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Clinical question: Can a trigger tool identify harms for hospitalized children?

Background: An estimated 400,000 people die annually in the United States as a result of hospital-associated harm. The Centers for Medicare and Medicaid Services define harm as “unintended physical injury … by medical care that required additional monitoring, treatment, or hospitalization or that resulted in death.” Although harm is common, voluntary reporting of events has been shown to capture only 2%-8% of harm. Global Trigger Tools (GTT) are an alternative to voluntary reports. These tools use “triggers,” or clues, to help reviewers identify potential harms when reviewing the electronic heath record. The Institute for Healthcare Improvement (IHI) has created an adult-focused GTT; however, no pediatric-focused GTT exists.

Study design: Cross-sectional, retrospective chart review.

Setting: Children <22 years old discharged from six freestanding U.S. children’s hospitals in February 2012.

Synopsis: In a prior paper, the authors described how they used a modified Delphi technique to develop a pediatric GTT based upon the IHI GTT. Here they piloted this new pediatric-focused GTT through a retrospective chart review. One clinical nonphysician reviewer and one physician reviewer were selected from each site and received training on use of the pediatric GTT and the identification of harms. One hundred charts from each site were randomly selected for application of the GTT. The reviewers examined the charts for harms and then applied the GTT. When reviewers found a harm, they determined the likelihood that the harm was preventable.

Of the 600 records reviewed, 240 harms were found. The GTT identified 1,093 potential harms, leading to identification of 204 harms. The remaining 36 harms did not cause a trigger and were found by chart review. The positive predictive value of the aggregate GTT was 22%. There were 40 harms per 100 patients, and 24.3% of patients had one or more harm. Sixty-eight percent of harms were of the least severe type, and only one led to a patient death. The most common harms were intravenous catheter infiltration, respiratory distress, constipation, pain, and surgical complications.

Bottom line: The pediatric GTT appears to be a moderately sensitive indicator for inpatient pediatric harm. Inpatient pediatric harm occurs frequently, with about one in four pediatric inpatients suffering from harm. Serious harm appears uncommon.

Citation: Stockwell DC, Bisarya H, Classen DC, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):1036-1042.

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Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: Can a trigger tool identify harms for hospitalized children?

Background: An estimated 400,000 people die annually in the United States as a result of hospital-associated harm. The Centers for Medicare and Medicaid Services define harm as “unintended physical injury … by medical care that required additional monitoring, treatment, or hospitalization or that resulted in death.” Although harm is common, voluntary reporting of events has been shown to capture only 2%-8% of harm. Global Trigger Tools (GTT) are an alternative to voluntary reports. These tools use “triggers,” or clues, to help reviewers identify potential harms when reviewing the electronic heath record. The Institute for Healthcare Improvement (IHI) has created an adult-focused GTT; however, no pediatric-focused GTT exists.

Study design: Cross-sectional, retrospective chart review.

Setting: Children <22 years old discharged from six freestanding U.S. children’s hospitals in February 2012.

Synopsis: In a prior paper, the authors described how they used a modified Delphi technique to develop a pediatric GTT based upon the IHI GTT. Here they piloted this new pediatric-focused GTT through a retrospective chart review. One clinical nonphysician reviewer and one physician reviewer were selected from each site and received training on use of the pediatric GTT and the identification of harms. One hundred charts from each site were randomly selected for application of the GTT. The reviewers examined the charts for harms and then applied the GTT. When reviewers found a harm, they determined the likelihood that the harm was preventable.

Of the 600 records reviewed, 240 harms were found. The GTT identified 1,093 potential harms, leading to identification of 204 harms. The remaining 36 harms did not cause a trigger and were found by chart review. The positive predictive value of the aggregate GTT was 22%. There were 40 harms per 100 patients, and 24.3% of patients had one or more harm. Sixty-eight percent of harms were of the least severe type, and only one led to a patient death. The most common harms were intravenous catheter infiltration, respiratory distress, constipation, pain, and surgical complications.

Bottom line: The pediatric GTT appears to be a moderately sensitive indicator for inpatient pediatric harm. Inpatient pediatric harm occurs frequently, with about one in four pediatric inpatients suffering from harm. Serious harm appears uncommon.

Citation: Stockwell DC, Bisarya H, Classen DC, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):1036-1042.

---

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: Can a trigger tool identify harms for hospitalized children?

Background: An estimated 400,000 people die annually in the United States as a result of hospital-associated harm. The Centers for Medicare and Medicaid Services define harm as “unintended physical injury … by medical care that required additional monitoring, treatment, or hospitalization or that resulted in death.” Although harm is common, voluntary reporting of events has been shown to capture only 2%-8% of harm. Global Trigger Tools (GTT) are an alternative to voluntary reports. These tools use “triggers,” or clues, to help reviewers identify potential harms when reviewing the electronic heath record. The Institute for Healthcare Improvement (IHI) has created an adult-focused GTT; however, no pediatric-focused GTT exists.

Study design: Cross-sectional, retrospective chart review.

Setting: Children <22 years old discharged from six freestanding U.S. children’s hospitals in February 2012.

Synopsis: In a prior paper, the authors described how they used a modified Delphi technique to develop a pediatric GTT based upon the IHI GTT. Here they piloted this new pediatric-focused GTT through a retrospective chart review. One clinical nonphysician reviewer and one physician reviewer were selected from each site and received training on use of the pediatric GTT and the identification of harms. One hundred charts from each site were randomly selected for application of the GTT. The reviewers examined the charts for harms and then applied the GTT. When reviewers found a harm, they determined the likelihood that the harm was preventable.

Of the 600 records reviewed, 240 harms were found. The GTT identified 1,093 potential harms, leading to identification of 204 harms. The remaining 36 harms did not cause a trigger and were found by chart review. The positive predictive value of the aggregate GTT was 22%. There were 40 harms per 100 patients, and 24.3% of patients had one or more harm. Sixty-eight percent of harms were of the least severe type, and only one led to a patient death. The most common harms were intravenous catheter infiltration, respiratory distress, constipation, pain, and surgical complications.

Bottom line: The pediatric GTT appears to be a moderately sensitive indicator for inpatient pediatric harm. Inpatient pediatric harm occurs frequently, with about one in four pediatric inpatients suffering from harm. Serious harm appears uncommon.

Citation: Stockwell DC, Bisarya H, Classen DC, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):1036-1042.

---

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: Can we dignify death in the ICU and ease the grieving process by soliciting wishes from patients, families, and care team members?

Background: The death of the critically ill patient in the ICU can be dehumanizing and overwhelming for the patient’s family and friends, leading to prolonged physical and psychological stress. These deaths might have similar effects on the clinicians caring for the patients.

Study design: Mixed methods.

Setting: Medical-surgical ICU at a 21-bed, academic tertiary medical center in Ontario, Canada.

Synopsis: Semi-structured interviews were conducted with at least one family member and three clinicians per patient. A total of 40 patients were screened and deemed eligible for inclusion. Only seven patients were able to provide input on the wishes or interviews; the others had impaired consciousness. The team obtained 163 wishes from those individuals, and was able to implement 159 of them (97.5%). At least three wishes from each patient-family dyad were implemented.

The wishes were classified into five categories:

• Humanizing the environment;
• Personal tributes;
• Family reconnections;
• Rituals and observances; and
• Paying it forward.

These wishes were implemented before (51.6%) and after (48.4%) death and were generally inexpensive (less than $200 per patient).

From the 160 interviews of 170 individuals, the central theme that emerged was personalization of the dying process in the ICU through three related domains: dignifying the patient, giving the family a voice, and fostering clinician compassion.

The 3 Wishes Project provides a framework to foster discussion among care team members and families to ensure personalization and dignity in the dying process.

Bottom line: Solicitation of wishes from dying patients, their families, and their care team members can have a positive impact by allowing individualized end-of-life care.

Citation: Cook D, Swinton M, Toledo F, et al. Personalizing death in the intensive care unit: the 3 Wishes Project: a mixed-methods study. Ann Intern Med. 2015;163(4):271-279.

Clinical question: Can we dignify death in the ICU and ease the grieving process by soliciting wishes from patients, families, and care team members?

Background: The death of the critically ill patient in the ICU can be dehumanizing and overwhelming for the patient’s family and friends, leading to prolonged physical and psychological stress. These deaths might have similar effects on the clinicians caring for the patients.

Study design: Mixed methods.

Setting: Medical-surgical ICU at a 21-bed, academic tertiary medical center in Ontario, Canada.

Synopsis: Semi-structured interviews were conducted with at least one family member and three clinicians per patient. A total of 40 patients were screened and deemed eligible for inclusion. Only seven patients were able to provide input on the wishes or interviews; the others had impaired consciousness. The team obtained 163 wishes from those individuals, and was able to implement 159 of them (97.5%). At least three wishes from each patient-family dyad were implemented.

The wishes were classified into five categories:

• Humanizing the environment;
• Personal tributes;
• Family reconnections;
• Rituals and observances; and
• Paying it forward.

These wishes were implemented before (51.6%) and after (48.4%) death and were generally inexpensive (less than $200 per patient).

From the 160 interviews of 170 individuals, the central theme that emerged was personalization of the dying process in the ICU through three related domains: dignifying the patient, giving the family a voice, and fostering clinician compassion.

The 3 Wishes Project provides a framework to foster discussion among care team members and families to ensure personalization and dignity in the dying process.

Bottom line: Solicitation of wishes from dying patients, their families, and their care team members can have a positive impact by allowing individualized end-of-life care.

Citation: Cook D, Swinton M, Toledo F, et al. Personalizing death in the intensive care unit: the 3 Wishes Project: a mixed-methods study. Ann Intern Med. 2015;163(4):271-279.

Clinical question: Can we dignify death in the ICU and ease the grieving process by soliciting wishes from patients, families, and care team members?

Background: The death of the critically ill patient in the ICU can be dehumanizing and overwhelming for the patient’s family and friends, leading to prolonged physical and psychological stress. These deaths might have similar effects on the clinicians caring for the patients.

Study design: Mixed methods.

Setting: Medical-surgical ICU at a 21-bed, academic tertiary medical center in Ontario, Canada.

Synopsis: Semi-structured interviews were conducted with at least one family member and three clinicians per patient. A total of 40 patients were screened and deemed eligible for inclusion. Only seven patients were able to provide input on the wishes or interviews; the others had impaired consciousness. The team obtained 163 wishes from those individuals, and was able to implement 159 of them (97.5%). At least three wishes from each patient-family dyad were implemented.

The wishes were classified into five categories:

• Humanizing the environment;
• Personal tributes;
• Family reconnections;
• Rituals and observances; and
• Paying it forward.

These wishes were implemented before (51.6%) and after (48.4%) death and were generally inexpensive (less than $200 per patient).

From the 160 interviews of 170 individuals, the central theme that emerged was personalization of the dying process in the ICU through three related domains: dignifying the patient, giving the family a voice, and fostering clinician compassion.

The 3 Wishes Project provides a framework to foster discussion among care team members and families to ensure personalization and dignity in the dying process.

Bottom line: Solicitation of wishes from dying patients, their families, and their care team members can have a positive impact by allowing individualized end-of-life care.

Citation: Cook D, Swinton M, Toledo F, et al. Personalizing death in the intensive care unit: the 3 Wishes Project: a mixed-methods study. Ann Intern Med. 2015;163(4):271-279.

NEW YORK  - Health care professionals should be highly suspicious of megacolon in Clostridium difficile-infected patients and have a low threshold for transferring infected patients to intensive care units, Veterans Affairs researchers warn.

"The incidence of Clostridium difficile-associated megacolon has nearly tripled and mortality has nearly doubled over the past decade," Dr. SreyRam Kuy from the Overton Brooks VA Medical Center in Shreveport, Louisiana, said by email.

"It could be argued that this increased incidence may be due in part to improvements in detection of Clostridium difficile," she said. "However, this increase over the past decade . . . correlates with prior work by the Agency for Healthcare Research and Quality, which showed a 74% increase in the overall number of hospital discharges with Clostridium difficile infections from 1993-2001, in the decade prior to our study."

Dr. Kuy and colleagues analyzed records in the Nationwide Inpatient Sample (2000-2010) and identified patients with both C. difficile infection and megacolon.

They identified 28,219 cases of C. difficile infection, or 0.38% of all hospitalized patients, in 2000. That grew to more than 68,600 cases, or 0.88% of hospitalized patients, in 2010.

While the overall incidence of megacolon remained steady at 0.02% of hospitalized patients from 2000 to 2010, the rate of megacolon cases tied to C. diff infection increased from 3.61% in 2000 to 9.39% in 2010 (p<0.05).

"Compared with patients with megacolon but without C. difficile infection, patients with C. difficile-associated megacolon are significantly older, are more likely to have an urgent or emergent admission, are more likely to be admitted from the emergency department or transferred from another hospital, and are more likely to be treated at large, urban, teaching hospitals," the researchers write in an article online Oct. 7 in JAMA Surgery.

They report that the mean length of hospital stay for patients with C. difficile-associated megacolon was 16.13 days, the mean cost of hospitalization came to $41,968, and 50.7% required transitional care after hospital discharge. The mortality among these patients went up from 13.56% in 2000 to 24.45% in 2010, and peaked at 30.03% in 2007 (p<0.05).

"The rise in mortality is also alarming," Dr. Kuy said. "Potentially, this rise in mortality could be attributed to changes in virulence of Clostridium difficile strains, though we are unable to determine this due to limitations of the dataset utilized for this research. Other factors that can affect mortality are antibiotic regimen, severity of disease, physical exam findings, immunosuppression, presence of end organ failure, patient frailty status, APACHE (Acute Physiology and Chronic Health Evaluation) score, signs of sepsis, and leukocytosis, which have been identified as factors associated with mortality in prior published reports."

"This study draws attention to the tremendous burden of Clostridium difficile on patient mortality, health care costs and resources, transitional care utilization, and the extremely important need for aggressive prevention of this iatrogenic disease," she concluded.

The authors reported no funding or disclosures.

NEW YORK  - Health care professionals should be highly suspicious of megacolon in Clostridium difficile-infected patients and have a low threshold for transferring infected patients to intensive care units, Veterans Affairs researchers warn.

"The incidence of Clostridium difficile-associated megacolon has nearly tripled and mortality has nearly doubled over the past decade," Dr. SreyRam Kuy from the Overton Brooks VA Medical Center in Shreveport, Louisiana, said by email.

"It could be argued that this increased incidence may be due in part to improvements in detection of Clostridium difficile," she said. "However, this increase over the past decade . . . correlates with prior work by the Agency for Healthcare Research and Quality, which showed a 74% increase in the overall number of hospital discharges with Clostridium difficile infections from 1993-2001, in the decade prior to our study."

Dr. Kuy and colleagues analyzed records in the Nationwide Inpatient Sample (2000-2010) and identified patients with both C. difficile infection and megacolon.

They identified 28,219 cases of C. difficile infection, or 0.38% of all hospitalized patients, in 2000. That grew to more than 68,600 cases, or 0.88% of hospitalized patients, in 2010.

While the overall incidence of megacolon remained steady at 0.02% of hospitalized patients from 2000 to 2010, the rate of megacolon cases tied to C. diff infection increased from 3.61% in 2000 to 9.39% in 2010 (p<0.05).

"Compared with patients with megacolon but without C. difficile infection, patients with C. difficile-associated megacolon are significantly older, are more likely to have an urgent or emergent admission, are more likely to be admitted from the emergency department or transferred from another hospital, and are more likely to be treated at large, urban, teaching hospitals," the researchers write in an article online Oct. 7 in JAMA Surgery.

They report that the mean length of hospital stay for patients with C. difficile-associated megacolon was 16.13 days, the mean cost of hospitalization came to $41,968, and 50.7% required transitional care after hospital discharge. The mortality among these patients went up from 13.56% in 2000 to 24.45% in 2010, and peaked at 30.03% in 2007 (p<0.05).

"The rise in mortality is also alarming," Dr. Kuy said. "Potentially, this rise in mortality could be attributed to changes in virulence of Clostridium difficile strains, though we are unable to determine this due to limitations of the dataset utilized for this research. Other factors that can affect mortality are antibiotic regimen, severity of disease, physical exam findings, immunosuppression, presence of end organ failure, patient frailty status, APACHE (Acute Physiology and Chronic Health Evaluation) score, signs of sepsis, and leukocytosis, which have been identified as factors associated with mortality in prior published reports."

"This study draws attention to the tremendous burden of Clostridium difficile on patient mortality, health care costs and resources, transitional care utilization, and the extremely important need for aggressive prevention of this iatrogenic disease," she concluded.

The authors reported no funding or disclosures.

NEW YORK  - Health care professionals should be highly suspicious of megacolon in Clostridium difficile-infected patients and have a low threshold for transferring infected patients to intensive care units, Veterans Affairs researchers warn.

"The incidence of Clostridium difficile-associated megacolon has nearly tripled and mortality has nearly doubled over the past decade," Dr. SreyRam Kuy from the Overton Brooks VA Medical Center in Shreveport, Louisiana, said by email.

"It could be argued that this increased incidence may be due in part to improvements in detection of Clostridium difficile," she said. "However, this increase over the past decade . . . correlates with prior work by the Agency for Healthcare Research and Quality, which showed a 74% increase in the overall number of hospital discharges with Clostridium difficile infections from 1993-2001, in the decade prior to our study."

Dr. Kuy and colleagues analyzed records in the Nationwide Inpatient Sample (2000-2010) and identified patients with both C. difficile infection and megacolon.

They identified 28,219 cases of C. difficile infection, or 0.38% of all hospitalized patients, in 2000. That grew to more than 68,600 cases, or 0.88% of hospitalized patients, in 2010.

While the overall incidence of megacolon remained steady at 0.02% of hospitalized patients from 2000 to 2010, the rate of megacolon cases tied to C. diff infection increased from 3.61% in 2000 to 9.39% in 2010 (p<0.05).

"Compared with patients with megacolon but without C. difficile infection, patients with C. difficile-associated megacolon are significantly older, are more likely to have an urgent or emergent admission, are more likely to be admitted from the emergency department or transferred from another hospital, and are more likely to be treated at large, urban, teaching hospitals," the researchers write in an article online Oct. 7 in JAMA Surgery.

They report that the mean length of hospital stay for patients with C. difficile-associated megacolon was 16.13 days, the mean cost of hospitalization came to $41,968, and 50.7% required transitional care after hospital discharge. The mortality among these patients went up from 13.56% in 2000 to 24.45% in 2010, and peaked at 30.03% in 2007 (p<0.05).

"The rise in mortality is also alarming," Dr. Kuy said. "Potentially, this rise in mortality could be attributed to changes in virulence of Clostridium difficile strains, though we are unable to determine this due to limitations of the dataset utilized for this research. Other factors that can affect mortality are antibiotic regimen, severity of disease, physical exam findings, immunosuppression, presence of end organ failure, patient frailty status, APACHE (Acute Physiology and Chronic Health Evaluation) score, signs of sepsis, and leukocytosis, which have been identified as factors associated with mortality in prior published reports."

"This study draws attention to the tremendous burden of Clostridium difficile on patient mortality, health care costs and resources, transitional care utilization, and the extremely important need for aggressive prevention of this iatrogenic disease," she concluded.

The authors reported no funding or disclosures.

NEW YORK - Most, but not all, guideline-recommended drugs and their combinations yield modest survival benefits in older adults with multiple chronic medical conditions, researchers report.

"Until there is better evidence in older adults with multiple chronic conditions, clinicians need to take a more thoughtful and nuanced approach to medication prescribing," Dr. Mary E. Tinetti from Yale School of Medicine, New Haven, Connecticut said by email. "This is particularly supported by the fact that outside of perhaps anticoagulation for atrial fibrillation, the magnitude of benefit for most of these medications is quite modest."

Nearly 40% of adults 65 years and older take at least five prescription medications, but the benefits of drugs prescribed for a single condition are difficult to ascertain in the

presence of multiple conditions and drugs.

Dr. Tinetti and colleagues used data from the Medicare Current Beneficiary Survey to estimate the association between nine guideline-recommended and commonly prescribed drugs and death in more than 8,500 Medicare participants (mean age, 77.4 years).

The nine drugs included beta-blockers; calcium channel blockers; clopidogrel; metformin; renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazide diuretics; and warfarin.

The most common medical conditions included hypertension, hyperlipidemia, diabetes, and coronary artery disease, the researchers report in The BMJ, online Oct. 2. More than half of the participants took at least three of the nine study drugs, and the mean number of total drugs was 10.0.

The benefits on survival of beta-blockers, calcium channel blockers, RAS blockers, statins, and warfarin were comparable to those reported in randomized controlled trials, although for beta-blockers and warfarin they varied according to coexisting conditions.

Clopidogrel, metformin, and SSRIs/SNRIs, however, were not associated with survival benefits.

The association between drug use and mortality risk was generally similar across patterns of coexisting conditions, suggesting to the researchers "that benefits often remain despite comorbidity."

"Research focused on identifying the medications that have the greatest benefit (defined by patient's outcomes priority such as improved symptoms, optimal physical or cognitive function, or survival) and least harm for key subpopulations of individuals with varying combinations of coexisting conditions should be a top priority," Dr. Tinetti said. "Ironically, although these are the major users of health care, they have largely been ignored in research."

"Many individuals, although they have many conditions, only one or two are really affecting the outcomes that matter most to them," Dr. Tinetti said. "Therefore, medication regimens can be simplified by eliminating medications for conditions that are not likely to benefit the individuals outcome priority, such as improved symptoms, optimal physical or cognitive function, or simplified treatment regimens."

"We know that about one in five individuals are currently receiving guideline-recommended medications for one condition that may be harming another," Dr. Tinetti concluded. "A careful medication review will review these potential offending medications. Given the marginal benefit of each individual medication, and the importance of avoiding harm, potentially offending medications should be discontinued."

Dr. Una Makris from UT Southwestern Medical Center and Dallas VA Medical Center has reported on high-risk medication use among older veterans with chronic pain. She said by email, "As clinicians we need to understand that not all of the outcomes we measure and not all of the medical conditions a patient has will be perceived as equally important (by the patient), so involving patients in the decision of which medications (even if guideline concordant) to add or remove is integral. How we communicate with and educate our older patients about their chronic conditions and the risks/benefits of each medication is evolving; this often differs between specialty providers and primary care providers."

Dr. Makris added, "This publication should heighten our awareness that patients, especially older adults, often have multiple comorbidities that can be treated with multiple guideline driven therapies and that our goal is really to work with patients to determine which combination of drugs and for which condition optimizes the risks/benefits for that individual."

NEW YORK - Most, but not all, guideline-recommended drugs and their combinations yield modest survival benefits in older adults with multiple chronic medical conditions, researchers report.

"Until there is better evidence in older adults with multiple chronic conditions, clinicians need to take a more thoughtful and nuanced approach to medication prescribing," Dr. Mary E. Tinetti from Yale School of Medicine, New Haven, Connecticut said by email. "This is particularly supported by the fact that outside of perhaps anticoagulation for atrial fibrillation, the magnitude of benefit for most of these medications is quite modest."

Nearly 40% of adults 65 years and older take at least five prescription medications, but the benefits of drugs prescribed for a single condition are difficult to ascertain in the

presence of multiple conditions and drugs.

Dr. Tinetti and colleagues used data from the Medicare Current Beneficiary Survey to estimate the association between nine guideline-recommended and commonly prescribed drugs and death in more than 8,500 Medicare participants (mean age, 77.4 years).

The nine drugs included beta-blockers; calcium channel blockers; clopidogrel; metformin; renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazide diuretics; and warfarin.

The most common medical conditions included hypertension, hyperlipidemia, diabetes, and coronary artery disease, the researchers report in The BMJ, online Oct. 2. More than half of the participants took at least three of the nine study drugs, and the mean number of total drugs was 10.0.

The benefits on survival of beta-blockers, calcium channel blockers, RAS blockers, statins, and warfarin were comparable to those reported in randomized controlled trials, although for beta-blockers and warfarin they varied according to coexisting conditions.

Clopidogrel, metformin, and SSRIs/SNRIs, however, were not associated with survival benefits.

The association between drug use and mortality risk was generally similar across patterns of coexisting conditions, suggesting to the researchers "that benefits often remain despite comorbidity."

"Research focused on identifying the medications that have the greatest benefit (defined by patient's outcomes priority such as improved symptoms, optimal physical or cognitive function, or survival) and least harm for key subpopulations of individuals with varying combinations of coexisting conditions should be a top priority," Dr. Tinetti said. "Ironically, although these are the major users of health care, they have largely been ignored in research."

"Many individuals, although they have many conditions, only one or two are really affecting the outcomes that matter most to them," Dr. Tinetti said. "Therefore, medication regimens can be simplified by eliminating medications for conditions that are not likely to benefit the individuals outcome priority, such as improved symptoms, optimal physical or cognitive function, or simplified treatment regimens."

"We know that about one in five individuals are currently receiving guideline-recommended medications for one condition that may be harming another," Dr. Tinetti concluded. "A careful medication review will review these potential offending medications. Given the marginal benefit of each individual medication, and the importance of avoiding harm, potentially offending medications should be discontinued."

Dr. Una Makris from UT Southwestern Medical Center and Dallas VA Medical Center has reported on high-risk medication use among older veterans with chronic pain. She said by email, "As clinicians we need to understand that not all of the outcomes we measure and not all of the medical conditions a patient has will be perceived as equally important (by the patient), so involving patients in the decision of which medications (even if guideline concordant) to add or remove is integral. How we communicate with and educate our older patients about their chronic conditions and the risks/benefits of each medication is evolving; this often differs between specialty providers and primary care providers."

Dr. Makris added, "This publication should heighten our awareness that patients, especially older adults, often have multiple comorbidities that can be treated with multiple guideline driven therapies and that our goal is really to work with patients to determine which combination of drugs and for which condition optimizes the risks/benefits for that individual."

NEW YORK - Most, but not all, guideline-recommended drugs and their combinations yield modest survival benefits in older adults with multiple chronic medical conditions, researchers report.

"Until there is better evidence in older adults with multiple chronic conditions, clinicians need to take a more thoughtful and nuanced approach to medication prescribing," Dr. Mary E. Tinetti from Yale School of Medicine, New Haven, Connecticut said by email. "This is particularly supported by the fact that outside of perhaps anticoagulation for atrial fibrillation, the magnitude of benefit for most of these medications is quite modest."

Nearly 40% of adults 65 years and older take at least five prescription medications, but the benefits of drugs prescribed for a single condition are difficult to ascertain in the

presence of multiple conditions and drugs.

Dr. Tinetti and colleagues used data from the Medicare Current Beneficiary Survey to estimate the association between nine guideline-recommended and commonly prescribed drugs and death in more than 8,500 Medicare participants (mean age, 77.4 years).

The nine drugs included beta-blockers; calcium channel blockers; clopidogrel; metformin; renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazide diuretics; and warfarin.

The most common medical conditions included hypertension, hyperlipidemia, diabetes, and coronary artery disease, the researchers report in The BMJ, online Oct. 2. More than half of the participants took at least three of the nine study drugs, and the mean number of total drugs was 10.0.

The benefits on survival of beta-blockers, calcium channel blockers, RAS blockers, statins, and warfarin were comparable to those reported in randomized controlled trials, although for beta-blockers and warfarin they varied according to coexisting conditions.

Clopidogrel, metformin, and SSRIs/SNRIs, however, were not associated with survival benefits.

The association between drug use and mortality risk was generally similar across patterns of coexisting conditions, suggesting to the researchers "that benefits often remain despite comorbidity."

"Research focused on identifying the medications that have the greatest benefit (defined by patient's outcomes priority such as improved symptoms, optimal physical or cognitive function, or survival) and least harm for key subpopulations of individuals with varying combinations of coexisting conditions should be a top priority," Dr. Tinetti said. "Ironically, although these are the major users of health care, they have largely been ignored in research."

"Many individuals, although they have many conditions, only one or two are really affecting the outcomes that matter most to them," Dr. Tinetti said. "Therefore, medication regimens can be simplified by eliminating medications for conditions that are not likely to benefit the individuals outcome priority, such as improved symptoms, optimal physical or cognitive function, or simplified treatment regimens."

"We know that about one in five individuals are currently receiving guideline-recommended medications for one condition that may be harming another," Dr. Tinetti concluded. "A careful medication review will review these potential offending medications. Given the marginal benefit of each individual medication, and the importance of avoiding harm, potentially offending medications should be discontinued."

Dr. Una Makris from UT Southwestern Medical Center and Dallas VA Medical Center has reported on high-risk medication use among older veterans with chronic pain. She said by email, "As clinicians we need to understand that not all of the outcomes we measure and not all of the medical conditions a patient has will be perceived as equally important (by the patient), so involving patients in the decision of which medications (even if guideline concordant) to add or remove is integral. How we communicate with and educate our older patients about their chronic conditions and the risks/benefits of each medication is evolving; this often differs between specialty providers and primary care providers."

Dr. Makris added, "This publication should heighten our awareness that patients, especially older adults, often have multiple comorbidities that can be treated with multiple guideline driven therapies and that our goal is really to work with patients to determine which combination of drugs and for which condition optimizes the risks/benefits for that individual."

NEW YORK  - A novel warfarin composite measure (WCM) that combines percent time in therapeutic range (TTR) and international normalized ratio (INR) variability might be useful in comparing anticoagulation clinic performance rankings, researchers report.

TTR reflects the intensity of anticoagulation, whereas INR variability reflects its stability. Both are important measures of anticoagulation quality, and previous studies have suggested their combination provides added value.

Dr. Zayd Razouki from Durham VA Medical Center in North Carolina and colleagues developed the WCM, which combines standardized TTR and standardized log INR variability, and examined its feasibility for profiling anticoagulation clinics in the Veterans Health Administration.

WCM's hazard ratios for fatal bleeding and ischemic stroke were greater with very poor control or poor control, compared with those with TTR or INR variability, the researchers report in Circulation Cardiovascular Quality and Outcomes, online September 29.

In contrast, WCM's hazard ratios for major bleeding were larger than those with INR variability but not significantly different from those with TTR.

As for patient level outcomes, WCM was no better than TTR or INR variability.

At the anticoagulation clinic level, WCM reconciled moderately well the discordance in rankings that occurred when using TTR or INR variability separately.

"We would recommend the use of WCM as a performance measure for clinic profiling, as it seems to identify different clinics as outliers," the researchers conclude. "Both on an empirical and a theoretical basis, WCM captures more completely relevant dimensions of anticoagulation control than its component measures."

Dr. Gabriel Vanerio from CASMU Arrhythmia Service in Montevideo, Uruguay, recently demonstrated the usefulness of INR variability for assessing anticoagulation quality. While admitting that the WCM is "very well constructed," he said by email, "I do not believe that this new measurement will be clinically useful."

Instead, Dr. Vanerio suggested that physicians should take home "the importance of anticoagulation quality control" as the main message of this report.

Dr. Razouki did not respond to a request for comments.

NEW YORK  - A novel warfarin composite measure (WCM) that combines percent time in therapeutic range (TTR) and international normalized ratio (INR) variability might be useful in comparing anticoagulation clinic performance rankings, researchers report.

TTR reflects the intensity of anticoagulation, whereas INR variability reflects its stability. Both are important measures of anticoagulation quality, and previous studies have suggested their combination provides added value.

Dr. Zayd Razouki from Durham VA Medical Center in North Carolina and colleagues developed the WCM, which combines standardized TTR and standardized log INR variability, and examined its feasibility for profiling anticoagulation clinics in the Veterans Health Administration.

WCM's hazard ratios for fatal bleeding and ischemic stroke were greater with very poor control or poor control, compared with those with TTR or INR variability, the researchers report in Circulation Cardiovascular Quality and Outcomes, online September 29.

In contrast, WCM's hazard ratios for major bleeding were larger than those with INR variability but not significantly different from those with TTR.

As for patient level outcomes, WCM was no better than TTR or INR variability.

At the anticoagulation clinic level, WCM reconciled moderately well the discordance in rankings that occurred when using TTR or INR variability separately.

"We would recommend the use of WCM as a performance measure for clinic profiling, as it seems to identify different clinics as outliers," the researchers conclude. "Both on an empirical and a theoretical basis, WCM captures more completely relevant dimensions of anticoagulation control than its component measures."

Dr. Gabriel Vanerio from CASMU Arrhythmia Service in Montevideo, Uruguay, recently demonstrated the usefulness of INR variability for assessing anticoagulation quality. While admitting that the WCM is "very well constructed," he said by email, "I do not believe that this new measurement will be clinically useful."

Instead, Dr. Vanerio suggested that physicians should take home "the importance of anticoagulation quality control" as the main message of this report.

Dr. Razouki did not respond to a request for comments.

NEW YORK  - A novel warfarin composite measure (WCM) that combines percent time in therapeutic range (TTR) and international normalized ratio (INR) variability might be useful in comparing anticoagulation clinic performance rankings, researchers report.

TTR reflects the intensity of anticoagulation, whereas INR variability reflects its stability. Both are important measures of anticoagulation quality, and previous studies have suggested their combination provides added value.

Dr. Zayd Razouki from Durham VA Medical Center in North Carolina and colleagues developed the WCM, which combines standardized TTR and standardized log INR variability, and examined its feasibility for profiling anticoagulation clinics in the Veterans Health Administration.

WCM's hazard ratios for fatal bleeding and ischemic stroke were greater with very poor control or poor control, compared with those with TTR or INR variability, the researchers report in Circulation Cardiovascular Quality and Outcomes, online September 29.

In contrast, WCM's hazard ratios for major bleeding were larger than those with INR variability but not significantly different from those with TTR.

As for patient level outcomes, WCM was no better than TTR or INR variability.

At the anticoagulation clinic level, WCM reconciled moderately well the discordance in rankings that occurred when using TTR or INR variability separately.

"We would recommend the use of WCM as a performance measure for clinic profiling, as it seems to identify different clinics as outliers," the researchers conclude. "Both on an empirical and a theoretical basis, WCM captures more completely relevant dimensions of anticoagulation control than its component measures."

Dr. Gabriel Vanerio from CASMU Arrhythmia Service in Montevideo, Uruguay, recently demonstrated the usefulness of INR variability for assessing anticoagulation quality. While admitting that the WCM is "very well constructed," he said by email, "I do not believe that this new measurement will be clinically useful."

Instead, Dr. Vanerio suggested that physicians should take home "the importance of anticoagulation quality control" as the main message of this report.

Dr. Razouki did not respond to a request for comments.

Bilal Hameed, MD, assistant professor of medicine in the Division of Gastroenterology at the University of California San Francisco, reviewed a wide range of serious and life-threatening medical complications resulting from cirrhosis during the annual UCSF Management of the Hospitalized Patient conference.

Recurring complications of cirrhosis can include ascites, acute variceal and portal hypertensive bleeds, hepatic encephalopathy, bacterial peritonitis, acute renal failure, sepsis, and a host of other infections. In many cases, options for treatment are limited as the patient develops decompensated cirrhosis.

Poor prognosis makes it important to urge these patients to get on a liver transplantation list, sooner rather than later, Dr. Hameed told hospitalists attending his small-group session. “Liver transplantation has changed this field,” he said. “Call us to see if your patient might be a candidate.”

Unlike kidney and some other transplant lists, where patients must wait for their turn, liver transplants are assigned based on need, as reflected in the patient’s Model for End-Stage Liver Disease (MELD) score, an objective clinical scale derived from blood values.

“Patients do really well on transplants, with 60% survival at 10 years,” he said. He also noted patients with advanced, decompensated disease who do not find a place on the transplant list might instead be candidates for palliative care or hospice referral.

Many conditions, such as infections, can still be managed with timely treatment, returning the patient back to baseline. “The risk of infection is very high. Starting antibiotics early can help,” Dr. Hameed said.

And for conditions where fluid volume is an issue, including spontaneous bacterial peritonitis, hypernatremia, or intrinsic renal disease, albumin is recommended as the evidence-based treatment of choice. “Please don’t over-transfuse these patients,” he said.

Jeannie Yip, MD, a nocturnist at Kaiser Foundation Hospital in Oakland, Calif., said that she frequently admits these kinds of patients to her hospital. For her, Dr. Hameed’s albumin recommendation was the most important lesson.

“I was still using IV fluids in patients coming in with volume depletion, to rule out acute renal failure. It’s always a dilemma if you have a hypotensive patient with low sodium and low blood pressure, who tells you: ‘I haven’t eaten for a week,’” she explained. “It’s been hard for me not to give them fluids. But after listening to this talk, I see that I should give albumin, instead.” TH

Bilal Hameed, MD, assistant professor of medicine in the Division of Gastroenterology at the University of California San Francisco, reviewed a wide range of serious and life-threatening medical complications resulting from cirrhosis during the annual UCSF Management of the Hospitalized Patient conference.

Recurring complications of cirrhosis can include ascites, acute variceal and portal hypertensive bleeds, hepatic encephalopathy, bacterial peritonitis, acute renal failure, sepsis, and a host of other infections. In many cases, options for treatment are limited as the patient develops decompensated cirrhosis.

Poor prognosis makes it important to urge these patients to get on a liver transplantation list, sooner rather than later, Dr. Hameed told hospitalists attending his small-group session. “Liver transplantation has changed this field,” he said. “Call us to see if your patient might be a candidate.”

Unlike kidney and some other transplant lists, where patients must wait for their turn, liver transplants are assigned based on need, as reflected in the patient’s Model for End-Stage Liver Disease (MELD) score, an objective clinical scale derived from blood values.

“Patients do really well on transplants, with 60% survival at 10 years,” he said. He also noted patients with advanced, decompensated disease who do not find a place on the transplant list might instead be candidates for palliative care or hospice referral.

Many conditions, such as infections, can still be managed with timely treatment, returning the patient back to baseline. “The risk of infection is very high. Starting antibiotics early can help,” Dr. Hameed said.

And for conditions where fluid volume is an issue, including spontaneous bacterial peritonitis, hypernatremia, or intrinsic renal disease, albumin is recommended as the evidence-based treatment of choice. “Please don’t over-transfuse these patients,” he said.

Jeannie Yip, MD, a nocturnist at Kaiser Foundation Hospital in Oakland, Calif., said that she frequently admits these kinds of patients to her hospital. For her, Dr. Hameed’s albumin recommendation was the most important lesson.

“I was still using IV fluids in patients coming in with volume depletion, to rule out acute renal failure. It’s always a dilemma if you have a hypotensive patient with low sodium and low blood pressure, who tells you: ‘I haven’t eaten for a week,’” she explained. “It’s been hard for me not to give them fluids. But after listening to this talk, I see that I should give albumin, instead.” TH

Bilal Hameed, MD, assistant professor of medicine in the Division of Gastroenterology at the University of California San Francisco, reviewed a wide range of serious and life-threatening medical complications resulting from cirrhosis during the annual UCSF Management of the Hospitalized Patient conference.

Recurring complications of cirrhosis can include ascites, acute variceal and portal hypertensive bleeds, hepatic encephalopathy, bacterial peritonitis, acute renal failure, sepsis, and a host of other infections. In many cases, options for treatment are limited as the patient develops decompensated cirrhosis.

Poor prognosis makes it important to urge these patients to get on a liver transplantation list, sooner rather than later, Dr. Hameed told hospitalists attending his small-group session. “Liver transplantation has changed this field,” he said. “Call us to see if your patient might be a candidate.”

Unlike kidney and some other transplant lists, where patients must wait for their turn, liver transplants are assigned based on need, as reflected in the patient’s Model for End-Stage Liver Disease (MELD) score, an objective clinical scale derived from blood values.

“Patients do really well on transplants, with 60% survival at 10 years,” he said. He also noted patients with advanced, decompensated disease who do not find a place on the transplant list might instead be candidates for palliative care or hospice referral.

Many conditions, such as infections, can still be managed with timely treatment, returning the patient back to baseline. “The risk of infection is very high. Starting antibiotics early can help,” Dr. Hameed said.

And for conditions where fluid volume is an issue, including spontaneous bacterial peritonitis, hypernatremia, or intrinsic renal disease, albumin is recommended as the evidence-based treatment of choice. “Please don’t over-transfuse these patients,” he said.

Jeannie Yip, MD, a nocturnist at Kaiser Foundation Hospital in Oakland, Calif., said that she frequently admits these kinds of patients to her hospital. For her, Dr. Hameed’s albumin recommendation was the most important lesson.

“I was still using IV fluids in patients coming in with volume depletion, to rule out acute renal failure. It’s always a dilemma if you have a hypotensive patient with low sodium and low blood pressure, who tells you: ‘I haven’t eaten for a week,’” she explained. “It’s been hard for me not to give them fluids. But after listening to this talk, I see that I should give albumin, instead.” TH

NEW YORK  - The five-factor ORBIT bleeding score accurately predicts major bleeding risk in patients with atrial fibrillation (AF) who are taking oral anticoagulants (OACs), researchers report.

"The ORBIT score highlights modifiable factors that increase bleeding risk and can help providers identify high-risk AF patients for closer monitoring," Dr. Emily C. O'Brien, from Duke Clinical Research Institute, Durham, North Carolina, said by email. "Along with clinical judgment, the ORBIT score can be used to give an estimate of bleeding risk for any AF patient considering OAC treatment."

Two existing bleeding scores - HAS-BLED and ATRIA - are based on small numbers of events and have shown inconsistent performance. They also may require elements that are not available for all OAC users, the researchers wrote.

Dr. O'Brien's team developed a five-element bleeding score and compared its performance with those of HAS-BLED and ATRIA using data from the ORBIT-AF and ROCKET-AF studies.

The numerical score included the five strongest predictors of bleeding:

-Older age (75 years and above): one point

-Reduced hemoglobin, hematocrit, or history of anemia: two points

-Bleeding history: two points

-Insufficient kidney function (eGFR below 60 mL/min/1.73 m2): one point

-Treatment with an antiplatelet agent: one point

Observed bleeding rates in the ORBIT-AF participants increased with increasing ORBIT bleeding score: from 2.4 per 100 patient-years in the low-risk group (scores 0-2) to 4.7 per 100 patient-years in the medium-risk group (score 3) to 8.1 per 100 patient-years in the high-risk group (scores 4-7), according to the Sept. 30 European Heart Journal online report.

In both the ORBIT-AF and ROCKET-AF cohorts, the ORBIT bleeding score showed better discrimination than the HAS-BLED and ATRIA scores.

Model calibration analysis also showed superior calibration for the ORBIT bleeding score. The HAS-BLED score showed relatively poor calibration for low-risk score strata, whereas the ATRIA score showed poor calibration for most risk groups.

"The ORBIT score is a simple, useful tool that predicts bleeding as well as other, more complicated scores and can be used in any AF patient regardless of the type of OAC he or she is taking," Dr. O'Brien said.

"For chronic conditions like AF, periodic assessment of risk for adverse events is important to support clinical decision-making," Dr. O'Brien explained. "Risk factors may

change over time particularly as patients get older. Therefore, incorporating new data on these factors into longitudinal risk assessment provides an optimal framework for ongoing AF management."

"While bleeding risk estimation can be helpful in identifying high-risk AF patients for closer monitoring, it is important to note that prior work has demonstrated a net clinical benefit of OAC even in patients with high estimated bleeding risk," the researchers wrote. "Further, while risk scores provide important information to the clinician for estimating risk of adverse events, they represent only one consideration relevant to therapeutic decision making."

Janssen Scientific Affairs sponsors ORBIT-AF; the Agency for Healthcare Research and Quality partially supported this research. Ten coauthors reported relevant relationships.

NEW YORK  - The five-factor ORBIT bleeding score accurately predicts major bleeding risk in patients with atrial fibrillation (AF) who are taking oral anticoagulants (OACs), researchers report.

"The ORBIT score highlights modifiable factors that increase bleeding risk and can help providers identify high-risk AF patients for closer monitoring," Dr. Emily C. O'Brien, from Duke Clinical Research Institute, Durham, North Carolina, said by email. "Along with clinical judgment, the ORBIT score can be used to give an estimate of bleeding risk for any AF patient considering OAC treatment."

Two existing bleeding scores - HAS-BLED and ATRIA - are based on small numbers of events and have shown inconsistent performance. They also may require elements that are not available for all OAC users, the researchers wrote.

Dr. O'Brien's team developed a five-element bleeding score and compared its performance with those of HAS-BLED and ATRIA using data from the ORBIT-AF and ROCKET-AF studies.

The numerical score included the five strongest predictors of bleeding:

-Older age (75 years and above): one point

-Reduced hemoglobin, hematocrit, or history of anemia: two points

-Bleeding history: two points

-Insufficient kidney function (eGFR below 60 mL/min/1.73 m2): one point

-Treatment with an antiplatelet agent: one point

Observed bleeding rates in the ORBIT-AF participants increased with increasing ORBIT bleeding score: from 2.4 per 100 patient-years in the low-risk group (scores 0-2) to 4.7 per 100 patient-years in the medium-risk group (score 3) to 8.1 per 100 patient-years in the high-risk group (scores 4-7), according to the Sept. 30 European Heart Journal online report.

In both the ORBIT-AF and ROCKET-AF cohorts, the ORBIT bleeding score showed better discrimination than the HAS-BLED and ATRIA scores.

Model calibration analysis also showed superior calibration for the ORBIT bleeding score. The HAS-BLED score showed relatively poor calibration for low-risk score strata, whereas the ATRIA score showed poor calibration for most risk groups.

"The ORBIT score is a simple, useful tool that predicts bleeding as well as other, more complicated scores and can be used in any AF patient regardless of the type of OAC he or she is taking," Dr. O'Brien said.

"For chronic conditions like AF, periodic assessment of risk for adverse events is important to support clinical decision-making," Dr. O'Brien explained. "Risk factors may

change over time particularly as patients get older. Therefore, incorporating new data on these factors into longitudinal risk assessment provides an optimal framework for ongoing AF management."

"While bleeding risk estimation can be helpful in identifying high-risk AF patients for closer monitoring, it is important to note that prior work has demonstrated a net clinical benefit of OAC even in patients with high estimated bleeding risk," the researchers wrote. "Further, while risk scores provide important information to the clinician for estimating risk of adverse events, they represent only one consideration relevant to therapeutic decision making."

Janssen Scientific Affairs sponsors ORBIT-AF; the Agency for Healthcare Research and Quality partially supported this research. Ten coauthors reported relevant relationships.

NEW YORK  - The five-factor ORBIT bleeding score accurately predicts major bleeding risk in patients with atrial fibrillation (AF) who are taking oral anticoagulants (OACs), researchers report.

"The ORBIT score highlights modifiable factors that increase bleeding risk and can help providers identify high-risk AF patients for closer monitoring," Dr. Emily C. O'Brien, from Duke Clinical Research Institute, Durham, North Carolina, said by email. "Along with clinical judgment, the ORBIT score can be used to give an estimate of bleeding risk for any AF patient considering OAC treatment."

Two existing bleeding scores - HAS-BLED and ATRIA - are based on small numbers of events and have shown inconsistent performance. They also may require elements that are not available for all OAC users, the researchers wrote.

Dr. O'Brien's team developed a five-element bleeding score and compared its performance with those of HAS-BLED and ATRIA using data from the ORBIT-AF and ROCKET-AF studies.

The numerical score included the five strongest predictors of bleeding:

-Older age (75 years and above): one point

-Reduced hemoglobin, hematocrit, or history of anemia: two points

-Bleeding history: two points

-Insufficient kidney function (eGFR below 60 mL/min/1.73 m2): one point

-Treatment with an antiplatelet agent: one point

Observed bleeding rates in the ORBIT-AF participants increased with increasing ORBIT bleeding score: from 2.4 per 100 patient-years in the low-risk group (scores 0-2) to 4.7 per 100 patient-years in the medium-risk group (score 3) to 8.1 per 100 patient-years in the high-risk group (scores 4-7), according to the Sept. 30 European Heart Journal online report.

In both the ORBIT-AF and ROCKET-AF cohorts, the ORBIT bleeding score showed better discrimination than the HAS-BLED and ATRIA scores.

Model calibration analysis also showed superior calibration for the ORBIT bleeding score. The HAS-BLED score showed relatively poor calibration for low-risk score strata, whereas the ATRIA score showed poor calibration for most risk groups.

"The ORBIT score is a simple, useful tool that predicts bleeding as well as other, more complicated scores and can be used in any AF patient regardless of the type of OAC he or she is taking," Dr. O'Brien said.

"For chronic conditions like AF, periodic assessment of risk for adverse events is important to support clinical decision-making," Dr. O'Brien explained. "Risk factors may

change over time particularly as patients get older. Therefore, incorporating new data on these factors into longitudinal risk assessment provides an optimal framework for ongoing AF management."

"While bleeding risk estimation can be helpful in identifying high-risk AF patients for closer monitoring, it is important to note that prior work has demonstrated a net clinical benefit of OAC even in patients with high estimated bleeding risk," the researchers wrote. "Further, while risk scores provide important information to the clinician for estimating risk of adverse events, they represent only one consideration relevant to therapeutic decision making."

Janssen Scientific Affairs sponsors ORBIT-AF; the Agency for Healthcare Research and Quality partially supported this research. Ten coauthors reported relevant relationships.

Half of U.S. physicians are experiencing some of the symptoms of burnout, with even higher rates for general internists. Implementation of the electronic health record (EHR) has been cited as the biggest driver of physician job dissatisfaction, Christine Sinsky, MD, a former hospitalist and currently vice president of professional satisfaction at the American Medical Association (AMA), told attendees at the 19th Management of the Hospitalized Patient Conference, presented by the University of California-San Francisco.¹

Dr. Sinsky deemed physician discontent “the canary in the coal mine” for a dysfunctional healthcare system. After visiting 23 high-functioning medical teams, Dr. Sinsky said she had found that 70% to 80% of physician work output could be considered waste, defined as work that doesn’t need to be done and doesn’t add value to the patient. The AMA, she said, has made a commitment to addressing physicians’ dissatisfaction and burnout.

Dr. Sinsky offered a number of suggestions for physicians and the larger system. Among them was the suggestion for medical teams to employ a documentation specialist, or scribe, to accompany physicians on patient rounds to help with the clerical tasks that divert physicians from patient care. She also cited David Reuben, MD, a gerontologist at UCLA whose JAMA IM study documented his training of physician “practice partners,” often medical or nursing students, who help queue up orders in the EHR, and the improved patient satisfaction that resulted.²

“Be bold,” she advised hospitalists. “The patient care delivery modes of the future can’t be met with staffing models from the past.” TH

References

1. Friedberg M, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, Calif.: RAND Corporation, 2013. http://www.rand.org/pubs/research_reports/RR439. Also available in print form.
2. Reuben DB, Knudsen J, Senelick W, Glazier E, Koretz BK. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174(7):1190–1193.

Half of U.S. physicians are experiencing some of the symptoms of burnout, with even higher rates for general internists. Implementation of the electronic health record (EHR) has been cited as the biggest driver of physician job dissatisfaction, Christine Sinsky, MD, a former hospitalist and currently vice president of professional satisfaction at the American Medical Association (AMA), told attendees at the 19th Management of the Hospitalized Patient Conference, presented by the University of California-San Francisco.¹

Dr. Sinsky deemed physician discontent “the canary in the coal mine” for a dysfunctional healthcare system. After visiting 23 high-functioning medical teams, Dr. Sinsky said she had found that 70% to 80% of physician work output could be considered waste, defined as work that doesn’t need to be done and doesn’t add value to the patient. The AMA, she said, has made a commitment to addressing physicians’ dissatisfaction and burnout.

Dr. Sinsky offered a number of suggestions for physicians and the larger system. Among them was the suggestion for medical teams to employ a documentation specialist, or scribe, to accompany physicians on patient rounds to help with the clerical tasks that divert physicians from patient care. She also cited David Reuben, MD, a gerontologist at UCLA whose JAMA IM study documented his training of physician “practice partners,” often medical or nursing students, who help queue up orders in the EHR, and the improved patient satisfaction that resulted.²

“Be bold,” she advised hospitalists. “The patient care delivery modes of the future can’t be met with staffing models from the past.” TH

References

1. Friedberg M, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, Calif.: RAND Corporation, 2013. http://www.rand.org/pubs/research_reports/RR439. Also available in print form.
2. Reuben DB, Knudsen J, Senelick W, Glazier E, Koretz BK. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174(7):1190–1193.

Half of U.S. physicians are experiencing some of the symptoms of burnout, with even higher rates for general internists. Implementation of the electronic health record (EHR) has been cited as the biggest driver of physician job dissatisfaction, Christine Sinsky, MD, a former hospitalist and currently vice president of professional satisfaction at the American Medical Association (AMA), told attendees at the 19th Management of the Hospitalized Patient Conference, presented by the University of California-San Francisco.¹

Dr. Sinsky deemed physician discontent “the canary in the coal mine” for a dysfunctional healthcare system. After visiting 23 high-functioning medical teams, Dr. Sinsky said she had found that 70% to 80% of physician work output could be considered waste, defined as work that doesn’t need to be done and doesn’t add value to the patient. The AMA, she said, has made a commitment to addressing physicians’ dissatisfaction and burnout.

Dr. Sinsky offered a number of suggestions for physicians and the larger system. Among them was the suggestion for medical teams to employ a documentation specialist, or scribe, to accompany physicians on patient rounds to help with the clerical tasks that divert physicians from patient care. She also cited David Reuben, MD, a gerontologist at UCLA whose JAMA IM study documented his training of physician “practice partners,” often medical or nursing students, who help queue up orders in the EHR, and the improved patient satisfaction that resulted.²

“Be bold,” she advised hospitalists. “The patient care delivery modes of the future can’t be met with staffing models from the past.” TH

References

1. Friedberg M, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, Calif.: RAND Corporation, 2013. http://www.rand.org/pubs/research_reports/RR439. Also available in print form.
2. Reuben DB, Knudsen J, Senelick W, Glazier E, Koretz BK. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174(7):1190–1193.

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.

“[Hospitalists] must be mindful of the risks and benefits,” she said.

Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.

“[Hospitalists] must be mindful of the risks and benefits,” she said.

Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.

“[Hospitalists] must be mindful of the risks and benefits,” she said.

Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH

A new study has found that a pharmacist-led intervention featuring three outreach phone calls in the 30-day postdischarge period can help reduce patients' readmissions and ED visits.

Recently published in the Journal of Hospital Medicine, the report found that 39% of patients who received only one postdischarge call at the end of the 30-day time frame were either readmitted to the hospital or visited the ED within 30 days of discharge. By comparison, 24.8% of patients who received three phone calls, at days 3, 14, and 30 postdischarge, had a readmission or ED visit.

"The unique thing about this is we added three postdischarge phone calls," says senior author Michael Postelnick, RPh, BCPS, senior infectious diseases pharmacist at Northwestern Memorial Hospital in Chicago. "Most studies look at one or, at most, two. But we thought of the midpoint of the 30-day period postdischarge as a very hazardous time, a time that would benefit from pharmacist contact to make sure that patients were continuing on their plan and not having any problems."

The research showed that the number of outreach calls in the 30-day postdischarge period did not significantly impact the number of adverse drug events or medication errors reported nor did it affect patients’ knowledge about their medications as measured by Hospital Consumer Assessment of Healthcare Providers and Systems scores.

Postelnick says he thinks a larger study may bear evidence that pharmacist-led interventions can impact those areas, as well. Either way, the research suggests that multiple "touch points" are needed to reinforce postdischarge instructions given at a "very chaotic time," he adds.

"All the [patient] education one does upon discharge, there's likely to be little retention of that," Postelnick adds. "As patients settle more into their usual routine, they become more receptive to learning about what they need to do to ensure that they can maintain their health. Even at 72 hours, they're starting to settle, but by the time you hit the 14-day period, you can have a good discussion with them."

Visit our website for more information on pharmacists and care transitions.

A new study has found that a pharmacist-led intervention featuring three outreach phone calls in the 30-day postdischarge period can help reduce patients' readmissions and ED visits.

Recently published in the Journal of Hospital Medicine, the report found that 39% of patients who received only one postdischarge call at the end of the 30-day time frame were either readmitted to the hospital or visited the ED within 30 days of discharge. By comparison, 24.8% of patients who received three phone calls, at days 3, 14, and 30 postdischarge, had a readmission or ED visit.

"The unique thing about this is we added three postdischarge phone calls," says senior author Michael Postelnick, RPh, BCPS, senior infectious diseases pharmacist at Northwestern Memorial Hospital in Chicago. "Most studies look at one or, at most, two. But we thought of the midpoint of the 30-day period postdischarge as a very hazardous time, a time that would benefit from pharmacist contact to make sure that patients were continuing on their plan and not having any problems."

The research showed that the number of outreach calls in the 30-day postdischarge period did not significantly impact the number of adverse drug events or medication errors reported nor did it affect patients’ knowledge about their medications as measured by Hospital Consumer Assessment of Healthcare Providers and Systems scores.

Postelnick says he thinks a larger study may bear evidence that pharmacist-led interventions can impact those areas, as well. Either way, the research suggests that multiple "touch points" are needed to reinforce postdischarge instructions given at a "very chaotic time," he adds.

"All the [patient] education one does upon discharge, there's likely to be little retention of that," Postelnick adds. "As patients settle more into their usual routine, they become more receptive to learning about what they need to do to ensure that they can maintain their health. Even at 72 hours, they're starting to settle, but by the time you hit the 14-day period, you can have a good discussion with them."

Visit our website for more information on pharmacists and care transitions.

A new study has found that a pharmacist-led intervention featuring three outreach phone calls in the 30-day postdischarge period can help reduce patients' readmissions and ED visits.

Recently published in the Journal of Hospital Medicine, the report found that 39% of patients who received only one postdischarge call at the end of the 30-day time frame were either readmitted to the hospital or visited the ED within 30 days of discharge. By comparison, 24.8% of patients who received three phone calls, at days 3, 14, and 30 postdischarge, had a readmission or ED visit.

"The unique thing about this is we added three postdischarge phone calls," says senior author Michael Postelnick, RPh, BCPS, senior infectious diseases pharmacist at Northwestern Memorial Hospital in Chicago. "Most studies look at one or, at most, two. But we thought of the midpoint of the 30-day period postdischarge as a very hazardous time, a time that would benefit from pharmacist contact to make sure that patients were continuing on their plan and not having any problems."

The research showed that the number of outreach calls in the 30-day postdischarge period did not significantly impact the number of adverse drug events or medication errors reported nor did it affect patients’ knowledge about their medications as measured by Hospital Consumer Assessment of Healthcare Providers and Systems scores.

Postelnick says he thinks a larger study may bear evidence that pharmacist-led interventions can impact those areas, as well. Either way, the research suggests that multiple "touch points" are needed to reinforce postdischarge instructions given at a "very chaotic time," he adds.

"All the [patient] education one does upon discharge, there's likely to be little retention of that," Postelnick adds. "As patients settle more into their usual routine, they become more receptive to learning about what they need to do to ensure that they can maintain their health. Even at 72 hours, they're starting to settle, but by the time you hit the 14-day period, you can have a good discussion with them."

Visit our website for more information on pharmacists and care transitions.