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An experimental antibody developed by Merck & Co Inc was shown in pivotal studies to reduce by about 10 percentage points the risk that infection with Clostridium difficile will recur.

In the United States, C. difficile infects nearly half a million people each year and contributes to around 29,000 deaths. The infection is treated with standard antibiotics, which also wipe out healthy bacteria that normally keep C. difficile under control.

Merck said two Phase 3 studies found 12 weeks of treatment with antibiotics and a one-time infusion of bezlotoxumab, designed to block the ability of a toxin to bind to cells, reduced to about 15% the risk that C. difficile would recur. The studies found that the infection recurred in about 25% of patients treated with antibiotics and a placebo.

"We have therapies to treat the initial episode, but this infection comes back frequently - there is a 25% risk of recurrence after the first time, and that rises to 40% or even 60% after the second infection," said Nick Kartsonis, associate vice president in clinical research, infectious diseases at Merck.

The studies showed no benefit from a second experimental antibody, actoxumab, either alone or in combination with bezlotoxumab. Merck said the actoxumab arm was stopped for efficacy and safety reasons after an interim analysis.

The studies were presented September 20 at the Interscience Conference of Antimicrobial Agents and Chemotherapy (ICAAC) and International Congress of Chemotherapy and Infection (ICC) joint meeting in San Diego.

Bezlotoxumab is a selective, fully-human, monoclonal antibody designed to neutralize C. difficile toxin B.

The company said it plans to file before the end of the year for regulatory approval of bezlotoxumab, which it licensed from Massachusetts Biologic Laboratories and Medarex, now owned by Bristol-Myers Squibb.

Side effects, including nausea, diarrhea and urinary tract infection, occurred at similar rates for patients in both the treatment and placebo arms of the trials.

The incidence of C. difficile infection has risen sharply over the last two decades and is now a leading cause of healthcare-acquired infections in community hospitals in the United States, according to the U.S. Centers for Disease Control and Prevention.

Other companies are working on vaccines against C. difficile. Doctors are also treating patients with "stool transplants," which involves inserting fecal material from a healthy person into the gut of someone with severe diarrhea in order to restore friendly bacteria.

An experimental antibody developed by Merck & Co Inc was shown in pivotal studies to reduce by about 10 percentage points the risk that infection with Clostridium difficile will recur.

In the United States, C. difficile infects nearly half a million people each year and contributes to around 29,000 deaths. The infection is treated with standard antibiotics, which also wipe out healthy bacteria that normally keep C. difficile under control.

Merck said two Phase 3 studies found 12 weeks of treatment with antibiotics and a one-time infusion of bezlotoxumab, designed to block the ability of a toxin to bind to cells, reduced to about 15% the risk that C. difficile would recur. The studies found that the infection recurred in about 25% of patients treated with antibiotics and a placebo.

"We have therapies to treat the initial episode, but this infection comes back frequently - there is a 25% risk of recurrence after the first time, and that rises to 40% or even 60% after the second infection," said Nick Kartsonis, associate vice president in clinical research, infectious diseases at Merck.

The studies showed no benefit from a second experimental antibody, actoxumab, either alone or in combination with bezlotoxumab. Merck said the actoxumab arm was stopped for efficacy and safety reasons after an interim analysis.

The studies were presented September 20 at the Interscience Conference of Antimicrobial Agents and Chemotherapy (ICAAC) and International Congress of Chemotherapy and Infection (ICC) joint meeting in San Diego.

Bezlotoxumab is a selective, fully-human, monoclonal antibody designed to neutralize C. difficile toxin B.

The company said it plans to file before the end of the year for regulatory approval of bezlotoxumab, which it licensed from Massachusetts Biologic Laboratories and Medarex, now owned by Bristol-Myers Squibb.

Side effects, including nausea, diarrhea and urinary tract infection, occurred at similar rates for patients in both the treatment and placebo arms of the trials.

The incidence of C. difficile infection has risen sharply over the last two decades and is now a leading cause of healthcare-acquired infections in community hospitals in the United States, according to the U.S. Centers for Disease Control and Prevention.

Other companies are working on vaccines against C. difficile. Doctors are also treating patients with "stool transplants," which involves inserting fecal material from a healthy person into the gut of someone with severe diarrhea in order to restore friendly bacteria.

An experimental antibody developed by Merck & Co Inc was shown in pivotal studies to reduce by about 10 percentage points the risk that infection with Clostridium difficile will recur.

In the United States, C. difficile infects nearly half a million people each year and contributes to around 29,000 deaths. The infection is treated with standard antibiotics, which also wipe out healthy bacteria that normally keep C. difficile under control.

Merck said two Phase 3 studies found 12 weeks of treatment with antibiotics and a one-time infusion of bezlotoxumab, designed to block the ability of a toxin to bind to cells, reduced to about 15% the risk that C. difficile would recur. The studies found that the infection recurred in about 25% of patients treated with antibiotics and a placebo.

"We have therapies to treat the initial episode, but this infection comes back frequently - there is a 25% risk of recurrence after the first time, and that rises to 40% or even 60% after the second infection," said Nick Kartsonis, associate vice president in clinical research, infectious diseases at Merck.

The studies showed no benefit from a second experimental antibody, actoxumab, either alone or in combination with bezlotoxumab. Merck said the actoxumab arm was stopped for efficacy and safety reasons after an interim analysis.

The studies were presented September 20 at the Interscience Conference of Antimicrobial Agents and Chemotherapy (ICAAC) and International Congress of Chemotherapy and Infection (ICC) joint meeting in San Diego.

Bezlotoxumab is a selective, fully-human, monoclonal antibody designed to neutralize C. difficile toxin B.

The company said it plans to file before the end of the year for regulatory approval of bezlotoxumab, which it licensed from Massachusetts Biologic Laboratories and Medarex, now owned by Bristol-Myers Squibb.

Side effects, including nausea, diarrhea and urinary tract infection, occurred at similar rates for patients in both the treatment and placebo arms of the trials.

The incidence of C. difficile infection has risen sharply over the last two decades and is now a leading cause of healthcare-acquired infections in community hospitals in the United States, according to the U.S. Centers for Disease Control and Prevention.

Other companies are working on vaccines against C. difficile. Doctors are also treating patients with "stool transplants," which involves inserting fecal material from a healthy person into the gut of someone with severe diarrhea in order to restore friendly bacteria.

It is Tuesday morning, and I drag myself out of bed after a very restless night. It is day number three of a syndrome of fatigue, headache, and moderate productive cough. I have been on service for eight days of a two-week stretch; I am hoping to “make it to the end of the week.” I convince myself I am “not that sick” and head into work for a long day of rounds, after two cups of coffee and 600 mg of Motrin. Throughout the day, I try to hide my cough from my residents and students, and especially the nurses and my patients. I have a pocket full of cough drops and a cup of ice water at hand to stifle any coughing fits that could reveal how I actually feel. This is not the first time I have come to work only “half well.” I convince myself I am not contagious, as long as I wash my hands and control my cough. Without a fever, how could I possibly justify calling in a colleague to cover for me?

I am not alone in my psychological justifications for coming to work. A recent JAMA Pediatrics article found that 83% of clinicians admitted to coming to work while sick, while 95% admitted to knowing that it could be dangerous to their patients.^1,2 The study surveyed approximately 500 attendings and 250 advanced practice providers at the Children’s Hospital of Philadelphia. A substantial minority of providers (9%) admitted to coming to work sick at least five times in the past year.

The reasons these providers gave for working in spite of being ill likely ring true with each and every hospitalist in the field: They were concerned about 1) letting down their patients or 2) hospital staffing in their absence. Most providers also expressed concern about the continuity of care for their patients in their absence. Most also admitted that they feared being ostracized by their colleagues and believed that there were unwritten but real expectations for them to work regardless of personal illness.

Historically, physicians and other healthcare providers have been widely believed to be relatively immune to mundane ailments, by themselves and by others. How incredibly rare it is to hear, “Sorry, your doctor is sick; we have to reschedule your visit.” Even when afflicted by physical impairments, physicians have long considered it more “honorable” to work through these infirmities than to resign to physical limitations and ask for help.

Misguided or Mishandled

This sense of duty starts early in medical training and continues throughout a physician’s early career. I discovered this firsthand during my internship after suffering a stress fracture in my foot. I woke up one morning with significant foot pain and swelling but hobbled through rounds without a word spoken about my limp. By the afternoon, I could hardly bear weight on my foot, so one of my fellow interns suggested I limp over to the orthopedic clinic; thankfully, they saw me the same day, diagnosed the stress fracture, and fitted me in a walking cast. The next day on rounds, when I asked my attending if we could take the elevator up the two floors to the next patient, he looked annoyed and said I could meet them there; they scurried up the stairs. For the next few weeks, I never missed a minute of work but kept trailing behind and missing key pieces of presentations and information from rounds, having to hobble back and forth to the elevator between floors.

The lesson I quickly learned back then was that if I was not “fit for duty” with any sort of physical ailment, it was clearly my problem to make up for my deficits, because the work expectations would go unchanged. Although a stress fracture did not put my patients at risk, the experience sent a strong message: Regardless of the impact on patients, it is always better to come to work than to stay home, whatever the type or degree of affliction.

The JAMA Pediatrics study did find substantial differences in the types of symptoms that would keep a provider at home: While 75% reported they would come to work with a cough and rhinorrhea, 30% would come with diarrhea, 16% would come with a fever, and only 5% would come with vomiting.

To be honest, this sounds about right in comparison to what my threshold would be, and it is about what I would accept as reasonable from a colleague. I do hope that if I were “really sick,” with fever and/or vomiting, I would have the good sense to stay home and ask for coverage, and I hope my colleagues and I would support each other in these decisions.

The study really gets at the sociocultural factors that steer physicians into making such decisions, based on the conditions for being excused that they think are socially acceptable. I suspect these are similar to those that other industries would also consider acceptable. But, of course, the difference is that workers in other industries are less likely to cause harm to large numbers of vulnerable and innocent “bystanders.” Adding to the problem, there is no good “definition” for what is “too sick”; although it is complicated and varies by person, the definition should at least take into account the level of potential contagion and risk to patients.

The authors suggest that, in order to remedy this longstanding situation, open dialogue needs to take place among physician groups to reduce the ambiguity about what is appropriate. A good start would be the generation of clear policies that restrict providers from coming to work with specifics signs/symptoms.

As hospitalists, we should all discuss the article within our groups and honestly determine in advance what our “code of conduct” should be for illnesses, based on our provider mix and our patient populations. (Decisions for ICU, medical-surgical, or oncology may vary.) This would reduce ambiguity and create new social norms about when to stay home. In addition, administrative and provider group leaders need to show strong leadership and support for such policies and ensure adequate staffing in the event of appropriate callouts. Such policies need to ensure that callouts are equitable and non-punitive. These relatively simple measures would go a long way in reducing the risk of illness among ourselves and our patients.

References

1. Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: A mixed methods analysis [published online ahead of print July 6, 2015]. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.0684.
2. Starke JR, Jackson MA. When the health care worker is sick: primum non nocere [published online ahead of print July 6, 2015]. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.0994.

It is Tuesday morning, and I drag myself out of bed after a very restless night. It is day number three of a syndrome of fatigue, headache, and moderate productive cough. I have been on service for eight days of a two-week stretch; I am hoping to “make it to the end of the week.” I convince myself I am “not that sick” and head into work for a long day of rounds, after two cups of coffee and 600 mg of Motrin. Throughout the day, I try to hide my cough from my residents and students, and especially the nurses and my patients. I have a pocket full of cough drops and a cup of ice water at hand to stifle any coughing fits that could reveal how I actually feel. This is not the first time I have come to work only “half well.” I convince myself I am not contagious, as long as I wash my hands and control my cough. Without a fever, how could I possibly justify calling in a colleague to cover for me?

I am not alone in my psychological justifications for coming to work. A recent JAMA Pediatrics article found that 83% of clinicians admitted to coming to work while sick, while 95% admitted to knowing that it could be dangerous to their patients.^1,2 The study surveyed approximately 500 attendings and 250 advanced practice providers at the Children’s Hospital of Philadelphia. A substantial minority of providers (9%) admitted to coming to work sick at least five times in the past year.

The reasons these providers gave for working in spite of being ill likely ring true with each and every hospitalist in the field: They were concerned about 1) letting down their patients or 2) hospital staffing in their absence. Most providers also expressed concern about the continuity of care for their patients in their absence. Most also admitted that they feared being ostracized by their colleagues and believed that there were unwritten but real expectations for them to work regardless of personal illness.

Historically, physicians and other healthcare providers have been widely believed to be relatively immune to mundane ailments, by themselves and by others. How incredibly rare it is to hear, “Sorry, your doctor is sick; we have to reschedule your visit.” Even when afflicted by physical impairments, physicians have long considered it more “honorable” to work through these infirmities than to resign to physical limitations and ask for help.

Misguided or Mishandled

This sense of duty starts early in medical training and continues throughout a physician’s early career. I discovered this firsthand during my internship after suffering a stress fracture in my foot. I woke up one morning with significant foot pain and swelling but hobbled through rounds without a word spoken about my limp. By the afternoon, I could hardly bear weight on my foot, so one of my fellow interns suggested I limp over to the orthopedic clinic; thankfully, they saw me the same day, diagnosed the stress fracture, and fitted me in a walking cast. The next day on rounds, when I asked my attending if we could take the elevator up the two floors to the next patient, he looked annoyed and said I could meet them there; they scurried up the stairs. For the next few weeks, I never missed a minute of work but kept trailing behind and missing key pieces of presentations and information from rounds, having to hobble back and forth to the elevator between floors.

The lesson I quickly learned back then was that if I was not “fit for duty” with any sort of physical ailment, it was clearly my problem to make up for my deficits, because the work expectations would go unchanged. Although a stress fracture did not put my patients at risk, the experience sent a strong message: Regardless of the impact on patients, it is always better to come to work than to stay home, whatever the type or degree of affliction.

The JAMA Pediatrics study did find substantial differences in the types of symptoms that would keep a provider at home: While 75% reported they would come to work with a cough and rhinorrhea, 30% would come with diarrhea, 16% would come with a fever, and only 5% would come with vomiting.

To be honest, this sounds about right in comparison to what my threshold would be, and it is about what I would accept as reasonable from a colleague. I do hope that if I were “really sick,” with fever and/or vomiting, I would have the good sense to stay home and ask for coverage, and I hope my colleagues and I would support each other in these decisions.

The study really gets at the sociocultural factors that steer physicians into making such decisions, based on the conditions for being excused that they think are socially acceptable. I suspect these are similar to those that other industries would also consider acceptable. But, of course, the difference is that workers in other industries are less likely to cause harm to large numbers of vulnerable and innocent “bystanders.” Adding to the problem, there is no good “definition” for what is “too sick”; although it is complicated and varies by person, the definition should at least take into account the level of potential contagion and risk to patients.

The authors suggest that, in order to remedy this longstanding situation, open dialogue needs to take place among physician groups to reduce the ambiguity about what is appropriate. A good start would be the generation of clear policies that restrict providers from coming to work with specifics signs/symptoms.

As hospitalists, we should all discuss the article within our groups and honestly determine in advance what our “code of conduct” should be for illnesses, based on our provider mix and our patient populations. (Decisions for ICU, medical-surgical, or oncology may vary.) This would reduce ambiguity and create new social norms about when to stay home. In addition, administrative and provider group leaders need to show strong leadership and support for such policies and ensure adequate staffing in the event of appropriate callouts. Such policies need to ensure that callouts are equitable and non-punitive. These relatively simple measures would go a long way in reducing the risk of illness among ourselves and our patients.

References

1. Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: A mixed methods analysis [published online ahead of print July 6, 2015]. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.0684.
2. Starke JR, Jackson MA. When the health care worker is sick: primum non nocere [published online ahead of print July 6, 2015]. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.0994.

It is Tuesday morning, and I drag myself out of bed after a very restless night. It is day number three of a syndrome of fatigue, headache, and moderate productive cough. I have been on service for eight days of a two-week stretch; I am hoping to “make it to the end of the week.” I convince myself I am “not that sick” and head into work for a long day of rounds, after two cups of coffee and 600 mg of Motrin. Throughout the day, I try to hide my cough from my residents and students, and especially the nurses and my patients. I have a pocket full of cough drops and a cup of ice water at hand to stifle any coughing fits that could reveal how I actually feel. This is not the first time I have come to work only “half well.” I convince myself I am not contagious, as long as I wash my hands and control my cough. Without a fever, how could I possibly justify calling in a colleague to cover for me?

I am not alone in my psychological justifications for coming to work. A recent JAMA Pediatrics article found that 83% of clinicians admitted to coming to work while sick, while 95% admitted to knowing that it could be dangerous to their patients.^1,2 The study surveyed approximately 500 attendings and 250 advanced practice providers at the Children’s Hospital of Philadelphia. A substantial minority of providers (9%) admitted to coming to work sick at least five times in the past year.

The reasons these providers gave for working in spite of being ill likely ring true with each and every hospitalist in the field: They were concerned about 1) letting down their patients or 2) hospital staffing in their absence. Most providers also expressed concern about the continuity of care for their patients in their absence. Most also admitted that they feared being ostracized by their colleagues and believed that there were unwritten but real expectations for them to work regardless of personal illness.

Historically, physicians and other healthcare providers have been widely believed to be relatively immune to mundane ailments, by themselves and by others. How incredibly rare it is to hear, “Sorry, your doctor is sick; we have to reschedule your visit.” Even when afflicted by physical impairments, physicians have long considered it more “honorable” to work through these infirmities than to resign to physical limitations and ask for help.

Misguided or Mishandled

This sense of duty starts early in medical training and continues throughout a physician’s early career. I discovered this firsthand during my internship after suffering a stress fracture in my foot. I woke up one morning with significant foot pain and swelling but hobbled through rounds without a word spoken about my limp. By the afternoon, I could hardly bear weight on my foot, so one of my fellow interns suggested I limp over to the orthopedic clinic; thankfully, they saw me the same day, diagnosed the stress fracture, and fitted me in a walking cast. The next day on rounds, when I asked my attending if we could take the elevator up the two floors to the next patient, he looked annoyed and said I could meet them there; they scurried up the stairs. For the next few weeks, I never missed a minute of work but kept trailing behind and missing key pieces of presentations and information from rounds, having to hobble back and forth to the elevator between floors.

The lesson I quickly learned back then was that if I was not “fit for duty” with any sort of physical ailment, it was clearly my problem to make up for my deficits, because the work expectations would go unchanged. Although a stress fracture did not put my patients at risk, the experience sent a strong message: Regardless of the impact on patients, it is always better to come to work than to stay home, whatever the type or degree of affliction.

The JAMA Pediatrics study did find substantial differences in the types of symptoms that would keep a provider at home: While 75% reported they would come to work with a cough and rhinorrhea, 30% would come with diarrhea, 16% would come with a fever, and only 5% would come with vomiting.

To be honest, this sounds about right in comparison to what my threshold would be, and it is about what I would accept as reasonable from a colleague. I do hope that if I were “really sick,” with fever and/or vomiting, I would have the good sense to stay home and ask for coverage, and I hope my colleagues and I would support each other in these decisions.

The study really gets at the sociocultural factors that steer physicians into making such decisions, based on the conditions for being excused that they think are socially acceptable. I suspect these are similar to those that other industries would also consider acceptable. But, of course, the difference is that workers in other industries are less likely to cause harm to large numbers of vulnerable and innocent “bystanders.” Adding to the problem, there is no good “definition” for what is “too sick”; although it is complicated and varies by person, the definition should at least take into account the level of potential contagion and risk to patients.

The authors suggest that, in order to remedy this longstanding situation, open dialogue needs to take place among physician groups to reduce the ambiguity about what is appropriate. A good start would be the generation of clear policies that restrict providers from coming to work with specifics signs/symptoms.

As hospitalists, we should all discuss the article within our groups and honestly determine in advance what our “code of conduct” should be for illnesses, based on our provider mix and our patient populations. (Decisions for ICU, medical-surgical, or oncology may vary.) This would reduce ambiguity and create new social norms about when to stay home. In addition, administrative and provider group leaders need to show strong leadership and support for such policies and ensure adequate staffing in the event of appropriate callouts. Such policies need to ensure that callouts are equitable and non-punitive. These relatively simple measures would go a long way in reducing the risk of illness among ourselves and our patients.

References

1. Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: A mixed methods analysis [published online ahead of print July 6, 2015]. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.0684.
2. Starke JR, Jackson MA. When the health care worker is sick: primum non nocere [published online ahead of print July 6, 2015]. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.0994.

You shouldn’t maintain things that do not deliver the value you anticipated when you first put them in place. For example, I thought Netflix streaming would be terrific, but I have used it so infrequently that it probably costs me $50 per movie or show watched. I should probably dump it.

Your hospitalist group might have some operational practices that are not as valuable as they seem and could be replaced with something better. For many groups, this might include doing away with a separate daytime admitter shift and a morning meeting to distribute the overnight admissions.

Daytime Admission Shift

My experience is that hospitalist groups with more than about five daytime doctors almost always have a day-shift person dedicated to seeing new admissions. In most cases, this procedure is implemented with the idea of reducing the stress of other day-shift doctors, who don’t have to interrupt rounds to admit a new patient. Some see a dedicated admitter as a tool to improve ED throughput, because this doctor isn’t tied up with rounds and can immediately start seeing a new admission.

I think an admitter shift does deliver both of these benefits, but its costs make it suboptimal in most settings. For example, a single admitter will impede ED throughput any time more than one new admission is waiting to be seen, and for most groups that will be much of the day. In fact, improved ED throughput is best achieved by having many hospitalists available for admissions, not just a single admitter. (There are many other factors influencing ED throughput, such as whether ED doctors simply send patients to their “floor” bed prior to being seen by a hospitalist. But for this article, I’m just considering the influence of a dedicated admitter.)

I think “silo-ing” work into different roles, such as separating rounding and admitting, makes it more difficult to ensure that each is always working productively. There are likely to be times when the admitter has little or nothing to do, even though the rounders are very busy. Or perhaps the rounders aren’t very busy, but the admitter has just been asked to admit four ED patients at the same time.

While protecting rounders from the stress of admissions is valuable, it comes at the cost of a net increase in hospitalist work, because a new doctor must get to know the patient on the day following admission. And this admitter-to-rounder handoff serves as another opportunity for errors—and probably lowers patient satisfaction.

I think most groups should consider moving the admitter shift into an additional rounder position, dividing admissions across all of the doctors working during the daytime. For example, a group that has six rounders and a separate admitter would change to seven rounders, each available to admit every seventh daytime admission. Each would bear the meaningful stress of having rounds interrupted to admit a new patient, but accepting every seventh daytime admission shouldn’t be too difficult on most days.

Don’t forget that eliminating the admitter means that the list of new patients you take on each morning will be shorter. Mornings may be a little less stressful.

A.M. Distribution

The daytime doctors at many hospitalist groups meet each morning to discuss how the new admissions from the prior night (or even the last 24 hours) will be distributed. Or perhaps one person, sometimes a nurse or clerical staff, arrives very early each day to do this.

Although it might take some careful planning, I think most groups that use this sort of morning distribution should abandon it for a better system. Consider a group in which all six daytime doctors spend an average of 20 minutes distributing patients each morning. Twenty minutes (0.33 hours) times six doctors times 365 days comes to 730 hours annually.

Assuming these doctors are compensated at typical rates, the practice is spending more than $100,000 annually just so the doctors can distribute patients each morning. On top of this, nurses and others at the hospital are usually delayed in learning which daytime hospitalist is caring for each patient. These costs seem unreasonably high.

An alternative is to develop a system by which any admitter, such as a night doctor, who will not be providing subsequent care to a patient can identify by name the doctor who will be providing that care. During the admission encounter, the admitter can tell patient/family, “Dr. Boswell will be taking over your care starting tomorrow. He’s a great guy and has been named one of Portland’s best doctors.” This seems so much better than saying, “One of my partners will be taking over tomorrow. I don’t know which of my partners it will be, but they’re all good doctors.” And Dr. Boswell’s name can be entered into the attending physician field of the EHR so that all hospital staff will know without delay.

MedAptus has recently launched software they call “Assign” that may be able to replace the morning meeting and automate assigning new admissions to each hospitalist. I haven’t seen it in operation, so I can’t speak for its effectiveness, but it might be worthwhile for some groups.

Practical Considerations

The changes I’ve described above might not be optimal for every group, and they may take meaningful work to implement. But I don’t think the difficulty of these things is the biggest barrier. The biggest barrier is probably just inertia in most cases, the same reason I’m still a Netflix streaming subscriber even though I almost never watch it. I did, however, really enjoy the Nexflix original series Lilyhammer.

You shouldn’t maintain things that do not deliver the value you anticipated when you first put them in place. For example, I thought Netflix streaming would be terrific, but I have used it so infrequently that it probably costs me $50 per movie or show watched. I should probably dump it.

Your hospitalist group might have some operational practices that are not as valuable as they seem and could be replaced with something better. For many groups, this might include doing away with a separate daytime admitter shift and a morning meeting to distribute the overnight admissions.

Daytime Admission Shift

My experience is that hospitalist groups with more than about five daytime doctors almost always have a day-shift person dedicated to seeing new admissions. In most cases, this procedure is implemented with the idea of reducing the stress of other day-shift doctors, who don’t have to interrupt rounds to admit a new patient. Some see a dedicated admitter as a tool to improve ED throughput, because this doctor isn’t tied up with rounds and can immediately start seeing a new admission.

I think an admitter shift does deliver both of these benefits, but its costs make it suboptimal in most settings. For example, a single admitter will impede ED throughput any time more than one new admission is waiting to be seen, and for most groups that will be much of the day. In fact, improved ED throughput is best achieved by having many hospitalists available for admissions, not just a single admitter. (There are many other factors influencing ED throughput, such as whether ED doctors simply send patients to their “floor” bed prior to being seen by a hospitalist. But for this article, I’m just considering the influence of a dedicated admitter.)

I think “silo-ing” work into different roles, such as separating rounding and admitting, makes it more difficult to ensure that each is always working productively. There are likely to be times when the admitter has little or nothing to do, even though the rounders are very busy. Or perhaps the rounders aren’t very busy, but the admitter has just been asked to admit four ED patients at the same time.

While protecting rounders from the stress of admissions is valuable, it comes at the cost of a net increase in hospitalist work, because a new doctor must get to know the patient on the day following admission. And this admitter-to-rounder handoff serves as another opportunity for errors—and probably lowers patient satisfaction.

I think most groups should consider moving the admitter shift into an additional rounder position, dividing admissions across all of the doctors working during the daytime. For example, a group that has six rounders and a separate admitter would change to seven rounders, each available to admit every seventh daytime admission. Each would bear the meaningful stress of having rounds interrupted to admit a new patient, but accepting every seventh daytime admission shouldn’t be too difficult on most days.

Don’t forget that eliminating the admitter means that the list of new patients you take on each morning will be shorter. Mornings may be a little less stressful.

A.M. Distribution

The daytime doctors at many hospitalist groups meet each morning to discuss how the new admissions from the prior night (or even the last 24 hours) will be distributed. Or perhaps one person, sometimes a nurse or clerical staff, arrives very early each day to do this.

Although it might take some careful planning, I think most groups that use this sort of morning distribution should abandon it for a better system. Consider a group in which all six daytime doctors spend an average of 20 minutes distributing patients each morning. Twenty minutes (0.33 hours) times six doctors times 365 days comes to 730 hours annually.

Assuming these doctors are compensated at typical rates, the practice is spending more than $100,000 annually just so the doctors can distribute patients each morning. On top of this, nurses and others at the hospital are usually delayed in learning which daytime hospitalist is caring for each patient. These costs seem unreasonably high.

An alternative is to develop a system by which any admitter, such as a night doctor, who will not be providing subsequent care to a patient can identify by name the doctor who will be providing that care. During the admission encounter, the admitter can tell patient/family, “Dr. Boswell will be taking over your care starting tomorrow. He’s a great guy and has been named one of Portland’s best doctors.” This seems so much better than saying, “One of my partners will be taking over tomorrow. I don’t know which of my partners it will be, but they’re all good doctors.” And Dr. Boswell’s name can be entered into the attending physician field of the EHR so that all hospital staff will know without delay.

MedAptus has recently launched software they call “Assign” that may be able to replace the morning meeting and automate assigning new admissions to each hospitalist. I haven’t seen it in operation, so I can’t speak for its effectiveness, but it might be worthwhile for some groups.

Practical Considerations

The changes I’ve described above might not be optimal for every group, and they may take meaningful work to implement. But I don’t think the difficulty of these things is the biggest barrier. The biggest barrier is probably just inertia in most cases, the same reason I’m still a Netflix streaming subscriber even though I almost never watch it. I did, however, really enjoy the Nexflix original series Lilyhammer.

You shouldn’t maintain things that do not deliver the value you anticipated when you first put them in place. For example, I thought Netflix streaming would be terrific, but I have used it so infrequently that it probably costs me $50 per movie or show watched. I should probably dump it.

Your hospitalist group might have some operational practices that are not as valuable as they seem and could be replaced with something better. For many groups, this might include doing away with a separate daytime admitter shift and a morning meeting to distribute the overnight admissions.

Daytime Admission Shift

My experience is that hospitalist groups with more than about five daytime doctors almost always have a day-shift person dedicated to seeing new admissions. In most cases, this procedure is implemented with the idea of reducing the stress of other day-shift doctors, who don’t have to interrupt rounds to admit a new patient. Some see a dedicated admitter as a tool to improve ED throughput, because this doctor isn’t tied up with rounds and can immediately start seeing a new admission.

I think an admitter shift does deliver both of these benefits, but its costs make it suboptimal in most settings. For example, a single admitter will impede ED throughput any time more than one new admission is waiting to be seen, and for most groups that will be much of the day. In fact, improved ED throughput is best achieved by having many hospitalists available for admissions, not just a single admitter. (There are many other factors influencing ED throughput, such as whether ED doctors simply send patients to their “floor” bed prior to being seen by a hospitalist. But for this article, I’m just considering the influence of a dedicated admitter.)

I think “silo-ing” work into different roles, such as separating rounding and admitting, makes it more difficult to ensure that each is always working productively. There are likely to be times when the admitter has little or nothing to do, even though the rounders are very busy. Or perhaps the rounders aren’t very busy, but the admitter has just been asked to admit four ED patients at the same time.

While protecting rounders from the stress of admissions is valuable, it comes at the cost of a net increase in hospitalist work, because a new doctor must get to know the patient on the day following admission. And this admitter-to-rounder handoff serves as another opportunity for errors—and probably lowers patient satisfaction.

I think most groups should consider moving the admitter shift into an additional rounder position, dividing admissions across all of the doctors working during the daytime. For example, a group that has six rounders and a separate admitter would change to seven rounders, each available to admit every seventh daytime admission. Each would bear the meaningful stress of having rounds interrupted to admit a new patient, but accepting every seventh daytime admission shouldn’t be too difficult on most days.

Don’t forget that eliminating the admitter means that the list of new patients you take on each morning will be shorter. Mornings may be a little less stressful.

A.M. Distribution

The daytime doctors at many hospitalist groups meet each morning to discuss how the new admissions from the prior night (or even the last 24 hours) will be distributed. Or perhaps one person, sometimes a nurse or clerical staff, arrives very early each day to do this.

Although it might take some careful planning, I think most groups that use this sort of morning distribution should abandon it for a better system. Consider a group in which all six daytime doctors spend an average of 20 minutes distributing patients each morning. Twenty minutes (0.33 hours) times six doctors times 365 days comes to 730 hours annually.

Assuming these doctors are compensated at typical rates, the practice is spending more than $100,000 annually just so the doctors can distribute patients each morning. On top of this, nurses and others at the hospital are usually delayed in learning which daytime hospitalist is caring for each patient. These costs seem unreasonably high.

An alternative is to develop a system by which any admitter, such as a night doctor, who will not be providing subsequent care to a patient can identify by name the doctor who will be providing that care. During the admission encounter, the admitter can tell patient/family, “Dr. Boswell will be taking over your care starting tomorrow. He’s a great guy and has been named one of Portland’s best doctors.” This seems so much better than saying, “One of my partners will be taking over tomorrow. I don’t know which of my partners it will be, but they’re all good doctors.” And Dr. Boswell’s name can be entered into the attending physician field of the EHR so that all hospital staff will know without delay.

MedAptus has recently launched software they call “Assign” that may be able to replace the morning meeting and automate assigning new admissions to each hospitalist. I haven’t seen it in operation, so I can’t speak for its effectiveness, but it might be worthwhile for some groups.

Practical Considerations

The changes I’ve described above might not be optimal for every group, and they may take meaningful work to implement. But I don’t think the difficulty of these things is the biggest barrier. The biggest barrier is probably just inertia in most cases, the same reason I’m still a Netflix streaming subscriber even though I almost never watch it. I did, however, really enjoy the Nexflix original series Lilyhammer.

Are hospitals going to be allowed to start “patient profiling” in order to reduce costs? Hospitals already frequently operate their own state departments and perform “extraordinary medical renditions” on uninsured, critically ill noncitizens. Do you really expect us to believe they are identifying these patients in order to provide them more appropriate services? My impression is that since this group has been identified as a cost driver, the aim of any intervention is saving money for the hospital rather than rendering appropriate care.

—Tom Horiagon

Dr. Hospitalist responds:

As hospitalists, we are best positioned to manage the balance among medical, social, and fiduciary responsibilities. The article addresses the data that shows what most of us already know: Most patients who have multiple readmissions have many co-morbid conditions and/or psychiatric and social issues. Hospitalists have the opportunity to use everything in the patient’s history and profile to prescribe the appropriate treatment plan. When we find the right solutions, it would be helpful to us all if they were not only cost effective but also right for the patient.

Although I prefer to not use the term “patient profiling” because of the associated negative connotations, I do believe there are occasions we face with our patients when the most “appropriate service” may not be clinically relevant at all.

For example, we recently began a quality initiative project in our hospital to identify those with acute or chronic pain and the most frequent admissions (greater than 10) in a calendar year. We identified a patient who had a total of 43 admissions across four different hospitals in one calendar year. Clearly, the best care for this individual would be to get him an apartment.

We know that many of these “frequent flyers” tend to absorb vast amounts of our healthcare dollars with multiple imaging studies, lab work, and time taken away from other patients, not to mention the emotional toll some of these patients take on the clinical staff.

Discussions on such matters as tort reform, futile care, and patient nonadherence (many factors and much more complex) have been going on for some time. I don’t see our politicians developing the intestinal fortitude to address these problems any time soon. With our national healthcare expenditures reaching $2.9 trillion (or $9,255 per person in 2013, per cms.gov), who is best situated to make ground level changes than hospitalists? It really doesn’t matter whether these patients are insured or uninsured, whether they are citizens or noncitizens, or whether “an intervention is saving money for the hospital.” In the end, many are utilizing more than their share of medical allocations, and we as taxpayers get to cover that cost.

I believe we can be good doctors and, at the same time, good stewards of our nation’s healthcare dollars.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions.

Are hospitals going to be allowed to start “patient profiling” in order to reduce costs? Hospitals already frequently operate their own state departments and perform “extraordinary medical renditions” on uninsured, critically ill noncitizens. Do you really expect us to believe they are identifying these patients in order to provide them more appropriate services? My impression is that since this group has been identified as a cost driver, the aim of any intervention is saving money for the hospital rather than rendering appropriate care.

—Tom Horiagon

Dr. Hospitalist responds:

As hospitalists, we are best positioned to manage the balance among medical, social, and fiduciary responsibilities. The article addresses the data that shows what most of us already know: Most patients who have multiple readmissions have many co-morbid conditions and/or psychiatric and social issues. Hospitalists have the opportunity to use everything in the patient’s history and profile to prescribe the appropriate treatment plan. When we find the right solutions, it would be helpful to us all if they were not only cost effective but also right for the patient.

Although I prefer to not use the term “patient profiling” because of the associated negative connotations, I do believe there are occasions we face with our patients when the most “appropriate service” may not be clinically relevant at all.

For example, we recently began a quality initiative project in our hospital to identify those with acute or chronic pain and the most frequent admissions (greater than 10) in a calendar year. We identified a patient who had a total of 43 admissions across four different hospitals in one calendar year. Clearly, the best care for this individual would be to get him an apartment.

We know that many of these “frequent flyers” tend to absorb vast amounts of our healthcare dollars with multiple imaging studies, lab work, and time taken away from other patients, not to mention the emotional toll some of these patients take on the clinical staff.

Discussions on such matters as tort reform, futile care, and patient nonadherence (many factors and much more complex) have been going on for some time. I don’t see our politicians developing the intestinal fortitude to address these problems any time soon. With our national healthcare expenditures reaching $2.9 trillion (or $9,255 per person in 2013, per cms.gov), who is best situated to make ground level changes than hospitalists? It really doesn’t matter whether these patients are insured or uninsured, whether they are citizens or noncitizens, or whether “an intervention is saving money for the hospital.” In the end, many are utilizing more than their share of medical allocations, and we as taxpayers get to cover that cost.

I believe we can be good doctors and, at the same time, good stewards of our nation’s healthcare dollars.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions.

Are hospitals going to be allowed to start “patient profiling” in order to reduce costs? Hospitals already frequently operate their own state departments and perform “extraordinary medical renditions” on uninsured, critically ill noncitizens. Do you really expect us to believe they are identifying these patients in order to provide them more appropriate services? My impression is that since this group has been identified as a cost driver, the aim of any intervention is saving money for the hospital rather than rendering appropriate care.

—Tom Horiagon

Dr. Hospitalist responds:

As hospitalists, we are best positioned to manage the balance among medical, social, and fiduciary responsibilities. The article addresses the data that shows what most of us already know: Most patients who have multiple readmissions have many co-morbid conditions and/or psychiatric and social issues. Hospitalists have the opportunity to use everything in the patient’s history and profile to prescribe the appropriate treatment plan. When we find the right solutions, it would be helpful to us all if they were not only cost effective but also right for the patient.

Although I prefer to not use the term “patient profiling” because of the associated negative connotations, I do believe there are occasions we face with our patients when the most “appropriate service” may not be clinically relevant at all.

For example, we recently began a quality initiative project in our hospital to identify those with acute or chronic pain and the most frequent admissions (greater than 10) in a calendar year. We identified a patient who had a total of 43 admissions across four different hospitals in one calendar year. Clearly, the best care for this individual would be to get him an apartment.

We know that many of these “frequent flyers” tend to absorb vast amounts of our healthcare dollars with multiple imaging studies, lab work, and time taken away from other patients, not to mention the emotional toll some of these patients take on the clinical staff.

Discussions on such matters as tort reform, futile care, and patient nonadherence (many factors and much more complex) have been going on for some time. I don’t see our politicians developing the intestinal fortitude to address these problems any time soon. With our national healthcare expenditures reaching $2.9 trillion (or $9,255 per person in 2013, per cms.gov), who is best situated to make ground level changes than hospitalists? It really doesn’t matter whether these patients are insured or uninsured, whether they are citizens or noncitizens, or whether “an intervention is saving money for the hospital.” In the end, many are utilizing more than their share of medical allocations, and we as taxpayers get to cover that cost.

I believe we can be good doctors and, at the same time, good stewards of our nation’s healthcare dollars.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions.

NEW YORK - Shari Cayle, 75, called "Miracle Mama" by her family ever since she beat back advanced colon cancer seven years ago, is still undergoing treatment and living alone.

"I don't want my grandchildren to remember me as the sick one, I want to be the fun one," said Cayle, who is testing a device that passively monitors her activity. "My family knows what I'm doing and I don't think they should have to change their life around to make sure I'm OK."

Onkol, a product inspired by Cayle that monitors her front door, reminds her when to take her medication and can alert her family if she falls, has allowed her to remain independent at home. Devised by her son Marc, it will hit the U.S. market next year.

As more American seniors plan to remain at home rather than enter a nursing facility, new startups and some well-known technology brands are connecting them to family and healthcare providers.

The noninvasive devices sit in the background as users go about their normal routine. Through Bluetooth technology they are able to gather information and send it to family or doctors when, for example, a sensor reads that a pill box was opened or a wireless medical device such as a glucose monitor is used.

According to PricewaterhouseCoopers' Health Research Institute, at-home options like these will disrupt roughly $64 billion of traditional U.S. provider revenue in the next 20 years.

Monitoring devices for the elderly started with products like privately-held Life Alert, which leapt into public awareness nearly 30 years ago with TV ads showing the elderly "Mrs. Fletcher" reaching for her Life Alert pendant and telling an operator, "I've fallen and I can't get up!"

Now companies like Nortek Security & Control and small startups are taking that much further.

The challenge though is that older consumers may not be ready to use the technology and their medical, security and wellness needs may differ significantly. There are also safety and privacy risks.

"There's a lot of potential, but a big gap between what seniors want and what the market can provide," said Harry Wang, director of health and mobile product research at Parks Associates.

NURSE MOLLY

Milwaukee-based Onkol developed a rectangular hub, roughly the size of a tissue box, that passively monitors things like what their blood glucose reading is and when they open their refrigerator. There is also a wristband that can be pressed for help in an emergency.

"The advantage of it is that the person, the patient, doesn't have to worry about hooking it up and doing stuff with the computer, their kids do that," said Cayle, whose son co-founded Onkol.

Sensely is another device used by providers like Kaiser Permanente, based in California, and the National Health Service in the United Kingdom. Since 2013, its virtual nurse Molly has connected patients with doctors from a mobile device. She asks how they are feeling and lets them know when it is time to take a health reading.

Another startup, San Francisco-based Lively began selling its product to consumers in 2012. Similarly, it collects information from sensors and connects to a smart watch that tracks customers' footsteps, routine and can even call emergency services. Next year it will connect with medical devices, send data to physicians and enable video consultations that can replace some doctor's appointments.

Venture firms including Fenox Venture Capital, Maveron, Capital Midwest Fund and LaunchPad Digital Health have contributed millions of dollars to these startups.

Ideal Life, founded in 2002, which sells it own devices to providers, plans to release its own consumer version next year.

"The clinical community is more open than they've even been before in piloting and testing new technology," said founder Jason Goldberg.

Just this summer, Nortek bought a personal emergency response system called Libris and a healthcare platform from Numera, a health technology company, for $12 million. At the same time, Nortek said some of its smart home customers like ADT Corp want to expand into health and wellness offerings. The goal is to offer software that connects with customers' current systems as well as medical, fitness, emergency and security devices.

"In the smart home and health space today you see a lot of single purpose solutions that don't offer a full connectivity platform, like a smart watch or pressure sensor in a bed," said Mike O'Neal, Nortek Security & Control president. "We're creating that connectivity."

A July study from AARP showed Americans 50 years and older want activity monitors like Fitbit and Jawbone to have more relevant sensors to monitor health conditions and 89% cited difficulties with set up.

"They (companies) have great technology, but when you can't open the package or you can't find directions that's a problem," said Jody Holtzman, senior vice president of thought leadership at AARP.

Such products may help doctors keep up with a growing elderly population. Research firm Gartner estimates that in the next 40 years, one-third of the population in developed countries will be 65 years or older, thus making it impossible to keep everyone who needs care in the hospital.

NEW YORK - Shari Cayle, 75, called "Miracle Mama" by her family ever since she beat back advanced colon cancer seven years ago, is still undergoing treatment and living alone.

"I don't want my grandchildren to remember me as the sick one, I want to be the fun one," said Cayle, who is testing a device that passively monitors her activity. "My family knows what I'm doing and I don't think they should have to change their life around to make sure I'm OK."

Onkol, a product inspired by Cayle that monitors her front door, reminds her when to take her medication and can alert her family if she falls, has allowed her to remain independent at home. Devised by her son Marc, it will hit the U.S. market next year.

As more American seniors plan to remain at home rather than enter a nursing facility, new startups and some well-known technology brands are connecting them to family and healthcare providers.

The noninvasive devices sit in the background as users go about their normal routine. Through Bluetooth technology they are able to gather information and send it to family or doctors when, for example, a sensor reads that a pill box was opened or a wireless medical device such as a glucose monitor is used.

According to PricewaterhouseCoopers' Health Research Institute, at-home options like these will disrupt roughly $64 billion of traditional U.S. provider revenue in the next 20 years.

Monitoring devices for the elderly started with products like privately-held Life Alert, which leapt into public awareness nearly 30 years ago with TV ads showing the elderly "Mrs. Fletcher" reaching for her Life Alert pendant and telling an operator, "I've fallen and I can't get up!"

Now companies like Nortek Security & Control and small startups are taking that much further.

The challenge though is that older consumers may not be ready to use the technology and their medical, security and wellness needs may differ significantly. There are also safety and privacy risks.

"There's a lot of potential, but a big gap between what seniors want and what the market can provide," said Harry Wang, director of health and mobile product research at Parks Associates.

NURSE MOLLY

Milwaukee-based Onkol developed a rectangular hub, roughly the size of a tissue box, that passively monitors things like what their blood glucose reading is and when they open their refrigerator. There is also a wristband that can be pressed for help in an emergency.

"The advantage of it is that the person, the patient, doesn't have to worry about hooking it up and doing stuff with the computer, their kids do that," said Cayle, whose son co-founded Onkol.

Sensely is another device used by providers like Kaiser Permanente, based in California, and the National Health Service in the United Kingdom. Since 2013, its virtual nurse Molly has connected patients with doctors from a mobile device. She asks how they are feeling and lets them know when it is time to take a health reading.

Another startup, San Francisco-based Lively began selling its product to consumers in 2012. Similarly, it collects information from sensors and connects to a smart watch that tracks customers' footsteps, routine and can even call emergency services. Next year it will connect with medical devices, send data to physicians and enable video consultations that can replace some doctor's appointments.

Venture firms including Fenox Venture Capital, Maveron, Capital Midwest Fund and LaunchPad Digital Health have contributed millions of dollars to these startups.

Ideal Life, founded in 2002, which sells it own devices to providers, plans to release its own consumer version next year.

"The clinical community is more open than they've even been before in piloting and testing new technology," said founder Jason Goldberg.

Just this summer, Nortek bought a personal emergency response system called Libris and a healthcare platform from Numera, a health technology company, for $12 million. At the same time, Nortek said some of its smart home customers like ADT Corp want to expand into health and wellness offerings. The goal is to offer software that connects with customers' current systems as well as medical, fitness, emergency and security devices.

"In the smart home and health space today you see a lot of single purpose solutions that don't offer a full connectivity platform, like a smart watch or pressure sensor in a bed," said Mike O'Neal, Nortek Security & Control president. "We're creating that connectivity."

A July study from AARP showed Americans 50 years and older want activity monitors like Fitbit and Jawbone to have more relevant sensors to monitor health conditions and 89% cited difficulties with set up.

"They (companies) have great technology, but when you can't open the package or you can't find directions that's a problem," said Jody Holtzman, senior vice president of thought leadership at AARP.

Such products may help doctors keep up with a growing elderly population. Research firm Gartner estimates that in the next 40 years, one-third of the population in developed countries will be 65 years or older, thus making it impossible to keep everyone who needs care in the hospital.

NEW YORK - Shari Cayle, 75, called "Miracle Mama" by her family ever since she beat back advanced colon cancer seven years ago, is still undergoing treatment and living alone.

"I don't want my grandchildren to remember me as the sick one, I want to be the fun one," said Cayle, who is testing a device that passively monitors her activity. "My family knows what I'm doing and I don't think they should have to change their life around to make sure I'm OK."

Onkol, a product inspired by Cayle that monitors her front door, reminds her when to take her medication and can alert her family if she falls, has allowed her to remain independent at home. Devised by her son Marc, it will hit the U.S. market next year.

As more American seniors plan to remain at home rather than enter a nursing facility, new startups and some well-known technology brands are connecting them to family and healthcare providers.

The noninvasive devices sit in the background as users go about their normal routine. Through Bluetooth technology they are able to gather information and send it to family or doctors when, for example, a sensor reads that a pill box was opened or a wireless medical device such as a glucose monitor is used.

According to PricewaterhouseCoopers' Health Research Institute, at-home options like these will disrupt roughly $64 billion of traditional U.S. provider revenue in the next 20 years.

Monitoring devices for the elderly started with products like privately-held Life Alert, which leapt into public awareness nearly 30 years ago with TV ads showing the elderly "Mrs. Fletcher" reaching for her Life Alert pendant and telling an operator, "I've fallen and I can't get up!"

Now companies like Nortek Security & Control and small startups are taking that much further.

The challenge though is that older consumers may not be ready to use the technology and their medical, security and wellness needs may differ significantly. There are also safety and privacy risks.

"There's a lot of potential, but a big gap between what seniors want and what the market can provide," said Harry Wang, director of health and mobile product research at Parks Associates.

NURSE MOLLY

Milwaukee-based Onkol developed a rectangular hub, roughly the size of a tissue box, that passively monitors things like what their blood glucose reading is and when they open their refrigerator. There is also a wristband that can be pressed for help in an emergency.

"The advantage of it is that the person, the patient, doesn't have to worry about hooking it up and doing stuff with the computer, their kids do that," said Cayle, whose son co-founded Onkol.

Sensely is another device used by providers like Kaiser Permanente, based in California, and the National Health Service in the United Kingdom. Since 2013, its virtual nurse Molly has connected patients with doctors from a mobile device. She asks how they are feeling and lets them know when it is time to take a health reading.

Another startup, San Francisco-based Lively began selling its product to consumers in 2012. Similarly, it collects information from sensors and connects to a smart watch that tracks customers' footsteps, routine and can even call emergency services. Next year it will connect with medical devices, send data to physicians and enable video consultations that can replace some doctor's appointments.

Venture firms including Fenox Venture Capital, Maveron, Capital Midwest Fund and LaunchPad Digital Health have contributed millions of dollars to these startups.

Ideal Life, founded in 2002, which sells it own devices to providers, plans to release its own consumer version next year.

"The clinical community is more open than they've even been before in piloting and testing new technology," said founder Jason Goldberg.

Just this summer, Nortek bought a personal emergency response system called Libris and a healthcare platform from Numera, a health technology company, for $12 million. At the same time, Nortek said some of its smart home customers like ADT Corp want to expand into health and wellness offerings. The goal is to offer software that connects with customers' current systems as well as medical, fitness, emergency and security devices.

"In the smart home and health space today you see a lot of single purpose solutions that don't offer a full connectivity platform, like a smart watch or pressure sensor in a bed," said Mike O'Neal, Nortek Security & Control president. "We're creating that connectivity."

A July study from AARP showed Americans 50 years and older want activity monitors like Fitbit and Jawbone to have more relevant sensors to monitor health conditions and 89% cited difficulties with set up.

"They (companies) have great technology, but when you can't open the package or you can't find directions that's a problem," said Jody Holtzman, senior vice president of thought leadership at AARP.

Such products may help doctors keep up with a growing elderly population. Research firm Gartner estimates that in the next 40 years, one-third of the population in developed countries will be 65 years or older, thus making it impossible to keep everyone who needs care in the hospital.

NEW YORK - Chemotherapy-related hospitalization happens much more often in the real world than in drug trials, according to a new study.

Patients with advanced lung cancer receiving chemotherapy in real-world settings were almost eight times more likely to be hospitalized during treatment than those participating in clinical trials.

What's more, very few clinical trials even report how often participants are hospitalized during the research, the study authors found.

"Clinical trials should be routinely reporting their hospitalization rates so we know what to expect," said senior author Dr. Monika Krzyzanowska of the Princess Margaret Cancer Center in Toronto, Canada. "I think that (hospitalization is) actually much more common than we ever anticipated," Krzyzanowska said.

For the new meta-analysis, released online September 17 in JAMA Oncology, the researchers looked at data on patients receiving chemotherapy for metastatic non-small-cell lung cancer, from five reports of clinical trials with a total of 3962 people that specified how many hospitalizations occurred, and five studies involving 8624 people receiving chemotherapy in real-world settings.

Overall, 51% of the real-world patients were hospitalized during their treatments, compared to 16% of those in clinical trials.

Some of the research looked at factors related to the risk of hospitalization like the type of chemotherapy used and hospital performance measures, but results varied from study to study and Krzyzanowska said that she can't say with confidence which factors may be tied to an increased risk of being hospitalized.

But, she said, similar patterns of high hospitalizations are likely to be found among people with other cancers and on other types of treatments.

"I think this is unfortunately a common phenomenon across disease site and treatment regimen," Krzyzanowska said.

Knowing how much time patients may spend in hospitals during chemotherapy might help them and their doctors in deciding which treatment is right, Krzyzanowska said.

"I think the low-hanging fruit is that clinical trials should start reporting hospitalizations," she said of the findings.

With that kind of data, the researchers suggest, scientists can calculate the risk of hospitalization per month of chemotherapy and ultimately provide that to patients.

Krzyzanowska also said she'd like to look at what factors drive hospitalizations among cancer patients receiving chemotherapy.

"I definitely think there is a substantial portion of people whose symptoms can be managed earlier so they don't end up in the hospital," she said.

NEW YORK - Chemotherapy-related hospitalization happens much more often in the real world than in drug trials, according to a new study.

Patients with advanced lung cancer receiving chemotherapy in real-world settings were almost eight times more likely to be hospitalized during treatment than those participating in clinical trials.

What's more, very few clinical trials even report how often participants are hospitalized during the research, the study authors found.

"Clinical trials should be routinely reporting their hospitalization rates so we know what to expect," said senior author Dr. Monika Krzyzanowska of the Princess Margaret Cancer Center in Toronto, Canada. "I think that (hospitalization is) actually much more common than we ever anticipated," Krzyzanowska said.

For the new meta-analysis, released online September 17 in JAMA Oncology, the researchers looked at data on patients receiving chemotherapy for metastatic non-small-cell lung cancer, from five reports of clinical trials with a total of 3962 people that specified how many hospitalizations occurred, and five studies involving 8624 people receiving chemotherapy in real-world settings.

Overall, 51% of the real-world patients were hospitalized during their treatments, compared to 16% of those in clinical trials.

Some of the research looked at factors related to the risk of hospitalization like the type of chemotherapy used and hospital performance measures, but results varied from study to study and Krzyzanowska said that she can't say with confidence which factors may be tied to an increased risk of being hospitalized.

But, she said, similar patterns of high hospitalizations are likely to be found among people with other cancers and on other types of treatments.

"I think this is unfortunately a common phenomenon across disease site and treatment regimen," Krzyzanowska said.

Knowing how much time patients may spend in hospitals during chemotherapy might help them and their doctors in deciding which treatment is right, Krzyzanowska said.

"I think the low-hanging fruit is that clinical trials should start reporting hospitalizations," she said of the findings.

With that kind of data, the researchers suggest, scientists can calculate the risk of hospitalization per month of chemotherapy and ultimately provide that to patients.

Krzyzanowska also said she'd like to look at what factors drive hospitalizations among cancer patients receiving chemotherapy.

"I definitely think there is a substantial portion of people whose symptoms can be managed earlier so they don't end up in the hospital," she said.

NEW YORK - Chemotherapy-related hospitalization happens much more often in the real world than in drug trials, according to a new study.

Patients with advanced lung cancer receiving chemotherapy in real-world settings were almost eight times more likely to be hospitalized during treatment than those participating in clinical trials.

What's more, very few clinical trials even report how often participants are hospitalized during the research, the study authors found.

"Clinical trials should be routinely reporting their hospitalization rates so we know what to expect," said senior author Dr. Monika Krzyzanowska of the Princess Margaret Cancer Center in Toronto, Canada. "I think that (hospitalization is) actually much more common than we ever anticipated," Krzyzanowska said.

For the new meta-analysis, released online September 17 in JAMA Oncology, the researchers looked at data on patients receiving chemotherapy for metastatic non-small-cell lung cancer, from five reports of clinical trials with a total of 3962 people that specified how many hospitalizations occurred, and five studies involving 8624 people receiving chemotherapy in real-world settings.

Overall, 51% of the real-world patients were hospitalized during their treatments, compared to 16% of those in clinical trials.

Some of the research looked at factors related to the risk of hospitalization like the type of chemotherapy used and hospital performance measures, but results varied from study to study and Krzyzanowska said that she can't say with confidence which factors may be tied to an increased risk of being hospitalized.

But, she said, similar patterns of high hospitalizations are likely to be found among people with other cancers and on other types of treatments.

"I think this is unfortunately a common phenomenon across disease site and treatment regimen," Krzyzanowska said.

Knowing how much time patients may spend in hospitals during chemotherapy might help them and their doctors in deciding which treatment is right, Krzyzanowska said.

"I think the low-hanging fruit is that clinical trials should start reporting hospitalizations," she said of the findings.

With that kind of data, the researchers suggest, scientists can calculate the risk of hospitalization per month of chemotherapy and ultimately provide that to patients.

Krzyzanowska also said she'd like to look at what factors drive hospitalizations among cancer patients receiving chemotherapy.

"I definitely think there is a substantial portion of people whose symptoms can be managed earlier so they don't end up in the hospital," she said.

NEW YORK  - Older adults living in long-term care are more than twice as likely as their peers living at home to suffer a fracture, and a new guideline endorsed by the Scientific Advisory Council of Osteoporosis Canada explains how to reduce their risk.

Residents of long-term care tend to be frailer and have more health problems than similar people who live on their own, which explains the higher risk of fractures in long-term care facilities, said lead author Dr. Alexandra Papaioannou of McMaster University and Hamilton Health Sciences in Hamilton, Ontario.

"Up to a third of seniors in long-term care suffer a fracture," often of the hip or spine, she said. For these residents, "long-term care is their home, the nurses know them, and acute care can be a frightening traumatic experience for residents."

The authors developed the new guideline based on input from older people and their families, who most wanted to avoid pain, loss of activity, and hospitalization, Papaioannou said. They also studied published literature on the risks and benefits of strategies to prevent fracture.

The guideline strongly recommends calcium supplementation of 1200 mg or three servings of dairy daily for people older than 70. These calcium levels reduce hip fracture risk and slightly reduce the risk of other fractures, but they may also cause gastrointestinal side effects. For residents who want to avoid these, supplementation may not be a good option, the authors write.

Residents at high risk of fracture, i.e., those with prior fracture of the hip or spine, more than one prior fracture, or one prior fracture and recent use of glucocorticoids, should also take daily vitamin D3 supplements, which are more affordable than vitamin D2, the authors wrote online September 14 in CMAJ.

They also recommend that high-risk residents take alendronate weekly, or risedronate weekly or monthly, as first-line therapy to prevent fractures, as long as they do not have difficulty swallowing and can remain upright for 30 minutes after administration, and they do not have severe renal insufficiency.

For residents who are at high risk of fractures and who have difficulty taking oral medications, they recommend zoledronic acid or denosumab as first-line therapy.

High-risk residents who are mobile should wear hip-protectors, which can protect against fracture in the event of a fall. Low-risk residents who are mobile may wear the devices, depending on their values and preferences.

Balance, strength, and functional exercise can help prevent falls for low-risk residents, and may be useful for high-risk residents, but the exercise itself increases the risk of fall slightly.

Lastly, the authors recommend that all residents have "multifactorial interventions" that are tailored to each individual and include medication reviews, environmental hazard assessment, assistive device use, exercise, and educational interventions for staff.

"Many residents have multiple medical conditions and we need to make sure that they include their lifespan and goals of care in the assessment," Papaioannou said. "The goals of those with short lifespans may be very different from those with longer lifespans."

These recommendations are similar to those for residential care facilities in Australia and the ones made by the Society for Post-Acute and Long-Term Care Medicine in the U.S., the authors point out.

"The document is an excellent guide on how to identify patients at risk, who should be treated and how," said Dr. Gustavo Duque, director of the Musculoskeletal Ageing Research Program at the University of Sydney in Australia.

Doctors often reduce medications for residents who are admitted to nursing homes without realizing that those with osteoporosis or previous fractures are more likely to suffer a fracture at their new residence than in the community, Duque, who was not involved in writing the new guideline, said by email.

"Ceasing osteoporosis treatment has demonstrated to increase the risk of fractures," Duque said. "Unfortunately we see that situation every day."

NEW YORK  - Older adults living in long-term care are more than twice as likely as their peers living at home to suffer a fracture, and a new guideline endorsed by the Scientific Advisory Council of Osteoporosis Canada explains how to reduce their risk.

Residents of long-term care tend to be frailer and have more health problems than similar people who live on their own, which explains the higher risk of fractures in long-term care facilities, said lead author Dr. Alexandra Papaioannou of McMaster University and Hamilton Health Sciences in Hamilton, Ontario.

"Up to a third of seniors in long-term care suffer a fracture," often of the hip or spine, she said. For these residents, "long-term care is their home, the nurses know them, and acute care can be a frightening traumatic experience for residents."

The authors developed the new guideline based on input from older people and their families, who most wanted to avoid pain, loss of activity, and hospitalization, Papaioannou said. They also studied published literature on the risks and benefits of strategies to prevent fracture.

The guideline strongly recommends calcium supplementation of 1200 mg or three servings of dairy daily for people older than 70. These calcium levels reduce hip fracture risk and slightly reduce the risk of other fractures, but they may also cause gastrointestinal side effects. For residents who want to avoid these, supplementation may not be a good option, the authors write.

Residents at high risk of fracture, i.e., those with prior fracture of the hip or spine, more than one prior fracture, or one prior fracture and recent use of glucocorticoids, should also take daily vitamin D3 supplements, which are more affordable than vitamin D2, the authors wrote online September 14 in CMAJ.

They also recommend that high-risk residents take alendronate weekly, or risedronate weekly or monthly, as first-line therapy to prevent fractures, as long as they do not have difficulty swallowing and can remain upright for 30 minutes after administration, and they do not have severe renal insufficiency.

For residents who are at high risk of fractures and who have difficulty taking oral medications, they recommend zoledronic acid or denosumab as first-line therapy.

High-risk residents who are mobile should wear hip-protectors, which can protect against fracture in the event of a fall. Low-risk residents who are mobile may wear the devices, depending on their values and preferences.

Balance, strength, and functional exercise can help prevent falls for low-risk residents, and may be useful for high-risk residents, but the exercise itself increases the risk of fall slightly.

Lastly, the authors recommend that all residents have "multifactorial interventions" that are tailored to each individual and include medication reviews, environmental hazard assessment, assistive device use, exercise, and educational interventions for staff.

"Many residents have multiple medical conditions and we need to make sure that they include their lifespan and goals of care in the assessment," Papaioannou said. "The goals of those with short lifespans may be very different from those with longer lifespans."

These recommendations are similar to those for residential care facilities in Australia and the ones made by the Society for Post-Acute and Long-Term Care Medicine in the U.S., the authors point out.

"The document is an excellent guide on how to identify patients at risk, who should be treated and how," said Dr. Gustavo Duque, director of the Musculoskeletal Ageing Research Program at the University of Sydney in Australia.

Doctors often reduce medications for residents who are admitted to nursing homes without realizing that those with osteoporosis or previous fractures are more likely to suffer a fracture at their new residence than in the community, Duque, who was not involved in writing the new guideline, said by email.

"Ceasing osteoporosis treatment has demonstrated to increase the risk of fractures," Duque said. "Unfortunately we see that situation every day."

NEW YORK  - Older adults living in long-term care are more than twice as likely as their peers living at home to suffer a fracture, and a new guideline endorsed by the Scientific Advisory Council of Osteoporosis Canada explains how to reduce their risk.

Residents of long-term care tend to be frailer and have more health problems than similar people who live on their own, which explains the higher risk of fractures in long-term care facilities, said lead author Dr. Alexandra Papaioannou of McMaster University and Hamilton Health Sciences in Hamilton, Ontario.

"Up to a third of seniors in long-term care suffer a fracture," often of the hip or spine, she said. For these residents, "long-term care is their home, the nurses know them, and acute care can be a frightening traumatic experience for residents."

The authors developed the new guideline based on input from older people and their families, who most wanted to avoid pain, loss of activity, and hospitalization, Papaioannou said. They also studied published literature on the risks and benefits of strategies to prevent fracture.

The guideline strongly recommends calcium supplementation of 1200 mg or three servings of dairy daily for people older than 70. These calcium levels reduce hip fracture risk and slightly reduce the risk of other fractures, but they may also cause gastrointestinal side effects. For residents who want to avoid these, supplementation may not be a good option, the authors write.

Residents at high risk of fracture, i.e., those with prior fracture of the hip or spine, more than one prior fracture, or one prior fracture and recent use of glucocorticoids, should also take daily vitamin D3 supplements, which are more affordable than vitamin D2, the authors wrote online September 14 in CMAJ.

They also recommend that high-risk residents take alendronate weekly, or risedronate weekly or monthly, as first-line therapy to prevent fractures, as long as they do not have difficulty swallowing and can remain upright for 30 minutes after administration, and they do not have severe renal insufficiency.

For residents who are at high risk of fractures and who have difficulty taking oral medications, they recommend zoledronic acid or denosumab as first-line therapy.

High-risk residents who are mobile should wear hip-protectors, which can protect against fracture in the event of a fall. Low-risk residents who are mobile may wear the devices, depending on their values and preferences.

Balance, strength, and functional exercise can help prevent falls for low-risk residents, and may be useful for high-risk residents, but the exercise itself increases the risk of fall slightly.

Lastly, the authors recommend that all residents have "multifactorial interventions" that are tailored to each individual and include medication reviews, environmental hazard assessment, assistive device use, exercise, and educational interventions for staff.

"Many residents have multiple medical conditions and we need to make sure that they include their lifespan and goals of care in the assessment," Papaioannou said. "The goals of those with short lifespans may be very different from those with longer lifespans."

These recommendations are similar to those for residential care facilities in Australia and the ones made by the Society for Post-Acute and Long-Term Care Medicine in the U.S., the authors point out.

"The document is an excellent guide on how to identify patients at risk, who should be treated and how," said Dr. Gustavo Duque, director of the Musculoskeletal Ageing Research Program at the University of Sydney in Australia.

Doctors often reduce medications for residents who are admitted to nursing homes without realizing that those with osteoporosis or previous fractures are more likely to suffer a fracture at their new residence than in the community, Duque, who was not involved in writing the new guideline, said by email.

"Ceasing osteoporosis treatment has demonstrated to increase the risk of fractures," Duque said. "Unfortunately we see that situation every day."

NEW YORK - Diabetes patients in the Kaiser Health System spent more days with their prescribed statins on hand if they used Kaiser's online refill tool, a study shows.

The researchers looked specifically at racial and ethnic minorities and found that while these groups had poorer medication adherence than white patients before using the online refills, using the online refills conferred the same benefit for every group.

"Many other systems are implementing online portals other than Kaiser," said lead author Dr. Courtney Lyles in a phone interview. "The key message that our study puts forward is that providing tools to help with medication adherence is critical."

Lyles, an affiliate investigator at the Kaiser Permanente Division of Research and assistant professor at the University of California, San Francisco, and her colleagues studied patients in the type 2 diabetes registry in Kaiser Permanente Northern California between 2006 and 2012.

All had access to online patient tools that allow for viewing medical history and visit summaries, viewing laboratory results, scheduling appointments, sending and receiving secure email messages with providers, and requesting prescription refills.

Patients could request a prescription refill online and receive the medication by mail or pick it up in person at the pharmacy.

The researchers compared diabetes patients with statin prescriptions who used the online refill tool to those who did not, and compared individual patients before and after they started using the online refills.

According to pharmacy data, at baseline, whites on average spent about 12% of the time without having the medicine on hand, compared to about 16% of the time for blacks and Latinos, and about 13% of the time for Asians and Filipinos.

But when patients switched from other refill habits to exclusively online refills, they reduced their time without statins by more than 3%, the researchers reported in an article online September 2 in the Journal of the American Medical Informatics Association.

Racial and ethnic minority patients are less likely to use online portals, even after adjusting for Internet access or use of Internet in everyday life, Lyles said.

"There is a concern that if particular populations are less likely to use these portals, then perhaps the benefits will be differential," she said. "But we found that racial minorities are less likely to use it overall, but have the same benefit in adherence."

Online portals do appear to make prescription refills more convenient, and people using the portals reduced the number of days without medication by 10 or 15 days per year, according to Dr. Jessica S. Ancker, a health care policy researcher at Weill Cornell Medical College in New York City, who was not part of the new study.

Healthcare organizations started offering online portals as a "leap of faith," assuming they would improve patient experiences, but without any concrete proof, she said.

"A new wave of research measures whether it's improving things," she said.

The Agency for Healthcare Research and Quality funded this research.

NEW YORK - Diabetes patients in the Kaiser Health System spent more days with their prescribed statins on hand if they used Kaiser's online refill tool, a study shows.

The researchers looked specifically at racial and ethnic minorities and found that while these groups had poorer medication adherence than white patients before using the online refills, using the online refills conferred the same benefit for every group.

"Many other systems are implementing online portals other than Kaiser," said lead author Dr. Courtney Lyles in a phone interview. "The key message that our study puts forward is that providing tools to help with medication adherence is critical."

Lyles, an affiliate investigator at the Kaiser Permanente Division of Research and assistant professor at the University of California, San Francisco, and her colleagues studied patients in the type 2 diabetes registry in Kaiser Permanente Northern California between 2006 and 2012.

All had access to online patient tools that allow for viewing medical history and visit summaries, viewing laboratory results, scheduling appointments, sending and receiving secure email messages with providers, and requesting prescription refills.

Patients could request a prescription refill online and receive the medication by mail or pick it up in person at the pharmacy.

The researchers compared diabetes patients with statin prescriptions who used the online refill tool to those who did not, and compared individual patients before and after they started using the online refills.

According to pharmacy data, at baseline, whites on average spent about 12% of the time without having the medicine on hand, compared to about 16% of the time for blacks and Latinos, and about 13% of the time for Asians and Filipinos.

But when patients switched from other refill habits to exclusively online refills, they reduced their time without statins by more than 3%, the researchers reported in an article online September 2 in the Journal of the American Medical Informatics Association.

Racial and ethnic minority patients are less likely to use online portals, even after adjusting for Internet access or use of Internet in everyday life, Lyles said.

"There is a concern that if particular populations are less likely to use these portals, then perhaps the benefits will be differential," she said. "But we found that racial minorities are less likely to use it overall, but have the same benefit in adherence."

Online portals do appear to make prescription refills more convenient, and people using the portals reduced the number of days without medication by 10 or 15 days per year, according to Dr. Jessica S. Ancker, a health care policy researcher at Weill Cornell Medical College in New York City, who was not part of the new study.

Healthcare organizations started offering online portals as a "leap of faith," assuming they would improve patient experiences, but without any concrete proof, she said.

"A new wave of research measures whether it's improving things," she said.

The Agency for Healthcare Research and Quality funded this research.

NEW YORK - Diabetes patients in the Kaiser Health System spent more days with their prescribed statins on hand if they used Kaiser's online refill tool, a study shows.

The researchers looked specifically at racial and ethnic minorities and found that while these groups had poorer medication adherence than white patients before using the online refills, using the online refills conferred the same benefit for every group.

"Many other systems are implementing online portals other than Kaiser," said lead author Dr. Courtney Lyles in a phone interview. "The key message that our study puts forward is that providing tools to help with medication adherence is critical."

Lyles, an affiliate investigator at the Kaiser Permanente Division of Research and assistant professor at the University of California, San Francisco, and her colleagues studied patients in the type 2 diabetes registry in Kaiser Permanente Northern California between 2006 and 2012.

All had access to online patient tools that allow for viewing medical history and visit summaries, viewing laboratory results, scheduling appointments, sending and receiving secure email messages with providers, and requesting prescription refills.

Patients could request a prescription refill online and receive the medication by mail or pick it up in person at the pharmacy.

The researchers compared diabetes patients with statin prescriptions who used the online refill tool to those who did not, and compared individual patients before and after they started using the online refills.

According to pharmacy data, at baseline, whites on average spent about 12% of the time without having the medicine on hand, compared to about 16% of the time for blacks and Latinos, and about 13% of the time for Asians and Filipinos.

But when patients switched from other refill habits to exclusively online refills, they reduced their time without statins by more than 3%, the researchers reported in an article online September 2 in the Journal of the American Medical Informatics Association.

Racial and ethnic minority patients are less likely to use online portals, even after adjusting for Internet access or use of Internet in everyday life, Lyles said.

"There is a concern that if particular populations are less likely to use these portals, then perhaps the benefits will be differential," she said. "But we found that racial minorities are less likely to use it overall, but have the same benefit in adherence."

Online portals do appear to make prescription refills more convenient, and people using the portals reduced the number of days without medication by 10 or 15 days per year, according to Dr. Jessica S. Ancker, a health care policy researcher at Weill Cornell Medical College in New York City, who was not part of the new study.

Healthcare organizations started offering online portals as a "leap of faith," assuming they would improve patient experiences, but without any concrete proof, she said.

"A new wave of research measures whether it's improving things," she said.

The Agency for Healthcare Research and Quality funded this research.

After a heart attack, black patients typically don't live as long as whites - a racial difference that is starkest among the affluent - according to a new U.S. study.

Researchers evaluated data on more than 132,000 white heart attack patients and almost 9,000 black patients covered by Medicare, the government health program for the elderly and disabled. They used postal codes to assess income levels in patients' communities.

After 17 years of follow-up, the overall survival rate was 7.4 percent for white patients and 5.7 percent for black patients, according to the results published in Circulation, the journal of the American Heart Association.

On average, across all ages, white patients in low-income areas lived longer after a heart attack - about 5.6 years compared with 5.4 years for black patients. But in high-income communities, the gap widened to a life expectancy of seven years for white people and 6.3 years for black individuals.

"We found that socioeconomic status did not explain the racial disparities in life expectancy after a heart attack," lead study author Dr. Emily Bucholz of Boston Children's Hospital said by email.

"Contrary to common belief, this suggests that improving socioeconomic standing may improve outcomes for black and white patients globally but is unlikely to eliminate racial disparities in health," Bucholz added.

To see how race and class impact heart attack outcomes, Bucholz and colleagues reviewed health records collected from 1994 to 1996 for patients aged 65 to 90 years.

Just 6.3 percent of the patients were black, and only 6.8 percent lived in low-income communities, based on the typical household income in their postal codes.

Among white patients under 80, life expectancy was longest for patients in the most affluent neighborhoods and it got progressively shorter for middle-income and poor communities, the study found.

By contrast, life expectancy was similar for black patients residing in poor and middle-income communities across all ages. Only black patients under age 75 living in affluent areas had a survival advantage compared with their peers in less wealthy neighborhoods.

One shortcoming of the study is that it included a small proportion of black and poor patients, the authors acknowledge. It's also possible that using postal codes to assess income may have led to some instances where income levels were inflated or underestimated, the authors note.

It's possible that black patients living in affluent areas don't fare as well as white patients because they don't have the same amount of social support from their peers, said Dr. Joaquin Cigarroa, a cardiovascular medicine researcher at Oregon Health & Science University in Portland.

In poor neighborhoods, black patients may face additional challenges to surviving a heart attack, added Cigarroa, who wasn't involved in the study.

"They more often live in low socioeconomic segments of our community that often have less access to health care resources and less access to stores with good nutrition," Cigarroa said by email. "In addition, these segments of our community are often not ideally configured for promoting physical activity with parks, sidewalks, bike lanes, etc."

The study findings highlight a need to improve outcomes among poor and black patients and suggest some differences in heart attack survival may come down to disparities in quality of care, said senior study author Dr. Harlan Krumholz of Yale University School of Medicine in New Haven, Connecticut.

Because black patients have a greater burden of heart disease than white people, doctors may also need to focus more on prevention in this community, Krumholz said by email.

"Healthy heart habits may be even more important for African-Americans, for whom avoiding a heart attack is even more important given their worse outcomes after the event," Krumholz said.

After a heart attack, black patients typically don't live as long as whites - a racial difference that is starkest among the affluent - according to a new U.S. study.

Researchers evaluated data on more than 132,000 white heart attack patients and almost 9,000 black patients covered by Medicare, the government health program for the elderly and disabled. They used postal codes to assess income levels in patients' communities.

After 17 years of follow-up, the overall survival rate was 7.4 percent for white patients and 5.7 percent for black patients, according to the results published in Circulation, the journal of the American Heart Association.

On average, across all ages, white patients in low-income areas lived longer after a heart attack - about 5.6 years compared with 5.4 years for black patients. But in high-income communities, the gap widened to a life expectancy of seven years for white people and 6.3 years for black individuals.

"We found that socioeconomic status did not explain the racial disparities in life expectancy after a heart attack," lead study author Dr. Emily Bucholz of Boston Children's Hospital said by email.

"Contrary to common belief, this suggests that improving socioeconomic standing may improve outcomes for black and white patients globally but is unlikely to eliminate racial disparities in health," Bucholz added.

To see how race and class impact heart attack outcomes, Bucholz and colleagues reviewed health records collected from 1994 to 1996 for patients aged 65 to 90 years.

Just 6.3 percent of the patients were black, and only 6.8 percent lived in low-income communities, based on the typical household income in their postal codes.

Among white patients under 80, life expectancy was longest for patients in the most affluent neighborhoods and it got progressively shorter for middle-income and poor communities, the study found.

By contrast, life expectancy was similar for black patients residing in poor and middle-income communities across all ages. Only black patients under age 75 living in affluent areas had a survival advantage compared with their peers in less wealthy neighborhoods.

One shortcoming of the study is that it included a small proportion of black and poor patients, the authors acknowledge. It's also possible that using postal codes to assess income may have led to some instances where income levels were inflated or underestimated, the authors note.

It's possible that black patients living in affluent areas don't fare as well as white patients because they don't have the same amount of social support from their peers, said Dr. Joaquin Cigarroa, a cardiovascular medicine researcher at Oregon Health & Science University in Portland.

In poor neighborhoods, black patients may face additional challenges to surviving a heart attack, added Cigarroa, who wasn't involved in the study.

"They more often live in low socioeconomic segments of our community that often have less access to health care resources and less access to stores with good nutrition," Cigarroa said by email. "In addition, these segments of our community are often not ideally configured for promoting physical activity with parks, sidewalks, bike lanes, etc."

The study findings highlight a need to improve outcomes among poor and black patients and suggest some differences in heart attack survival may come down to disparities in quality of care, said senior study author Dr. Harlan Krumholz of Yale University School of Medicine in New Haven, Connecticut.

Because black patients have a greater burden of heart disease than white people, doctors may also need to focus more on prevention in this community, Krumholz said by email.

"Healthy heart habits may be even more important for African-Americans, for whom avoiding a heart attack is even more important given their worse outcomes after the event," Krumholz said.

After a heart attack, black patients typically don't live as long as whites - a racial difference that is starkest among the affluent - according to a new U.S. study.

Researchers evaluated data on more than 132,000 white heart attack patients and almost 9,000 black patients covered by Medicare, the government health program for the elderly and disabled. They used postal codes to assess income levels in patients' communities.

After 17 years of follow-up, the overall survival rate was 7.4 percent for white patients and 5.7 percent for black patients, according to the results published in Circulation, the journal of the American Heart Association.

On average, across all ages, white patients in low-income areas lived longer after a heart attack - about 5.6 years compared with 5.4 years for black patients. But in high-income communities, the gap widened to a life expectancy of seven years for white people and 6.3 years for black individuals.

"We found that socioeconomic status did not explain the racial disparities in life expectancy after a heart attack," lead study author Dr. Emily Bucholz of Boston Children's Hospital said by email.

"Contrary to common belief, this suggests that improving socioeconomic standing may improve outcomes for black and white patients globally but is unlikely to eliminate racial disparities in health," Bucholz added.

To see how race and class impact heart attack outcomes, Bucholz and colleagues reviewed health records collected from 1994 to 1996 for patients aged 65 to 90 years.

Just 6.3 percent of the patients were black, and only 6.8 percent lived in low-income communities, based on the typical household income in their postal codes.

Among white patients under 80, life expectancy was longest for patients in the most affluent neighborhoods and it got progressively shorter for middle-income and poor communities, the study found.

By contrast, life expectancy was similar for black patients residing in poor and middle-income communities across all ages. Only black patients under age 75 living in affluent areas had a survival advantage compared with their peers in less wealthy neighborhoods.

One shortcoming of the study is that it included a small proportion of black and poor patients, the authors acknowledge. It's also possible that using postal codes to assess income may have led to some instances where income levels were inflated or underestimated, the authors note.

It's possible that black patients living in affluent areas don't fare as well as white patients because they don't have the same amount of social support from their peers, said Dr. Joaquin Cigarroa, a cardiovascular medicine researcher at Oregon Health & Science University in Portland.

In poor neighborhoods, black patients may face additional challenges to surviving a heart attack, added Cigarroa, who wasn't involved in the study.

"They more often live in low socioeconomic segments of our community that often have less access to health care resources and less access to stores with good nutrition," Cigarroa said by email. "In addition, these segments of our community are often not ideally configured for promoting physical activity with parks, sidewalks, bike lanes, etc."

The study findings highlight a need to improve outcomes among poor and black patients and suggest some differences in heart attack survival may come down to disparities in quality of care, said senior study author Dr. Harlan Krumholz of Yale University School of Medicine in New Haven, Connecticut.

Because black patients have a greater burden of heart disease than white people, doctors may also need to focus more on prevention in this community, Krumholz said by email.

"Healthy heart habits may be even more important for African-Americans, for whom avoiding a heart attack is even more important given their worse outcomes after the event," Krumholz said.

Earning credit for continuing medical education (CME) is a little easier for hospitalists and other physicians.

A collaboration between the American Board of Internal Medicine (ABIM) and the Accreditation Council for Continuing Medical Education (ACCME) will enable physicians who are engaged in lifelong learning to use those activities toward completion of requirements for ABIM’s Maintenance of Certification (MOC) program.

The collaboration expands physicians’ options to receive MOC credit and helps CME providers to “offer more lifelong learning options with MOC credit to internists and subspecialties,” according to an ABIM announcement.

The ABIM-ACCME collaboration exempts CME providers from applying for ABIM approval for each MOC activity. Instead, CME providers can use a shared system to record information about CME and ABIM MOC activities.

“I think the ABIM wanted to recognize this CME as fulfilling the spirit of MOC, but up until now, it was really hard to ensure that the ‘CME’ was meaningful and not tainted by third-party sponsorship,” writes ABIM Council member and former SHM President Jeffrey Wiese, MD, MHM, in an email to The Hospitalist. “This collaboration enables physicians to get MOC credit for the CME that they are acquiring and, importantly, ensures that the CME that counts toward MOC meets the standards of the ABIM without having to go through an extensive approval process.”

Hospitalists also have the option to use the Focused Practice in Hospital Medicine exam, but not all do. Therefore, the streamlined network for reporting activity means that hospitalists will see a real benefit.

“There haven’t been a lot of modules built for hospital medicine like there have been for ambulatory medicine or the subspecialties,” Dr. Wiese adds. “Hospitalists have struggled to find medical knowledge modules that gave MOC credit and [that] fit with what they were doing in their practice. This collaboration solves that, as it opens a door for many CME activities that will satisfy both MOC credit and speak to the practice of hospital medicine.”

Visit our website for more information on continuing medical education in hospital medicine.

Earning credit for continuing medical education (CME) is a little easier for hospitalists and other physicians.

A collaboration between the American Board of Internal Medicine (ABIM) and the Accreditation Council for Continuing Medical Education (ACCME) will enable physicians who are engaged in lifelong learning to use those activities toward completion of requirements for ABIM’s Maintenance of Certification (MOC) program.

The collaboration expands physicians’ options to receive MOC credit and helps CME providers to “offer more lifelong learning options with MOC credit to internists and subspecialties,” according to an ABIM announcement.

The ABIM-ACCME collaboration exempts CME providers from applying for ABIM approval for each MOC activity. Instead, CME providers can use a shared system to record information about CME and ABIM MOC activities.

“I think the ABIM wanted to recognize this CME as fulfilling the spirit of MOC, but up until now, it was really hard to ensure that the ‘CME’ was meaningful and not tainted by third-party sponsorship,” writes ABIM Council member and former SHM President Jeffrey Wiese, MD, MHM, in an email to The Hospitalist. “This collaboration enables physicians to get MOC credit for the CME that they are acquiring and, importantly, ensures that the CME that counts toward MOC meets the standards of the ABIM without having to go through an extensive approval process.”

Hospitalists also have the option to use the Focused Practice in Hospital Medicine exam, but not all do. Therefore, the streamlined network for reporting activity means that hospitalists will see a real benefit.

“There haven’t been a lot of modules built for hospital medicine like there have been for ambulatory medicine or the subspecialties,” Dr. Wiese adds. “Hospitalists have struggled to find medical knowledge modules that gave MOC credit and [that] fit with what they were doing in their practice. This collaboration solves that, as it opens a door for many CME activities that will satisfy both MOC credit and speak to the practice of hospital medicine.”

Visit our website for more information on continuing medical education in hospital medicine.

Earning credit for continuing medical education (CME) is a little easier for hospitalists and other physicians.

A collaboration between the American Board of Internal Medicine (ABIM) and the Accreditation Council for Continuing Medical Education (ACCME) will enable physicians who are engaged in lifelong learning to use those activities toward completion of requirements for ABIM’s Maintenance of Certification (MOC) program.

The collaboration expands physicians’ options to receive MOC credit and helps CME providers to “offer more lifelong learning options with MOC credit to internists and subspecialties,” according to an ABIM announcement.

The ABIM-ACCME collaboration exempts CME providers from applying for ABIM approval for each MOC activity. Instead, CME providers can use a shared system to record information about CME and ABIM MOC activities.

“I think the ABIM wanted to recognize this CME as fulfilling the spirit of MOC, but up until now, it was really hard to ensure that the ‘CME’ was meaningful and not tainted by third-party sponsorship,” writes ABIM Council member and former SHM President Jeffrey Wiese, MD, MHM, in an email to The Hospitalist. “This collaboration enables physicians to get MOC credit for the CME that they are acquiring and, importantly, ensures that the CME that counts toward MOC meets the standards of the ABIM without having to go through an extensive approval process.”

Hospitalists also have the option to use the Focused Practice in Hospital Medicine exam, but not all do. Therefore, the streamlined network for reporting activity means that hospitalists will see a real benefit.

“There haven’t been a lot of modules built for hospital medicine like there have been for ambulatory medicine or the subspecialties,” Dr. Wiese adds. “Hospitalists have struggled to find medical knowledge modules that gave MOC credit and [that] fit with what they were doing in their practice. This collaboration solves that, as it opens a door for many CME activities that will satisfy both MOC credit and speak to the practice of hospital medicine.”

Visit our website for more information on continuing medical education in hospital medicine.