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Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin scale.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups. The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. New Engl J Med. 2015;372(24):2296–2306.

Visit our website for more hospitalist reviews of HM-focused research.

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin scale.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups. The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. New Engl J Med. 2015;372(24):2296–2306.

Visit our website for more hospitalist reviews of HM-focused research.

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin scale.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups. The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. New Engl J Med. 2015;372(24):2296–2306.

Visit our website for more hospitalist reviews of HM-focused research.

Even before HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), hospital leaders and clinicians were striving to provide not only high quality care, but a place patients choose to meet their future healthcare needs. Just this week, US News and World Report published an article entitled "The Patient Wish List." Although not a list generated from a scientific study, the author, Peter Pronovost, MD, PhD, who is the director of the Armstrong Institute for Patient Safety and Quality and senior vice president for patient safety and quality at Johns Hopkins Medicine, worked with Jan Hill, patient relations director at Johns Hopkins, to develop a list intended to be a "conversation starter."

So, how does this apply to hospitalists? Many of the items on the list are an easy fix and don't cost a thing. Here are a few areas hospitalist can impact:

1. I want to sleep. For example: are there standing overnight test orders that could be provided during the day?
2. Reduce noise outside my room, particularly at night. How can hospitalists contribute to reducing hallway and nursing station noise?
3. Knock before entering. It's a sign of respect to knock before entering the patient's room. Sitting down while talking to the patient and introducing yourself are also key.
4. Keep me (and my family) updated. Are you always updating the patient and family about the plan of care and if things change?
5. I want to be a part of my care. Do you always use language patients (and families) can easily understand? How do you ensure patients (and families) understand the plan of care?
6. Be professional, always. No matter where you are in the hospital, patients and families are watching you closely. Ask yourself, "How I perceive you is often how I perceive the hospital and care that I am receiving."

What else can you do to improve the patient's experience in your hospital? TH

Even before HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), hospital leaders and clinicians were striving to provide not only high quality care, but a place patients choose to meet their future healthcare needs. Just this week, US News and World Report published an article entitled "The Patient Wish List." Although not a list generated from a scientific study, the author, Peter Pronovost, MD, PhD, who is the director of the Armstrong Institute for Patient Safety and Quality and senior vice president for patient safety and quality at Johns Hopkins Medicine, worked with Jan Hill, patient relations director at Johns Hopkins, to develop a list intended to be a "conversation starter."

So, how does this apply to hospitalists? Many of the items on the list are an easy fix and don't cost a thing. Here are a few areas hospitalist can impact:

1. I want to sleep. For example: are there standing overnight test orders that could be provided during the day?
2. Reduce noise outside my room, particularly at night. How can hospitalists contribute to reducing hallway and nursing station noise?
3. Knock before entering. It's a sign of respect to knock before entering the patient's room. Sitting down while talking to the patient and introducing yourself are also key.
4. Keep me (and my family) updated. Are you always updating the patient and family about the plan of care and if things change?
5. I want to be a part of my care. Do you always use language patients (and families) can easily understand? How do you ensure patients (and families) understand the plan of care?
6. Be professional, always. No matter where you are in the hospital, patients and families are watching you closely. Ask yourself, "How I perceive you is often how I perceive the hospital and care that I am receiving."

What else can you do to improve the patient's experience in your hospital? TH

Even before HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), hospital leaders and clinicians were striving to provide not only high quality care, but a place patients choose to meet their future healthcare needs. Just this week, US News and World Report published an article entitled "The Patient Wish List." Although not a list generated from a scientific study, the author, Peter Pronovost, MD, PhD, who is the director of the Armstrong Institute for Patient Safety and Quality and senior vice president for patient safety and quality at Johns Hopkins Medicine, worked with Jan Hill, patient relations director at Johns Hopkins, to develop a list intended to be a "conversation starter."

So, how does this apply to hospitalists? Many of the items on the list are an easy fix and don't cost a thing. Here are a few areas hospitalist can impact:

1. I want to sleep. For example: are there standing overnight test orders that could be provided during the day?
2. Reduce noise outside my room, particularly at night. How can hospitalists contribute to reducing hallway and nursing station noise?
3. Knock before entering. It's a sign of respect to knock before entering the patient's room. Sitting down while talking to the patient and introducing yourself are also key.
4. Keep me (and my family) updated. Are you always updating the patient and family about the plan of care and if things change?
5. I want to be a part of my care. Do you always use language patients (and families) can easily understand? How do you ensure patients (and families) understand the plan of care?
6. Be professional, always. No matter where you are in the hospital, patients and families are watching you closely. Ask yourself, "How I perceive you is often how I perceive the hospital and care that I am receiving."

What else can you do to improve the patient's experience in your hospital? TH

The U.S. Food and Drug Administration on Friday gave accelerated approval to Boehringer Ingelheim's Praxbind (idarucizumab) for use in patients who are taking the anticoagulant Pradaxa (dabigatran) during emergency situations when there is a need to reverse Pradaxa's blood-thinning effects.

"The anticoagulant effects of Pradaxa are important and life-saving for some patients, but there are situations where reversal of the drug's effects is medically necessary," Dr. Richard Pazdur, director of the Office of Hematology and Oncology Products in the FDA's Center for Drug Evaluation and Research, said in a statement.

"Today's approval offers the medical community an important tool for managing patients taking Pradaxa in emergency or life-threatening situations when bleeding can't be controlled," he added.

The FDA approved Pradaxa in 2010 to prevent stroke and systemic blood clots in patients with atrial fibrillation, as well as for the treatment and prevention of deep venous thrombosis and pulmonary embolism.

Praxbind is the first reversal agent approved specifically for Pradaxa and works by binding to the drug compound to neutralize its effect, the FDA said.

The U.S. Food and Drug Administration on Friday gave accelerated approval to Boehringer Ingelheim's Praxbind (idarucizumab) for use in patients who are taking the anticoagulant Pradaxa (dabigatran) during emergency situations when there is a need to reverse Pradaxa's blood-thinning effects.

"The anticoagulant effects of Pradaxa are important and life-saving for some patients, but there are situations where reversal of the drug's effects is medically necessary," Dr. Richard Pazdur, director of the Office of Hematology and Oncology Products in the FDA's Center for Drug Evaluation and Research, said in a statement.

"Today's approval offers the medical community an important tool for managing patients taking Pradaxa in emergency or life-threatening situations when bleeding can't be controlled," he added.

The FDA approved Pradaxa in 2010 to prevent stroke and systemic blood clots in patients with atrial fibrillation, as well as for the treatment and prevention of deep venous thrombosis and pulmonary embolism.

Praxbind is the first reversal agent approved specifically for Pradaxa and works by binding to the drug compound to neutralize its effect, the FDA said.

The U.S. Food and Drug Administration on Friday gave accelerated approval to Boehringer Ingelheim's Praxbind (idarucizumab) for use in patients who are taking the anticoagulant Pradaxa (dabigatran) during emergency situations when there is a need to reverse Pradaxa's blood-thinning effects.

"The anticoagulant effects of Pradaxa are important and life-saving for some patients, but there are situations where reversal of the drug's effects is medically necessary," Dr. Richard Pazdur, director of the Office of Hematology and Oncology Products in the FDA's Center for Drug Evaluation and Research, said in a statement.

"Today's approval offers the medical community an important tool for managing patients taking Pradaxa in emergency or life-threatening situations when bleeding can't be controlled," he added.

The FDA approved Pradaxa in 2010 to prevent stroke and systemic blood clots in patients with atrial fibrillation, as well as for the treatment and prevention of deep venous thrombosis and pulmonary embolism.

Praxbind is the first reversal agent approved specifically for Pradaxa and works by binding to the drug compound to neutralize its effect, the FDA said.

The social determinants of health are a root cause of readmissions in the most heavily readmitted patients, according to data analyzed in a recent study published in the Journal of Hospital Medicine. The study's lead author, Marilyn Szekendi, PhD, discusses the research, and Dr. Bradley Flansbaum weighs in on the difficulty of effecting a policy solution for a population without much political voice.

The social determinants of health are a root cause of readmissions in the most heavily readmitted patients, according to data analyzed in a recent study published in the Journal of Hospital Medicine. The study's lead author, Marilyn Szekendi, PhD, discusses the research, and Dr. Bradley Flansbaum weighs in on the difficulty of effecting a policy solution for a population without much political voice.

The social determinants of health are a root cause of readmissions in the most heavily readmitted patients, according to data analyzed in a recent study published in the Journal of Hospital Medicine. The study's lead author, Marilyn Szekendi, PhD, discusses the research, and Dr. Bradley Flansbaum weighs in on the difficulty of effecting a policy solution for a population without much political voice.

Michael Murphy, MD, the co-founder and CEO of ScribeAmerica, talks about the business model that has led to the growing use of medical scribes.

 

Michael Murphy, MD, the co-founder and CEO of ScribeAmerica, talks about the business model that has led to the growing use of medical scribes.

 

Michael Murphy, MD, the co-founder and CEO of ScribeAmerica, talks about the business model that has led to the growing use of medical scribes.

 

Listen to excerpts of Carol Patton’s interview, including Dr. Maki’s explaining the complexities of tandem surfing, his thoughts on the ocean’s spiritual appeal, and he and his wife’s work as intimacy therapists.

http://www.the-hospitalist.org/wp-content/uploads/2015/10/LanceMaki_FINAL-LO-Q_100715.mp3

 

Listen to excerpts of Carol Patton’s interview, including Dr. Maki’s explaining the complexities of tandem surfing, his thoughts on the ocean’s spiritual appeal, and he and his wife’s work as intimacy therapists.

http://www.the-hospitalist.org/wp-content/uploads/2015/10/LanceMaki_FINAL-LO-Q_100715.mp3

 

Listen to excerpts of Carol Patton’s interview, including Dr. Maki’s explaining the complexities of tandem surfing, his thoughts on the ocean’s spiritual appeal, and he and his wife’s work as intimacy therapists.

http://www.the-hospitalist.org/wp-content/uploads/2015/10/LanceMaki_FINAL-LO-Q_100715.mp3

 

The Joint Commission has launched a new online resource for patients and hospitalists to help change mindsets and start conversations about proper antibiotic usage.

The SpeakUp: Antibiotics campaign is a package of free materials, including an infographic illustrating which illnesses may require an antibiotic, a list of questions for patients to ask when prescribed an antibiotic, a podcast, and a video reminding patients that antibiotics are not needed for colds or the flu.

“The new SpeakUp campaign provides a variety of resources to help patients and caregivers understand that how they use antibiotics today can affect how well the drugs work for them tomorrow,” says Lisa Waldowski, MS, APRN, CIC, infection control specialist at The Joint Commission.

The primary audience for these materials is the consumer, but hospitalists and healthcare workers are the crucial secondary audience. “This is a partnership; the knowledge needs to go both ways,” Waldowski says. “Sometimes there’s an expectation that when you see a physician, you are somehow shortchanged if you don’t leave with a prescription for an antibiotic.

There’s an education that needs to go on in the mindset of the physician, [in terms of] looking at whether this situation warrants an antibiotic and educating the patient if it does not. It takes time to have that conversation.”

The campaign can also provide a starting point for hospitalists to make changes in the workplace. “The information needs to be digested by everyone individually, but collectively in the organization where you work, this can lead to an antibiotic stewardship program, a coordinated intervention,” she says. She recommends a multidisciplinary approach. “Sometimes successful programs are led by a physician, and they have a strong pharmacy component, working together and supporting one another to use antibiotics appropriately.”

Visit our website for more information on antibiotic overuse.

The Joint Commission has launched a new online resource for patients and hospitalists to help change mindsets and start conversations about proper antibiotic usage.

The SpeakUp: Antibiotics campaign is a package of free materials, including an infographic illustrating which illnesses may require an antibiotic, a list of questions for patients to ask when prescribed an antibiotic, a podcast, and a video reminding patients that antibiotics are not needed for colds or the flu.

“The new SpeakUp campaign provides a variety of resources to help patients and caregivers understand that how they use antibiotics today can affect how well the drugs work for them tomorrow,” says Lisa Waldowski, MS, APRN, CIC, infection control specialist at The Joint Commission.

The primary audience for these materials is the consumer, but hospitalists and healthcare workers are the crucial secondary audience. “This is a partnership; the knowledge needs to go both ways,” Waldowski says. “Sometimes there’s an expectation that when you see a physician, you are somehow shortchanged if you don’t leave with a prescription for an antibiotic.

There’s an education that needs to go on in the mindset of the physician, [in terms of] looking at whether this situation warrants an antibiotic and educating the patient if it does not. It takes time to have that conversation.”

The campaign can also provide a starting point for hospitalists to make changes in the workplace. “The information needs to be digested by everyone individually, but collectively in the organization where you work, this can lead to an antibiotic stewardship program, a coordinated intervention,” she says. She recommends a multidisciplinary approach. “Sometimes successful programs are led by a physician, and they have a strong pharmacy component, working together and supporting one another to use antibiotics appropriately.”

Visit our website for more information on antibiotic overuse.

The Joint Commission has launched a new online resource for patients and hospitalists to help change mindsets and start conversations about proper antibiotic usage.

The SpeakUp: Antibiotics campaign is a package of free materials, including an infographic illustrating which illnesses may require an antibiotic, a list of questions for patients to ask when prescribed an antibiotic, a podcast, and a video reminding patients that antibiotics are not needed for colds or the flu.

“The new SpeakUp campaign provides a variety of resources to help patients and caregivers understand that how they use antibiotics today can affect how well the drugs work for them tomorrow,” says Lisa Waldowski, MS, APRN, CIC, infection control specialist at The Joint Commission.

The primary audience for these materials is the consumer, but hospitalists and healthcare workers are the crucial secondary audience. “This is a partnership; the knowledge needs to go both ways,” Waldowski says. “Sometimes there’s an expectation that when you see a physician, you are somehow shortchanged if you don’t leave with a prescription for an antibiotic.

There’s an education that needs to go on in the mindset of the physician, [in terms of] looking at whether this situation warrants an antibiotic and educating the patient if it does not. It takes time to have that conversation.”

The campaign can also provide a starting point for hospitalists to make changes in the workplace. “The information needs to be digested by everyone individually, but collectively in the organization where you work, this can lead to an antibiotic stewardship program, a coordinated intervention,” she says. She recommends a multidisciplinary approach. “Sometimes successful programs are led by a physician, and they have a strong pharmacy component, working together and supporting one another to use antibiotics appropriately.”

Visit our website for more information on antibiotic overuse.

The Centers for Medicare & Medicaid Services (CMS) has wrapped up a test run of a new measure for readmission of heart failure patients as the federal agency tries to educate hospitals and hospitalists before formally including it as a quality metric in fiscal year 2018.

The trial concludes October 7, 2015, for the new claims-based measurement, excess days in acute care (EDAC) after hospitalization for heart failure. It captures the number of days within the 30-day postdischarge period that a patient spends in acute care following an index admission for heart failure. The measure will be included in CMS’ Hospital Inpatient Quality Reporting Program in fiscal year 2018, but the agency plans to publicly report hospitals’ results on Hospital Compare next year.

CMS hopes the new measure will help educate hospitals and hospitalists about 30-day postdischarge outcomes for patients with heart failure and provide a better understanding of what services are utilized, which could translate to better interventions. CMS spokesperson Alper Ozinal says that hospitalists currently get “little feedback about what happens to their patients after discharge.”

“CMS found substantial variation in utilization across hospitals, which suggests an opportunity for improvement in transitional care practices,” Ozinal says. “CMS anticipates that the measure will support hospital efforts to further optimize quality of care, particularly the quality of transitional care, by providing a more comprehensive picture of postdischarge events.”

The measure’s trial run, which began September 8, 2015, measured Medicare fee-for-service patients age 65 and older who were hospitalized with a principal discharge diagnosis of heart failure. The outcomes are risk-adjusted, taking into account age, sex, and comorbidities.

Once the results are calculated, CMS will post a report on the QualityNet website. Comments are welcome as CMS is expected to discuss whether tweaks are needed in the measure’s methodology.

Visit our website for more information on hospital readmissions.

The Centers for Medicare & Medicaid Services (CMS) has wrapped up a test run of a new measure for readmission of heart failure patients as the federal agency tries to educate hospitals and hospitalists before formally including it as a quality metric in fiscal year 2018.

The trial concludes October 7, 2015, for the new claims-based measurement, excess days in acute care (EDAC) after hospitalization for heart failure. It captures the number of days within the 30-day postdischarge period that a patient spends in acute care following an index admission for heart failure. The measure will be included in CMS’ Hospital Inpatient Quality Reporting Program in fiscal year 2018, but the agency plans to publicly report hospitals’ results on Hospital Compare next year.

CMS hopes the new measure will help educate hospitals and hospitalists about 30-day postdischarge outcomes for patients with heart failure and provide a better understanding of what services are utilized, which could translate to better interventions. CMS spokesperson Alper Ozinal says that hospitalists currently get “little feedback about what happens to their patients after discharge.”

“CMS found substantial variation in utilization across hospitals, which suggests an opportunity for improvement in transitional care practices,” Ozinal says. “CMS anticipates that the measure will support hospital efforts to further optimize quality of care, particularly the quality of transitional care, by providing a more comprehensive picture of postdischarge events.”

The measure’s trial run, which began September 8, 2015, measured Medicare fee-for-service patients age 65 and older who were hospitalized with a principal discharge diagnosis of heart failure. The outcomes are risk-adjusted, taking into account age, sex, and comorbidities.

Once the results are calculated, CMS will post a report on the QualityNet website. Comments are welcome as CMS is expected to discuss whether tweaks are needed in the measure’s methodology.

Visit our website for more information on hospital readmissions.

The Centers for Medicare & Medicaid Services (CMS) has wrapped up a test run of a new measure for readmission of heart failure patients as the federal agency tries to educate hospitals and hospitalists before formally including it as a quality metric in fiscal year 2018.

The trial concludes October 7, 2015, for the new claims-based measurement, excess days in acute care (EDAC) after hospitalization for heart failure. It captures the number of days within the 30-day postdischarge period that a patient spends in acute care following an index admission for heart failure. The measure will be included in CMS’ Hospital Inpatient Quality Reporting Program in fiscal year 2018, but the agency plans to publicly report hospitals’ results on Hospital Compare next year.

CMS hopes the new measure will help educate hospitals and hospitalists about 30-day postdischarge outcomes for patients with heart failure and provide a better understanding of what services are utilized, which could translate to better interventions. CMS spokesperson Alper Ozinal says that hospitalists currently get “little feedback about what happens to their patients after discharge.”

“CMS found substantial variation in utilization across hospitals, which suggests an opportunity for improvement in transitional care practices,” Ozinal says. “CMS anticipates that the measure will support hospital efforts to further optimize quality of care, particularly the quality of transitional care, by providing a more comprehensive picture of postdischarge events.”

The measure’s trial run, which began September 8, 2015, measured Medicare fee-for-service patients age 65 and older who were hospitalized with a principal discharge diagnosis of heart failure. The outcomes are risk-adjusted, taking into account age, sex, and comorbidities.

Once the results are calculated, CMS will post a report on the QualityNet website. Comments are welcome as CMS is expected to discuss whether tweaks are needed in the measure’s methodology.

Visit our website for more information on hospital readmissions.

The electronic health record (EHR) has many benefits:

• Improved patient care;
• Improved care coordination;
• Improved diagnostics and patient outcomes;
• Increased patient participation; and
• Increased practice efficiencies and cost savings.¹

EHRs also introduce risks, however. Heightened concern about EHR misuse and vulnerability elevates the level of scrutiny placed on provider documentation as it relates to billing and coding. Without clear guidelines from the Centers for Medicare and Medicaid Services (CMS) or other payers, the potential for unintentional misapplication exists. Auditor misinterpretation is also possible. Providers should utilize simple defensive documentation principles to support their services and minimize their risks.

Reason for Encounter

Under section 1862 (a)(1)(A) of the Social Security Act, the Medicare Program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).²

A payer can determine if a service is “reasonable and necessary” based on the service indication. The reason for the patient encounter, otherwise known as the chief complaint, must be evident. This can be a symptom, problem, condition, diagnosis, physician-recommended return, or another factor that necessitates the encounter.¹ It cannot be inferred and must be clearly stated in the documentation. Without it, a payer may question the medical necessity of the service, especially if it involves hospital-based services in the course of which multiple specialists will see the patient on any given date. Payers are likely to deny services that cannot be easily differentiated (e.g. “no c/o”). Furthermore, payers can deny concurrent care services for the following reasons:³

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate/overlap those of the other provider without any recognizable distinction.

Providers should be specific in identifying the encounter reason, as in the following examples: “Patient seen for shortness of breath” or “Patient with COPD, feeling improved with 3L O2 NC.”

Assessment and Plan

Accurately representing patient complexity for every visit throughout the hospitalization presents its challenges. Although the problem list may not dramatically change day to day, providers must formulate an assessment of the patient’s condition with a corresponding plan of care for each encounter. Documenting problems without a corresponding plan of care does not substantiate physician participation in the management of that problem. Providing a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) minimizes the complexity and effort put forth in the encounter and could result in auditor downgrading upon documentation review.

Developing shortcuts might falsely minimize the provider’s documentation burden. An electronic documentation system might make it possible to copy previous progress notes into the current encounter to save time; however, the previously entered information could include elements that do not require reassessment during a subsequent encounter or contain information about conditions that are being managed concurrently by another specialist (e.g. CKD being managed by the nephrologist). Leaving the copied information unmodified may not accurately reflect the patient’s current condition or the care provided by the hospitalist during the current encounter. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care relevant to that date.

According to the Office of Inspector General (OIG), “inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”⁴

An equally problematic EHR function involves “overdocumentation,” the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services.4 EHR technology has the ability to auto-populate fields using templates built into the system or generate extensive documentation on the basis of a single click. The OIG cautions providers to use these features carefully, because they can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.⁴

 

An example is the inclusion of the same lab results more than once. Although clinicians include this information as a reference to avoid having to “find it somewhere in the chart” when it is needed—as a basis for comparison, for example—auditors mistake this as an attempt to gain credit for the daily review of the same “old” information. Including only relevant data will mitigate this concern.

Authorship

Dates and signatures are essential to each encounter. Medicare requires services provided/ordered to be authenticated by the author.⁵ A reviewer must be able to identify each individual who performs, documents, and bills for a service on a given date. Progress notes that fail to identify the service date or service provider will likely result in denial.

Additionally, a service is questioned when two different sets of handwriting appear on a note, yet only one signature is provided. Since the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.

Notes that contain an illegible signature are equally problematic. If the legibility of the signature prevents the reviewer from correctly identifying the rendering provider, the service may be denied.

CMS has instructed Medicare contractors to request a signed provider attestation before issuing a denial.⁵ The provider should print his/her name beside the signature or include a separate signature sheet with the requested documentation to assist the reviewer in provider identification. Stamped signatures are not acceptable under any circumstance. Medicare accepts only handwritten or electronic signatures.⁵

---

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. HealthIT.gov. Benefits of electronic health records (EHRs). Accessed August 1, 2015.
2. Social Security Administration. Exclusions from coverage and Medicare as secondary payer. Accessed August 1, 2015.
3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15—Covered medical and other health services. Chapter 15, Section 30.E. Concurrent care. Accessed August 1, 2015.
4. Department of Health and Human Services. Office of Inspector General. CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs. Accessed August 1, 2015.
5. Centers for Medicare and Medicaid Services. Signature guidelines for medical review purposes. Accessed August 1, 2015.
6. Centers for Medicare and Medicaid Services. 1995 documentation guidelines for evaluation and management services. Accessed August 1, 2015.

The electronic health record (EHR) has many benefits:

• Improved patient care;
• Improved care coordination;
• Improved diagnostics and patient outcomes;
• Increased patient participation; and
• Increased practice efficiencies and cost savings.¹

EHRs also introduce risks, however. Heightened concern about EHR misuse and vulnerability elevates the level of scrutiny placed on provider documentation as it relates to billing and coding. Without clear guidelines from the Centers for Medicare and Medicaid Services (CMS) or other payers, the potential for unintentional misapplication exists. Auditor misinterpretation is also possible. Providers should utilize simple defensive documentation principles to support their services and minimize their risks.

Reason for Encounter

Under section 1862 (a)(1)(A) of the Social Security Act, the Medicare Program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).²

A payer can determine if a service is “reasonable and necessary” based on the service indication. The reason for the patient encounter, otherwise known as the chief complaint, must be evident. This can be a symptom, problem, condition, diagnosis, physician-recommended return, or another factor that necessitates the encounter.¹ It cannot be inferred and must be clearly stated in the documentation. Without it, a payer may question the medical necessity of the service, especially if it involves hospital-based services in the course of which multiple specialists will see the patient on any given date. Payers are likely to deny services that cannot be easily differentiated (e.g. “no c/o”). Furthermore, payers can deny concurrent care services for the following reasons:³

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate/overlap those of the other provider without any recognizable distinction.

Providers should be specific in identifying the encounter reason, as in the following examples: “Patient seen for shortness of breath” or “Patient with COPD, feeling improved with 3L O2 NC.”

Assessment and Plan

Accurately representing patient complexity for every visit throughout the hospitalization presents its challenges. Although the problem list may not dramatically change day to day, providers must formulate an assessment of the patient’s condition with a corresponding plan of care for each encounter. Documenting problems without a corresponding plan of care does not substantiate physician participation in the management of that problem. Providing a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) minimizes the complexity and effort put forth in the encounter and could result in auditor downgrading upon documentation review.

Developing shortcuts might falsely minimize the provider’s documentation burden. An electronic documentation system might make it possible to copy previous progress notes into the current encounter to save time; however, the previously entered information could include elements that do not require reassessment during a subsequent encounter or contain information about conditions that are being managed concurrently by another specialist (e.g. CKD being managed by the nephrologist). Leaving the copied information unmodified may not accurately reflect the patient’s current condition or the care provided by the hospitalist during the current encounter. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care relevant to that date.

According to the Office of Inspector General (OIG), “inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”⁴

An equally problematic EHR function involves “overdocumentation,” the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services.4 EHR technology has the ability to auto-populate fields using templates built into the system or generate extensive documentation on the basis of a single click. The OIG cautions providers to use these features carefully, because they can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.⁴

 

An example is the inclusion of the same lab results more than once. Although clinicians include this information as a reference to avoid having to “find it somewhere in the chart” when it is needed—as a basis for comparison, for example—auditors mistake this as an attempt to gain credit for the daily review of the same “old” information. Including only relevant data will mitigate this concern.

Authorship

Dates and signatures are essential to each encounter. Medicare requires services provided/ordered to be authenticated by the author.⁵ A reviewer must be able to identify each individual who performs, documents, and bills for a service on a given date. Progress notes that fail to identify the service date or service provider will likely result in denial.

Additionally, a service is questioned when two different sets of handwriting appear on a note, yet only one signature is provided. Since the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.

Notes that contain an illegible signature are equally problematic. If the legibility of the signature prevents the reviewer from correctly identifying the rendering provider, the service may be denied.

CMS has instructed Medicare contractors to request a signed provider attestation before issuing a denial.⁵ The provider should print his/her name beside the signature or include a separate signature sheet with the requested documentation to assist the reviewer in provider identification. Stamped signatures are not acceptable under any circumstance. Medicare accepts only handwritten or electronic signatures.⁵

---

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. HealthIT.gov. Benefits of electronic health records (EHRs). Accessed August 1, 2015.
2. Social Security Administration. Exclusions from coverage and Medicare as secondary payer. Accessed August 1, 2015.
3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15—Covered medical and other health services. Chapter 15, Section 30.E. Concurrent care. Accessed August 1, 2015.
4. Department of Health and Human Services. Office of Inspector General. CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs. Accessed August 1, 2015.
5. Centers for Medicare and Medicaid Services. Signature guidelines for medical review purposes. Accessed August 1, 2015.
6. Centers for Medicare and Medicaid Services. 1995 documentation guidelines for evaluation and management services. Accessed August 1, 2015.

The electronic health record (EHR) has many benefits:

• Improved patient care;
• Improved care coordination;
• Improved diagnostics and patient outcomes;
• Increased patient participation; and
• Increased practice efficiencies and cost savings.¹

EHRs also introduce risks, however. Heightened concern about EHR misuse and vulnerability elevates the level of scrutiny placed on provider documentation as it relates to billing and coding. Without clear guidelines from the Centers for Medicare and Medicaid Services (CMS) or other payers, the potential for unintentional misapplication exists. Auditor misinterpretation is also possible. Providers should utilize simple defensive documentation principles to support their services and minimize their risks.

Reason for Encounter

Under section 1862 (a)(1)(A) of the Social Security Act, the Medicare Program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).²

A payer can determine if a service is “reasonable and necessary” based on the service indication. The reason for the patient encounter, otherwise known as the chief complaint, must be evident. This can be a symptom, problem, condition, diagnosis, physician-recommended return, or another factor that necessitates the encounter.¹ It cannot be inferred and must be clearly stated in the documentation. Without it, a payer may question the medical necessity of the service, especially if it involves hospital-based services in the course of which multiple specialists will see the patient on any given date. Payers are likely to deny services that cannot be easily differentiated (e.g. “no c/o”). Furthermore, payers can deny concurrent care services for the following reasons:³

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate/overlap those of the other provider without any recognizable distinction.

Providers should be specific in identifying the encounter reason, as in the following examples: “Patient seen for shortness of breath” or “Patient with COPD, feeling improved with 3L O2 NC.”

Assessment and Plan

Accurately representing patient complexity for every visit throughout the hospitalization presents its challenges. Although the problem list may not dramatically change day to day, providers must formulate an assessment of the patient’s condition with a corresponding plan of care for each encounter. Documenting problems without a corresponding plan of care does not substantiate physician participation in the management of that problem. Providing a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) minimizes the complexity and effort put forth in the encounter and could result in auditor downgrading upon documentation review.

Developing shortcuts might falsely minimize the provider’s documentation burden. An electronic documentation system might make it possible to copy previous progress notes into the current encounter to save time; however, the previously entered information could include elements that do not require reassessment during a subsequent encounter or contain information about conditions that are being managed concurrently by another specialist (e.g. CKD being managed by the nephrologist). Leaving the copied information unmodified may not accurately reflect the patient’s current condition or the care provided by the hospitalist during the current encounter. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care relevant to that date.

According to the Office of Inspector General (OIG), “inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”⁴

An equally problematic EHR function involves “overdocumentation,” the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services.4 EHR technology has the ability to auto-populate fields using templates built into the system or generate extensive documentation on the basis of a single click. The OIG cautions providers to use these features carefully, because they can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.⁴

 

An example is the inclusion of the same lab results more than once. Although clinicians include this information as a reference to avoid having to “find it somewhere in the chart” when it is needed—as a basis for comparison, for example—auditors mistake this as an attempt to gain credit for the daily review of the same “old” information. Including only relevant data will mitigate this concern.

Authorship

Dates and signatures are essential to each encounter. Medicare requires services provided/ordered to be authenticated by the author.⁵ A reviewer must be able to identify each individual who performs, documents, and bills for a service on a given date. Progress notes that fail to identify the service date or service provider will likely result in denial.

Additionally, a service is questioned when two different sets of handwriting appear on a note, yet only one signature is provided. Since the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.

Notes that contain an illegible signature are equally problematic. If the legibility of the signature prevents the reviewer from correctly identifying the rendering provider, the service may be denied.

CMS has instructed Medicare contractors to request a signed provider attestation before issuing a denial.⁵ The provider should print his/her name beside the signature or include a separate signature sheet with the requested documentation to assist the reviewer in provider identification. Stamped signatures are not acceptable under any circumstance. Medicare accepts only handwritten or electronic signatures.⁵

---

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. HealthIT.gov. Benefits of electronic health records (EHRs). Accessed August 1, 2015.
2. Social Security Administration. Exclusions from coverage and Medicare as secondary payer. Accessed August 1, 2015.
3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15—Covered medical and other health services. Chapter 15, Section 30.E. Concurrent care. Accessed August 1, 2015.
4. Department of Health and Human Services. Office of Inspector General. CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs. Accessed August 1, 2015.
5. Centers for Medicare and Medicaid Services. Signature guidelines for medical review purposes. Accessed August 1, 2015.
6. Centers for Medicare and Medicaid Services. 1995 documentation guidelines for evaluation and management services. Accessed August 1, 2015.

Clinical question: In infants younger than three months of age with bacteremic urinary tract infection (UTI), how sensitive and specific are urinalysis (UA) findings?

Background: Infants are commonly hospitalized with UTIs. The gold standard for diagnosis is considered to be urine culture. When compared to this gold standard, the sensitivity of UA findings for the diagnosis of UTI has been previously reported to be around 75% to 85%; however, a positive urine culture alone in the setting of negative UA may not be reflective of a UTI due to asymptomatic bacteriuria or contamination. The 2011 American Academy of Pediatrics clinical guideline for UTIs suggests that the diagnosis should require positive urine culture in addition to abnormal UA. These guidelines do not include infants younger than two months of age, and positive cultures in this age group are generally regarded as a UTI and treated as such. Positive culture results with the same organism in the urine and blood indicates very low likelihood of contamination or asymptomatic bacteriuria, and patients with bacteremic UTI are likely to have a true infection.

Study design: Multicenter, retrospective, cross-sectional study.

Setting: Twenty hospitals in eleven hospital systems.

Synopsis: Researchers used a multicenter microbiology database to identify infants younger than three months of age with bacteremic UTI (same pathogenic organism in blood and urine). Data was collected on UA, including microscopy [white blood cells per high-power field (WBC/HPF), bacteria], dipstick [nitrites, leukocyte esterase (LE)], and urine culture in colony-forming units per mL (CFU/mL).

Exclusions included:

• Major comorbidities (defined in this study as neuromuscular conditions such as spina bifida, previous urologic surgery other than circumcision, or immunodeficiency);
• Patients managed in an ICU setting; and
• Patients with indwelling urinary or central venous catheters at the time of culture.

A total of 276 infants with bacteremic UTI were identified, with 31 exclusions (12 with no UA performed, 19 with cultures with <50,000 CFU/mL). The remaining 245 infants were included for analysis. The control group was a random sampling of 115 similarly aged infants who underwent evaluation for serious bacterial infection and had negative urine cultures.

Comparison between the study group (bacteremic UTI) and the controls showed:

• LE (including any “positive” LE) had a sensitivity of 97.6%, specificity of 93.9%;
• Considering “trace” LE as negative changed the sensitivity and specificity to 95.7% and 97.4%, respectively; and
• Positive nitrites had a specificity of 100%.

A definition of positive UA that includes pyuria (greater than 3 WBC/HPF) and/or any LE was highly sensitive (99.5%) and specific (87.8%). All but one of 203 infants with bacteremic UTI who had complete UA results were positive for LE and/or WBC/HPF. The one exception was a 64-day-old girl with Group B Streptococcus infection. Bacteria on microscopy showed poor specificity.

The authors discussed two possible explanations for the study’s finding of high sensitivity of the UA, including:

• The UA is in fact highly sensitive, and previous studies have been flawed by a faulty gold standard (positive cultures due to asymptomatic bacteriuria or contamination); or
• Screening tests are more sensitive in the setting of severe disease (in this case, UTI with bacteremia).

The second explanation is controversial, and the authors of this article cite previous studies showing minimal differences between UTI with or without bacteremia.

Bottom line: In infants younger than three months of age with bacteremic UTI, the findings of pyuria and/or any LE on UA are reliable predictors of infection, with higher sensitivity than previously reported.

Citation: Schroeder AR, Chang PW, Shen MW, Biondi EA, Greenhow TL. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics. 2015;135(6):965-71.

 

---

Dr. Galloway is a pediatric hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D., assistant professor of pediatrics at the University of South Dakota Sanford School of Medicine, and vice chief of the division of hospital pediatrics at USD SSOM and Sanford Children’s Hospital.

Clinical question: In infants younger than three months of age with bacteremic urinary tract infection (UTI), how sensitive and specific are urinalysis (UA) findings?

Background: Infants are commonly hospitalized with UTIs. The gold standard for diagnosis is considered to be urine culture. When compared to this gold standard, the sensitivity of UA findings for the diagnosis of UTI has been previously reported to be around 75% to 85%; however, a positive urine culture alone in the setting of negative UA may not be reflective of a UTI due to asymptomatic bacteriuria or contamination. The 2011 American Academy of Pediatrics clinical guideline for UTIs suggests that the diagnosis should require positive urine culture in addition to abnormal UA. These guidelines do not include infants younger than two months of age, and positive cultures in this age group are generally regarded as a UTI and treated as such. Positive culture results with the same organism in the urine and blood indicates very low likelihood of contamination or asymptomatic bacteriuria, and patients with bacteremic UTI are likely to have a true infection.

Study design: Multicenter, retrospective, cross-sectional study.

Setting: Twenty hospitals in eleven hospital systems.

Synopsis: Researchers used a multicenter microbiology database to identify infants younger than three months of age with bacteremic UTI (same pathogenic organism in blood and urine). Data was collected on UA, including microscopy [white blood cells per high-power field (WBC/HPF), bacteria], dipstick [nitrites, leukocyte esterase (LE)], and urine culture in colony-forming units per mL (CFU/mL).

Exclusions included:

• Major comorbidities (defined in this study as neuromuscular conditions such as spina bifida, previous urologic surgery other than circumcision, or immunodeficiency);
• Patients managed in an ICU setting; and
• Patients with indwelling urinary or central venous catheters at the time of culture.

A total of 276 infants with bacteremic UTI were identified, with 31 exclusions (12 with no UA performed, 19 with cultures with <50,000 CFU/mL). The remaining 245 infants were included for analysis. The control group was a random sampling of 115 similarly aged infants who underwent evaluation for serious bacterial infection and had negative urine cultures.

Comparison between the study group (bacteremic UTI) and the controls showed:

• LE (including any “positive” LE) had a sensitivity of 97.6%, specificity of 93.9%;
• Considering “trace” LE as negative changed the sensitivity and specificity to 95.7% and 97.4%, respectively; and
• Positive nitrites had a specificity of 100%.

A definition of positive UA that includes pyuria (greater than 3 WBC/HPF) and/or any LE was highly sensitive (99.5%) and specific (87.8%). All but one of 203 infants with bacteremic UTI who had complete UA results were positive for LE and/or WBC/HPF. The one exception was a 64-day-old girl with Group B Streptococcus infection. Bacteria on microscopy showed poor specificity.

The authors discussed two possible explanations for the study’s finding of high sensitivity of the UA, including:

• The UA is in fact highly sensitive, and previous studies have been flawed by a faulty gold standard (positive cultures due to asymptomatic bacteriuria or contamination); or
• Screening tests are more sensitive in the setting of severe disease (in this case, UTI with bacteremia).

The second explanation is controversial, and the authors of this article cite previous studies showing minimal differences between UTI with or without bacteremia.

Bottom line: In infants younger than three months of age with bacteremic UTI, the findings of pyuria and/or any LE on UA are reliable predictors of infection, with higher sensitivity than previously reported.

Citation: Schroeder AR, Chang PW, Shen MW, Biondi EA, Greenhow TL. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics. 2015;135(6):965-71.

 

---

Dr. Galloway is a pediatric hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D., assistant professor of pediatrics at the University of South Dakota Sanford School of Medicine, and vice chief of the division of hospital pediatrics at USD SSOM and Sanford Children’s Hospital.

Clinical question: In infants younger than three months of age with bacteremic urinary tract infection (UTI), how sensitive and specific are urinalysis (UA) findings?

Background: Infants are commonly hospitalized with UTIs. The gold standard for diagnosis is considered to be urine culture. When compared to this gold standard, the sensitivity of UA findings for the diagnosis of UTI has been previously reported to be around 75% to 85%; however, a positive urine culture alone in the setting of negative UA may not be reflective of a UTI due to asymptomatic bacteriuria or contamination. The 2011 American Academy of Pediatrics clinical guideline for UTIs suggests that the diagnosis should require positive urine culture in addition to abnormal UA. These guidelines do not include infants younger than two months of age, and positive cultures in this age group are generally regarded as a UTI and treated as such. Positive culture results with the same organism in the urine and blood indicates very low likelihood of contamination or asymptomatic bacteriuria, and patients with bacteremic UTI are likely to have a true infection.

Study design: Multicenter, retrospective, cross-sectional study.

Setting: Twenty hospitals in eleven hospital systems.

Synopsis: Researchers used a multicenter microbiology database to identify infants younger than three months of age with bacteremic UTI (same pathogenic organism in blood and urine). Data was collected on UA, including microscopy [white blood cells per high-power field (WBC/HPF), bacteria], dipstick [nitrites, leukocyte esterase (LE)], and urine culture in colony-forming units per mL (CFU/mL).

Exclusions included:

• Major comorbidities (defined in this study as neuromuscular conditions such as spina bifida, previous urologic surgery other than circumcision, or immunodeficiency);
• Patients managed in an ICU setting; and
• Patients with indwelling urinary or central venous catheters at the time of culture.

A total of 276 infants with bacteremic UTI were identified, with 31 exclusions (12 with no UA performed, 19 with cultures with <50,000 CFU/mL). The remaining 245 infants were included for analysis. The control group was a random sampling of 115 similarly aged infants who underwent evaluation for serious bacterial infection and had negative urine cultures.

Comparison between the study group (bacteremic UTI) and the controls showed:

• LE (including any “positive” LE) had a sensitivity of 97.6%, specificity of 93.9%;
• Considering “trace” LE as negative changed the sensitivity and specificity to 95.7% and 97.4%, respectively; and
• Positive nitrites had a specificity of 100%.

A definition of positive UA that includes pyuria (greater than 3 WBC/HPF) and/or any LE was highly sensitive (99.5%) and specific (87.8%). All but one of 203 infants with bacteremic UTI who had complete UA results were positive for LE and/or WBC/HPF. The one exception was a 64-day-old girl with Group B Streptococcus infection. Bacteria on microscopy showed poor specificity.

The authors discussed two possible explanations for the study’s finding of high sensitivity of the UA, including:

• The UA is in fact highly sensitive, and previous studies have been flawed by a faulty gold standard (positive cultures due to asymptomatic bacteriuria or contamination); or
• Screening tests are more sensitive in the setting of severe disease (in this case, UTI with bacteremia).

The second explanation is controversial, and the authors of this article cite previous studies showing minimal differences between UTI with or without bacteremia.

Bottom line: In infants younger than three months of age with bacteremic UTI, the findings of pyuria and/or any LE on UA are reliable predictors of infection, with higher sensitivity than previously reported.

Citation: Schroeder AR, Chang PW, Shen MW, Biondi EA, Greenhow TL. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics. 2015;135(6):965-71.

 

---

Dr. Galloway is a pediatric hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D., assistant professor of pediatrics at the University of South Dakota Sanford School of Medicine, and vice chief of the division of hospital pediatrics at USD SSOM and Sanford Children’s Hospital.