level, hospitalists can work with post-acute and other partnering providers to help identify what, if any, existing medical record technologies can be made to interface with one another—or if there are any adequate workarounds to facilitate the transfer of patient information and support the continuity of care post-discharge.

Other technology tools, such as telemedicine programs or remote patient monitoring, may also be options hospitalists may want to champion as a way to help manage episodes of care that extend beyond the acute-care hospital stay.

Looking Ahead

There’s no doubt risk-based payment models will continue to gain prevalence in the healthcare market. By thinking beyond the hospital, hospitalists can take a more active role in achieving success in these new models. TH

Risk-based payment models are becoming increasingly common in healthcare. Programs and initiatives such as Medicare Advantage, accountable care organizations (ACOs), and bundled payments are tasking hospitals, physicians, post-acute, and other providers with better managing patient care to improve outcomes and lower costs.

According to the Kaiser Family Foundation, Medicare Advantage—through which providers accept full risk to treat patients for a fixed annual rate—grew by more than 1 million beneficiaries between March 2014 and March 2015. Today, 31%, or almost one in three Medicare beneficiaries, are enrolled in a Medicare Advantage plan.

The much newer ACO and bundled payment models are also growing quickly. And by the end of 2018, the Department of Health & Human Services would like to move more than 50% of Medicare payments into such models.

According to healthcare intelligence firm Leavitt Partners, in early 2015 there were 744 active ACOs in the U.S., up from just 64 at the same time in 2011. Those organizations, through which providers collaborate to manage the cost and quality of care for a patient population, grew by about 4.5 million covered lives between the beginning of 2014 and 2015, reaching 23.5 million participants.

The somewhat similar Bundled Payment for Care Improvement (BPCI) initiative had more than 2,100 participating providers as of August 2015, including acute-care hospitals, skilled nursing facilities (SNFs), physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies working together to assume financial risk for certain episodes of care based upon specific diagnosis-related groups (DRGs).

As this growth continues, hospitalists are uniquely positioned to drive success in risk-based payment models if they can become more “longitudinally” involved in patient care rather than focused solely on inpatient services. That means partnering with providers outside the hospital, extending their own practice beyond the hospital, and leveraging technology.

Partnering outside the Hospital

In a recent series of “On the Horizon” articles in The Hospitalist, Win Whitcomb, MD, MHM, argues that hospitalists hoping to capitalize on savings from the BPCI program must think “beyond the four walls” of the hospital to how they can impact the cost and quality of care in the post-acute setting as well as readmission rates. I couldn’t agree more.

The “buying power” hospitalists wield with their referral patterns puts them in a unique position to influence the quality of care at post-acute facilities, thereby benefiting hospitals and their patients.

Traditionally, a hospitalist discharging a patient to a SNF would not ordinarily recommend a particular facility. They likely would leave the mandated “patient choice” presentation to the case manager. And that presentation normally would consist of a list of facilities in the market, with little to no quality or cost information associated with any of the facilities. This process essentially becomes a roll of the dice as to whether the best facility is chosen for particular patients and their conditions.

Under risk-based payment models, hospitalists should consider working with SNFs to help them develop clinical protocols that reduce costly lengths of stay and hospital readmission rates. In return for improving their efficiency and care, the hospitalists can help increase referrals to those SNFs by designing a process (in partnership with the discharge-planning staff) that will provide information on cost and quality of post-discharge options for patients and families. Given the information, patients and families are much more likely to choose a facility that benefits them and, in turn, benefits the system.

Broaden Your Practice

In addition, hospitalists should consider hiring or designating personnel to help manage patients in a post-discharge environment.

In particular, HM groups are increasingly partnering with or hiring “SNFists” to manage the patients they discharge from hospitals. As the name suggests, SNFists are dedicated to treating patients in the SNF environment, just as hospitalists treat patients in the hospital. Nurse practitioners and physician assistants are playing an increasingly important role in this space.

By partnering with SNFists (internal or external to the hospital medicine practice), hospitalists can ensure better continuity of care after discharge and a higher level of care than patients typically receive in a post-acute setting. Often, SNFists are able to detect declines in a patient’s condition early enough to intervene and prevent a hospital readmission. Similarly, their supervision and communication with the hospitalist helps ensure the patient is following the discharge plan and more likely to achieve a prompt recovery.

Leveraging Technology

Though providers across healthcare settings are embracing technology systems such as electronic medical records, most continue to struggle with the lack of system interoperability for adequately sharing patient information.

On a local level, hospitalists can work with post-acute and other partnering providers to help identify what, if any, existing medical record technologies can be made to interface with one another—or if there are any adequate workarounds to facilitate the transfer of patient information and support the continuity of care post-discharge.

Other technology tools, such as telemedicine programs or remote patient monitoring, may also be options hospitalists may want to champion as a way to help manage episodes of care that extend beyond the acute-care hospital stay.

Looking Ahead

There’s no doubt risk-based payment models will continue to gain prevalence in the healthcare market. By thinking beyond the hospital, hospitalists can take a more active role in achieving success in these new models. TH

Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?

Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.

Study design: Retrospective review.

Setting: Anthem insurance members.

Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.

Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.

The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.

Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.

Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.

Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?

Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.

Study design: Retrospective review.

Setting: Anthem insurance members.

Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.

Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.

The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.

Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.

Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.

Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?

Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.

Study design: Retrospective review.

Setting: Anthem insurance members.

Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.

Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.

The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.

Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.

Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.

The diversity of hospitalist practice—from the variety of settings (such as inpatient acute, observation, post-discharge clinics, and post-acute-care facilities) to the differences in relationships with their facilities—is a strength of the specialty. It reflects the ability of the specialty to adapt to the unique needs of its local patients and institutions.

At the same time, it presents some unique challenges to developing strategies for identifying and assessing hospitalists. As the Medicare physician payment system moves toward value-based payment, hospitalists must report quality measures in the Physician Quality Reporting System (PQRS) or face ever-increasing penalties.

Many hospitalists are part of multispecialty groups aligned with a range of physicians employed by the same facility, including many academic hospitalists and those in integrated healthcare systems. Frequently for hospitalists in these groups, the group reports via a group-practice reporting option that uses measures for outpatient providers, capitalizing on the performances of those outpatient primary care providers in the group and making it generally unnecessary for these hospitalists to independently worry about PQRS reporting. Due to their employment model, they might also be somewhat insulated from seeing firsthand any value-based reimbursement adjustments from Medicare.

Hospitalists commonly are employed by single-specialty groups, medium or large in number of HM-focused providers, or increasingly a mix of hospitalists, emergency physicians, and hospitalists focused on skilled nursing facility (SNF) care. Still others are in small hospitalist groups or independent practitioners of hospital medicine. For these hospitalists, successful reporting of PQRS is important; they cannot rely on broad-based primary care group reporting options, and penalties can have an immediate impact on revenue streams.

PQRS, just like its hospital counterpart, the Inpatient Quality Reporting (IQR) system, was designed for use in an isolated healthcare delivery silo: PQRS was meant for physicians; IQR, for hospitals. This explicit design makes the measuring of hospitalists difficult within the current value-based payment programs because while the patient-care goals of hospitalists and their hospitals overlap, hospitalists are forced to report on physician-level metrics. Following this silo logic, the Centers for Medicare & Medicaid Services (CMS) has been removing physician-level PQRS measures that it views as redundant with facility-level IQR metrics, which has contributed to the detrimental reduction of relevant PQRS metrics for hospitalists over the years.

However, in large part due to the significant advocacy efforts of SHM around last year’s Medicare Access and CHIP Reauthorization Act (MACRA), CMS now has the ability to reverse this trend and include metrics from other programs, such as IQR metrics, as part of the quality or cost component of physician value-based payment. This would help to eliminate the artificial misalignment of quality goals and metrics for hospitalists and their facilities. Including hospital IQR metrics in the mandatory Medicare physician reporting programs would help to ensure hospitalists receive credit for the care they are providing for hospitalized patients and for the measures they are commonly held accountable for as part of their jobs.

As SHM advocates for hospitalists as the new Merit-Based Incentive Payment System (MIPS) reporting program unrolls as part of MACRA, we will keep these principles in mind: reduce administrative and reporting burdens, make metrics and their resulting data as actionable and useful as possible, and account for the important work hospitalists are doing in their facilities. As we are looking ahead at the future, we encourage you to make sure you are reporting in PQRS for 2016.

For more information about 2016 PQRS reporting, visit www.hospitalmedicine.org/pqrs. TH

Joshua Lapps is SHM’s government relations manager.

The diversity of hospitalist practice—from the variety of settings (such as inpatient acute, observation, post-discharge clinics, and post-acute-care facilities) to the differences in relationships with their facilities—is a strength of the specialty. It reflects the ability of the specialty to adapt to the unique needs of its local patients and institutions.

At the same time, it presents some unique challenges to developing strategies for identifying and assessing hospitalists. As the Medicare physician payment system moves toward value-based payment, hospitalists must report quality measures in the Physician Quality Reporting System (PQRS) or face ever-increasing penalties.

Many hospitalists are part of multispecialty groups aligned with a range of physicians employed by the same facility, including many academic hospitalists and those in integrated healthcare systems. Frequently for hospitalists in these groups, the group reports via a group-practice reporting option that uses measures for outpatient providers, capitalizing on the performances of those outpatient primary care providers in the group and making it generally unnecessary for these hospitalists to independently worry about PQRS reporting. Due to their employment model, they might also be somewhat insulated from seeing firsthand any value-based reimbursement adjustments from Medicare.

Hospitalists commonly are employed by single-specialty groups, medium or large in number of HM-focused providers, or increasingly a mix of hospitalists, emergency physicians, and hospitalists focused on skilled nursing facility (SNF) care. Still others are in small hospitalist groups or independent practitioners of hospital medicine. For these hospitalists, successful reporting of PQRS is important; they cannot rely on broad-based primary care group reporting options, and penalties can have an immediate impact on revenue streams.

PQRS, just like its hospital counterpart, the Inpatient Quality Reporting (IQR) system, was designed for use in an isolated healthcare delivery silo: PQRS was meant for physicians; IQR, for hospitals. This explicit design makes the measuring of hospitalists difficult within the current value-based payment programs because while the patient-care goals of hospitalists and their hospitals overlap, hospitalists are forced to report on physician-level metrics. Following this silo logic, the Centers for Medicare & Medicaid Services (CMS) has been removing physician-level PQRS measures that it views as redundant with facility-level IQR metrics, which has contributed to the detrimental reduction of relevant PQRS metrics for hospitalists over the years.

However, in large part due to the significant advocacy efforts of SHM around last year’s Medicare Access and CHIP Reauthorization Act (MACRA), CMS now has the ability to reverse this trend and include metrics from other programs, such as IQR metrics, as part of the quality or cost component of physician value-based payment. This would help to eliminate the artificial misalignment of quality goals and metrics for hospitalists and their facilities. Including hospital IQR metrics in the mandatory Medicare physician reporting programs would help to ensure hospitalists receive credit for the care they are providing for hospitalized patients and for the measures they are commonly held accountable for as part of their jobs.

As SHM advocates for hospitalists as the new Merit-Based Incentive Payment System (MIPS) reporting program unrolls as part of MACRA, we will keep these principles in mind: reduce administrative and reporting burdens, make metrics and their resulting data as actionable and useful as possible, and account for the important work hospitalists are doing in their facilities. As we are looking ahead at the future, we encourage you to make sure you are reporting in PQRS for 2016.

For more information about 2016 PQRS reporting, visit www.hospitalmedicine.org/pqrs. TH

Joshua Lapps is SHM’s government relations manager.

The diversity of hospitalist practice—from the variety of settings (such as inpatient acute, observation, post-discharge clinics, and post-acute-care facilities) to the differences in relationships with their facilities—is a strength of the specialty. It reflects the ability of the specialty to adapt to the unique needs of its local patients and institutions.

At the same time, it presents some unique challenges to developing strategies for identifying and assessing hospitalists. As the Medicare physician payment system moves toward value-based payment, hospitalists must report quality measures in the Physician Quality Reporting System (PQRS) or face ever-increasing penalties.

Many hospitalists are part of multispecialty groups aligned with a range of physicians employed by the same facility, including many academic hospitalists and those in integrated healthcare systems. Frequently for hospitalists in these groups, the group reports via a group-practice reporting option that uses measures for outpatient providers, capitalizing on the performances of those outpatient primary care providers in the group and making it generally unnecessary for these hospitalists to independently worry about PQRS reporting. Due to their employment model, they might also be somewhat insulated from seeing firsthand any value-based reimbursement adjustments from Medicare.

Hospitalists commonly are employed by single-specialty groups, medium or large in number of HM-focused providers, or increasingly a mix of hospitalists, emergency physicians, and hospitalists focused on skilled nursing facility (SNF) care. Still others are in small hospitalist groups or independent practitioners of hospital medicine. For these hospitalists, successful reporting of PQRS is important; they cannot rely on broad-based primary care group reporting options, and penalties can have an immediate impact on revenue streams.

PQRS, just like its hospital counterpart, the Inpatient Quality Reporting (IQR) system, was designed for use in an isolated healthcare delivery silo: PQRS was meant for physicians; IQR, for hospitals. This explicit design makes the measuring of hospitalists difficult within the current value-based payment programs because while the patient-care goals of hospitalists and their hospitals overlap, hospitalists are forced to report on physician-level metrics. Following this silo logic, the Centers for Medicare & Medicaid Services (CMS) has been removing physician-level PQRS measures that it views as redundant with facility-level IQR metrics, which has contributed to the detrimental reduction of relevant PQRS metrics for hospitalists over the years.

However, in large part due to the significant advocacy efforts of SHM around last year’s Medicare Access and CHIP Reauthorization Act (MACRA), CMS now has the ability to reverse this trend and include metrics from other programs, such as IQR metrics, as part of the quality or cost component of physician value-based payment. This would help to eliminate the artificial misalignment of quality goals and metrics for hospitalists and their facilities. Including hospital IQR metrics in the mandatory Medicare physician reporting programs would help to ensure hospitalists receive credit for the care they are providing for hospitalized patients and for the measures they are commonly held accountable for as part of their jobs.

As SHM advocates for hospitalists as the new Merit-Based Incentive Payment System (MIPS) reporting program unrolls as part of MACRA, we will keep these principles in mind: reduce administrative and reporting burdens, make metrics and their resulting data as actionable and useful as possible, and account for the important work hospitalists are doing in their facilities. As we are looking ahead at the future, we encourage you to make sure you are reporting in PQRS for 2016.

For more information about 2016 PQRS reporting, visit www.hospitalmedicine.org/pqrs. TH

Joshua Lapps is SHM’s government relations manager.

Case No. 1

A 41-year-old woman with a history of asthma presents to the emergency department (ED) with shortness of breath and wheezing. She is diagnosed with a mild asthma exacerbation. After three albuterol nebulizer treatments, she still has wheezing on physical examination but appears comfortable and has no oxygen requirement. She has a primary medical doctor at the hospital and follows up with her regularly.

The hospitalist recommends that she stay in the hospital for further treatment, but the patient says she has a nebulizer machine at home and asks to be discharged. In addition, she is worried about her frail elderly mother, for whom she is the primary caretaker. The hospitalist acknowledges her concerns but continues to recommend that she remain in the hospital for additional care and monitoring. She becomes visibly upset and insists that she must return home. She asks for prescriptions for albuterol and prednisone and is discharged against medical advice (AMA).

Case No. 2

A 52-year-old man with a history of hypertension and diabetes presents to the ED with left foot pain. He frequently presents with this complaint but often leaves AMA before treatment is completed. He has no known physical address or telephone number and has no known outpatient healthcare providers. Physical examination reveals several ulcers on the dorsum of the foot, one with purulent drainage, and generalized lower extremity pallor. His left leg is cool to the touch, and vascular surgery is consulted for suspected limb-threatening ischemia; IV antibiotics are started for suspected osteomyelitis.

During the interview, he states that he wishes to leave the hospital because he has “things to take care of.” The hospitalist recommends that he remain in the hospital for limb-preserving surgery and antibiotics. He then explains that he is homeless and needs to return to his shelter to keep his bed. He is able to articulate the risks of premature discharge and the medical concerns, and it is determined that he has the capacity to participate in discharge planning. The hospitalist therefore discharges him AMA.

Background

AMA discharges represent 1%–2% of all inpatient discharges.¹,² Despite being a small percentage of total discharges, these patients have disproportionately high healthcare costs. One study reported that healthcare costs among these patients were 56% higher than expected.² Furthermore, AMA patients suffer higher than expected rates of morbidity, mortality, and hospital readmission.

For example, in one case-control study in an urban teaching hospital, patients discharged AMA from the general medicine service had a 21% 15-day readmission rate compared to a 3% readmission rate among age, gender, and diagnosis-matched controls.^3,4,5

Additionally, history of AMA discharge appears to confer risk of increased future utilization of healthcare resources. In a cohort study of hospital admissions among HIV-infected patients with high rates of intravenous drug abuse, patients discharged AMA (13% of the cohort) were not only more likely to be readmitted within 30 days for a related diagnosis (odds ratio = 5.0) but also were more likely to have increased length of stay during the year following the index admission.⁶

These studies highlight the barriers to safe and effective transitions of care for this vulnerable population and demonstrate the increased burden that this population places on the health system.

Several retrospective studies have identified psychosocial and demographic risk factors associated with AMA discharge. These include younger age, male sex, substance abuse, lack of a primary care physician or health insurance, and history of previous AMA discharge.^1,3,7,8 Insurance status is also associated with AMA discharge, with increased odds of AMA discharge among Medicare and Medicaid patients and patients without health insurance.^9,10

Of note, one study found that race did not act as an independent predictor of AMA discharge when adjusted for age, gender, and socioeconomic factors.¹¹

The AMA population is clinically heterogeneous. Among patients with pneumonia, for example, Saitz et al showed that a patient’s documented clinical severity did not independently predict AMA discharge, suggesting that there is great clinical heterogeneity even among AMA patients with similar admission diagnoses.¹²

These studies highlight the clinical and demographic heterogeneity within this population, suggesting that patients discharged AMA require individualized attention from hospitalists and other healthcare providers.

Patients describe numerous motivations for leaving the hospital prematurely, including needing to pick up public-assistance checks, personal financial issues, and familial obligations.¹³ Interestingly, in the cohort of HIV patients referenced above, discharge on the day welfare checks were distributed was an independent predictor of AMA discharge.⁶ In focus groups composed of patients discharged AMA and their treating nurses and physicians, several themes were identified as potential contributors to AMA discharge, including drug addiction, pain management issues, external obligations, wait time, the physician’s bedside manner, being in a teaching hospital, and communication issues.¹⁴

Clearly, patients have a diversity of reasons for requesting to be discharged AMA, and further research is necessary to define clear and potentially modifiable risk factors.

Discussion

The clinical scenarios outlined above present two patients with very different clinical presentations and outpatient support systems as well as demonstrate the great variability in clinical risk at the time of discharge AMA. These examples emphasize the importance of an individualized approach to care for each patient.

In Case No. 1, the patient is admitted with a mild asthma exacerbation with persistent bronchospasm, though she clinically appears well and has reliable follow-up. In contrast, in Case No. 2, the patient has life-threatening disease and no established primary care physician or mechanism for outpatient care. These examples demonstrate extremes on the clinical and psychosocial spectrum of patients requesting an “early” discharge and suggest that no two patients at risk of AMA discharge are the same. Patient 1 could likely be safely managed at home with close outpatient follow-up, while Patient 2 presents a high-risk scenario with very few safe outpatient treatment options.

We suggest that an individualized approach be taken for each patient, with attention to both clinical and psychosocial risk. In clinically low-risk cases (e.g., Case No. 1), an approach that prioritizes shared decision making and coordination with the outpatient care team may be preferable to an AMA discharge, particularly given the often adversarial nature of the later.² In such cases, a collaborative approach may provide greater opportunity for harm reduction, provision of appropriate prescriptions, and follow-up appointments. In clinically high-risk patients such as Case No. 2, however, premature discharge is clearly inappropriate. Even in such clinically high-risk cases, however, we argue that a collaborative strategy aimed at identifying and addressing the patient’s psychosocial concerns is appropriate, as such an approach promotes shared decision making, builds trust between the patient and the care team, and therefore may facilitate improved follow-up at the time of discharge. Research is needed to formally assess the optimal approach for this patient population, including impact on rates of AMA discharge and the quality of post-discharge follow-up.

At present, the decision to classify a discharge as AMA falls solely on the treating provider, and we suspect that there is great variability in practice patterns, particularly as there are few established professional society practice guidelines regarding this difficult issue. As with all discharges from the hospital, the burden falls on the provider to engage the patient in shared decision making and ensure that the patient has the capacity to understand the risks and benefits of the proposed treatment plan. It is in this spirit that simply “filling out an AMA form” does not provide legal protection to a physician who does not adequately explain the full risks and benefits of refusal of inpatient treatment.^2,15

We propose that a high-quality AMA discharge be defined as a discharge in which the patient is informed of the clinical team’s determination that further hospitalization is required but elects to leave the hospital, and it includes a clear discussion of the risks of outpatient treatment, a determination of capacity, and an exploration of safe alternative care plans that could satisfy both the patient’s medical and social needs. This definition places the burden on hospitalists and other providers to fully explore the motivations behind a patient’s request to leave the hospital and treats psychosocial motivators for premature discharge as variables in the complex risk-benefit analysis that underlies the informed consent discussion prior to AMA discharge.

Furthermore, AMA discharge does not obviate a physician’s responsibility to advocate for a patient’s well-being, and therefore an AMA discharge should be accompanied by reasonable efforts to coordinate a patient’s ongoing outpatient care. Of note, this approach is consistent with previous reviews and attempts to balance the physician’s duty to honor a patient’s autonomy with the responsibility to protect the patient from harm.^2,16

Conclusion

Patients discharged AMA are a diverse population at markedly increased risk of morbidity, readmissions, and subsequent healthcare cost. We argue that in all cases of a potential premature discharge, a collaborative and patient-centered approach is crucial. Such an approach allows the provider to identify and address the patient’s concerns regarding further inpatient care, to explore possible safe outpatient treatment options, to document patient capacity, and to provide appropriate harm-reduction measures such as prescriptions.

Further research into the current practice patterns of hospitalists and other providers is necessary to allow for the formulation and adoption of best practices and implementation of appropriate harm-reduction strategies. TH

Dr. Tummalapalli is an internal medicine resident in the department of medicine at Icahn School of Medicine at Mount Sinai in New York City. Dr. Goodman is a hospitalist in the division of hospital medicine, department of medicine, at the Icahn School of Medicine at Mount Sinai.

References

1. Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56(5):325-327.
2. Kahle CH, Rubio ML, Santos RA. Discharges against medical advice: considerations for the hospitalist and the patient. Hospital Medicine Clinics. 2015;4(3):421-429.
3. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119(4):924-929.
4. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168(4):417-420.
5. Glasgow JM, Vaughn-Sarrazin MV, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Int Med. 2010;25(9):926-929.
6. Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O’Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002;167(6):633-637.
7. Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Int Med. 1995; 10(7);403-405.
8. O’Hara D, Hart W, McDonald I. Leaving hospital against medical advice. J Qual Clin Pract.1996;16(3):157-164.
9. Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97(12): 2204-2208.
10. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568-571.
11. Franks P, Meldrum S, Fiscella K. Discharges against medical advice: are race/ethnicity predictors? J Gen Intern Med. 2006;21(9):955-960.
12. Saitz R, Ghali WA, Moskowitz MA. Characteristics of patients with pneumonia who are discharged from hospitals against medical advice. Am J Med. 1999;107(5):507-509.
13. Alfandre, DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.
14. Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care. 2010;19(5):420-424. doi: 10.1136/qshc.2009.036269.
15. Battenfeld v. Gregory, 589 A.2d 1059, 1061 (N.J. Super. Ct. App. Div. 1991).
16. Berger J. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3(5):403-408.

Case No. 1

A 41-year-old woman with a history of asthma presents to the emergency department (ED) with shortness of breath and wheezing. She is diagnosed with a mild asthma exacerbation. After three albuterol nebulizer treatments, she still has wheezing on physical examination but appears comfortable and has no oxygen requirement. She has a primary medical doctor at the hospital and follows up with her regularly.

The hospitalist recommends that she stay in the hospital for further treatment, but the patient says she has a nebulizer machine at home and asks to be discharged. In addition, she is worried about her frail elderly mother, for whom she is the primary caretaker. The hospitalist acknowledges her concerns but continues to recommend that she remain in the hospital for additional care and monitoring. She becomes visibly upset and insists that she must return home. She asks for prescriptions for albuterol and prednisone and is discharged against medical advice (AMA).

Case No. 2

A 52-year-old man with a history of hypertension and diabetes presents to the ED with left foot pain. He frequently presents with this complaint but often leaves AMA before treatment is completed. He has no known physical address or telephone number and has no known outpatient healthcare providers. Physical examination reveals several ulcers on the dorsum of the foot, one with purulent drainage, and generalized lower extremity pallor. His left leg is cool to the touch, and vascular surgery is consulted for suspected limb-threatening ischemia; IV antibiotics are started for suspected osteomyelitis.

During the interview, he states that he wishes to leave the hospital because he has “things to take care of.” The hospitalist recommends that he remain in the hospital for limb-preserving surgery and antibiotics. He then explains that he is homeless and needs to return to his shelter to keep his bed. He is able to articulate the risks of premature discharge and the medical concerns, and it is determined that he has the capacity to participate in discharge planning. The hospitalist therefore discharges him AMA.

Background

AMA discharges represent 1%–2% of all inpatient discharges.¹,² Despite being a small percentage of total discharges, these patients have disproportionately high healthcare costs. One study reported that healthcare costs among these patients were 56% higher than expected.² Furthermore, AMA patients suffer higher than expected rates of morbidity, mortality, and hospital readmission.

For example, in one case-control study in an urban teaching hospital, patients discharged AMA from the general medicine service had a 21% 15-day readmission rate compared to a 3% readmission rate among age, gender, and diagnosis-matched controls.^3,4,5

Additionally, history of AMA discharge appears to confer risk of increased future utilization of healthcare resources. In a cohort study of hospital admissions among HIV-infected patients with high rates of intravenous drug abuse, patients discharged AMA (13% of the cohort) were not only more likely to be readmitted within 30 days for a related diagnosis (odds ratio = 5.0) but also were more likely to have increased length of stay during the year following the index admission.⁶

These studies highlight the barriers to safe and effective transitions of care for this vulnerable population and demonstrate the increased burden that this population places on the health system.

Several retrospective studies have identified psychosocial and demographic risk factors associated with AMA discharge. These include younger age, male sex, substance abuse, lack of a primary care physician or health insurance, and history of previous AMA discharge.^1,3,7,8 Insurance status is also associated with AMA discharge, with increased odds of AMA discharge among Medicare and Medicaid patients and patients without health insurance.^9,10

Of note, one study found that race did not act as an independent predictor of AMA discharge when adjusted for age, gender, and socioeconomic factors.¹¹

The AMA population is clinically heterogeneous. Among patients with pneumonia, for example, Saitz et al showed that a patient’s documented clinical severity did not independently predict AMA discharge, suggesting that there is great clinical heterogeneity even among AMA patients with similar admission diagnoses.¹²

These studies highlight the clinical and demographic heterogeneity within this population, suggesting that patients discharged AMA require individualized attention from hospitalists and other healthcare providers.

Patients describe numerous motivations for leaving the hospital prematurely, including needing to pick up public-assistance checks, personal financial issues, and familial obligations.¹³ Interestingly, in the cohort of HIV patients referenced above, discharge on the day welfare checks were distributed was an independent predictor of AMA discharge.⁶ In focus groups composed of patients discharged AMA and their treating nurses and physicians, several themes were identified as potential contributors to AMA discharge, including drug addiction, pain management issues, external obligations, wait time, the physician’s bedside manner, being in a teaching hospital, and communication issues.¹⁴

Clearly, patients have a diversity of reasons for requesting to be discharged AMA, and further research is necessary to define clear and potentially modifiable risk factors.

Discussion

The clinical scenarios outlined above present two patients with very different clinical presentations and outpatient support systems as well as demonstrate the great variability in clinical risk at the time of discharge AMA. These examples emphasize the importance of an individualized approach to care for each patient.

In Case No. 1, the patient is admitted with a mild asthma exacerbation with persistent bronchospasm, though she clinically appears well and has reliable follow-up. In contrast, in Case No. 2, the patient has life-threatening disease and no established primary care physician or mechanism for outpatient care. These examples demonstrate extremes on the clinical and psychosocial spectrum of patients requesting an “early” discharge and suggest that no two patients at risk of AMA discharge are the same. Patient 1 could likely be safely managed at home with close outpatient follow-up, while Patient 2 presents a high-risk scenario with very few safe outpatient treatment options.

We suggest that an individualized approach be taken for each patient, with attention to both clinical and psychosocial risk. In clinically low-risk cases (e.g., Case No. 1), an approach that prioritizes shared decision making and coordination with the outpatient care team may be preferable to an AMA discharge, particularly given the often adversarial nature of the later.² In such cases, a collaborative approach may provide greater opportunity for harm reduction, provision of appropriate prescriptions, and follow-up appointments. In clinically high-risk patients such as Case No. 2, however, premature discharge is clearly inappropriate. Even in such clinically high-risk cases, however, we argue that a collaborative strategy aimed at identifying and addressing the patient’s psychosocial concerns is appropriate, as such an approach promotes shared decision making, builds trust between the patient and the care team, and therefore may facilitate improved follow-up at the time of discharge. Research is needed to formally assess the optimal approach for this patient population, including impact on rates of AMA discharge and the quality of post-discharge follow-up.

At present, the decision to classify a discharge as AMA falls solely on the treating provider, and we suspect that there is great variability in practice patterns, particularly as there are few established professional society practice guidelines regarding this difficult issue. As with all discharges from the hospital, the burden falls on the provider to engage the patient in shared decision making and ensure that the patient has the capacity to understand the risks and benefits of the proposed treatment plan. It is in this spirit that simply “filling out an AMA form” does not provide legal protection to a physician who does not adequately explain the full risks and benefits of refusal of inpatient treatment.^2,15

We propose that a high-quality AMA discharge be defined as a discharge in which the patient is informed of the clinical team’s determination that further hospitalization is required but elects to leave the hospital, and it includes a clear discussion of the risks of outpatient treatment, a determination of capacity, and an exploration of safe alternative care plans that could satisfy both the patient’s medical and social needs. This definition places the burden on hospitalists and other providers to fully explore the motivations behind a patient’s request to leave the hospital and treats psychosocial motivators for premature discharge as variables in the complex risk-benefit analysis that underlies the informed consent discussion prior to AMA discharge.

Furthermore, AMA discharge does not obviate a physician’s responsibility to advocate for a patient’s well-being, and therefore an AMA discharge should be accompanied by reasonable efforts to coordinate a patient’s ongoing outpatient care. Of note, this approach is consistent with previous reviews and attempts to balance the physician’s duty to honor a patient’s autonomy with the responsibility to protect the patient from harm.^2,16

Conclusion

Patients discharged AMA are a diverse population at markedly increased risk of morbidity, readmissions, and subsequent healthcare cost. We argue that in all cases of a potential premature discharge, a collaborative and patient-centered approach is crucial. Such an approach allows the provider to identify and address the patient’s concerns regarding further inpatient care, to explore possible safe outpatient treatment options, to document patient capacity, and to provide appropriate harm-reduction measures such as prescriptions.

Further research into the current practice patterns of hospitalists and other providers is necessary to allow for the formulation and adoption of best practices and implementation of appropriate harm-reduction strategies. TH

Dr. Tummalapalli is an internal medicine resident in the department of medicine at Icahn School of Medicine at Mount Sinai in New York City. Dr. Goodman is a hospitalist in the division of hospital medicine, department of medicine, at the Icahn School of Medicine at Mount Sinai.

References

1. Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56(5):325-327.
2. Kahle CH, Rubio ML, Santos RA. Discharges against medical advice: considerations for the hospitalist and the patient. Hospital Medicine Clinics. 2015;4(3):421-429.
3. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119(4):924-929.
4. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168(4):417-420.
5. Glasgow JM, Vaughn-Sarrazin MV, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Int Med. 2010;25(9):926-929.
6. Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O’Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002;167(6):633-637.
7. Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Int Med. 1995; 10(7);403-405.
8. O’Hara D, Hart W, McDonald I. Leaving hospital against medical advice. J Qual Clin Pract.1996;16(3):157-164.
9. Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97(12): 2204-2208.
10. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568-571.
11. Franks P, Meldrum S, Fiscella K. Discharges against medical advice: are race/ethnicity predictors? J Gen Intern Med. 2006;21(9):955-960.
12. Saitz R, Ghali WA, Moskowitz MA. Characteristics of patients with pneumonia who are discharged from hospitals against medical advice. Am J Med. 1999;107(5):507-509.
13. Alfandre, DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.
14. Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care. 2010;19(5):420-424. doi: 10.1136/qshc.2009.036269.
15. Battenfeld v. Gregory, 589 A.2d 1059, 1061 (N.J. Super. Ct. App. Div. 1991).
16. Berger J. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3(5):403-408.

Case No. 1

A 41-year-old woman with a history of asthma presents to the emergency department (ED) with shortness of breath and wheezing. She is diagnosed with a mild asthma exacerbation. After three albuterol nebulizer treatments, she still has wheezing on physical examination but appears comfortable and has no oxygen requirement. She has a primary medical doctor at the hospital and follows up with her regularly.

The hospitalist recommends that she stay in the hospital for further treatment, but the patient says she has a nebulizer machine at home and asks to be discharged. In addition, she is worried about her frail elderly mother, for whom she is the primary caretaker. The hospitalist acknowledges her concerns but continues to recommend that she remain in the hospital for additional care and monitoring. She becomes visibly upset and insists that she must return home. She asks for prescriptions for albuterol and prednisone and is discharged against medical advice (AMA).

Case No. 2

A 52-year-old man with a history of hypertension and diabetes presents to the ED with left foot pain. He frequently presents with this complaint but often leaves AMA before treatment is completed. He has no known physical address or telephone number and has no known outpatient healthcare providers. Physical examination reveals several ulcers on the dorsum of the foot, one with purulent drainage, and generalized lower extremity pallor. His left leg is cool to the touch, and vascular surgery is consulted for suspected limb-threatening ischemia; IV antibiotics are started for suspected osteomyelitis.

During the interview, he states that he wishes to leave the hospital because he has “things to take care of.” The hospitalist recommends that he remain in the hospital for limb-preserving surgery and antibiotics. He then explains that he is homeless and needs to return to his shelter to keep his bed. He is able to articulate the risks of premature discharge and the medical concerns, and it is determined that he has the capacity to participate in discharge planning. The hospitalist therefore discharges him AMA.

Background

AMA discharges represent 1%–2% of all inpatient discharges.¹,² Despite being a small percentage of total discharges, these patients have disproportionately high healthcare costs. One study reported that healthcare costs among these patients were 56% higher than expected.² Furthermore, AMA patients suffer higher than expected rates of morbidity, mortality, and hospital readmission.

For example, in one case-control study in an urban teaching hospital, patients discharged AMA from the general medicine service had a 21% 15-day readmission rate compared to a 3% readmission rate among age, gender, and diagnosis-matched controls.^3,4,5

Additionally, history of AMA discharge appears to confer risk of increased future utilization of healthcare resources. In a cohort study of hospital admissions among HIV-infected patients with high rates of intravenous drug abuse, patients discharged AMA (13% of the cohort) were not only more likely to be readmitted within 30 days for a related diagnosis (odds ratio = 5.0) but also were more likely to have increased length of stay during the year following the index admission.⁶

These studies highlight the barriers to safe and effective transitions of care for this vulnerable population and demonstrate the increased burden that this population places on the health system.

Several retrospective studies have identified psychosocial and demographic risk factors associated with AMA discharge. These include younger age, male sex, substance abuse, lack of a primary care physician or health insurance, and history of previous AMA discharge.^1,3,7,8 Insurance status is also associated with AMA discharge, with increased odds of AMA discharge among Medicare and Medicaid patients and patients without health insurance.^9,10

Of note, one study found that race did not act as an independent predictor of AMA discharge when adjusted for age, gender, and socioeconomic factors.¹¹

The AMA population is clinically heterogeneous. Among patients with pneumonia, for example, Saitz et al showed that a patient’s documented clinical severity did not independently predict AMA discharge, suggesting that there is great clinical heterogeneity even among AMA patients with similar admission diagnoses.¹²

These studies highlight the clinical and demographic heterogeneity within this population, suggesting that patients discharged AMA require individualized attention from hospitalists and other healthcare providers.

Patients describe numerous motivations for leaving the hospital prematurely, including needing to pick up public-assistance checks, personal financial issues, and familial obligations.¹³ Interestingly, in the cohort of HIV patients referenced above, discharge on the day welfare checks were distributed was an independent predictor of AMA discharge.⁶ In focus groups composed of patients discharged AMA and their treating nurses and physicians, several themes were identified as potential contributors to AMA discharge, including drug addiction, pain management issues, external obligations, wait time, the physician’s bedside manner, being in a teaching hospital, and communication issues.¹⁴

Clearly, patients have a diversity of reasons for requesting to be discharged AMA, and further research is necessary to define clear and potentially modifiable risk factors.

Discussion

The clinical scenarios outlined above present two patients with very different clinical presentations and outpatient support systems as well as demonstrate the great variability in clinical risk at the time of discharge AMA. These examples emphasize the importance of an individualized approach to care for each patient.

In Case No. 1, the patient is admitted with a mild asthma exacerbation with persistent bronchospasm, though she clinically appears well and has reliable follow-up. In contrast, in Case No. 2, the patient has life-threatening disease and no established primary care physician or mechanism for outpatient care. These examples demonstrate extremes on the clinical and psychosocial spectrum of patients requesting an “early” discharge and suggest that no two patients at risk of AMA discharge are the same. Patient 1 could likely be safely managed at home with close outpatient follow-up, while Patient 2 presents a high-risk scenario with very few safe outpatient treatment options.

We suggest that an individualized approach be taken for each patient, with attention to both clinical and psychosocial risk. In clinically low-risk cases (e.g., Case No. 1), an approach that prioritizes shared decision making and coordination with the outpatient care team may be preferable to an AMA discharge, particularly given the often adversarial nature of the later.² In such cases, a collaborative approach may provide greater opportunity for harm reduction, provision of appropriate prescriptions, and follow-up appointments. In clinically high-risk patients such as Case No. 2, however, premature discharge is clearly inappropriate. Even in such clinically high-risk cases, however, we argue that a collaborative strategy aimed at identifying and addressing the patient’s psychosocial concerns is appropriate, as such an approach promotes shared decision making, builds trust between the patient and the care team, and therefore may facilitate improved follow-up at the time of discharge. Research is needed to formally assess the optimal approach for this patient population, including impact on rates of AMA discharge and the quality of post-discharge follow-up.

At present, the decision to classify a discharge as AMA falls solely on the treating provider, and we suspect that there is great variability in practice patterns, particularly as there are few established professional society practice guidelines regarding this difficult issue. As with all discharges from the hospital, the burden falls on the provider to engage the patient in shared decision making and ensure that the patient has the capacity to understand the risks and benefits of the proposed treatment plan. It is in this spirit that simply “filling out an AMA form” does not provide legal protection to a physician who does not adequately explain the full risks and benefits of refusal of inpatient treatment.^2,15

We propose that a high-quality AMA discharge be defined as a discharge in which the patient is informed of the clinical team’s determination that further hospitalization is required but elects to leave the hospital, and it includes a clear discussion of the risks of outpatient treatment, a determination of capacity, and an exploration of safe alternative care plans that could satisfy both the patient’s medical and social needs. This definition places the burden on hospitalists and other providers to fully explore the motivations behind a patient’s request to leave the hospital and treats psychosocial motivators for premature discharge as variables in the complex risk-benefit analysis that underlies the informed consent discussion prior to AMA discharge.

Furthermore, AMA discharge does not obviate a physician’s responsibility to advocate for a patient’s well-being, and therefore an AMA discharge should be accompanied by reasonable efforts to coordinate a patient’s ongoing outpatient care. Of note, this approach is consistent with previous reviews and attempts to balance the physician’s duty to honor a patient’s autonomy with the responsibility to protect the patient from harm.^2,16

Conclusion

Patients discharged AMA are a diverse population at markedly increased risk of morbidity, readmissions, and subsequent healthcare cost. We argue that in all cases of a potential premature discharge, a collaborative and patient-centered approach is crucial. Such an approach allows the provider to identify and address the patient’s concerns regarding further inpatient care, to explore possible safe outpatient treatment options, to document patient capacity, and to provide appropriate harm-reduction measures such as prescriptions.

Further research into the current practice patterns of hospitalists and other providers is necessary to allow for the formulation and adoption of best practices and implementation of appropriate harm-reduction strategies. TH

Dr. Tummalapalli is an internal medicine resident in the department of medicine at Icahn School of Medicine at Mount Sinai in New York City. Dr. Goodman is a hospitalist in the division of hospital medicine, department of medicine, at the Icahn School of Medicine at Mount Sinai.

References

1. Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56(5):325-327.
2. Kahle CH, Rubio ML, Santos RA. Discharges against medical advice: considerations for the hospitalist and the patient. Hospital Medicine Clinics. 2015;4(3):421-429.
3. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119(4):924-929.
4. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168(4):417-420.
5. Glasgow JM, Vaughn-Sarrazin MV, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Int Med. 2010;25(9):926-929.
6. Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O’Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002;167(6):633-637.
7. Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Int Med. 1995; 10(7);403-405.
8. O’Hara D, Hart W, McDonald I. Leaving hospital against medical advice. J Qual Clin Pract.1996;16(3):157-164.
9. Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97(12): 2204-2208.
10. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568-571.
11. Franks P, Meldrum S, Fiscella K. Discharges against medical advice: are race/ethnicity predictors? J Gen Intern Med. 2006;21(9):955-960.
12. Saitz R, Ghali WA, Moskowitz MA. Characteristics of patients with pneumonia who are discharged from hospitals against medical advice. Am J Med. 1999;107(5):507-509.
13. Alfandre, DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.
14. Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care. 2010;19(5):420-424. doi: 10.1136/qshc.2009.036269.
15. Battenfeld v. Gregory, 589 A.2d 1059, 1061 (N.J. Super. Ct. App. Div. 1991).
16. Berger J. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3(5):403-408.