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Pediatric Hospital Medicine 2014: Over-Diagnosis Is Harming Children
Presenters
Eric Coon, Ricardo Quinonez, Alan Schroeder
Summary
One of PHM2014’s first breakout sessions, coming on the heels of Dr. Meuthing’s opening talk on reducing serious safety events, focused on the topic of over-diagnosis in pediatric HM and its contribution to patient harm. The first key point is the distinction between over-diagnosis and mis-diagnosis. Over-diagnosis is the identification of an abnormality where detection will not benefit the patient. This is different from mis-diagnosis or incorrect diagnosis. Over-diagnosis has grown over the years due to several causes, including our fear of missing a diagnosis and increasing use of screening tests.
The speakers outlined many, varied drivers of over-diagnosis, including physicians’ unawareness of over-diagnosis, physicians’ discomfort with uncertainty, system incentives such as fee for service which reimburses or rewards increased testing, quality measures based on usage and testing, a perceived imperative to use testing and technology because it is available, and physicians’ inherent belief in technology and its results.
The classic example of over-diagnosis in pediatrics is asymptomatic urinary screening for neuroblastomas, where studies showed an increase in testing, an increase in diagnosis, but no change in mortality. A current example is children receiving head CT scans for minor head trauma that can lead to a diagnosis of small asymptomatic head bleeds or non-displaced skull fractures, which can then lead to PICU admissions, transfers to higher level centers, prophylactic administration of anti-seizure medications, and repeat CT scans.
From the patient perspective, over-diagnosis can lead to unnecessary hospitalizations, inappropriate medications and treatments, and increased patient or parental anxiety secondary being given a label of a diagnosis or disease.
Key Takeaway
The bottom line for physicians to consider when ordering a test is not just does the patient benefit from detection or diagnosis, but also what is the potential harm?
James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.
Presenters
Eric Coon, Ricardo Quinonez, Alan Schroeder
Summary
One of PHM2014’s first breakout sessions, coming on the heels of Dr. Meuthing’s opening talk on reducing serious safety events, focused on the topic of over-diagnosis in pediatric HM and its contribution to patient harm. The first key point is the distinction between over-diagnosis and mis-diagnosis. Over-diagnosis is the identification of an abnormality where detection will not benefit the patient. This is different from mis-diagnosis or incorrect diagnosis. Over-diagnosis has grown over the years due to several causes, including our fear of missing a diagnosis and increasing use of screening tests.
The speakers outlined many, varied drivers of over-diagnosis, including physicians’ unawareness of over-diagnosis, physicians’ discomfort with uncertainty, system incentives such as fee for service which reimburses or rewards increased testing, quality measures based on usage and testing, a perceived imperative to use testing and technology because it is available, and physicians’ inherent belief in technology and its results.
The classic example of over-diagnosis in pediatrics is asymptomatic urinary screening for neuroblastomas, where studies showed an increase in testing, an increase in diagnosis, but no change in mortality. A current example is children receiving head CT scans for minor head trauma that can lead to a diagnosis of small asymptomatic head bleeds or non-displaced skull fractures, which can then lead to PICU admissions, transfers to higher level centers, prophylactic administration of anti-seizure medications, and repeat CT scans.
From the patient perspective, over-diagnosis can lead to unnecessary hospitalizations, inappropriate medications and treatments, and increased patient or parental anxiety secondary being given a label of a diagnosis or disease.
Key Takeaway
The bottom line for physicians to consider when ordering a test is not just does the patient benefit from detection or diagnosis, but also what is the potential harm?
James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.
Presenters
Eric Coon, Ricardo Quinonez, Alan Schroeder
Summary
One of PHM2014’s first breakout sessions, coming on the heels of Dr. Meuthing’s opening talk on reducing serious safety events, focused on the topic of over-diagnosis in pediatric HM and its contribution to patient harm. The first key point is the distinction between over-diagnosis and mis-diagnosis. Over-diagnosis is the identification of an abnormality where detection will not benefit the patient. This is different from mis-diagnosis or incorrect diagnosis. Over-diagnosis has grown over the years due to several causes, including our fear of missing a diagnosis and increasing use of screening tests.
The speakers outlined many, varied drivers of over-diagnosis, including physicians’ unawareness of over-diagnosis, physicians’ discomfort with uncertainty, system incentives such as fee for service which reimburses or rewards increased testing, quality measures based on usage and testing, a perceived imperative to use testing and technology because it is available, and physicians’ inherent belief in technology and its results.
The classic example of over-diagnosis in pediatrics is asymptomatic urinary screening for neuroblastomas, where studies showed an increase in testing, an increase in diagnosis, but no change in mortality. A current example is children receiving head CT scans for minor head trauma that can lead to a diagnosis of small asymptomatic head bleeds or non-displaced skull fractures, which can then lead to PICU admissions, transfers to higher level centers, prophylactic administration of anti-seizure medications, and repeat CT scans.
From the patient perspective, over-diagnosis can lead to unnecessary hospitalizations, inappropriate medications and treatments, and increased patient or parental anxiety secondary being given a label of a diagnosis or disease.
Key Takeaway
The bottom line for physicians to consider when ordering a test is not just does the patient benefit from detection or diagnosis, but also what is the potential harm?
James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.
Pediatric Hospital Medicine 2014: Building Blocks in the Evolution of a Successful Distributed Hospitalist Program
Presenters
Dan Hale, MD, FAAP, and Elisabeth Schainker, MD, FAAP, The Floating Hospital for Children at Tufts Medical Center, Boston
Summary
"Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high-quality and sustainable program,” said Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”
Dr. Elisabeth Schainker, chief of hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.
This workshop reviewed the fundamentals that programs should review before starting and also periodically after established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine were used as a starting point for program self-evaluation. These “building blocks” include:
• Establish the rationale for the program and include all stakeholders;
• Financial expectations; • Define scope of practice;
• Nursing and referral physician collaboration;
• Assess staffing and workload expectations;
• Referral base; and
• Basic code and emergency preparedness.
Ongoing program development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:
• Communication and collaboration with other hospital departments (emergency, radiology, surgery, etc.);
• Newborn medicine care;
• Internal group clinical practice guidelines;
• Co-management of surgical or specialty patients;
• Transfers from other hospitals or continuing care from tertiary care centers;
• Pediatric code teams and rapid response teams;
• Advanced code and emergency preparedness and mock code training; and
• Nursing education.
These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program. The essentials of a successful distributed network of multiple hospitalist program site were also described. After assuring the fundamentals are present at each site, transparency and institutional alignment are imperative.
Key Takeaways
1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.
2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.
3. After a program is established and fundamentals are in place, other important advance practices can be added on. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.
4. For a multiple site or distributed program, high level collaboration and transparency is essential.
Dr. Hale is a past member of Team Hospitalist and is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.
Presenters
Dan Hale, MD, FAAP, and Elisabeth Schainker, MD, FAAP, The Floating Hospital for Children at Tufts Medical Center, Boston
Summary
"Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high-quality and sustainable program,” said Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”
Dr. Elisabeth Schainker, chief of hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.
This workshop reviewed the fundamentals that programs should review before starting and also periodically after established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine were used as a starting point for program self-evaluation. These “building blocks” include:
• Establish the rationale for the program and include all stakeholders;
• Financial expectations; • Define scope of practice;
• Nursing and referral physician collaboration;
• Assess staffing and workload expectations;
• Referral base; and
• Basic code and emergency preparedness.
Ongoing program development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:
• Communication and collaboration with other hospital departments (emergency, radiology, surgery, etc.);
• Newborn medicine care;
• Internal group clinical practice guidelines;
• Co-management of surgical or specialty patients;
• Transfers from other hospitals or continuing care from tertiary care centers;
• Pediatric code teams and rapid response teams;
• Advanced code and emergency preparedness and mock code training; and
• Nursing education.
These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program. The essentials of a successful distributed network of multiple hospitalist program site were also described. After assuring the fundamentals are present at each site, transparency and institutional alignment are imperative.
Key Takeaways
1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.
2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.
3. After a program is established and fundamentals are in place, other important advance practices can be added on. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.
4. For a multiple site or distributed program, high level collaboration and transparency is essential.
Dr. Hale is a past member of Team Hospitalist and is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.
Presenters
Dan Hale, MD, FAAP, and Elisabeth Schainker, MD, FAAP, The Floating Hospital for Children at Tufts Medical Center, Boston
Summary
"Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high-quality and sustainable program,” said Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”
Dr. Elisabeth Schainker, chief of hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.
This workshop reviewed the fundamentals that programs should review before starting and also periodically after established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine were used as a starting point for program self-evaluation. These “building blocks” include:
• Establish the rationale for the program and include all stakeholders;
• Financial expectations; • Define scope of practice;
• Nursing and referral physician collaboration;
• Assess staffing and workload expectations;
• Referral base; and
• Basic code and emergency preparedness.
Ongoing program development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:
• Communication and collaboration with other hospital departments (emergency, radiology, surgery, etc.);
• Newborn medicine care;
• Internal group clinical practice guidelines;
• Co-management of surgical or specialty patients;
• Transfers from other hospitals or continuing care from tertiary care centers;
• Pediatric code teams and rapid response teams;
• Advanced code and emergency preparedness and mock code training; and
• Nursing education.
These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program. The essentials of a successful distributed network of multiple hospitalist program site were also described. After assuring the fundamentals are present at each site, transparency and institutional alignment are imperative.
Key Takeaways
1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.
2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.
3. After a program is established and fundamentals are in place, other important advance practices can be added on. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.
4. For a multiple site or distributed program, high level collaboration and transparency is essential.
Dr. Hale is a past member of Team Hospitalist and is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.
Increase in Hospitalist Workload Associated With Higher LOS and Cost
Clinical question
Does increased hospitalist workload affect efficiency and quality of care?
Bottom line
Increased hospitalist workload is associated with increased cost and length of stay (LOS). Quality metrics such as 30-day readmission rate, in-hospital mortality, and patient satisfaction were not affected by changes in workload. (LOE = 2b)
Reference
Study design
Cohort (retrospective)
Funding source
Other
Allocation
Uncertain
Setting
Inpatient (any location)
Synopsis
Using data abstracted from the central data warehouse of an academic community health system, these authors examined the association between hospitalist workload and the efficiency and quality of care provided. A private hospitalist group that provided 24-hour care to patients at 2 hospitals within the system was selected for the study. Patients included were those who either had an attending of record or had admission and discharge bills submitted by a physician in this hospitalist group. Physician daily workload was measured using the total number of relative value units (RVUs) generated and the physician’s census as determined by the number of billable encounters submitted. Efficiency was measured by LOS and cost. Quality was measured by in-hospital mortality, rapid response team activation, 30-day readmission rate, and patient satisfaction. Models were adjusted for patient characteristics, including demographics; severity of illness; visit characteristics, including admission day of the week; and hospital-level characteristics, including hospital occupancy. Approximately 20,000 hospitalizations were included in the study. Hospitalists had a mean of 15.5 patient encounters and 28.6 RVUs per day. Results for LOS were stratified by hospital occupancy. For less than 75% occupancy, LOS increased linearly from 5.5 days to 7.5 days as workload increased. For greater than 85% occupancy, the change in LOS was J-shaped with a significant increase around an RVU of 30 or a census of 17. Cost also increased with higher workloads. For every unit increase in RVU, cost increased by $111; for every unit increase in census, cost increased by $205 (after adjustment for LOS). There were no significant associations with change in workload and patient satisfaction, in-hospital mortality, rapid response team activation, or 30-day readmission rate.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does increased hospitalist workload affect efficiency and quality of care?
Bottom line
Increased hospitalist workload is associated with increased cost and length of stay (LOS). Quality metrics such as 30-day readmission rate, in-hospital mortality, and patient satisfaction were not affected by changes in workload. (LOE = 2b)
Reference
Study design
Cohort (retrospective)
Funding source
Other
Allocation
Uncertain
Setting
Inpatient (any location)
Synopsis
Using data abstracted from the central data warehouse of an academic community health system, these authors examined the association between hospitalist workload and the efficiency and quality of care provided. A private hospitalist group that provided 24-hour care to patients at 2 hospitals within the system was selected for the study. Patients included were those who either had an attending of record or had admission and discharge bills submitted by a physician in this hospitalist group. Physician daily workload was measured using the total number of relative value units (RVUs) generated and the physician’s census as determined by the number of billable encounters submitted. Efficiency was measured by LOS and cost. Quality was measured by in-hospital mortality, rapid response team activation, 30-day readmission rate, and patient satisfaction. Models were adjusted for patient characteristics, including demographics; severity of illness; visit characteristics, including admission day of the week; and hospital-level characteristics, including hospital occupancy. Approximately 20,000 hospitalizations were included in the study. Hospitalists had a mean of 15.5 patient encounters and 28.6 RVUs per day. Results for LOS were stratified by hospital occupancy. For less than 75% occupancy, LOS increased linearly from 5.5 days to 7.5 days as workload increased. For greater than 85% occupancy, the change in LOS was J-shaped with a significant increase around an RVU of 30 or a census of 17. Cost also increased with higher workloads. For every unit increase in RVU, cost increased by $111; for every unit increase in census, cost increased by $205 (after adjustment for LOS). There were no significant associations with change in workload and patient satisfaction, in-hospital mortality, rapid response team activation, or 30-day readmission rate.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Does increased hospitalist workload affect efficiency and quality of care?
Bottom line
Increased hospitalist workload is associated with increased cost and length of stay (LOS). Quality metrics such as 30-day readmission rate, in-hospital mortality, and patient satisfaction were not affected by changes in workload. (LOE = 2b)
Reference
Study design
Cohort (retrospective)
Funding source
Other
Allocation
Uncertain
Setting
Inpatient (any location)
Synopsis
Using data abstracted from the central data warehouse of an academic community health system, these authors examined the association between hospitalist workload and the efficiency and quality of care provided. A private hospitalist group that provided 24-hour care to patients at 2 hospitals within the system was selected for the study. Patients included were those who either had an attending of record or had admission and discharge bills submitted by a physician in this hospitalist group. Physician daily workload was measured using the total number of relative value units (RVUs) generated and the physician’s census as determined by the number of billable encounters submitted. Efficiency was measured by LOS and cost. Quality was measured by in-hospital mortality, rapid response team activation, 30-day readmission rate, and patient satisfaction. Models were adjusted for patient characteristics, including demographics; severity of illness; visit characteristics, including admission day of the week; and hospital-level characteristics, including hospital occupancy. Approximately 20,000 hospitalizations were included in the study. Hospitalists had a mean of 15.5 patient encounters and 28.6 RVUs per day. Results for LOS were stratified by hospital occupancy. For less than 75% occupancy, LOS increased linearly from 5.5 days to 7.5 days as workload increased. For greater than 85% occupancy, the change in LOS was J-shaped with a significant increase around an RVU of 30 or a census of 17. Cost also increased with higher workloads. For every unit increase in RVU, cost increased by $111; for every unit increase in census, cost increased by $205 (after adjustment for LOS). There were no significant associations with change in workload and patient satisfaction, in-hospital mortality, rapid response team activation, or 30-day readmission rate.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Anticoagulant Plus NSAID or Aspirin Use Associated With Increased Bleeding Risk
Clinical question
For patients with acute venous thromboembolism, is the use of anticoagulants plus nonsteroidal anti-inflammatory drugs or aspirin associated with an increased risk of bleeding?
Bottom line
For patients treated with anticoagulants for acute venous thromboembolism (VTE), the use of concomitant nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin is associated with an increased risk of bleeding. This can occur in patients treated with rivaroxaban, as well as in those treated with enoxaparin plus a vitamin K antagonist (VKA). (LOE = 2b)
Reference
Study design
Cohort (prospective)
Funding source
Industry
Allocation
Uncertain
Setting
Outpatient (any)
Synopsis
The worldwide EINSTEIN DVT and EINSTEIN PE clinical trials compared rivaroxaban with enoxaparin plus a VKA for the treatment of acute VTE. These investigators used data from this cohort to examine the association between rivaroxaban or enoxaparin-VKA plus concomitant NSAID or aspirin use and the risk of clinically relevant and major bleeding. Clinically relevant bleeding was defined as nonmajor bleeding that resulted in either medical intervention, temporary cessation of study treatment, or patient discomfort. Major bleeding was that which resulted in death, occurred at a critical site, required tranfusion of at least 2 units of red blood cells, or was associated with a 2 g/dL drop in hemoglobin. The cohort comprised 8246 patients, with half receiving rivaroxaban and half receiving enoxaparin-VKA. The NSAID analysis was adjusted for sex, as there were more women in the NSAID group. The aspirin analysis was adjusted for age and creatinine clearance, as patients in the aspirin group tended to be older with worse kidney function than the nonaspirin group. The NSAID or aspirin exposure period included 7 days after stopping the medication to reflect an ongoing risk. Clinically relevant bleeding was more likely to occur in the NSAID group as compared with the non-NSAID group (37.5 bleeding events per 100 patient-years vs 16.6 per 100 patient-years; hazard ratio [HR] = 1.77; 95% CI, 1.46-2.14). Findings were similar for both the NSAID-rivaroxaban-treated patients and NSAID-enoxaparin-VKA-treated patients. In the aspirin group, clinically relevant bleeding was also increased as compared with the nonaspirin group (36.6 bleeding events per 100 patient-years vs 16.9 per 100 patient-years; HR = 1.70; 1.38-2.11). For both the NSAID and the aspirin groups, the bleeding events were spread evenly over the duration of the use, suggesting that longer duration of use does not increase the risk of bleeding. Major bleeding increased 2.4-fold in the NSAID group and 1.5-fold in the aspirin group.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
For patients with acute venous thromboembolism, is the use of anticoagulants plus nonsteroidal anti-inflammatory drugs or aspirin associated with an increased risk of bleeding?
Bottom line
For patients treated with anticoagulants for acute venous thromboembolism (VTE), the use of concomitant nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin is associated with an increased risk of bleeding. This can occur in patients treated with rivaroxaban, as well as in those treated with enoxaparin plus a vitamin K antagonist (VKA). (LOE = 2b)
Reference
Study design
Cohort (prospective)
Funding source
Industry
Allocation
Uncertain
Setting
Outpatient (any)
Synopsis
The worldwide EINSTEIN DVT and EINSTEIN PE clinical trials compared rivaroxaban with enoxaparin plus a VKA for the treatment of acute VTE. These investigators used data from this cohort to examine the association between rivaroxaban or enoxaparin-VKA plus concomitant NSAID or aspirin use and the risk of clinically relevant and major bleeding. Clinically relevant bleeding was defined as nonmajor bleeding that resulted in either medical intervention, temporary cessation of study treatment, or patient discomfort. Major bleeding was that which resulted in death, occurred at a critical site, required tranfusion of at least 2 units of red blood cells, or was associated with a 2 g/dL drop in hemoglobin. The cohort comprised 8246 patients, with half receiving rivaroxaban and half receiving enoxaparin-VKA. The NSAID analysis was adjusted for sex, as there were more women in the NSAID group. The aspirin analysis was adjusted for age and creatinine clearance, as patients in the aspirin group tended to be older with worse kidney function than the nonaspirin group. The NSAID or aspirin exposure period included 7 days after stopping the medication to reflect an ongoing risk. Clinically relevant bleeding was more likely to occur in the NSAID group as compared with the non-NSAID group (37.5 bleeding events per 100 patient-years vs 16.6 per 100 patient-years; hazard ratio [HR] = 1.77; 95% CI, 1.46-2.14). Findings were similar for both the NSAID-rivaroxaban-treated patients and NSAID-enoxaparin-VKA-treated patients. In the aspirin group, clinically relevant bleeding was also increased as compared with the nonaspirin group (36.6 bleeding events per 100 patient-years vs 16.9 per 100 patient-years; HR = 1.70; 1.38-2.11). For both the NSAID and the aspirin groups, the bleeding events were spread evenly over the duration of the use, suggesting that longer duration of use does not increase the risk of bleeding. Major bleeding increased 2.4-fold in the NSAID group and 1.5-fold in the aspirin group.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
For patients with acute venous thromboembolism, is the use of anticoagulants plus nonsteroidal anti-inflammatory drugs or aspirin associated with an increased risk of bleeding?
Bottom line
For patients treated with anticoagulants for acute venous thromboembolism (VTE), the use of concomitant nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin is associated with an increased risk of bleeding. This can occur in patients treated with rivaroxaban, as well as in those treated with enoxaparin plus a vitamin K antagonist (VKA). (LOE = 2b)
Reference
Study design
Cohort (prospective)
Funding source
Industry
Allocation
Uncertain
Setting
Outpatient (any)
Synopsis
The worldwide EINSTEIN DVT and EINSTEIN PE clinical trials compared rivaroxaban with enoxaparin plus a VKA for the treatment of acute VTE. These investigators used data from this cohort to examine the association between rivaroxaban or enoxaparin-VKA plus concomitant NSAID or aspirin use and the risk of clinically relevant and major bleeding. Clinically relevant bleeding was defined as nonmajor bleeding that resulted in either medical intervention, temporary cessation of study treatment, or patient discomfort. Major bleeding was that which resulted in death, occurred at a critical site, required tranfusion of at least 2 units of red blood cells, or was associated with a 2 g/dL drop in hemoglobin. The cohort comprised 8246 patients, with half receiving rivaroxaban and half receiving enoxaparin-VKA. The NSAID analysis was adjusted for sex, as there were more women in the NSAID group. The aspirin analysis was adjusted for age and creatinine clearance, as patients in the aspirin group tended to be older with worse kidney function than the nonaspirin group. The NSAID or aspirin exposure period included 7 days after stopping the medication to reflect an ongoing risk. Clinically relevant bleeding was more likely to occur in the NSAID group as compared with the non-NSAID group (37.5 bleeding events per 100 patient-years vs 16.6 per 100 patient-years; hazard ratio [HR] = 1.77; 95% CI, 1.46-2.14). Findings were similar for both the NSAID-rivaroxaban-treated patients and NSAID-enoxaparin-VKA-treated patients. In the aspirin group, clinically relevant bleeding was also increased as compared with the nonaspirin group (36.6 bleeding events per 100 patient-years vs 16.9 per 100 patient-years; HR = 1.70; 1.38-2.11). For both the NSAID and the aspirin groups, the bleeding events were spread evenly over the duration of the use, suggesting that longer duration of use does not increase the risk of bleeding. Major bleeding increased 2.4-fold in the NSAID group and 1.5-fold in the aspirin group.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Prevention of HF Readmissions: Best Results With Home Visits and Multidisciplinary Clinics
Clinical question
Which transitional care interventions are most effective in preventing readmissions in patients hospitalized with heart failure?
Bottom line
Moderate-to-high strength of evidence supports the use of home-visiting programs and outpatient multidisciplinary heart failure (MDS-HF) clinics to reduce readmission rates and mortality for hospitalized HF patients at 3 months to 6 months. Structured telephone support may also decrease mortality and HF-specific readmissions, but does not affect all-cause readmissions.(LOE = 1a)
Reference
Study design
Meta-analysis (randomized controlled trials)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
These authors searched multiple databases, including MEDLINE and the Cochrane Library, as well as reference lists of pertinent articles to find randomized controlled trials that compared transitional care interventions with either other interventions or usual care for patients hospitalized with HF with a focus on readmission rates and mortality. The interventions had to include at least one of the following components: patient/caregiver education, scheduled outpatient clinic visits, home visits, telemonitoring, structured telephone support, transition coaching, or increased provider continuity. Two authors independently reviewed the 47 selected studies for risk of bias. Studies with high or unclear risk of bias were not included in the meta-analysis. Results for readmission rates and mortality were stratified by intervention category and strength of evidence (SOE) grades were provided. For 30-day outcomes, a high-intensity home-visiting program consisting of 8 scheduled home visits starting at 24 hours after discharge decreased all-cause readmissions (number needed to treat [NNT] = 6) but the SOE was low. For 3-month to 6-month outcomes, data from 9 trials of home-visiting programs with varying intensities showed a reduction in all-cause readmissions (NNT= 9; SOE = high). Similarly, data from 2 trials of scheduled outpatient visits with MDS-HF clinics revealed lower readmission rates (NNT= 8; SOE = high). For HF-specific readmissions, 2 interventions, home-visiting programs and structured telephone support, decreased rates at 3 months to 6 months (home visits: NNT = 7; SOE = moderate; structured telephone support: NNT = 14; SOE = high). Finally, several interventions reduced mortality as compared to usual care at 3 to 6 months with moderate SOE, including home-visiting programs (NNT = 33), MDS-HF clinics (NNT = 18), and structured telephone support (NNT = 27). There were no significant benefits noted with scheduled visits to nurse-led clinics or primary care clinics or with educational interventions, although in most cases, there was insufficient evidence to determine whether these intervention were effective.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Which transitional care interventions are most effective in preventing readmissions in patients hospitalized with heart failure?
Bottom line
Moderate-to-high strength of evidence supports the use of home-visiting programs and outpatient multidisciplinary heart failure (MDS-HF) clinics to reduce readmission rates and mortality for hospitalized HF patients at 3 months to 6 months. Structured telephone support may also decrease mortality and HF-specific readmissions, but does not affect all-cause readmissions.(LOE = 1a)
Reference
Study design
Meta-analysis (randomized controlled trials)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
These authors searched multiple databases, including MEDLINE and the Cochrane Library, as well as reference lists of pertinent articles to find randomized controlled trials that compared transitional care interventions with either other interventions or usual care for patients hospitalized with HF with a focus on readmission rates and mortality. The interventions had to include at least one of the following components: patient/caregiver education, scheduled outpatient clinic visits, home visits, telemonitoring, structured telephone support, transition coaching, or increased provider continuity. Two authors independently reviewed the 47 selected studies for risk of bias. Studies with high or unclear risk of bias were not included in the meta-analysis. Results for readmission rates and mortality were stratified by intervention category and strength of evidence (SOE) grades were provided. For 30-day outcomes, a high-intensity home-visiting program consisting of 8 scheduled home visits starting at 24 hours after discharge decreased all-cause readmissions (number needed to treat [NNT] = 6) but the SOE was low. For 3-month to 6-month outcomes, data from 9 trials of home-visiting programs with varying intensities showed a reduction in all-cause readmissions (NNT= 9; SOE = high). Similarly, data from 2 trials of scheduled outpatient visits with MDS-HF clinics revealed lower readmission rates (NNT= 8; SOE = high). For HF-specific readmissions, 2 interventions, home-visiting programs and structured telephone support, decreased rates at 3 months to 6 months (home visits: NNT = 7; SOE = moderate; structured telephone support: NNT = 14; SOE = high). Finally, several interventions reduced mortality as compared to usual care at 3 to 6 months with moderate SOE, including home-visiting programs (NNT = 33), MDS-HF clinics (NNT = 18), and structured telephone support (NNT = 27). There were no significant benefits noted with scheduled visits to nurse-led clinics or primary care clinics or with educational interventions, although in most cases, there was insufficient evidence to determine whether these intervention were effective.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question
Which transitional care interventions are most effective in preventing readmissions in patients hospitalized with heart failure?
Bottom line
Moderate-to-high strength of evidence supports the use of home-visiting programs and outpatient multidisciplinary heart failure (MDS-HF) clinics to reduce readmission rates and mortality for hospitalized HF patients at 3 months to 6 months. Structured telephone support may also decrease mortality and HF-specific readmissions, but does not affect all-cause readmissions.(LOE = 1a)
Reference
Study design
Meta-analysis (randomized controlled trials)
Funding source
Government
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
These authors searched multiple databases, including MEDLINE and the Cochrane Library, as well as reference lists of pertinent articles to find randomized controlled trials that compared transitional care interventions with either other interventions or usual care for patients hospitalized with HF with a focus on readmission rates and mortality. The interventions had to include at least one of the following components: patient/caregiver education, scheduled outpatient clinic visits, home visits, telemonitoring, structured telephone support, transition coaching, or increased provider continuity. Two authors independently reviewed the 47 selected studies for risk of bias. Studies with high or unclear risk of bias were not included in the meta-analysis. Results for readmission rates and mortality were stratified by intervention category and strength of evidence (SOE) grades were provided. For 30-day outcomes, a high-intensity home-visiting program consisting of 8 scheduled home visits starting at 24 hours after discharge decreased all-cause readmissions (number needed to treat [NNT] = 6) but the SOE was low. For 3-month to 6-month outcomes, data from 9 trials of home-visiting programs with varying intensities showed a reduction in all-cause readmissions (NNT= 9; SOE = high). Similarly, data from 2 trials of scheduled outpatient visits with MDS-HF clinics revealed lower readmission rates (NNT= 8; SOE = high). For HF-specific readmissions, 2 interventions, home-visiting programs and structured telephone support, decreased rates at 3 months to 6 months (home visits: NNT = 7; SOE = moderate; structured telephone support: NNT = 14; SOE = high). Finally, several interventions reduced mortality as compared to usual care at 3 to 6 months with moderate SOE, including home-visiting programs (NNT = 33), MDS-HF clinics (NNT = 18), and structured telephone support (NNT = 27). There were no significant benefits noted with scheduled visits to nurse-led clinics or primary care clinics or with educational interventions, although in most cases, there was insufficient evidence to determine whether these intervention were effective.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Society of Hospital Medicine Backs Bill to Modify Hospital Readmissions Program
The Society of Hospital Medicine (SHM) is supporting a Congressional push to tweak which admissions factors are taken into consideration in the federal Hospital Readmissions Reduction Program.
Hospitalist and SHM President Burke Kealey, MD, SFHM, says that the Establishing Beneficiary Equity in the Hospital Readmission Program Act (H.R. 4188) would help "level the playing field."
Sponsored by U.S. Representative James Renacci (R-Ohio), the proposal seeks to "exclude from the program admissions related to transplants, end-stage renal disease, burns, trauma, psychosis, or substance abuse." It also would require the U.S. Department of Health & Human Services (HHS) "in applying requirements for the excess readmission ratio to provide for a risk adjustment" that would take into account the percentage of inpatients eligible for both Medicare and Medicaid to avoid unfairly penalizing hospitals that treat the most vulnerable populations.
"We feel that some hospitals may be being unfairly handled in this program," Dr. Kealey says. "Those are the hospitals that are having to deal with more complex populations or lower-SES [socioeconomic status] populations. Those are the hospitalists that actually need the most resources to help prevent readmissions, and they end up losing in this whole equation."
In a letter to Rep. Renacci outlining SHM's support for the bill, Dr. Kealey notes that the current readmissions reduction program "needs fine-tuning to better account for preventable readmission."
Dr. Kealey also says he believes attempts by HHS to address readmissions are well-intentioned. However, as the program is implemented, he wants the government to be flexible in dealing with hospitals, particularly those dealing with complex populations or large groups of low-SES patients.
"We feel [these are] valuable programs, and in general, they help move the country in the right direction," Dr. Kealey says. "But they certainly need to be open and available to be modified and changed to fit conditions better."
SHM's program to reduce hospital readmissions, Project BOOST, is accepting applications to its 2014 cohort through August 30. TH
Visit our website for more information on hospital readmissions penalties.
The Society of Hospital Medicine (SHM) is supporting a Congressional push to tweak which admissions factors are taken into consideration in the federal Hospital Readmissions Reduction Program.
Hospitalist and SHM President Burke Kealey, MD, SFHM, says that the Establishing Beneficiary Equity in the Hospital Readmission Program Act (H.R. 4188) would help "level the playing field."
Sponsored by U.S. Representative James Renacci (R-Ohio), the proposal seeks to "exclude from the program admissions related to transplants, end-stage renal disease, burns, trauma, psychosis, or substance abuse." It also would require the U.S. Department of Health & Human Services (HHS) "in applying requirements for the excess readmission ratio to provide for a risk adjustment" that would take into account the percentage of inpatients eligible for both Medicare and Medicaid to avoid unfairly penalizing hospitals that treat the most vulnerable populations.
"We feel that some hospitals may be being unfairly handled in this program," Dr. Kealey says. "Those are the hospitals that are having to deal with more complex populations or lower-SES [socioeconomic status] populations. Those are the hospitalists that actually need the most resources to help prevent readmissions, and they end up losing in this whole equation."
In a letter to Rep. Renacci outlining SHM's support for the bill, Dr. Kealey notes that the current readmissions reduction program "needs fine-tuning to better account for preventable readmission."
Dr. Kealey also says he believes attempts by HHS to address readmissions are well-intentioned. However, as the program is implemented, he wants the government to be flexible in dealing with hospitals, particularly those dealing with complex populations or large groups of low-SES patients.
"We feel [these are] valuable programs, and in general, they help move the country in the right direction," Dr. Kealey says. "But they certainly need to be open and available to be modified and changed to fit conditions better."
SHM's program to reduce hospital readmissions, Project BOOST, is accepting applications to its 2014 cohort through August 30. TH
Visit our website for more information on hospital readmissions penalties.
The Society of Hospital Medicine (SHM) is supporting a Congressional push to tweak which admissions factors are taken into consideration in the federal Hospital Readmissions Reduction Program.
Hospitalist and SHM President Burke Kealey, MD, SFHM, says that the Establishing Beneficiary Equity in the Hospital Readmission Program Act (H.R. 4188) would help "level the playing field."
Sponsored by U.S. Representative James Renacci (R-Ohio), the proposal seeks to "exclude from the program admissions related to transplants, end-stage renal disease, burns, trauma, psychosis, or substance abuse." It also would require the U.S. Department of Health & Human Services (HHS) "in applying requirements for the excess readmission ratio to provide for a risk adjustment" that would take into account the percentage of inpatients eligible for both Medicare and Medicaid to avoid unfairly penalizing hospitals that treat the most vulnerable populations.
"We feel that some hospitals may be being unfairly handled in this program," Dr. Kealey says. "Those are the hospitals that are having to deal with more complex populations or lower-SES [socioeconomic status] populations. Those are the hospitalists that actually need the most resources to help prevent readmissions, and they end up losing in this whole equation."
In a letter to Rep. Renacci outlining SHM's support for the bill, Dr. Kealey notes that the current readmissions reduction program "needs fine-tuning to better account for preventable readmission."
Dr. Kealey also says he believes attempts by HHS to address readmissions are well-intentioned. However, as the program is implemented, he wants the government to be flexible in dealing with hospitals, particularly those dealing with complex populations or large groups of low-SES patients.
"We feel [these are] valuable programs, and in general, they help move the country in the right direction," Dr. Kealey says. "But they certainly need to be open and available to be modified and changed to fit conditions better."
SHM's program to reduce hospital readmissions, Project BOOST, is accepting applications to its 2014 cohort through August 30. TH
Visit our website for more information on hospital readmissions penalties.
Hospital-Acquired Bloodstream Infection Prevention Paying Off
A new report that shows efforts to prevent central-line-associated bloodstream infections (CLABSIs) saved the government at least $640 million over nearly 20 years is an example of how effective prevention campaigns can be, a veteran hospitalist says.
"The major idea of this report was to show us that complications like bloodstream infections are preventable," says Ketino Kobaidze MD, PhD, FHM, assistant professor of medicine and associate site director of the division of hospital medicine at the Emory University School of Medicine in Atlanta. "When you prevent these things, you can locate other things. That's what the major message is to any kind of healthcare provider."
Published in the June issue of Health Affairs, the report examines the results of CDC programs from 1990 to 2008 to prevent CLABSIs in critical care units and how prevention helped the Centers for Medicaid & Medicare Services (CMS) reduce the amount of reimbursement paid to hospitals for treating such infections.
The authors reported that from 1990 to 2008, between 40,556 and 75,067 CLABSIs were avoided in Medicare and Medicaid patients treated in critical care units. This resulted in:
• Net savings ranging from $640 million to $1.8 billion;
• Net savings per case ranging from $15,780 to $24,391; and
• Per dollar rate of return on CDC investments between $3.88 and $23.85.
"Now, you're basically expected for it to not happen at all," says Dr. Kobaidze, referring to a rule implemented by CMS in 2008 that ended reimbursements to hospitals for treating CLABSIs that weren't present upon admission.
With that rule, CMS included 10 categories of hospital-acquired conditions (HACs) for the payment provision rule, including stage III and IV pressure ulcers and falls that occur while the patient is in the hospital. The rule was updated in 2013 to include HACs related to surgical site infection with cardiac implantable electronic devices and iatrogenic pneumothorax with venous catheterization. TH
Visit our website for more information on bloodstream infection prevention.
A new report that shows efforts to prevent central-line-associated bloodstream infections (CLABSIs) saved the government at least $640 million over nearly 20 years is an example of how effective prevention campaigns can be, a veteran hospitalist says.
"The major idea of this report was to show us that complications like bloodstream infections are preventable," says Ketino Kobaidze MD, PhD, FHM, assistant professor of medicine and associate site director of the division of hospital medicine at the Emory University School of Medicine in Atlanta. "When you prevent these things, you can locate other things. That's what the major message is to any kind of healthcare provider."
Published in the June issue of Health Affairs, the report examines the results of CDC programs from 1990 to 2008 to prevent CLABSIs in critical care units and how prevention helped the Centers for Medicaid & Medicare Services (CMS) reduce the amount of reimbursement paid to hospitals for treating such infections.
The authors reported that from 1990 to 2008, between 40,556 and 75,067 CLABSIs were avoided in Medicare and Medicaid patients treated in critical care units. This resulted in:
• Net savings ranging from $640 million to $1.8 billion;
• Net savings per case ranging from $15,780 to $24,391; and
• Per dollar rate of return on CDC investments between $3.88 and $23.85.
"Now, you're basically expected for it to not happen at all," says Dr. Kobaidze, referring to a rule implemented by CMS in 2008 that ended reimbursements to hospitals for treating CLABSIs that weren't present upon admission.
With that rule, CMS included 10 categories of hospital-acquired conditions (HACs) for the payment provision rule, including stage III and IV pressure ulcers and falls that occur while the patient is in the hospital. The rule was updated in 2013 to include HACs related to surgical site infection with cardiac implantable electronic devices and iatrogenic pneumothorax with venous catheterization. TH
Visit our website for more information on bloodstream infection prevention.
A new report that shows efforts to prevent central-line-associated bloodstream infections (CLABSIs) saved the government at least $640 million over nearly 20 years is an example of how effective prevention campaigns can be, a veteran hospitalist says.
"The major idea of this report was to show us that complications like bloodstream infections are preventable," says Ketino Kobaidze MD, PhD, FHM, assistant professor of medicine and associate site director of the division of hospital medicine at the Emory University School of Medicine in Atlanta. "When you prevent these things, you can locate other things. That's what the major message is to any kind of healthcare provider."
Published in the June issue of Health Affairs, the report examines the results of CDC programs from 1990 to 2008 to prevent CLABSIs in critical care units and how prevention helped the Centers for Medicaid & Medicare Services (CMS) reduce the amount of reimbursement paid to hospitals for treating such infections.
The authors reported that from 1990 to 2008, between 40,556 and 75,067 CLABSIs were avoided in Medicare and Medicaid patients treated in critical care units. This resulted in:
• Net savings ranging from $640 million to $1.8 billion;
• Net savings per case ranging from $15,780 to $24,391; and
• Per dollar rate of return on CDC investments between $3.88 and $23.85.
"Now, you're basically expected for it to not happen at all," says Dr. Kobaidze, referring to a rule implemented by CMS in 2008 that ended reimbursements to hospitals for treating CLABSIs that weren't present upon admission.
With that rule, CMS included 10 categories of hospital-acquired conditions (HACs) for the payment provision rule, including stage III and IV pressure ulcers and falls that occur while the patient is in the hospital. The rule was updated in 2013 to include HACs related to surgical site infection with cardiac implantable electronic devices and iatrogenic pneumothorax with venous catheterization. TH
Visit our website for more information on bloodstream infection prevention.
Quality Initiatives Earn Low Marks
More than 70% of people who responded to a survey at The-Hospitalist.org had a negative opinion about how local and national quality initiatives (QI) have impacted their ability to care for hospitalized patients.
Survey respondents were asked to gauge the effectiveness of core measures, Physician Quality Reporting System (PQRS) reporting, and clinical reminders. A combined 38% of respondents said that QI measures produced little benefit for their patients or rarely addressed patients' acute issues. Another 21% of respondents labeled QI measures as "distractions," and 12% said QI measures affected their productivity.
Only 28% of respondents thought that QI have improved inpatient care, just 2% more than those who found "little benefit" to them (26%), indicating that 54% of respondents were nearly evenly split on whether QI measures directly benefit patients.
Felix Aguirre, MD, FHM, vice president of medical affairs for IPC: The Hospitalist Company and a member of SHM's Performance Measurement and Reporting Committee (PMRC), says while certain core measures, such as PQRS reporting, may not address the specific needs of all hospital patients, it does not make them unsuccessful.
"I think measures do improve care, even if it's not for my patients, [then] for the global population of patients," Dr. Aguirre says. "We're not moving the needle quickly by treating my patients; we're moving the needle slowly, but surely, by treating all patients."
PMRC chair Gregory B. Seymann, MD, SFHM, clinical professor and chief of the division of hospital medicine at University of California San Diego Health Sciences, says the variety of QI measures included in the survey may explain the difference in opinions.
"There are multiple different practice arrangements among the general population of hospitalists and thus many different ways an individual respondent might interact with the measures," Dr. Seymann says. TH
Visit our website for more information on quality initiatives.
More than 70% of people who responded to a survey at The-Hospitalist.org had a negative opinion about how local and national quality initiatives (QI) have impacted their ability to care for hospitalized patients.
Survey respondents were asked to gauge the effectiveness of core measures, Physician Quality Reporting System (PQRS) reporting, and clinical reminders. A combined 38% of respondents said that QI measures produced little benefit for their patients or rarely addressed patients' acute issues. Another 21% of respondents labeled QI measures as "distractions," and 12% said QI measures affected their productivity.
Only 28% of respondents thought that QI have improved inpatient care, just 2% more than those who found "little benefit" to them (26%), indicating that 54% of respondents were nearly evenly split on whether QI measures directly benefit patients.
Felix Aguirre, MD, FHM, vice president of medical affairs for IPC: The Hospitalist Company and a member of SHM's Performance Measurement and Reporting Committee (PMRC), says while certain core measures, such as PQRS reporting, may not address the specific needs of all hospital patients, it does not make them unsuccessful.
"I think measures do improve care, even if it's not for my patients, [then] for the global population of patients," Dr. Aguirre says. "We're not moving the needle quickly by treating my patients; we're moving the needle slowly, but surely, by treating all patients."
PMRC chair Gregory B. Seymann, MD, SFHM, clinical professor and chief of the division of hospital medicine at University of California San Diego Health Sciences, says the variety of QI measures included in the survey may explain the difference in opinions.
"There are multiple different practice arrangements among the general population of hospitalists and thus many different ways an individual respondent might interact with the measures," Dr. Seymann says. TH
Visit our website for more information on quality initiatives.
More than 70% of people who responded to a survey at The-Hospitalist.org had a negative opinion about how local and national quality initiatives (QI) have impacted their ability to care for hospitalized patients.
Survey respondents were asked to gauge the effectiveness of core measures, Physician Quality Reporting System (PQRS) reporting, and clinical reminders. A combined 38% of respondents said that QI measures produced little benefit for their patients or rarely addressed patients' acute issues. Another 21% of respondents labeled QI measures as "distractions," and 12% said QI measures affected their productivity.
Only 28% of respondents thought that QI have improved inpatient care, just 2% more than those who found "little benefit" to them (26%), indicating that 54% of respondents were nearly evenly split on whether QI measures directly benefit patients.
Felix Aguirre, MD, FHM, vice president of medical affairs for IPC: The Hospitalist Company and a member of SHM's Performance Measurement and Reporting Committee (PMRC), says while certain core measures, such as PQRS reporting, may not address the specific needs of all hospital patients, it does not make them unsuccessful.
"I think measures do improve care, even if it's not for my patients, [then] for the global population of patients," Dr. Aguirre says. "We're not moving the needle quickly by treating my patients; we're moving the needle slowly, but surely, by treating all patients."
PMRC chair Gregory B. Seymann, MD, SFHM, clinical professor and chief of the division of hospital medicine at University of California San Diego Health Sciences, says the variety of QI measures included in the survey may explain the difference in opinions.
"There are multiple different practice arrangements among the general population of hospitalists and thus many different ways an individual respondent might interact with the measures," Dr. Seymann says. TH
Visit our website for more information on quality initiatives.
Inhaled Corticosteroids Increase Risk of Serious Pneumonia in Patients with COPD
Clinical question: Does the risk of pneumonia vary for different inhaled agents?
Background: Inhaled corticosteroids (ICS) are known to increase the risk of pneumonia in COPD patients; duration, dosage, and various agents, especially fluticasone and budesonide, were investigated.
Study design: Nested, case-control analysis.
Setting: Quebec health insurance database for new users with COPD, 1990–2005, with follow-up through 2007.
Synopsis: Investigators analyzed 163,514 patients, including 20,344 patients with serious pneumonia; current use of ICS was associated with a 69% increase in the rate of serious pneumonia (RR 1.69; 95% CI 1.63-1.75). The increased risk was sustained with long-term use but declined gradually to zero at six months after stopping ICS. The risk of serious pneumonia was higher with fluticasone (RR 2.01; 95% CI 1.93-2.10) than budesonide (RR 1.17; 95% CI 1.09-1.26).
Bottom line: Fluticasone was associated with an increased risk of pneumonia in COPD patients, consistent with earlier clinical trials, but the risk with budesonide was much lower.
Citation: Suissa S, Patenaude V, Lapi F, Ernst P. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax. 2013;68(11):1029-1036.
Clinical question: Does the risk of pneumonia vary for different inhaled agents?
Background: Inhaled corticosteroids (ICS) are known to increase the risk of pneumonia in COPD patients; duration, dosage, and various agents, especially fluticasone and budesonide, were investigated.
Study design: Nested, case-control analysis.
Setting: Quebec health insurance database for new users with COPD, 1990–2005, with follow-up through 2007.
Synopsis: Investigators analyzed 163,514 patients, including 20,344 patients with serious pneumonia; current use of ICS was associated with a 69% increase in the rate of serious pneumonia (RR 1.69; 95% CI 1.63-1.75). The increased risk was sustained with long-term use but declined gradually to zero at six months after stopping ICS. The risk of serious pneumonia was higher with fluticasone (RR 2.01; 95% CI 1.93-2.10) than budesonide (RR 1.17; 95% CI 1.09-1.26).
Bottom line: Fluticasone was associated with an increased risk of pneumonia in COPD patients, consistent with earlier clinical trials, but the risk with budesonide was much lower.
Citation: Suissa S, Patenaude V, Lapi F, Ernst P. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax. 2013;68(11):1029-1036.
Clinical question: Does the risk of pneumonia vary for different inhaled agents?
Background: Inhaled corticosteroids (ICS) are known to increase the risk of pneumonia in COPD patients; duration, dosage, and various agents, especially fluticasone and budesonide, were investigated.
Study design: Nested, case-control analysis.
Setting: Quebec health insurance database for new users with COPD, 1990–2005, with follow-up through 2007.
Synopsis: Investigators analyzed 163,514 patients, including 20,344 patients with serious pneumonia; current use of ICS was associated with a 69% increase in the rate of serious pneumonia (RR 1.69; 95% CI 1.63-1.75). The increased risk was sustained with long-term use but declined gradually to zero at six months after stopping ICS. The risk of serious pneumonia was higher with fluticasone (RR 2.01; 95% CI 1.93-2.10) than budesonide (RR 1.17; 95% CI 1.09-1.26).
Bottom line: Fluticasone was associated with an increased risk of pneumonia in COPD patients, consistent with earlier clinical trials, but the risk with budesonide was much lower.
Citation: Suissa S, Patenaude V, Lapi F, Ernst P. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax. 2013;68(11):1029-1036.
LISTEN NOW: Highlights of the July 2014 issue of The Hospitalist newsmagazine
Highlights from The Hospitalist this month include hospitalist reactions to the once-again delayed implementation of the coding classification system ICD-10. Robert Tennant, senior policy advisor at Medical Group Management Association, shares his organization’s perspective on the postponement. Dr. Amy Boutwell, a hospitalist at Newton-Wellesley Hospital and president of Collaborative Healthcare Strategies, discusses Medicare’s new hospital discharge rules and the opportunity they hold for hospitalists. Elsewhere in this issue, we have an update on SHM’s Leadership Academy scheduled for November 3–6 in Honolulu, Hawaii, and the latest in clinical research, including a review of best practices for end-of-life care and when to suspect Kawasaki disease in infants.
Highlights from The Hospitalist this month include hospitalist reactions to the once-again delayed implementation of the coding classification system ICD-10. Robert Tennant, senior policy advisor at Medical Group Management Association, shares his organization’s perspective on the postponement. Dr. Amy Boutwell, a hospitalist at Newton-Wellesley Hospital and president of Collaborative Healthcare Strategies, discusses Medicare’s new hospital discharge rules and the opportunity they hold for hospitalists. Elsewhere in this issue, we have an update on SHM’s Leadership Academy scheduled for November 3–6 in Honolulu, Hawaii, and the latest in clinical research, including a review of best practices for end-of-life care and when to suspect Kawasaki disease in infants.
Highlights from The Hospitalist this month include hospitalist reactions to the once-again delayed implementation of the coding classification system ICD-10. Robert Tennant, senior policy advisor at Medical Group Management Association, shares his organization’s perspective on the postponement. Dr. Amy Boutwell, a hospitalist at Newton-Wellesley Hospital and president of Collaborative Healthcare Strategies, discusses Medicare’s new hospital discharge rules and the opportunity they hold for hospitalists. Elsewhere in this issue, we have an update on SHM’s Leadership Academy scheduled for November 3–6 in Honolulu, Hawaii, and the latest in clinical research, including a review of best practices for end-of-life care and when to suspect Kawasaki disease in infants.