patient - The Hospitalist

Transcription

KEY CLINICAL QUESTION
CONGRATULATIONS
ROBERT HARRINGTON JR., MD, SFHM
When Should
Hypopituitarism Be
Suspected? PAGE 13
2015 Awards of
Excellence Winners
Increased Diversity
Strengthens HM
PAGE 6
PAGE 38
Grand Award for
Magazines, Journals
and Tabloids
AN OFFICIAL PUBLICATION OF THE SOCIETY OF HOSPITAL MEDICINE
I VOLUME 19 No. 5 I MAY 2015 I
PATIENT
THE FUTURE HOSPITALIST
EXPERIENCE
Tips for understanding and
promoting patient satisfaction:
a guide for new—and future—
hospitalists
I By Christina R. Bergin, MD,
Cheryl W. O’Malley, MD, and
Christine Donahue, MD
P
National Gala
INSIDE
THOUSANDS TREK TO WASHINGTON, D.C.,
FOR HOSPITAL MEDICINE’S BIGGEST EVENT
KEYNOTES
PRACTICE MANAGEMENT
QUALITY
CLINICAL
Pronovost, Bisagnono, Wachter
Do you have skin in the game?
A playbook for new leaders
Session analysis by Team Hospitalist
PUBLIC POLICY
CAREER DEVELOPMENT
RIV COMPETITION
TECHNOLOGY
Hospitalists charge the Hill
Bigger and better than ever
What to look for in a mentor
What’s App?
13-PAGE SPECIAL REPORT, PAGE 15
atient satisfaction—“the patient
experience”—is given great
weight by hospitals and the
public alike. Physicians have always
aspired to take excellent care of patients.
What has changed is that assessments of
the patient experience are now being used
to measure and report the quality of our
care. Although there are many venues for
patients to share their opinions, including reviews and online ratings, only
the HCAHPS (Hospital Consumer
Assessment of Healthcare Providers
and Systems) survey is standardized and
allows for comparisons nationwide.
Given that HCAHPS is the standard by which hospitals, health systems,
and individual hospitalists are judged,
it is vital for us to understand the core
drivers of measured patient experience—especially the factors within our
control. Armed with this knowledge, we
can more effectively promote a positive
experience within our daily patient care.
Understanding HCAHPS
HCAHPS (H-caps) is a national,
standardized, and publicly reported
survey of patients’ experiences in the
hospital. The Centers for Medicare
and Medicaid Services (CMS) and
the Agency for Healthcare Research
and Quality (AHRQ) developed
and piloted the survey in 2002 and
launched it in October 2006, with
results first published in March 2008
on the Hospital Compare website
(www.medicare.gov/hospitalcompare).
continued on page
28
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Ajay Kumar, MD, FACP, SFHM, is Medicine\Internal Medicine
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He serves as Associate Editor for ClinicalAccess.
ϐǡ
visit mhprofessional.com/ca or email digitalsales@mhedu.com for a free trial.
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I By Kayla Pantano
Volume 19 Number 5
May 2015
EDITORIAL STAFF
EDITOR
PHYSICIAN EDITOR
Jason Carris
jcarris@wiley.com
Danielle B. Scheurer, MD, SFHM, MSCR
scheured@musc.edu
ASSOCIATE EDITOR
PEDIATRIC EDITOR
Donna Petrozzello
dpetrozzel@wiley.com
Weijen Chang, MD, FACP, SFHM
wwch@ucsd.edu
ART DIRECTOR
COORDINATING EDITORS
Paul Juestrich
pjuestri@wiley.com
Christine Donahue, MD
The Future Hospitalist
Jonathan Pell, MD
Key Clinical Guidelines
COPY EDITOR
Kathie Christian
CONTRIBUTING WRITERS
Troy Ahlstrom, MD, SFHM, Mark Bridenstine, MD, Alan Briones, MD, Christina R. Bergin, MD,
Dennis Chang, MD, Ethan Cumbler, MD, Christine Donahue, MD, Robert Harrington, Jr., MD,
SFHM, Richard Inman, MD, Joshua Lapps, Vinh-Tung Nguyen, MD, Cheryl W. O’Malley, MD,
Kayla Pantano, Richard Quinn, Maria Reyna, MD, Tuyet Trinh Truong, MD, Tao Xu, MD
ADVERTISING STAFF
PUBLISHING STAFF
DISPLAY ADVERTISING
EXECUTIVE EDITOR/PUBLISHER
Frank Cox, Joe Schuldner
Pharmaceutical Media Inc.
30 East 33rd Street
New York, NY 10016
Phone: 212-685-5010
Fax: 212-685-6126
info@pminy.com
Lisa Dionne
ldionne@wiley.com
MANAGER, DIGITAL MEDIA AND
STRATEGY, CUSTOM VENTURES
Jason Carris
jcarris@wiley.com
ASSOCIATE DIRECTOR,
ADVERTISING SALES
CLASSIFIED ADVERTISING
Eamon Wood
Phone: 212-904-0363
ewood@pminy.com
Michael Perlowitz
Phone: 212-904-0374
mperlowitz@pminy.com
Stephen Jezzard
sjezzard@wiley.com
SPONSORED CONTENT,
SUPPLEMENTS AND WEBINARS
Julie Jimenez
Phone: 212-904-0360
jjimenez@pminy.com
Michael Targowski
mtargowski@wiley.com
BPA Worldwide is a global industry
resource for verified audience data and
The Hospitalist is a member.
Grand Award for Magazines,
Journals and Tabloids
TEAM HOSPITALIST
Joshua Allen-Dicker, MD, MPH, Elizabeth A Cook, MD, Lisa Courtney, MBA, MSHA, Jasen W.
Gundersen, MD, MBA, SFHM, Sowmya Kanikkannan, MD, SFHM, Joshua LaBrin, MD, SFHM,
James W Levy PA-C, SFHM, Julianna Lindsey, MD, MBA, FHM, David M. Pressel, MD, PhD, FHM,
Monal B. Shah, MD, Amanda T. Trask, MBA, MHA, SFHM, David Weidig, MD,
Nancy K. Zeitoun, MD, FHM, Robert Zipper, MD, MMM, SFHM
THE SOCIETY OF HOSPITAL MEDICINE
Phone: 800-843-3360
Fax: 267-702-2690
Website: www.HospitalMedicine.org
Laurence Wellikson, MD, MHM, CEO
Brendon Shank, Associate Vice President, Communications
BOARD OF DIRECTORS
Robert Harrington, Jr, MD, SFHM, President
Brian Harte, MD, SFHM, President-Elect
Burke T. Kealey, MD, SFHM, Immediate Past President
Patrick Torcson, MD, MMM, SFHM, Treasurer
Danielle Scheurer, MD, MSCR, SFHM, Secretary
Nasim Afsar, MD, SFHM
Howard R. Epstein, MD, FHM
Erin Stucky Fisher, MD, MHM
Christopher Frost, MD, FHM
Jeffrey J. Glasheen, MD, SFHM
Ron Greeno, MD, MHM
Bradley Sharpe, MD, SFHM
HOW TO SUBSCRIBE
Print subscriptions are free for members of the SHM. Free access is also available online at www.the-hospitalist.org. Annual paid
subscriptions are available to all others for $154. To initiate a paid subscription, contact Wiley Subscription Services at:
Phone: 800.835.6770 (U.S. only) Email: cs-journals@wiley.com. The Hospitalist (ISSN: 1553-085X) is published monthly
on behalf of the Society of Hospital Medicine by Wiley Subscription Services, Inc., a Wiley Company, 111 River Street,
Hoboken, NJ 07030-5774. This publication is mailed periodicals rate. Postmaster, send address changes to Circulation
Manager, The Hospitalist, John Wiley & Sons, 111 River Street, 8-01, Hoboken, NJ 07030-5774. Printed in the United States
by Cenveo, Lancaster, Pa. Copyright 2015 Society of Hospital Medicine. All rights reserved. No part of this publication may be
reproduced, stored, or transmitted in any form or by any means and without the prior permission in writing from the copyright
holder. All materials published, including but not limited to original research, clinical notes, editorials, reviews, reports, letters,
and book reviews, represent the opinions and views of the authors and do not reflect any official policy or medical opinion of
the institutions with which the authors are affiliated, the Society of Hospital Medicine, or of the publisher unless this is clearly
specified. Materials published herein are intended to further general scientific research, understanding, and discussion only, and
are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by
physicians for any particular patient. While the editors, society, and publisher believe that drug selections and dosages and the
specifications and usage of equipment and devices as set forth herein are in accord with current recommendations and practices
at the time of publication, they accept no legal responsibility for any errors or omissions, and make no warranty, express or implied,
with respect to material contained herein. Publication of an advertisement or other discussions of products in this publication
should not be construed as an endorsement of the products or the manufacturers’ claims. Readers are encouraged to contact
the manufacturers with any questions about the features or limitations of the products mentioned.
To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.org/industry.
Team Hospitalist
Seats Seven
New Members
Elizabeth A. Cook, MD
Joshua LaBrin, MD, SFHM
Dr. Cook has served as
a hospitalist since 2001
and is medical director of the hospitalist
division for Medical
Associates of Central
Virginia in Lynchburg,
Va., where she provides
management and coordination of care for
acutely ill medical and surgical patients.
She also serves as supervising physician
at Matrix Medical Network, where she
provides oversight to nurse practitioners
through monthly chart reviews. Dr. Cook
completed her medical degree at Vanderbilt University in Nashville and her internship at the University of North Carolina at
Chapel Hill. Dr. Cook is board certified by
the American Board of Family Medicine,
is an SHM member, and serves on SHM’s
Family Medicine Committee.
Dr. LaBrin is assistant
clinical professor of
internal medicine at the
University of Utah at
Salt Lake City. He also
is a reviewer for Medical Education, Journal of
Hospital Medicine, and
Hospital Pediatrics. He completed his medical degree at Temple University in Philadelphia, Pa., and then his internship and
residency at the University of Pittsburgh.
He served as an HM fellow at Mayo Clinic
in Rochester, Minn.
QUOTABLE: “I started as a hospitalist thinking
it would be a transition to outpatient practice;
however, I fell in love with the energy and
experiences in the hospital. Being able to work
closely with specialists, nursing, and other
ancillary personnel to care for patients when
they are most in need is both an opportunity
and a privilege. I have moved into a leadership role, as well as returned to school for a
masters in public health. I am excited about
bringing my experience, passion, and interests
to a role on the editorial board. I am also looking forward to working with other hospitalists outside my local area to move forward the
practice of hospital medicine.”
Lisa Courtney, MBA, MSHA
Courtney serves as
director of operations at
Baptist Health Systems
in Birmingham, Ala.
She is responsible for
accounts receivable
management across a
multi-hospital hospitalist program; develops, maintains, and
attains budget objectives; and works with
the medical directors and hospital staff on
quality initiatives and process improvement
opportunities.
QUOTABLE: “The hospitalist director position
wasn’t a role I sought but one that I’m glad I
accepted. My boss told me, ‘Hospitalist medicine is fun.’ It has taken a few years to stabilize
staffing, but now I finally agree, hospitalist
medicine is fun. … Hospitalists are an integral
part of any healthcare system. They are vital
in leading change and innovation to provide
better care at lower cost. I feel blessed to be
part of the team. As a new member of The
Hospitalist’s editorial board, I hope to bring
new ideas and topics to a broad audience while
gaining the experience of working with some
of the top physicians and administrative staff
in their field.”
“Being a hospitalist made sense
for me. I enjoy the intensive part of caring for
the hospitalized setting in a team-based model.
The dynamic nature of the hospital and the
trainees never gets old. My mentors provided
a glimpse of the impact and satisfaction I too
could be a part of in hospital medicine.
QUOTABLE:
James W. Levy, PA-C, SFHM
Levy serves as co-owner
and vice president of
human resources at
iNDIGO Health Partners in Traverse City,
Mich. He graduated
from Indiana University in Bloomington
and completed his PA training at Indiana
University School of Medicine in Fort
Wayne. He’d previously received certificates in emergency medical technology and
operating room technology. He worked as
a hospitalist from 1998 to 2013 and is a
member of SHM’s NP/PA Committee.
QUOTABLE: “I believe the advent of hospitalist
medicine is the single most important innovation I have seen in 40 years of patient care. Of
the many rewards it has brought me, helping to
assemble highly functioning hospitalist teams
is the greatest. As a member of The Hospitalist’s editorial board, I hope to advance the
cause of hospitalist medicine, in general, and
especially as a way of benefitting small outlying
hospitals and the patients they serve.”
Amanda T. Trask, MBA,
MHA, SFHM
Trask is vice president
for the national hospital
medicine service line at
Catholic Health Initiatives (CHI), a nonprofit,
faith-based system operating in 19 states. Trask
focuses on improving
clinical and business outcomes through
enhancing collaboration, improving
processes, and optimizing current practices
of hospitalist providers practicing in CHI
hospitals. She earned her degrees at Georgia
continued on page
4
www.the-hospitalist.org I MAY 2015 I THE HOSPITALIST 3
Team Hospitalist Seats Seven New Members
State University in Atlanta, where she was
awarded the Public Health Service DHHS
Traineeship Grant and several academic
scholarships.
“Hospitalists have the opportunity to transform the delivery of acute care
and beyond, as population health care models
continue to advance. Being an administrative
hospitalist leader allows me to be influential
and involved in this transformation.
QUOTABLE:
David Weidig, MD
Dr. Weidig is system
director of hospital
medicine for Aurora
Health Care in Wisconsin. In 2007, he started
the Aurora Hospital
Medicine System with
one program and six
physicians; it has grown to 13 programs
and over 150 FTEs. He is responsible for
the co-development of the unit-based,
RN-physician collaborative care model,
recognized by the Robert Wood Johnson
Foundation as a top intra-collaborative care
model. Dr. Weidig completed his medical degree at Northwestern University in
Chicago and his internal medicine residency at Scripps Mercy Hospital in San Diego.
He served as president of SHM’s Pacific
Northwest Chapter from 2005 to 2007 and
is a member of the Multi-Site Hospitalist
Leader Task Force.
4
continued from page
3
QUOTABLE: “HM focuses on care delivery process
improvement that has a dramatic effect both
in efficiency and quality of outcomes. These
improvements are reaching a scale that may
be unprecedented in the history of U.S. healthcare. As a member of The Hospitalist’s editorial
board, I hope to share ideas and work with others
to further develop these care delivery models and
enhance their effect.”
Robert Zipper, MD, MMM, SFHM
Dr. Zipper is a regional
chief medical officer at
Tacoma, Wash.-based
Sound Physicians, where
he provides operational oversight of Sound’s
hospitalist, LTACH, post
acute, and transitional
care programs. He earned his master’s degree
in medical management at Carnegie Mellon
University in Pittsburgh, and his doctorate of
medicine at Wayne State University in Detroit.
He completed his internal medicine residency
at Allegheny General Hospital in Pittsburgh.
An active SHM member, he has served as
chairman of the SHM Leadership Committee. “My choice [to become a hospitalist] was more practical than anything else. I knew
that I liked inpatient medicine, and I could not
keep doing both inpatient and outpatient in the
manner I was. I was forced to choose, and within a
week of starting a focus on only hospital medicine,
I knew it was the right one.”
QUOTABLE:
THE HOSPITALIST I MAY 2015 I www.the-hospitalist.org
LISTEN TO EXCERPTS OF
OUR INTERVIEWS
Team Hospitalist
member David
Weidig, MD,
director of hospital
medicine for Aurora
Medical Group in
West Allis, Wis.,
talks about best practices for multisite hospital medicine.
New SHM President
Robert Harrington
Jr., MD, SFHM, talks
about his views on
hospital medicine, the
society, and the value
of diversity
and teamwork.
SHM founder
Win Whitcomb, MD,
MHM, chief medical officer of Remedy
Partners of Darien,
Conn., talks about
the annual practice
management pre-course in an everchanging healthcare landscape.
THIS MONTH’S
QUESTION:
Which coding mistake do you
most commonly make?
Listing the problem
without a plan
Failing to clearly
document the plan
Documenting your
consideration of the
appropriate data
Undervaluing the
patient’s complexity
Tons more HM15 photos available at
the-hospitalist.org.
I SOCIETY PAGES I News and information about SHM I By Brendon Shank
CONGRATULATIONS
SHM welcomes the newest Fellows, Senior Fellows, and Masters in Hospital Medicine
L
ast month, more than 230 hospitalists
were inducted as Fellows in Hospital
Medicine (FHM), Senior Fellows in
Hospital Medicine (SFHM), and Masters
in Hospital Medicine (MHM) by SHM
at the 2015 annual meeting at the Gaylord
National Resort and Convention Center in
National Harbor, Md.
This year represents the largest fellows
class in history, with 175 FHM and 61
SFHM honorees.
“Through their commitment to the
specialty, through education and selfimprovement, hospitalists earning the
Fellow and Senior Fellow designations
represent the very best of the hospital medicine movement and its goal to improve the
care of hospitalized patients,” says SHM
President Bob Harrington, MD, SFHM.
“I hope you will join me in congratulating
them in this professional milestone.”
Fellows and Senior Fellows have earned
the right to use the “FHM” and “SFHM”
designation.
MASTER IN HOSPITAL
MEDICINE, MHM
Bradley Flansbaum, DO, MPH, MHM
Larry Wellikson, MD, MHM
SENIOR FELLOW IN
HOSPITAL MEDICINE, SFHM
Amjad Ali, MD, SFHM
Demetria Austin, MD, SFHM
Guilherme Barcellos, MD, SFHM
Laurence Beer, MD, SFHM
David Blair, MD, SFHM
Apoorv Broor, MD, SFHM
Alfred Burger, MD, SFHM
Eric Chun MD, SFHM
Kelly Cunningham Sponsler, MD, SFHM
Dean Dalili, MD, SFHM
Nicole Duncan, ACNP, SFHM
Susan George, MD, MRCP, SFHM
Robert Goodman, MD, SFHM
Verna Greer, MD, SFHM
Zachariah Gurnsey, MD, SFHM
Caleb Perkins Hale, MD, SFHM
Michael Hilden, MD, SFHM
Joshua Hoffman, MD, SFHM
Timothy Idiaghe, MD, SFHM
Martin Izakovic, MD, PhD, SFHM
Hans Jeppesen, MD, MBA, SFHM
Melinda Johnson, MD, SFHM
Pieter Jugovic, BSC, CCFP, MD, MSC
Falguni Kalra, MD, SFHM
Ben Kerman, MD, SFHM
Vladimir Koren, MD, SFHM
Joshua Labrin, MD, SFHM
Clifton Lee, MD, SFHM
Michelle Marks, DO, SFHM
Heather Masters, MD, SFHM
Kai Mebust, MD, SFHM
Erin Meyer, DO, SFHM
Komron Ostovar, MD, SFHM
David Paje, MD, SFHM
Keshab Paudel, MD, MBA, SFHM
Pradeep Paul, MD, SFHM
Michael Perini, MD, SFHM
Eduardo Pinto, MD, SFHM
William Pittman III, MD, SFHM
Rupesh Prasad, MD, MPH, SFHM
James Principe, MD, SFHM
Romeo Quilatan Jr., MD, SFHM
of SHM and served as a
board member and officer;
today, he is a hospitalist at
Lenox Hill Hospital in New
York City and physician
editor for SHM’s blog, The
Hospital Leader.
Dr. Wellikson joined SHM
in January 2000 and serves as
SHM’s chief executive officer.
Drs. Flansbaum and
Wellikson join 16 other leaders in the specialty, including co-founders Win Whitcomb, MD, MHM, and
John Nelson, MD, MHM,
Outgoing SHM President Burke Kealey (center) awards SHM CEO
along with Bob Wachter,
Larry Wellikson (left) and Brad Flansbaum (right) with plaques for
their MHM inductions at HM15 in National Harbor, Md.
MD, MHM, who published
the seminal article for the
SHM also inducted two new Masters in hospitalist movement in a 1996 New England
Hospital Medicine, the highest honor from Journal of Medicine article.
SHM: Bradley Flansbaum, DO, MPH,
MHM, and Larry Wellikson, MD, MHM. Brendon Shank is SHM’s associate vice president of
Dr. Flansbaum was a founding member communications.
Vipulkumar Rana, MD, SFHM
EElizabeth Rice, MD, SFHM
Richard Rohrs, PA-C, SFHM
Gopal Sarker, MD, SFHM
Matthew Shaines, MD, SFHM
Larry Sharp, MD, SFHM
Barbara Slawski, MD, MS, SFHM
Christine Soong, MD, SFHM
Kelly Sopko, MD, SFHM
David Sperling, MD, SFHM
Dai Takahashi, DO, SFHM
Michael Teague, MD, SFHM
Rachel Thompson, MD, MPH, SFHM
Haruka Torok, MD, SFHM
Amanda Trask, MBA, MHA, CMPE, SFHM
S. Vatsavai MD, SFHM
Sriram Vissa, MD, SFHM
Peter Youngers Watson, MD, SFHM
Earl Webster, MD, SFHM
FELLOW IN HOSPITAL
MEDICINE, FHM
Abhijit Adhye, MD, MBBS, FHM
Samir Akach, MD, FHM
Radica Alicic, MD, FHM
Jeremiah Anders, MD, FHM
Mohsin Arshad, MD, FHM
Muhammed Azhar, MD, FHM
Amit Bansal, MD, CPE, FHM
Shahina Banthanavasi, MD, FHM
Dwight Benn, MD, FHM
Hardik Bhansali, MD, FHM
Dwight Blair, MD, FHM
Kevin Breger, MD, FHM
Ashley Busuttil, MD, FHM
Amy Carolan, MD, FHM
Dustin Chase, MD, FHM
Gaurav Chaturvedi, MD, FHM
Clifford Chen, MD, FHM
John Clark, MD, FHM
Charles Coffey Jr., MD, FHM
Matthew Connolly, MD, FHM
David Cooperberg, MD, FHM
Michael Craig, MD, MPH, FHM
Jonathan Crocker, MD, FHM
Jonathan Croft, DO, FHM
Adrienne Cruz, MD, FHM
Catherine Curley, MD, FHM
Manjula Dhayalan, MD, FHM
Andrew Dickerson, MD, FHM
Philip Dittmar, MD, FHM
Bruce Downes, MD, FHM
Amy Engelhardt, DO, FHM
Joseph Esherick, MD, FHM
Stephen Evans, MD, FHM
Arnold Facklam III, NP, FHM
Joseph Fleischer, MD, FHM
Therese Franco, MD, FHM
Slawomir Mark Fratczak, MD, FHM
Benjamin Frizner, MD, FHM
Cesar Fuentes, MD, FHM
Nikhil Gandhi, MD, FHM
Marina George, MD, FHM
Joseph Gergyes, MD, FHM
Stephen Gerke, FHM
Mandeep Gill, MD, FHM
Marlene Grenier, ACNP, FHM
Ryan Greysen, MD, FHM
Mandy Grubb Halford, MD, FHM
Benerji Gudapati, MD, FHM
Matthew Guiltinan, MD, FHM
Wesley Halford, MD, BMBS, FHM
Luke Hansen, MD, MHS, FHM
Dennis Harden, MD, FHM
Kenneth Hart, MD, FHM
Tom Herbert, MD, FHM
Matthew Hill, MD, FHM
Keri Holmes-Maybank, MD, FHM
Bjorn Holmstrom, MD, FHM
Anand Hongalgi, MD, FHM
William Housman, MD, FHM
Eduardo Iturrate, MD, MSW, FHM
Andy Jaffal, MD, FHM
Pranav Jain, MD, FHM
Jawali Jaranilla, MD, MPH, FHM
Shad Jawaid, MD, FHM
Jennifer Johnson, MD, FHM
Robert Johnson, MD, MBA, FHM
Joseph Joseph, MD, FHM
Sholeh Kamalian, MD, FHM
Kalyana Kanaparthy, MD, FHM
Thulasi Karakula, MD, FHM
Sunil Kartham, MD, FHM
Kalwinder Kaur, MD, FHM
Anne Marie Kelly, MD, FHM
Diane Kemper, ACNP, FHM
Uzma Khan, MD, FHM
Michael Khoury, MD, FHM
Gerard Kiernan, MD, FHM
Dmitry Kiyatkin, MD, FHM
Ashley Kliewer, MS, PA-C, FHM
James Knight, MD, FHM
Megan Knight, MPAS, PA-C, FHM
Vamshi Kolli, MD, FHM
Nitish Kosaraju, MD, FHM
James Kumar, MD, MS, FHM
Linda Kurian, MD, FHM
Binal Ladani, MD, FHM
S. Lancaster, DO, FHM
Kristen Lewis, MD, FHM
Steven Ligertwood, MD, BSC, FHM
Gerald Lim, MD, FHM
Goutham Malempati, MD, FHM
Oliver Marasigan, MD, FHM
Adnan Misellati, MD, FHM
Amanda Mixon, MD, MPH, MS, FHM
Shehnaz Mohsin, MD, FHM
Kayce Morton, DO, FHM
Ezz-Eldin Moukamal, MD, FHM
Stephanie Mueller, MD, FHM
Shahid Mughal, MD, FHM
Syed Naqvi, MD, FHM
Beth Natt, MD, MPH, FHM
Alejandro Necochea, MD, MPH, FHM
Attila Nemeth Jr., MD, FHM
Yarun, Nessa, MD, FHM
Georgina Nouaime, MD, FHM
Izabela Nowosielski, MD, FHM
Kelechi Okoli, MBBS, MHA, MRCP, FHM
Melissa Olken, MD, FHM
Olumuyiwa Omolayo, MD, FHM
Olivia Owusu-Boahen, MD, MPH, FHM
Abdullah Oz, MD, FHM
Deepak Pahuja, MD, MBA, FHM
Venkataraman Palabindala, MD, FHM
Sanket Parikh, MD, MBBS, FHM
Jason Parker, MD, FHM
Bina Patel, MD, FHM
Chirag Patel, DO, FHM
Suhel Patel, MD, FHM
Sunil Patel, ACNP, FHM
Kurt Pfeifer, MD, FHM
MaryEllen Pfeiffer, DO, FHM
Ludwig Pierre, MD, FHM
Saji Pillai, MD, FHM
Dmitriy Pinelis, MD, FHM
Valerie Press, MD, MPH, FHM
SHM’s
Fellows Program:
GROWING IN
NUMBERS AND
SCOPE
• From the inception of the
FHM program in 2009 to the
newest class in 2015, SHM has
recognized 1,130 FHM.
• The SFHM designation, initially
offered in 2010, has welcomed
426 Senior Fellows to date.
• Class of 2015 will be inducting
175 FHM and 61 SFHM, which
is a 30% increase over 2014 and
represents the largest Fellows
class in history.
• The Fellows Program overall
includes 27 practice administrators and 14 NP/PAs.
• The elite MHM designation has
been conferred upon a total of
18 outstanding hospitalists,
including two new MHM in the
class of 2015.
Ready to apply for the class
of 2016 fellows? Visit
www.hospitalmedicine.org/fellows
for deadlines and details.
Anwer Rahman, MD, FHM
M. Randhawa, MD, FHM
Suman Ravuri, MD, FHM
Kalpana Reddy, MD, FHM
Ronald Reynoso Hernandez, MD, FHM
Yanet Rios, MD, FHM
Anabelen Rivera De Rosales, MD, FHM
Hammad Rizvi, MD, MBA, FHM
Atif Rizwan, MD, FHM
Rodrigo Rocha, MD, FHM
J. Romano, DO, FHM
Joel Yitzhak Rosen, MD, FHM
Joshua Rosenberg, DO, FHM
Chris Ryan, MD, FHM
Salas Sabnis, MD, FHM
Muhannad Samaan, MD, MBA, FHM
Mauricio Sardan, MD, FHM
Jeffrey Schlaudecker, MD, MEd, FHM
Reham Shaaban, DO, FHM
Chirayu Shah, MD, MEd, FHM
Parth Shah, MBBS, MPH, FHM
Sarmad Siddiqui, MD, FHM
David Siew, MD, FHM
Alanna Small, MD, FHM
Jeremy Souder, MD, FHM
Victor Souza, MD, FHM
Karthik Srinivasan, MD, FHM
Scott Stephens, DO, FHM
David Susskind, FHM
Lakshmi Swaminathan, MD, MHSA, FHM
Piotr Tabaczewski, MD, PhD, FHM
Darlene Tad-y, MD, FHM
Kimberly Tartaglia, MD, FHM
Audrey Tio, MD, MHA, FHM
Ana Maria Torres, MD, FHM
Sean Tushla, MD, FHM
Chioma Udogu, MD, MPH, FHM
Charles, Ukpong, MD, FHM
Jitesh Vachhani, MD, FHM
Jay Varughese, MD, FHM
Carlos Villamarin, MD, FHM
Daniel Wagstaff, MD, FHM
Cynthia Wallace, MD, MPH, FHM
Scott Weiss, MD, FHM
Dale Wiersma, MD, FHM
Michael Williams, MD, FHM
Sheryl Williams, MD, FHM
Mohamed Yafai, MD, FHM
Roger Yu, MD, FHM
Nejat Zeyneloglu, MD, FHM
society pages continue on page
6
I SOCIETY PAGES I continued from page 5
2015 AWARDS OF
EXCELLENCE WINNERS
OUTSTANDING SERVICE IN
HOSPITAL MEDICINE
EXCELLENCE IN TEACHING
Anne Sheehy, MD, MS
Dr. Feldman founded
new Urban Health residency training programs
at Johns Hopkins. The
medicine-pediatrics
residency program
and internal medicine primary care track
admitted their first group of interns in July
2010 and 2011, respectively, and graduated
those first cohorts last June. This medicinepediatrics program is the first and only one of
its kind in the nation. Dr. Feldman secured
over $6 million in federal and foundation
grant funding to support this endeavor.
At the same time, he led a team effort
to build a perioperative and consultative medicine curriculum now known as
“Consultative and Perioperative Medicine
Essentials for Hospitalists,” which can be
found at SHMconsults.com. With more
than 18,000 users learning from more than
30 modules, this curriculum is now SHM’s
flagship CME offering and a key resource
for those preparing for the Focused Practice
in Hospital Medicine exam. The curriculum
has been built with over $1 million in industry grant funding.
Dr. Sheehy has been
a national role model
for how SHM and its
members can work
together to achieve positive change in healthcare both in research
and health policy. As a
result of her published research on the “twomidnight rule” and observation status, Dr.
Sheehy and SHM were invited to testify
before the House Committee on Ways and
Means Subcommittee on Health and the
Senate Special Committee on Aging. In
both of these instances, Dr. Sheehy shared the
honor, bringing all of hospital medicine into
the spotlight as a field of experts in this area.
EXCELLENCE IN RESEARCH
Daniel Brotman, MD, FHM
Dr. Brotman’s research
has helped improve the
care of thousands—if
not millions—of hospitalized patients. He
has achieved a prolific
research portfolio while
actively practicing as a
hospitalist, as well as director of the hospitalist service at Johns Hopkins Hospital
in Baltimore. His research has focused on
VTE and patient education and communication. He has published more than 60
papers, multiple invited review articles,
and a number of editorials. Since 1999, his
research efforts have resulted in funding of
more than $21 million.
CLINICAL EXCELLENCE
Jisu Kim, MD
Dr. Kim has established one of the largest surgical consult and
co-management services in the country, from
the ground up, at an
institution where many
surgeons historically
did not trust employed hospitalists. The
success of the consult service required a total
reorientation of institutional attitudes and
culture, a feat Dr. Kim was able to achieve
by providing superlative medical care to
patients on nonmedical services. Dr. Kim
is now nationally recognized as a leader in
inpatient hospital care and a critical part of
the neurosurgery team at Rush University
Medical Center in Chicago.
6
Leonard Feldman, MD, SFHM
EXCELLENCE IN
HOSPITAL MEDICINE FOR
NONPHYSICIANS
Tracy Cardin, ACNP-BC, FHM
Cardin is deeply
committed to collaborating with physicians
on the integration of
the role of NPs and PAs
in hospital medicine,
and in building a sense
of community among
NPs and PAs who are working in hospital
medicine. She has worked toward these goals
locally, regionally, and nationally through
her participation and leadership in SHM.
As co-chair of the Quality Improvement
Committee in the Section of Hospital Medicine at the University of Chicago, she has
played a pivotal role in developing quality initiatives that directly benefit both her
patients and providers in the section, including developing 360-degree evaluation tools
and working on interdisciplinary projects,
such as one that will enhance in-hospital
glucose management. As an active member
of the section’s Clinical Operations Committee, her input on ways to increase clinical
efficiency, restructure services, and improve
teamwork have led to improvements in the
daily operations of her section.
At SHM, Tracy has provided leadership to
NPs and PAs in her role as chair of the SHM
NP-PA Committee. She is a core contributor to The Hospital Leader, SHM’s official
blog, and was HM14 course director for
the pre-course on the role of NPs and PAs
in hospital medicine. This year, she was the
first nonphysician to be nominated for the
SHM board of directors.
EXCELLENCE IN
HUMANITARIAN SERVICE
Phuoc Le, MD, MPH,
Global Health Core
“Global Health Core,”
organized by Phuoc
Le, MD, MPH, has an
established, clear agenda for clinical work,
humanitarian aid,
quality improvement,
education, research,
and fundraising. The group quickly grew
from five to 12 faculty and brought focus
to international efforts, with much of the
work aimed at improving care at a particular
hospital in Hinche (pronounced “Ench”),
Haiti. Dr. Le and his team visit there, as
well as other sites in Burundi and Liberia,
several times a year, often taking residents
and students as part of the University of
California San Francisco’s Global Health
Hospital Medicine Fellowship program.
“Global Health Core” brought in supplies
and medications after the 2010 earthquake and established a meaningful quality improvement program. They developed educational programs for trainees and
created tighter partnerships with Partners in
Health, and have begun to grow collaborations with several other university programs
across the world.
Most recently, “Global Health Core”
traveled to western Africa to care for patients
inflicted with the Ebola virus, risking their
lives for the care of the most vulnerable.
TEAM AWARD IN QUALITY
IMPROVEMENT
Jason Stein, MD, SFHM,
CENTRIPITAL
Centripital, under the
leadership of Jason
Stein, MD, SFHM, is
responsible for helping more than 50
hospital units around
the world replicate
the Accountable Care
Unit (ACU) model of care. Dr. Stein is the
inventor of the ACU and structured interdisciplinary bedside rounds, the author of
an Accountable Care Unit implementation guide, and developer of the Structured
Interdisciplinary Bedside Rounds certification program.
Centripital is a 501(c)(3) nonprofit based
in Atlanta with the mission to train hospital
professionals to work together in high-functioning, patient-centered teams. Centripital
has helped more than 50 hospital units in
14 U.S. states and Australia replicate the
ACU model by combining on-site educational sessions with mentored implementation. ACUs in the U.S. and Australia
have been associated with improvements
in a range of outcomes, including reduced
in-hospital mortality, complications of care,
length of stay, and average cost per case,
along with increases in teamwork scores and
patient satisfaction.
JUNIOR INVESTIGATOR AWARD
S. Ryan Greysen, MD, MHS, MA
SHM’s
Research
Committee introduced
a new award this year to
recognize early-career
hospitalist researchers
who are leading the
way in their field. Dr.
Greysen is assistant
professor at the UCSF School of Medicine
and a hospitalist with training in social
sciences and health outcomes research. His
research focuses on transitions of care for
hospitalized older adults and interventions
to improve outcomes post-discharge. He is
an active member in SHM’s research initiatives and associate editor for the Journal of
Hospital Medicine.
Interested in
SHM’s 2016
Awards of
Excellence?
VISIT
www.hospitalmedicine.org/awards.
Family Medicine’s Increasing
Presence in Hospital Medicine
I By Troy Ahlstrom, MD, SFHM
Y
ears ago, I struggled with a difficult
decision. Given the fact that the
military disallowed dual training
tracks, such as internal medicine/pediatrics
(med/peds), I had to choose from internal
medicine (IM), pediatrics (Peds), or family
practice (FP) residencies. My personal
history and experiential
data remained incomplete
and the view ahead blurry;
still, the choice remained.
Over time, I’ve embraced
the uncertainty inherent
in most analyses. Such is
the case with the current
Dr. Ahlstrom
composition of specialties
that make up hospital medicine nationwide. Available data remains in flux, yet I
see apparent trends.
A new question in the 2014 State of
Hospital Medicine (SOHM) report asked,
“Did your hospital medicine group employ
hospitalist physicians trained and certified in
the following specialties…?” Strikingly, a full
59% of groups serving adult patients only
reported having at least one family medicinetrained provider in their midst! And in these
adult-only practices, 98% of groups utilized
at least one internal medicine physician,
24% reported a med/peds doc, and none
reported pediatricians.
Meanwhile, of 40 groups caring for children only, 95% reported using pediatrics,
2.5% internal medicine (huh?), 22.5% med/
peds, and zero FPs. The 19 groups serving
both adults and children revealed partici-
pation from all four nonsurgical hospitalist
specialties (IM, peds, FP, med/peds).
So what is the specialty distribution of
medical hospitalists overall? There’s no good
data about this.
The 2014 Medical Group Management
Association (MGMA) sample, licensed for
use in SOHM, reported data for roughly
4,200 community hospital medicine providers: 82% were internal medicine, 10% family
medicine, 7% pediatrics, and <1% med/peds.
MGMA, however, cautions against assuming that this represents the entire population
of hospitalists and their training. Although
representative of the groups who participated in the survey, it may not be representative of groups that didn’t participate,
and thus it would be misleading to suggest
that this distribution holds true nationally.
In an effort to corroborate the MGMA
distribution, I reviewed other compensation and productivity surveys; one such
survey, conducted by the American Medical Group Association, reported hospitalists by training program. It contained over
3,700 community hospital providers—89%
internal medicine, 6% family medicine, 5%
pediatrics—but did not inquire about medicine/pediatrics.
Finally, if one combines the academic and
community provider samples from MGMA
(n=4,867), the distribution is 80% IM,
8.5% FP, 10% peds, and <1% med/peds.
Which of these, if any, is the actual
distribution of nonprocedural hospitalists? Although we cannot know exactly, I
Figure 1. Specialty Composition of Survey Respondents
SURVEY
INSIGHTS
believe something close to the following to
be current state: internal medicine 80%,
family medicine 10%, pediatrics 10%, and
medicine/pediatrics <1%.
It is clear from survey trends that the
proportion of family medicine providers is
growing, while the internal medicine supermajority is shrinking somewhat. Pediatrics
appears to remain stable as a proportion of
the total, as does med/peds, with the latter
unable to grow in numbers proportionally
given the small number of providers nationally compared to the other three fields.
The growth of family medicine-trained
hospitalists relates to the continued high
demand for the profession, with such residents comprising the largest pool of available
providers, second only to internal medicine.
Based on the SHM survey, family medicine hospitalists seem to practice similarly to
IM; they generally see adults only. It appears
that they are accepted into traditional adult
hospitalist practices, readily contrasting with
groups serving children, which report no FP
participation. Meanwhile, med/peds hospitalists provide care across the spectrum of
hospitalist groups, though they often report
splitting their duties between adults-only
services and pediatric services.
As for me, a generation removed from my
election of a family practice internship and
subsequent transition to internal medicine
residency, I should not have worried so. Both
paths can lead to hospital medicine.
Dr. Ahlstrom is a hospitalist at Indigo Health Partners in
Traverse City, Mich., and a member of SHM’s Practice
Analysis Committee.
SOURCE: 2014 State of Hospital Medicine report
society pages continue on page
8
WE WELCOME THE NEWEST SHM MEMBERS
E. Gullion, MD, Alabama
E. Patterson, MD, Alabama
L. Scott, Alabama
L. Ledesma, Argentina
E. Kenfack, MD, Arizona
D. Lee, MBBS, Australia
M. Ambati, MD, California
B. Burg, California
A. Dermenchyan, California
T. Discoe, JD, California
M. Kumura, BSN, CCM, RN,
California
C. Ludlow, CFNP, California
L. Mills, MD, California
H. Monsef, DO, California
J. Nguyen, California
G. Pearlman, MD, California
S. Russell, California
J. Sy, California
B. Tompkins, MD, California
J. Zweig, California
A. Bahramirad, Colorado
S. Gu, Colorado
R. Jentzen, MD, Colorado
R. Redman, Colorado
P. Shingledecker, Colorado
M. Richi, Connecticut
V. Utagah Abaaba, MD, Florida
C. Cheung, MD, Florida
D. Cucoranu, MD, Florida
V. Gomez, Florida
T. Lee, MD, Florida
E. Molitch-Hou, MD, Florida
A. Parekh, Florida
W. Raza, Florida
A. Riviera, Florida
D. Scindia, MD, MBBS, Florida
N. Tocco, MD, Florida
M. Zimilevich, MD, Florida
R. Garcia, MD, Georgia
E. Marsh, MD, Georgia
K. Palmer, Georgia
K. Sidhpura, MD, Georgia
A. Balinger, MD, MHA, Idaho
S. Barnett, ACNP, Illinois
M. Bates, BC, BSN, RN, Illinois
C. Ezeokoli, MD, Illinois
N. George, Illinois
R. Golden, Illinois
S. Hohmann, PhD, Illinois
A. Kamdar, Illinois
M. Konanur, Illinois
J. Lee, Illinois
W. Lee, MD, Illinois
J. Little, NP, Illinois
J. Maganti, Illinois
A. Mumaw, Illinois
T. Timi Olutade, MD, Illinois
C. Pendley, Illinois
K. Pierko, MD, Illinois
L. Schwing, Illinois
U. Sharma, Illinois
M. Snyder, MBA, RN, Illinois
N. Tun, Illinois
S. Zarnstorff Green, ACNP, Illinois
R. Hollis, Indiana
T. Lewis, Iowa
N. Schlienz, RN, Iowa
M. Lawrence, Kansas
G. Allen, Kentucky
A. Gray, Kentucky
G. Bensabat, MD, Louisiana
C. Garner-Kuada, MD, Louisiana
P. Mowa, Louisiana
D. Picard, Louisiana
J. Prejeant, MD, Louisiana
S. Madireddy, MD, Maine
T. Prugar, Maine
K. Ahmed, MD, MBBS, Maryland
J. Barnett, PA, Maryland
C. DeMarco, Maryland
M. Forbes, CRNP, Maryland
H. Ghannoum, MD, Maryland
R. Khunkhun, Maryland
J. Kurtyka, MD, Maryland
L. Lucero-Ugalino, MD, Maryland
G. Luizaga Coca, Maryland
E. White, Maryland
J. Besaw, ANP, Massachusetts
M. Cupesi, MD, Massachusetts
K. Giannelli, PA-C, Massachusetts
S. Gupta, MD, Massachusetts
M. Hinrichsen, MD, Massachusetts
J. Kiss, MD, Massachusetts
R. Larios, MD, Massachusetts
R. Patel, Massachusetts
B. Turner, MBA, Massachusetts
S. Booth, Michigan
A. Chang, MD, PharmD, Michigan
J. Fehl, MD, Michigan
C. Hanson, Michigan
H. Imlay, Michigan
A. Michaels, MD, Michigan
M. Miller, PA-C, Michigan
R. Sohaney, Michigan
K. Ingraham, Minnesota
J. Kautz, Minnesota
U. Nwaononiwu, Minnesota
D. Scholl, Minnesota
C. Wemhoff, Minnesota
L. Didion, MD, FAAP, Mississippi
M. Hebert, Mississippi
N. Garner, Missouri
A. Jarori, Missouri
M. Kiefer, ACNP, ANP, APRN, RN,
Missouri
K. Raney, Missouri
C. Rasmussen, Missouri
E. Goroza, MD, Nevada
N. Houston, APRN, New Hampshire
H. Ip, New Hampshire
T. Nguyen, MD, New Hampshire
P. Airen, MD, New Jersey
M. Heching, New Jersey
Y. Hui, USA, New Jersey
R. Bair, MD, New Mexico
S. Burns, DO, New Mexico
F. Batiwalla, New York
J. Berman, MD, New York
new members continue on page
8
I SOCIETY PAGES I continued from page 7
POLICY
CORNER
Accountable Care 2.0
T
he Centers for Medicare and Medicaid Services (CMS) Innovation
Center recently announced the development of a new accountable care organization (ACO) model—the Next Generation
AC O — t h a t
I By Joshua Lapps hopes to move
closer to the
goal of efficient, coordinated care for Medicare beneficiaries.
“This ACO model provides for greater
engagement of beneficiaries, a more predictable, prospective financial model, and more
tools to coordinate care for beneficiaries,”
writes Patrick Conway, MD, MSc, chief
medical officer and deputy administrator for
innovation and quality at CMS, in a blog
post announcing the Next Generation ACO.
ACOs align hospitals, physicians, nursing facilities, and other critical healthcare
providers as a sort of one-stop shop for
seamless patient care across settings and
among providers. By bringing together the
full range of services, ACOs aim to provide
higher quality coordinated care while reducing costs for patients and Medicare.
Since the passage of the Affordable Care
Act, CMS has overseen two distinct tracks
for ACOs: the Medicare Shared Savings
Program and the Pioneer ACO. The Shared
Savings Program was a first step in moving
toward streamlined healthcare delivery
systems while incentivizing care coordination across settings. Pioneer ACOs, on the
other hand, were designed as a test for more
aggressive reforms that promised higher good reason. Hospitals form an integral part
potential rewards in exchange for higher risk, of an ACO, and hospitalists serve critical roles
while moving participants toward popula- within their hospitals. ACO goals read like a
tion-based payments.
laundry list of hospitalist goals and practice,
The Next Generation ACO builds off of such as reducing readmissions, maximizing
the Pioneer and Shared Savings Program efficiency, improving care transitions, and
ACO models to test whether the fundamen- reducing length of stay. The Next Generation
tal concepts behind an ACO—improving ACO model offers the potential to further
care and reducing costs—can be achieved capitalize on the expertise of hospitalists as the
using stronger financial incentives. Nota- healthcare system explores ways to move away
bly, the Next Generation ACO establishes from traditional fee-for-service payments.
stable, prospective targets
for benchmarking expenditures and offers an array
ACO goals read like a laundry list of
of payment mechanisms,
including capitation.
hospitalist goals and practice, such as
Participants of the Next
Generation ACO model
reducing readmissions, maximizing
will have new tools to
efficiency, improving care transitions,
help coordinate patient
care, including expanded
and reducing length of stay.
coverage for telehealth and
home health services and
increased access for skilled
nursing facility coverage without prior hospiThe way in which Medicare pays providers
talizations. Because the Next Generation is evolving rapidly as CMS seeks to reimACO model comes from the CMS Inno- burse for the quality rather than the quantity
vation Center, it’s specifically designed to of services provided to beneficiaries. Over
help policymakers evaluate the impact of the next five years, CMS has set aggresreimbursement and system changes with sive targets for transitioning fee-for-service
an eye toward scalability. The knowledge payments into value-based payment systems;
gained from this model could help structure the Next Generation ACO is one tool for
the Medicare payment system of tomorrow. helping to push that goal onward.
Hospitalists have long been interested in
the impact of ACOs on their practices, with Joshua Lapps is SHM’s manager of government relations.
WE WELCOME THE NEWEST SHM MEMBERS
N. Eisenberg, MD, New York
S. Eldakar-Hein, MD, FACP,
New York
J. Joseph, MD, New York
J. LaPadula, New York
L. Lee, New York
M. Light, MD, New York
S. Liu, New York
M. Luke, New York
A. Nigalaye, MD, MBA, New York
V. Pershad, New York
A. Potashinksy, New York
Q. Qi, New York
I. Rainey-Spence, MD, New York
J. Thakkar, MBBS, New York
E. Wang, MHA, New York
B. Wertheimer, New York
J. Williams, MD, MPH, New York
H. Yalamanchili, New York
A. Akinyelu, North Carolina
E. Clark, North Carolina
A. Craft, North Carolina
T. H
augh, MBA ACMPE,
North Carolina
L. Love, MD, North Carolina
S. Telloni, North Carolina
A. Timothy, DO, North Carolina
S. Shahmehdi, MD, North Carolina
O. Adetoro, MD, Ohio
8
P. Balusu, MD, Ohio
M. Bang, Ohio
J. Brown, Ohio
L. Herbst, Ohio
S. Mohapatra, Ohio
K. Coon, Oklahoma
P. Hucks, Oklahoma
R. Krishna, Oklahoma
J. Mathias, MD, Oklahoma
B. Wicks, Oklahoma
C. Hill, MD, Oregon
M. Mason, DO, Oregon
T. Shi, Oregon
S. Ashfaq, MD, Pennsylvania
P. Bhatia, MBBS, Pennsylvania
S. Calcar, Pennsylvania
S. Edla, Pennsylvania
D. Gujja, MD, Pennsylvania
M. Hallahan, DO, Pennsylvania
V. Karper, Pennsylvania
S. Katta, Pennsylvania
R. Kent, Pennsylvania
T. Kutz, Pennsylvania
W. Laibinis, DO, Pennsylvania
J. Lance, Pennsylvania
S. Mangla, Pennsylvania
V. Okeh, MD, Pennsylvania
M. Solontz, Pennsylvania
H. Zainah, MD, Rhode Island
continued from page
7
E. Irvin, MD, South Carolina
P. Meehan, South Carolina
B. Oberg-Higgins, South Carolina
G. Sullivan, South Carolina
C. Arenas, MA, South Dakota
O. Merunko, MD, South Dakota
B. Blevins, Tennessee
J. Boyle, Tennessee
C. Delashmitt, DO, Tennessee
T. Denham, Tennessee
S. Galloway, MD, Tennessee
E. Koscinski, DO, Tennessee
R. Nathan, Tennessee
B. Pope, Tennessee
J. Price, Tennessee
J. Shires, MD, Tennessee
T. Wootto, Tennessee
L. Zeng, MD, Tennessee
A. Bisen, MD, Texas
A. Campoy, MD, Texas
J. Ferguson, MD, Texas
L. Jordan, MD, Texas
T. Lopez, Texas
M. Mileur, Texas
E. Okeke, Texas
C. Sanchez, MD, Texas
S. Stoltz, MD, Texas
S. Torres, MD, Texas
L. Trujillo, Texas
T. Alzahrani, MBBS, Virginia
R. Amankona, MBchB, Virginia
J. Ampomah, MD, Virginia
B. Armock, Virginia
N. Atuahene, Virginia
P. Benton, MD, Virginia
J. Chaudhary, Virginia
S. Elfeky, Virginia
A. Mehta, Virginia
A. Morgan, Virginia
L. Roach, NP, Virginia
C. Stokes, DO, Virginia
S. Supplee, Virginia
N. Thrash, MD, Virginia
A. Zawoloka, Virginia
B. Kirov, MD, Washington
M. Rivers, MHA, Washington
R. Weston, Washington
T. Basen, MD, Washington, DC
J. Camba, MD, Washington, DC
E. Cranston, DO, Washington, DC
G. Magda, Washington, DC
A. Pham, MD, Washington, DC
K. Quinn, Washington, DC
T. Hoff Poole, West Virginia
M. Tesfai, West Virginia
K. Kultgen, MD, Wisconsin
G. Lamb, MD, FACP, Wisconsin
A. Polani, MBBS, Wisconsin
M. Zellmer, PA-C, PhD, Wisconsin
Society of Hospital
Medicine (SHM)American Academy
of Family Physicians
(AAFP) Joint Statement
on Hospitalists Trained
in Family Medicine
H
ospitalists are physicians whose
primary professional focus is
the general medical care of
hospitalized patients. Both the Society
of Hospital Medicine (SHM) and the
American Academy of Family Physicians
(AAFP) hold that the opportunity to participate as a Hospitalist should be granted
to all physicians commensurate with their
documented training and/or experience,
demonstrated abilities and current
competencies.
During their training Family Physicians
acquire the necessary attitudes, skills, and
knowledge that enable them to provide
continuing and comprehensive medical
care across the spectrum of care settings,
including the inpatient setting. Education
in the primary management of hospitalized patients occurs during the required
general inpatient ward and intensive
care unit experiences. In addition, Family
Physicians are required to train with general surgeons and surgical subspecialists,
enhancing recognition and understanding
of surgical disease states upon which
Hospitalists are frequently asked to
consult or co-manage. Family Medicine
training also encompasses additional
skills essential to the practice of Hospital
Medicine, including participation in quality
improvement, addressing the psychosocial needs of patients, coordinating
across levels of care, and functioning as
members of interdisciplinary teams.
Given this training, many Family
Physicians effectively manage their
patients in an inpatient setting after the
completion of their residency.
Demand for Hospitalists continues to
outweigh supply in the United States,
including needs in underserved and rural
areas. Hospitalists Trained in Family
Medicine (HTFM) fulfill an important public
health need by providing frontline inpatient services in a variety of geographic
settings. In addition, while many HTFM
focus exclusively on the care of adults,
others are providing inpatient care across
the spectrum of ages, as well as providing
obstetric services. More than two-thirds of
HTFM are also involved in the training of
residents and medical students, enhancing the skills of our future physicians.
Recognition of achievement by HTFM
from the SHM is available by meeting
standards set for all Hospitalists, regardless of residency training, in the form
of the designation of Fellow of Hospital
Medicine. HTFM also have the opportunity to professionally qualify and sit for
the Recognition of Focused Practice in
Hospital Medicine board examination.
This examination is administered and
recognized jointly by the American Board
of Family Medicine and the American
Board of Internal Medicine.
In consideration of the above factors,
both the Society of Hospital Medicine
and the American Academy of Family
Physicians endorse and encourage the
growing contribution of Hospitalists
Trained in Family Medicine.
CLINICAL
IN THE
LITERATURE
ITL: Physician Reviews of
HM-Related Research
I By Dennis Chang, MD, Alan Briones, MD, Maria Reyna, MD, Tao Xu, MD, Tuyet-Trinh Truong, MD, Vinh-Tung Nguyen, MD,
Division of Hospital Medicine, Department of Medicine, Mount Sinai Medical Center, New York City
IN THIS ISSUE
1. Risk of anticoagulant bridging prior to procedures, p. 9.
2. Multicomponent, nonpharmacological intervention reduced delirium and falls, p. 9.
3. Functional impairment associated with hospital readmission in Medicare seniors, p. 9.
4. Hospitalists’ overuse driven by desire to reassure patients, families, p. 9.
5. High-volume hospitals have higher readmission rates, p. 10.
6. Enriched nutritional formula helps heal pressure ulcers, p. 10.
7.High intracranial bleeding rate in patients with minor and minimal head injuries while on
warfarin, p. 10.
8. Bova risk model predicts 30-day pulmonary embolism-related complications, p. 10.
9. Noninvasive ventilation improves outcomes for hospitalized COPD patients, p. 11.
10. D-Dimer not reliable marker to stop anticoagulation therapy in men, p. 11.
1
Bridging during
Anticoagulation
Interruptions in Patients
with Atrial Fibrillation Leads to
Worse Outcomes
CLINICAL QUESTION: Is bridging anticoagulation for procedures associated with a
higher bleeding risk and increased adverse
outcomes compared to no bridging?
BACKGROUND: Practice guidelines have
been published to determine when, how,
and on whom to bridge anticoagulation for
procedures; however, uncertainty remains as
to whether or not bridging changes outcomes.
STUDY DESIGN: Prospective, observational
study.
SETTING: Outcomes Registry for Better
Informed treatment of Atrial Fibrillation
(ORBIT-AF) study.
SYNOPSIS: Investigators included 10,132
patients who were 18 years and older, with
a baseline EKG documenting atrial fibrillation (Afib) and undergoing procedures.
Interruptions of oral anticoagulation for
a procedure, as well as the use and type
of bridging method, were recorded. Six
hundred sixty-five patients (24%) used
bridging anticoagulation (73% low molecular weight heparin, 15% unfractionated
heparin) prior to a procedure. Bridged
patients were more likely to have had a
mechanical valve replacement (9.6% vs.
2.4%, P<0.0001) and prior stroke (22%
vs. 15%, P=0.0003).
Multivariate adjusted analysis showed
that bridged patients, compared with nonbridged patients, had higher rates of bleeding
(5.0% vs. 1.3%, adjusted odds ratio (OR)
3.84, P<0.0001) and an increased risk for
adverse events, including the composite of
myocardial infarction (MI), bleeding, stroke
or systemic embolism, hospitalization, or
death within 30 days (OR 1.94, 95% CI
1.38-271, P=0.0001). Rates of CHADS2
≥2 or CHA2DS2-VASc score ≥2 were similar
between bridged and nonbridged patients.
These results are observational and, therefore, a causal relationship cannot be established; however, the Effectiveness of Bridging Anticoagulation for Surgery (BRIDGE)
study will give us more insight and answers.
BOTTOM LINE: Bridging anticoagulation
prior to procedures is associated with a higher
risk of bleeding and adverse outcomes.
CITATION: Steinberg BA, Peterson ED,
Kim S, et al. Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial
fibrillation: Findings from the Outcomes
Registry for Better Informed Treatment of
Atrial Fibrillation (ORBIT-AF). Circulation. 2015;131(5):488-494.
2
Multicomponent,
Nonpharmacological
Intervention Reduced
Delirium, Falls
CLINICAL QUESTION: Are multicomponent, nonpharmacological interventions
effective in decreasing delirium and falls?
BACKGROUND: Delirium is prevalent
among elderly hospitalized patients and is
associated with increased morbidity, length
of stay, healthcare costs, and risk of institutionalization. Multicomponent nonpharmacologic interventions have been used to
prevent incident delirium in the elderly, but
data regarding their effectiveness and impact
on preventing poor outcomes are lacking.
STUDY DESIGN: Systematic literature
review and meta-analysis.
SETTING: Review of medical databases
from Jan. 1, 1999, to Dec. 31, 2013.
SYNOPSIS: Fourteen studies were included
involving 4,267 elderly patients from
12 acute medical and surgical sites from
around the world. There was a 53% reduction in delirium incidence associated with
multicomponent, nonpharmacological
interventions (OR, 0.47; 95% CI, 0.380.58). The odds of falling were 62% lower
among intervention patients compared
with controls (2.79 vs. 7.05 falls per 1,000
patient-days). The intervention group also
showed a decrease in length of stay, with a
mean difference of -0.16 (95% CI, -0.97 to
0.64) days and a 5% lower chance of institutionalization (95% CI, 0.71 to 1.26);
however, the differences were not statistically significant.
Although the small number and heterogeneity of the studies included limited
the analysis, the use of nonpharmacologic
interventions appears to be a low-risk,
low-cost strategy to prevent delirium. The
challenge for the hospitalist in developing
a nonpharmacological protocol is to determine which interventions to include; the
study did not look at which interventions
were most effective.
BOTTOM LINE: The use of multicomponent nonpharmacological interventions in
older patients can lower the risk of delirium
and falls.
CITATION: Hshieh TT, Yue J, Oh E,
et al. Effectiveness of multicomponent
nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med.
2015;175(4):512-520.
3
Functional Impairment
Associated with
Hospital Readmission in
Medicare Seniors
CLINICAL QUESTION: Is functional
impairment associated with an increased
risk of 30-day readmission?
BACKGROUND: Many Medicare seniors
suffer from some level of impairment in
functional status, which, in turn, has been
linked to high healthcare utilization. Studies
that examine the role of functional impairment with readmission rates are limited.
STUDY DESIGN: Prospective, cohort study.
SETTING: Seniors enrolled in the Health
and Retirement Study (HRS) with Medicare hospitalizations from Jan. 1, 2000, to
Dec. 31, 2010.
SYNOPSIS: The primary outcome was
readmissions within 30 days of discharge.
Activities of daily living (ADL) scale and
instrumental ADL were used as measures
of functional impairment.
Overall, 48.3% of patients had preadmission functional impairments with a readmission rate of 15.5%. There was a progressive
increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional
impairment, 14.3% with difficulty in one
or more instrumental ADLs (OR 1.06; 95%
CI 0.94-1.20), 14.4% with difficulty in one
or more ADLs (OR 1.08; 95% CI 0.961.21), 16.5% with dependency in one or
two ADLs (OR, 1.26; 95% CI 1.11-1.44),
and 18.2% with dependency in three or
more ADLs (OR 1.42; 95% CI 1.20-1.69).
This observation was more pronounced
in patients admitted for heart failure, MI,
and pneumonia (16.9% readmission rate
for no impairment vs. 25.7% dependency
in three or more ADLs, OR 1.70; 95% CI
1.04-2.78).
Although the study is limited by reliance
on survey data and Medicare claim data,
functional status may be an important variable in calculating readmission risk and a
potential target for intervention.
BOTTOM LINE: Functional impairment is
associated with an increased risk of 30-day
readmission, especially in patients admitted
for heart failure, MI, and pneumonia.
CITATION: Greysen SR, Stijacic Cenzer I,
Auerbach AD, Covinsky KE. Functional
impairment and hospital readmission
in Medicare seniors. JAMA Intern Med.
2015;175(4):559-565.
4
Hospitalists’ Overuse
Driven by Desire to
Reassure Patients,
Families
CLINICAL QUESTION: What is the extent
of, and factors associated with, testing overuse in U.S. hospitals for pre-operative evaluation and syncope.
continued on page
10
SHORT TAKES
STRATEGIES AVAILABLE
TO ENCOURAGE PATIENTS
TO REMIND HEALTHCARE
PROFESSIONALS ABOUT
THEIR HAND HYGIENE
A systematic review of 1,956 articles
found promising strategies that improve
patients’ participation in reminding
healthcare professionals (HCPs) about
their hand hygiene; the most effective
strategy was HCP encouragement.
CITATION: Davis R, Parand A, Pinto
A, Buetow S. Systematic review of the
effectiveness of strategies to encourage patients to remind healthcare
professionals about their hand hygiene.
J Hosp Infect. 2015;89(3):141-162.
I IN THE LITERATURE I continued from page 9
BACKGROUND: Little is known about the
extent and drivers of overuse by hospitalists.
STUDY DESIGN: Two vignettes (pre-operative evaluation and syncope) were mailed
to hospitalists. They were asked to identify
what most hospitalists at their institution
would recommend and “the most likely
primary driver of the hospitalist’s decision.”
SETTING: Random selection of hospitalists from SHM member database and SHM
national meeting attendees.
SYNOPSIS: Investigators mailed 1,753
surveys and received a 68% response rate.
For the pre-operative evaluation vignette,
52% of hospitalists reported overuse of preoperative testing. When a family member
was a physician and requested further testing, overuse increased significantly to 65%.
For the syncope vignette, any choice involving admission was considered overuse.
Eighty-two percent of respondents
reported overuse; when the wife was a
lawyer or requested further testing, overuse remained the same. Overuse in both
cases was more frequent due to a hospitalist’s desire to reassure patients or themselves,
rather than a belief that it was clinically indicated (pre-operative evaluation, 63% vs.
37%; syncope, 69% vs. 31%, P<0.001).
The survey responses do not necessarily
represent actual clinical choices, and the
hospitalist sample may not be representative
of all hospitalists; however, this study shows
that efforts to reduce overuse in hospitals
need to move beyond financial incentives
and/or informing providers of evidencebased recommendations.
BOTTOM LINE: A survey of hospitalists
showed substantial overuse in two common
clinical situations, syncope and pre-operative evaluation, mostly driven by a desire
to reassure patients, families, or themselves.
CITATION: Kachalia A, Berg A, Fagerlin A,
et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists.
Ann Intern Med. 2015;162(2):100-108.
5
Hospitals with Higher
Volumes Have Higher
Readmission Rates
CLINICAL QUESTION: Is there an association between hospital volume and hospital
readmission rates?
BACKGROUND: There is an established
association between high patient volume
and reduced complications or mortality
after surgical procedures; however, readmission represents a different type of quality metric than mortality or complications.
Studies on the association between hospital
patient volume and readmission rates have
been controversial.
STUDY DESIGN: Retrospective, crosssectional study.
SETTING: Acute care hospitals.
SYNOPSIS: The study included 6,916,644
admissions to 4,651 hospitals, where patients
were assigned to one of five cohorts: medicine, surgery/gynecology, cardiorespiratory,
cardiovascular, and neurology. The hospital
with the highest volume group had a hospital-wide mean standardized readmission
rate of 15.9%, while the hospital with the
lowest volume group had a readmission rate
of 14.7%. This was a 1.2 percentage point
absolute difference between the two hospitals (95% confidence interval 0.9 to 1.5).
This trend continued when specialty cohorts
10
were examined, with the exception of the
procedure-heavy cardiovascular cohort.
Results showed a trend toward decreased
readmission rates in lower-volume hospitals;
however, it is unclear why this trend exists.
Possible reasons include different patient
populations and different practitioner-topatient ratios in low-volume hospitals.
Limitations of this study are the inclusion
of only patients 65 years and older and the fact
that all admissions per patient were included,
which may bias the results against hospitals
with many frequently admitted patients.
BOTTOM LINE: Hospitals with high patient
volumes are associated with higher readmission rates, except in procedure-heavy patient
groups.
CITATION: Horwitz LI, Lin Z, Herrin J, et
al. Association of hospital volume with readmission rates: a retrospective cross-sectional
study. BMJ. 2005;350:h447.
6
Nutritional Formula
Enriched with Arginine,
Zinc, and Antioxidants
Helps Heal Pressure Ulcers
CLINICAL QUESTION: Does a high-calorie,
high-protein formula enriched with supplements of arginine, zinc, and antioxidants
improve pressure ulcer healing?
BACKGROUND: Malnutrition is thought
to be a major factor in the development and
poor healing of pressure ulcers. Trials evaluating whether or not the addition of antioxidants, arginine, and zinc to nutritional
formulas improves pressure ulcer healing
have been small and inconsistent.
STUDY DESIGN: Multicenter, randomized,
controlled, blinded trial.
SETTING: Long-term care facilities and
patients receiving home care services.
SYNOPSIS: Two hundred patients with
stage II, III, or IV pressure ulcers receiving
standardized wound care were randomly
assigned to a control formula or an experimental formula enriched with arginine,
zinc, and antioxidants. At eight weeks, the
experimental formula group had an 18.7%
(CI, 5.7% to 31.8%, P=0.017) mean reduction in pressure ulcer size compared with
the control formula group, although both
groups showed efficacy in wound healing.
Nutrition is an important part of wound
healing and should be incorporated into
the plan of care for the hospitalized patient
with pressure ulcers. Hospitalists should be
mindful that this study was conducted in
non-acute settings, with a chronically ill
patient population; more research needs
to be done to investigate the effect of
these specific immune-modulating nutritional supplements in acutely ill hospitalized patients, given the inconclusive safety
profile of certain nutrients such as arginine
in severe sepsis.
BOTTOM LINE: Enhanced nutritional
support with an oral nutritional formula
enriched with arginine, zinc, and antioxidants improves pressure ulcer healing in
malnourished patients already receiving
standard wound care.
CITATION: Cereda E, Klersy C, Serioli M,
Crespi A, D’Andrea F, OligoElement Sore
Trial Study Group. A nutritional formula
enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers:
a randomized trial. Ann Intern Med.
2015;162(3):167-174.
7
High Intracranial
Bleeding Rate in Patients
with Minor and Minimal
Head Injuries on Warfarin
CLINICAL QUESTION: Do minor and
minimal head injuries in patients on warfarin lead to significant intracranial bleed?
BACKGROUND: Warfarin use is common,
and many of these patients sustain minor
and minimal head injuries. When presenting to the ED, these patients pose a clinical dilemma regarding whether to obtain
neuroimaging and/or admit.
STUDY DESIGN: Retrospective cohort
study.
SETTING: Two urban tertiary care EDs in
Ottawa, Canada, over a two-year period.
SYNOPSIS: Using the Canadian National
Ambulatory Care Reporting System database and the associated coding data, 259
patients were identified that fit the inclusion criteria GCS ≥13 and INR >1.5. This
study showed that the rate of intracranial
bleeds in this group of patients was high
(15.9%); for minor and minimal head
injury groups, the rate was 21.9% and
4.8%, respectively. Additionally, loss of
consciousness was associated with higher
rates of intracranial bleeding.
The risk of intracranial bleed after a head
injury while on warfarin is considerably
high, particularly for those patients with
minor head injury (21.9%), which is about
three times the rate previously reported.
Hospitalists evaluating these patients
should consider obtaining neuroimaging.
Nonetheless, these rates may be overestimating the true prevalence due to the
following: 1) Coding data may overlook
minor and minimal head injuries in the
presence of more serious injuries, and 2)
patients with minimal head injuries may
not seek medical care.
BOTTOM LINE: Patients sustaining minor
head injury while on warfarin have a high
rate of intracranial bleed.
REFERENCE: Alrajhi KN, Perry JJ, Forster
AJ. Intracranial bleeds after minor and
minimal head injury in patients on warfarin. J Emer Med. 2015;48(2):137-142.
8
Bova Risk Model
Predicts 30-Day
Pulmonary EmbolismRelated Complications
CLINICAL QUESTION: Can the Bova risk
model stratify patients with acute PE into
stages of increasing risk for 30-day pulmonary embolism (PE)-related complications?
BACKGROUND: The Bova score is based
on four variables assessed at the time of PE
diagnosis: heart rate, systolic blood pressure, cardiac troponin, and a marker of right
ventricular (RV) dysfunction. In the original
study, the Bova risk model was derived from
2,874 normotensive patients with PE. This
study performed a retrospective validation of
this model on a different cohort of patients.
STUDY DESIGN: Retrospective cohort study.
SETTING: Academic urban ED in Madrid,
Spain.
SYNOPSIS: Investigators included 1,083
patients with normotensive PE, and the Bova
risk score classified 80% into class I, 15% into
class II, and 5% into class III—correlating
30-day PE-related complication rates were
4.4%, 18%, and 42%, respectively. When
dichotomized into low risk (class I and II)
SHORT TAKES
CORTICOSTEROIDS IMPROVE
OUTCOMES IN SEVERE
COMMUNITY-ACQUIRED
PNEUMONIA PATIENTS
A multicenter, randomized, doubleblind, placebo-controlled trial in Spain
showed that patients with severe
community-acquired pneumonia who
received intravenous methylprednisolone for five days within 36 hours of
admission had a lower risk of treatment
failure.
CITATION: Torres A, Sibila O, Ferrer M,
et al. Effect of corticosteroids on treatment failure among hospitalized
patients with severe communityacquired pneumonia and high inflammatory response: a randomized clinical
trial. JAMA. 2015;313(7):677-686.
PATIENT-RELATED FACTORS
LIMIT DISCUSSIONS OF
END-OF-LIFE CARE
Multicenter national survey among
physicians and nurses demonstrated
that the biggest barriers to engaging
in discussion of end-of-life care are
patients’ and families’ difficulty understanding limitations and complications
of life-sustaining treatments, patients’
lack of capacity to make decisions
about goals of care, and lack of agreement among family members about
goals of care.
CITATION: You JJ, Downar J, Fowler
RA, et al. Barriers to goals of care
discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians. JAMA Intern
Med. 2015;175(4):549-556.
END-OF-LIFE SYMPTOMS
REMAIN HIGH DESPITE
NATIONAL EFFORTS TO
IMPROVE END-OF-LIFE CARE
Prospective cohort study based on
proxy interviews found that in the last
year of life there were statistically
significant increases in prevalence of
any pain (11.9%), depression (26.6%),
and periodic confusion (31.3%).
CITATION: Singer AE, Meeker D,
Teno JM, Lynn J, Lunney JR, Lorenz
KA. Symptom trends in the last year of
life from 1998 to 2010: a cohort study.
Ann Intern Med. 2015;162(3):175183.
SUPERFICIAL VEIN
THROMBOSIS STRONGLY
ASSOCIATED WITH
DEVELOPMENT OF DEEP VEIN
THROMBOSIS
A nationwide cohort study in Denmark
found a strong relationship between
the incidence of superficial venous
thrombosis (SVT) and the subsequent
development of deep venous thrombosis in the first few months after SVT
diagnosis.
CITATION: Cannegieter SC, HorváthPuhó E, Schmidt M, et al. Risk of
venous and arterial thrombotic events
in patients diagnosed with superficial
vein thrombosis: a nationwide cohort
study. Blood. 2015;125(2):229-235.
versus intermediate to high risk (class III),
the model had a specificity of 97%, a positive predictive value of 42%, and a positive
likelihood ratio of 7.9 for predicting 30-day
PE-related complications.
The existing risk assessment models, the
pulmonary embolism severity index (PESI)
and the simplified PESI (sPESI), have been
extensively validated but were specifically
developed to identity patients with low risk
for mortality. The Bova risk model could be
used in a stepwise fashion, with the PESI or
sPESI model, to further assess intermediaterisk patients.
This model was derived and validated at
one single center, so the results may not be
generalizable. Additionally, the variables were
collected prospectively, but this validation
analysis was performed retrospectively.
BOTTOM LINE: The Bova risk model accurately stratifies patients with normotensive PE
into stages of increasing risk for developing
30-day PE-related complications.
CITATION: Fernández C, Bova C, Sanchez
O, et al. Validation of a model for identification of patients at intermediate to high risk for
complications associated with acute symptomatic pulmonary embolism [published online
ahead of print January 29, 2015]. Chest.
9
Noninvasive Ventilation
Improves Outcomes
in Hospitalized COPD
Patients
CLINICAL QUESTION: Do patients hospi-
talized with acute COPD exacerbations have
improved outcomes with noninvasive ventilation (NIV) compared to those treated with
invasive mechanical ventilation (IMV)?
BACKGROUND: Previous studies have
shown that in select patients, NIV has a
mortality benefit over IMV for acute COPD
exacerbations requiring hospitalization. NIV
may also decrease complication rates and
reduce length of stay; however, the previous
prospective studies have been small.
STUDY DESIGN: Retrospective cohort study.
SETTING: 420 structurally and geographically diverse U.S. hospitals.
SYNOPSIS: Using the Premier Healthcare
Informatics database, this study looked at
25,628 patients over 40 years old who were
hospitalized with COPD exacerbations.
Compared with patients who were initially
treated with IMV, patients treated with NIV
demonstrated lower mortality rates with an
odds ratio of 0.54, lower risk of hospitalacquired pneumonia with an odds ratio of
0.53, and a 32% cost reduction. They also
had shorter lengths of stay.
This was a retrospective study using a
limited data set, and the authors did not
have access to potentially confounding
factors between the two groups, including
vital signs and blood gases. Additionally, the
advantages of NIV were attenuated among
patients with pneumonia present on admission, patients with high burden of comorbid
PEDIATRIC HM LITERATURE I
diseases, and patients older than 85 years.
BOTTOM LINE: Treatment of acute COPD
exacerbations with NIV is associated with
lower mortality, lower costs, and shorter
length of stay as compared with IMV.
CITATION: Lindenauer PK, Stefan MS,
Shieh MS, Pekow PS, Rothberg MB, Hill
NS. Outcomes associated with invasive and
noninvasive ventilation among patients
hospitalized with exacerbations of chronic
obstructive pulmonary disease. JAMA Intern
Med. 2014;174(12):1982-1993.
10
D-Dimer Is Not a
Reliable Marker to
Stop Anticoagulation
Therapy in Men
CLINICAL QUESTION: In patients with
a first unprovoked VTE, is it safe to use a
normalized D-dimer test to stop anticoagulation therapy?
BACKGROUND: The risk of VTE recurrence after stopping anticoagulation is
higher in patients who have elevated
D-dimer levels after treatment. It is
unknown whether we can use normalized
D-dimer levels to guide the decision about
whether or not to stop anticoagulation.
STUDY DESIGN: Prospective cohort study.
SETTING: Thirteen university-affiliated
centers.
SYNOPSIS: Study authors screened 410
adult patients who had a first unprovoked
VTE and completed three to seven months
of anticoagulation therapy with D-dimer
tests. In patients with negative D-dimer tests,
anticoagulation was stopped, and D-dimer
tests were repeated after a month. In those
with two consecutive negative D-dimer tests,
anticoagulation was stopped indefinitely;
these patients were followed for an average of 2.2 years. Among those 319 patients,
there was an overall recurrent VTE rate of
6.7% per patient year. Subgroup analysis
was performed among men, women not on
estrogen therapy, and women on estrogen
therapy; recurrence rates per patient year
were 9.7%, 5.4%, and 0%, respectively.
This study used a point-of-care D-dimer
test that was either positive or negative; it is
unclear if the results can be generalized to
all D-dimer tests. Additionally, although the
study found a lower recurrence VTE rate
among women, the study was not powered
for the subgroups.
BOTTOM LINE: The high rate of recurrent
VTE among men makes the D-dimer test
an unsafe marker to use in deciding whether
or not to stop anticoagulation for an unprovoked VTE. Among women, D-dimer test
can potentially be used to guide length of
treatment, but, given the limitations of the
study, more evidence is needed.
CITATION: Kearon C, Spencer FA, O’Keaffe
D, et al. D-Dimer testing to select patients
with a first unprovoked venous thromboembolism who can stop anticoagulant therapy.
Ann Intern Med. 2015;162(1):27-34.
By Weijen W. Chang, MD, SFHM, FAAP
Now Is the Time for Just-In-Time (JIT) CPR Training
CLINICAL QUESTION: Does
the use of “just-in-time” (JIT)
CPR training, with or without
visual feedback (VisF), improve
the quality of CPR in simulated
pediatric cardiopulmonary arrest
(CPA)?
Reviewed by Pediatric Editor
Weijen Chang, MD, SFHM, FAAP,
associate clinical professor
of medicine and pediatrics at
the University of California at
San Diego School of Medicine,
and a hospitalist at both UCSD
Medical Center and Rady
Children’s Hospital.
BACKGROUND: Rates of
survival to discharge after
in-hospital pediatric CPA
range from 25%-50%, with
three-quarters of survivors
having good neurological
outcomes.1 The quality of basic
life support interventions has
been found to be a critical factor
influencing survival outcomes.1
Traditional basic life support
(BLS) training has not been
found to significantly increase
compliance with 2010 AHA
BLS Guidelines, however.2 Two
recent advances have been
found to improve the ability of
CPR providers to estimate chest
compression (CC) depth:
• JIT CPR training, where
learners are given videobased training immediately
before simulated CPA and
• real-time VisF, where
learners are given feedback
during CPR regarding rate
and depth of CC by a small
electronic device.
Visual CPR feedback devices
used in recent studies are small
(credit card-sized), are placed
in the middle of the chest, and
use accelerometer technology to
provide real-time data regarding
CC rate and depth. Prior studies
utilizing VisF technology have
found learners overestimate their
compliance with target CC depth
and rate.3
STUDY DESIGN: Prospective,
randomized, 2 x 2 factorialdesign trial.
SETTING: Ten tertiary care
teaching hospitals in the U.S. and
Canada.
SYNOPSIS: Researchers
recruited participants from
10 tertiary care teaching hospitals
that are part of the International
Network for Simulation-Based
Pediatric Innovation, Research,
and Education (INSPIRE).
Participants included medical
students, resident/fellow
physicians, nurses, and nurse
practitioners. Participants were
organized into teams of three,
with one participant designated
as team leader and two others
assigned to perform CCs. Teams
were then randomized into four
arms as follows:
• Arm 1: No JIT / no VisF
• Arm 2: No JIT / + VisF
• Arm 3: + JIT / no VisF
• Arm 4: + JIT / + VisF
All participants watched a
standard video orientation to
the study, practiced CPR for
two minutes, and participated
in a pediatric septic shock
simulation scenario (to minimize
the Hawthorne effect of being
videotaped). Depending on
randomization, some teams
received JIT CPR training prior
to a simulated pediatric CPA
scenario. Randomization also
determined which teams would
utilize a VisF device during CPR
to give feedback regarding rate
and depth of CCs. Actors were
used to play roles of respiratory
therapist and medication nurse,
and all sites used standardized
locations of defibrillator and
medication cart.
Overall, quality of CPR was
poor, but the JIT CPR training
and VisF real-time feedback did
result in improvement in CC
depth and rate compliance:
• JIT CPR training resulted in
a 20% absolute increase in
CC depth compliance and
a 12% increase in CC rate
compliance;
• Real-time VisF resulted in a
15% absolute increase in CC
depth compliance and a 40%
absolute increase in CC rate
compliance; and
• Use of both JIT CPR training
and real-time VisF during
CPA resulted in the highest
rates of CC depth and rate
compliance, but no significant
interaction effect was observed.
BOTTOM LINE: Use of JIT
CPR training prior to pediatric
CPA and a real-time visual
feedback device during CPR
improves compliance with CC
rate and depth guidelines during
simulated pediatric CPA.
CITATION: Cheng A, Brown
LL, Duff JP. Improving
cardiopulmonary resuscitation
with a CPR feedback device
and refresher simulations (CPR
CARES study): a randomized
clinical trial. JAMA Pediatr.
2015;169(2):137-144.
References
1. Topjian AA, Nadkarni VM, Berg RA.
Cardiopulmonary resuscitation in children.
Curr Opin Crit Care. 2009;15(3):203-208.
2. Sutton RM, Wolfe H, Nishisaki A. Pushing harder, pushing faster, minimizing
interruptions. . . but falling short of
2010 cardiopulmonary resuscitation
targets during in-hospital pediatric and
adolescent resuscitation. Resuscitation.
2013;84(12):1680-1684.
3. Cheng A, Overly F, Kessler D, et al.
Perception of CPR quality: influence of
CPR feedback, Just-in-Time CPR training
and provider role. Resuscitation. 2015;87:
44-50.
I TEAM HOSPITALIST I Q&A with our newest editorial advisory board members I By Richard Quinn
Difference Maker
New York hospitalist Nancy Zeitoun, MD, FHM, seeks better health outcomes
N
ancy Zeitoun, MD, FHM, sees her
expanding role as a leader at Long
Island Jewish Medical Center in
New Hyde Park, N.Y., as a chance to make
a difference. As co-site director for clinical
affairs in the division of hospital medicine
and assistant professor at Hofstra North
Shore-LIJ School of Medicine, she can
introduce her “own ideas to our evolving
and growing program.”
Now she’s brought that desire to share
ideas to Team Hospitalist, the volunteer
editorial advisory board of The Hospitalist.
Hospitalists have
a unique and global
vantage point of a
hospital’s intricate
network, making
them the most
valuable players on
the field. They see
opportunity in
instability and
uncertainty.
—Dr. Zeitoun
Question: Why did you choose a
career in medicine?
Answer: I consider it among the most
challenging professions, both intellectually
[conceptually] and physically [tangible].
Q: How/when did you decide to
become a hospitalist?
A: Ten years ago, I was entering the third
year of my four-year residency with the
motivation to pursue critical care medicine and with much less enthusiasm for
primary care than I had anticipated. One
of the junior faculty was my internal medicine teaching attending, and he described
his new role as a hospitalist. He preferred
inpatient care with a structured schedule,
less call time, and no outpatient responsibilities that required running between the
hospital and an office practice. He told me
this was where the future of medicine was
heading. It was the best of both worlds.
Q: Tell us about your mentor.
What did she mean to you? A: My mentor was my program director. I admired her for being a distinguished
woman in medicine with an academic position. She was a natural leader with passion
and vision that were electrifying. She motivated and inspired. She saw potential in her
residents and gave opportunity for any willing participant to advance.
Q: You say a structured yet
flexible day and multidisciplinary
work appeal to you. What do
you like most about being a
hospitalist?
A: Hospitalists have a unique and global
vantage point of a hospital’s intricate network,
making them the most valuable players on the
field. They see opportunity in instability and
uncertainty. Hospitalists are resourceful and
efficient, adhering to the business concepts
of competition, sustainability, conservation,
and stewardship. The challenges of the field
are vast but include a balance of clinical and
administrative roles, leading and implementing changes to daily practice and being the
constant in a sea of subspecialists.
The flexibility of the day allows for multitasking and setting priorities, so that patient
12
care is never compromised in an acute care
setting. A clinician can spend as much
time with a patient as needed without the
constraints of set appointments. areas that need change. It also allows you to
be an effective leader when you continue to
do the same work your colleagues do. You
are legitimate in their eyes!
Q: What do you dislike most
about being a hospitalist?
Q: As a hospitalist, seeing most
of your patients for the very first
time, what aspect of patient care
is most challenging for you?
A: Having to balance clinical work with
administrative and committee work.
Q: What’s the best advice you
ever received?
A: Be proactive and be a part of the solution, rather than wait for change to be
imposed. “Change is the only constant in
life.”—Heraclitus
Q: What’s the worst advice you
ever received?
A: Be friends with your boss.
Q: You’ve said you’d like to see
hospitalists have more impact
on lobbying and legislation. Can
you explain what you’d like to
see, and what you would see as
the benefit of that? A: Legislative action is spearheaded by the
leaders of large medical organizations speaking on behalf of all of their members. These
leaders tend to be either non-clinicians or
non-practicing physicians. However, differing viewpoints exist. Physicians don’t want
to be politicians or lobbyists. They have a
hard time agreeing on things and working
as a cohesive entity. So they leave others to
speak for them. Then they complain when
laws are passed without their say.
Hospitalists work in and help lead such
complex organizations. SHM is led by
physicians in practice. Events like Hospitalists on the Hill [at SHM’s annual meeting] encourage us to be more involved in
legislative advocacy.
Q: As an administrator, at
least part time, why is it
important for you to continue
seeing patients?
A: Clinical skills directly affect ability to
understand the “day to day” and target the
Check out
Dr. Zeitoun’s and
other Team Hospitalist
members’ session
analyses from Hospital
Medicine 2015.
A: Establishing trust and confidence by first
impressions.
Q: What aspect of patient care is
most rewarding?
A: Patient/family appreciation.
Q: As an assistant professor,
what aspect of teaching in the
21st century do you find most
difficult? And, what is most
enjoyable?
A: Less focus on protected/dedicated teaching time, because money drivers take precedence (i.e., length of stay, dispo, utilization,
billing and documentation). The new label
is “system-based practice.” This has led to
decreased bedside teaching.
Most enjoyable is working with eager
learners.
Q: You call your biggest
professional challenge taking
credit for your ideas. Why is that
difficult? Do you think that’s an
issue for a lot of hospitalists,
particularly given the specialty
focus on the multidisciplinary
team? A: Hospital medicine focuses on teamwork.
Hospitalists have figured out how to step
out of their silos and reach across the aisle
to accomplish some daunting tasks. Clinical
competence is obviously important, but the
ability to work together, check egos at the
door, and make individual sacrifices when
necessary is the only way a team succeeds.
The unintentional consequence is that they
don’t take credit because it’s the collective
effort that counts.
Richard Quinn is a freelance writer in New Jersey.
CLINICAL
KEY CLINICAL QUESTION
When should
hypopituitarism be
suspected?
I By Richard Inman, MD, Mark Bridenstine, MD, Ethan Cumbler, MD
• Central adrenal insufficiency lacks
the hyperpigmentation and hyperkalemia associated with primary
adrenal insufficiency.
• Central adrenal insufficiency
should be suspected in cases of
tumors or surgery in the region
of the pituitary; presentation can
be delayed following intracranial
radiation therapy.
• In cases of shock due to suspected panhypopituitarism,
intravenous levothyroxine should
be accompanied by stress-dose
steroids while awaiting laboratory
confirmation.
• When secondary (i.e., central)
hormone deficiencies are suspected, check both pituitary and
target organ hormones (e.g.
TSH and free T4) to determine
if the hypothalamic-pituitarytarget organ axis is “appropriate.”
Provocation testing may be
necessary to confirm.
A 53-year-old woman with a history of a
suprasellar meningioma resected nine years
ago with recurrence of a 4.5x2 cm mass one
year ago and recent ventriculoperitoneal
(VP) shunt placement for hydrocephalus
presented with altered mental status (AMS)
and hallucinations. She was admitted for
radiation therapy to the mass. The patient
had little improvement in her mental status
four weeks into a six-week, 4860 cGy course
of photon therapy.
The internal medicine service was
consulted for new onset tachycardia (103),
hypotension (83/55), and fever (38.6 C).
Laboratory data revealed a white blood
cell count 4.8 x 109 cells/L, sodium 137
mmol/L, potassium 4.1 mmol/L, chloride
110 mmol/L, bicarbonate 28 mmol/L,
blood urea nitrogen 3 mg/dl, creatinine
0.6 mg/dl, and glucose 91 mg/dl. Thyroidstimulating hormone (TSH) was low at 0.38
mIU/mL. Urine specific gravity was 1.006.
Workups for infectious and thromboembolic diseases were unremarkable.
Discussion
Hypopituitarism is a disorder of impaired
hormone production from the anterior and,
less commonly, posterior pituitary gland.
The condition can originate from several
broad categories of diseases affecting the
hypothalamus, pituitary stalk, or pituitary
gland. In adults, the etiology is often from
the mass effect of tumors or from treatment with surgery or radiotherapy. Other
causes include vascular, infectious, infiltrative, inflammatory, and idiopathic. Wellsubstantiated data on the incidence and
prevalence of hypopituitarism is sparse. It
has an estimated prevalence of 45.5 cases
per 100,000 and incidence of 4.2 cases per
100,000 per year.1
Clinical manifestations of hypopituitarism depend on the type and severity of
hormone deficiency. The consequences
of adrenal insufficiency (AI) range from
smoldering and nonspecific findings (e.g.
fatigue, lethargy, indistinct gastrointestinal symptoms, eosinophilia, fever) to fullfledged crisis (e.g. AMS, severe electrolyte
abnormalities, hemodynamic compromise,
shock). The presentation of central AI
(i.e., arising from hypothalamic or pituitary pathology) is often more subtle than
primary AI. In central AI, only glucocorticoid (GC) function is disrupted, leaving the
renin-angiotensin-aldosterone system and
mineralocorticoid (MC) function intact.
B
A
C
ROGER HARRIS / SCIENCE SOURCE
KEY POINTS
Case
Pituitary gland in the brain. Computer artwork of a person's head showing the left hemisphere of the
brain inside. The highlighted area (center) shows the pituitary gland. The pituitary gland is a small
endocrine gland about the size of a pea protruding off the bottom of the hypothalamus at the base of
the brain. It secretes hormones regulating homoeostasis, including trophic hormones that stimulate
other endocrine glands. It is functionally connected to and influenced by the hypothalamus.
This is in stark contrast to primary AI resulting from direct adrenal gland injury, which
nearly always disrupts both GC and MC
function, leading to more profound circulatory collapse and electrolyte disturbance.2
Aside from orthostatic blood pressure
or possible low-grade fever, few physical
exam features are associated with central AI.
Hyperpigmentation is not seen due to the
lack of anterior pituitary-derived melanocortins that stimulate melanocytes and
induce pigmentation. As for laboratory findings, hyperkalemia is a feature of primary
AI (due to hypoaldosteronism) but is not
seen in central AI. Hyponatremia occurs in
both types of AI and is vasopressin-mediated.
Hyponatremia is more common in primary
AI, resulting from appropriate vasopressin release that occurs due to hypotension.
Hyponatremia also occurs in secondary AI
because of increased vasopressin secretion
mediated directly by hypocortisolemia.3,4
In summary, hyperpigmentation and the
electrolyte pattern of hyponatremia and
hyperkalemia are distinguishing clinical
characteristics of primary AI, occurring in
up to 90% of cases, but these features would
not be expected with central AI.5
In the hospitalized patient with multiple active acute illnesses and infectious risk
factors, it can be difficult to recognize the
diagnosis of AI or hypopituitarism. Not
only do signs and symptoms frequently
overlap, but concomitant acute illness is
usually a triggering event. Crisis should
be suspected in the setting of unexplained
fever, dehydration, or shock out of proportion to severity of current illness.5
Not surprisingly, high rates of partial
or complete hypopituitarism are seen in
patients following surgical removal of pituitary tumors or nearby neoplasms (e.g. craniopharyngiomas). Both surgery and radiotherapy for non-pituitary brain tumors are
also major risk factors for development of
hypopituitarism, occurring in up to 38%
and 41% of patients, respectively.6 The
strongest predictors of hormone failure are
higher radiation doses, proximity to the
pituitary-hypothalamus, and longer time
interval after completion of radiotherapy.
Within 10 years after a median dose of 5000
rad (50Gy) directed at the skull base, nasopharynx, or cranium, up to three-fourths of
patients will develop some degree of pituitary insufficiency. Later onset of hormone
failure usually reflects hypothalamic injury,
whereas higher irradiation doses can lead to
earlier onset pituitary damage.5
Not all hormone-secreting cells of the
hypothalamus or pituitary are equally
continued on page
14
I KEY CLINICAL QUESTION I continued from page 13
susceptible to injury; there is a characteristic sequence of hormonal failure. The
typical order of hormone deficiency from
pituitary compression or destruction is as
follows: growth hormone (GH) > folliclestimulating hormone (FSH) > luteinizing
hormone (LH) > TSH > adrenocorticotropic hormone (ACTH) > vasopressin. A
similar pattern is seen following brain irradiation: GH > FSH and LH > ACTH >
TSH. A recent systematic review of 18 studies with 813 patients receiving cranial radi-
hypothalamic-pituitary axis feedback loops.
Thus, it can be more useful designating if
a high or low test value is appropriately or
inappropriately high or low. In the presented
case, low TSH level could be misinterpreted
as excess thyroid hormone supplementation. An appropriately elevated free T4 level
would confirm this, but an inappropriately
low free T4 would raise suspicion of central
hypothalamic-pituitary dysfunction.
With high enough clinical suspicion of
hypopituitarism, empiric treatment with
itary-adrenocortical hormone reserves,
precipitating adrenal crisis.5 Stress-dose
corticosteroids also ensure recruitment of
a mineralocorticoid response. Cortisol has
both GC and MC stimulating effects but is
rapidly metabolized to cortisone, which lacks
MC stimulating effects. Thus, high doses
overwhelm this conversion step and allow
remaining cortisol to stimulate MC receptors.2 These high doses may not be necessary
in secondary AI (i.e., preserved MC function) but would be reasonable in an unstable
With high enough clinical suspicion of hypopituitarism, empiric
treatment with thyroid supplementation and corticosteroids
should be started before confirmation of the diagnosis, to
prevent secondary organ dysfunction and improve morbidity
and mortality.
otherapy for non-pituitary tumors found
pituitary dysfunction was 45% for GH
deficiency, compared to 22% for ACTH
deficiency.7
Biochemical diagnosis of hypopituitarism
consists of measuring the various pituitary
and target hormone levels as well as provocation testing. When interpreting these
tests, whether to identify excess or deficient states, it is important to remember
the individual values are part of the broader
14
thyroid supplementation and corticosteroids should be started before confirmation of the diagnosis, to prevent secondary
organ dysfunction and improve morbidity
and mortality.2 Rapid administration with
intravenous levothyroxine can be given in
severe hypothyroidism or myxedema.
“Stress-dose” steroids are generally recommended for patients who are also administered levothyroxine, as the desired increased
in metabolic rate can deplete existing pitu-
patient or until confirmation is made with
an inappropriately low ACTH.
Back to the Case
Morning cortisol returned undetectable,
and ACTH was 14 pg/mL (6-58). Past
records revealed a down-trending TSH
from 1.12 to 0.38 mIU/mL, which had
inappropriately prompted a levothyroxine
dose reduction from 50 mcg to 25 mcg. A
free thyroxine (T4) was low at 0.67 ng/dL
(0.89-1.76). Estradiol, FSH, and LH were
undetectable. Prolactin was 23 ng/mL
(3-27). She was started on prednisone, 5 mg
daily, and her levothyroxine was adjusted
to a weight-based dose. Her fever resolved
with the initiation of prednisone, and all
cultures remained negative. Over two
weeks, she improved back to her baseline,
was discharged to a rehabilitation center,
and eventually returned home.
Dr. Inman is a hospitalist at St. Mary’s Hospital and Regional
Medical Center in Grand Junction, Colo. Dr. Bridenstine is an
endocrinologist at the University of Colorado Denver. Dr.
Cumbler is a hospitalist at the University of Colorado Denver.
References
1. Regal M, Pàramo C, Sierra SM, Garcia-Mayor RV.
Prevalence and incidence of hypopituitarism in an adult
Caucasian population in northwestern Spain.
Clin Endocrinol. 2001;55(6):735-740.
2. Bouillon R. Acute adrenal insufficiency. Endocrinol
Metab Clin North Am. 2006;35(4):767-75, ix.
3. Raff H. Glucocorticoid inhibition of neurohypophysial
vasopressin secretion. Am J Physiol. 1987;252(4 Pt
2):R635-644.
4. Erkut ZA, Pool C, Swaab DF. Glucocorticoids suppress
corticotropin-releasing hormone and vasopressin
expression in human hypothalamic neurons. J Clin
Endocrinol Metab. 1998;83(6):2066-2073.
5. Melmed S, Polonski KS, Reed Larsen P, Kronenberg
HM. Williams Textbook of Endocrinology. 12th ed.
Philadelphia, Pa.: Saunders/Elsevier; 2012.
6. Schneider HJ, Aimaretti G, Kreitschmann-Andermahr
I, Stalla GK, Ghigo E. Hypopituitarism. Lancet.
2007;369(9571):1461-1470.
7. Appelman-Dijkstra NM, Kokshoorn NE, Dekkers OM,
et al. Pituitary dysfunction in adult patients after cranial
radiotherapy: systematic review and meta-analysis.
J Clin Endocrinol Metabol. 2011;96(8):2330-2340.
Tons
more HM15
photos available at
the-hospitalist.org.
National
Gala
THOUSANDS TREK TO
WASHINGTON, D.C., FOR
HOSPITAL MEDICINE’S
BIGGEST EVENT
I By Richard Quinn
NATIONAL HARBOR, Md.—Cherry trees weren’t the only things that
blossomed around Washington last month. SHM’s annual meeting,
with roughly 2,500 attendees, featured 100 educational sessions, a day
of Congressional lobbying, and plenaries from the “Checklist Doctor”
and the Dean of Hospital Medicine. Pre-courses, the popular poster
competition, and updates on everything from anticoagulants to VTE
helped round out HM15, the specialty’s biggest annual event.
“I come to the meeting,” says new SHM President Robert Harrington,
Jr., MD, SFHM, “and then for the next 362 days, this is enough to get
me through the rest of the year …‘til I come back.”
INSIDE
16
Quality
Keynotes
17
18
Plant Your Flag
20
The Playbook
22
Clinical: Session
Analysis by
Team Hospitalist
Hill Day, c. 2015
25
19
26
Stars of the Show
Looking for
a Hero?
What’s App?
I STORIES BY RICHARD QUINN I PHOTOGRAPHS BY MANUEL NOGUERA
Quality Keynotes
HM15 speakers urge hospitalists to use technology, teamwork,
and talent to better healthcare
NATIONAL HARBOR, Md.—In the
convention business, some say an annual meeting is only as good as its keynote
addresses. Those people would call HM15
a home run, because the thousands of hospitalists who made their way to just outside the
nation’s capital last month were treated to a
trinity of talented talkers.
First up was patient safety guru Peter
Pronovost, MD, PhD, FCCM, senior vice
president for patient safety and quality at
Johns Hopkins Medicine in Baltimore.
Maureen Bisognano, president and CEO of
the Institute for Healthcare Improvement
LEFT: Peter J. Pronovost, MD, PhD,
FCCM, kicks off the speaker series
with his presentation about the quality
in healthcare during Day 2 of HM15.
RIGHT: Society of Hospital Medicine
incoming President Robert Harrington,
Jr., MD, SFHM, talks about the
importance of diversity at HM15.
16
(IHI), echoed his patient-centered focus
in her address. The four-day confab ended
with hospitalist dean Bob Wachter, MD,
MHM, reading from his new book, “The
Digital Doctor: Hope, Hype, and Harm at
the Dawn of Medicine’s Computer Age.”
The three came from different perspectives but ended up in the same place: Hospitalists can use technology, teamwork, and
talent to be the people who make healthcare
in this country safer. In fact, HM has the
responsibility to do so.
“We are the only hope that the healthcare
system has of improving quality and safety,”
Dr. Pronovost said.
Famous for creating a five-step checklist
designed to reduce the incidence of central
line-associated infections, he talked about
healthcare in terms of physicians telling
“depressing” stories that hold change back.
“The first is that we still tell a story that
harm is inevitable,” he said. “‘You’re sick,
you’re old, you’re young, stuff happens.’
Second, we still tell stories that [show that]
safety and quality are based on the heroism
of our clinicians rather than design of safe
systems. And, third, we still tell a story that ‘I
am powerless to do anything about it.’
“We need some new stories.”
Reframing the discussion of healthcare
into a story of preventing all harm is ambitious but doable, he added. Hospitalists
need to team with others,
though, because an overhauled healthcare system
needs buy-in from all
physicians.
“The trick of this is to
have enough details that
people want to join you,
but don’t completely tell
the story, because others
have to co-create it with
you,” Dr. Pronovost said.
“You tell the why and
the what, but the how is
co-created by all of your
colleagues who are working with you.”
Bisognano says hospitalists can help hospitalists achieve IHI’s Triple
Aim, an initiative to
simultaneously improve
the patient experience and the health of
populations, reducing the per capita cost
of healthcare. But, like Dr. Pronovost, her
argument is based on a new view of the
healthcare system.
“We need not a system that says, ‘What’s the
matter?’ but a system that understands deeply
what matters to each patient,” Bisognano said.
That prism requires speaking a new
“language,” one that uses quality of care
delivered and defines it more broadly than
simply mortality rates and adverse events.
“You can look at health and care, but you
also can drive out unnecessary cost,” she said.
“And being a former hospital CEO, I can say
it was magic when a clinician could walk in
and be able to talk in both languages.”
Dr. Wachter spoke of the past, present,
and future of the digital age of medicine.
He is as frustrated by poor electronic health
record (EHR) rollouts as front-line hospitalists but notes that healthcare in the past five
years has seen a digital revolution in a much
shorter time period than most industries,
thanks to federal incentives.
“Most fields that go digital do so over the
course of 10 or 20 years, in a very organic
way, with the early adopters, the rank and
file, and then the laggards,” he said. “And
in that kind of organic adoption curve, you
see problems arise, and people begin to deal
with them and understand them and mitigate them.
“What the federal intervention did was
essentially turbocharge the digitization of
healthcare. We’ve seen this in a very telescoped way. … It’s like we got started on a
huge dose of chemo, stat.”
Moving forward, Dr. Wachter said the
focus has to be on improving the use and integration of healthcare to ensure that it translates to better patient care. For example, going
to digital radiology has in many ways ended
the daily meetings that once were commonplace in hospital “film rooms.” In essence, the
move from “analog to digital” meant people
communicated less. Now, multidisciplinary
rounds and other unit-based approaches are
trying to recreate teamwork.
“Places are doing some pretty impressive
things to try to bring teams back together in a
digital environment,” Dr. Wachter said. “But,
the point is, I didn’t give this any thought.
I don’t know whether you did. What didn’t
cross my own cognitive radar screen was that
when we go digital, we will screw up the relationships, because people can now be wherever they want to be to do their work.”
LISTEN NOW
New SHM President Robert
Harrington Jr., MD, SFHM, talks
about his views on hospital
medicine, the society, and the value
of diversity and teamwork.
National Gala
Plant Your Flag
When it comes to quality and patient safety,
hospitalists have a large “stake in the game”
NATIONAL HARBOR, Md.—Don Lee,
MD, MPH, is building what one might call
an analog quality improvement (QI) project
focused on reducing readmissions. What the
medical director for clinical integration at
Columbia St. Mary’s in Milwaukee does is
work with patient navigators to make followup phone calls after discharge to get ahead of
potential issues.
What he wants to do is design a system
that ensures that happens.
So, he came to HM15 for help.
“I’m very interested in continuous quality improvement. I wanted to work on how
to not only get the project off the ground,
but also to make sure what we are doing is
good, and it’s doing what it’s supposed to be
doing,” Dr. Lee says.
Well, he came to the right place. Quality
and patient safety are hallmarks of the annual
meeting; this year’s gathering was no exception. Plenaries provided advice from national
thought leaders on improving safety by
improving the patient experience; breakout
sessions focused on how to build, maintain,
and sustain QI projects; and SHM unveiled
a new educational track dubbed the “DoctorPatient Relationship.”
Hospital medicine, and healthcare in a
broader sense, needs to be able to define safety
better to attack it proactively, says Maureen
Bisognano, president and CEO of the Institute for Healthcare Improvement (IHI). She
compared medicine to NASA, which tracks
its missions in a continuum of
both successes and failures to
understand what processes and
protocols lay behind each.
Medicine has no such pathway laid out to date, though
Bisognano said her task for the
next year is to try to define one.
“We don’t know what the
system of safety looks like,” she
said. “We don’t know how many
times we duplicate tests on admission because we haven’t connected
with primary care. We don’t know
how many times we send somebody home with inadequate social
support, no food, and no way to
pick up their prescription.
“We don’t have a sense of where
our near-misses are, so we don’t
Maureen Bisognano, president and CEO of the Institute
have a vision of safety.”
Healthcare Improvement, talks about “Leading TransHospitalist Kedar Mate, MD, of
formational Change” at HM15.
senior vice president for innovation at IHI, says that QI projects
can seem daunting in the midst of daily Dr. Mate, an assistant professor of medicine
censuses, hospital committee meetings, and at Weill Cornell Medical College in New
a myriad of other responsibilities physicians York City and a research fellow at Harvard
face. But much of that fear is perception. A Medical School’s Division of Global Health
project can be simple or system-wide. The Equity. “It’s not that mysterious. It’s kind of
trick is just getting started in the face of a straightforward thing, actually, if you work
through it logically and stepwise.”
perceived hurdles, he adds.
And, as front-line providers, hospitalists
“Language around quality improvement
tends to confuse and create mystery, and the are primed to lead healthcare systems in how
jargon and so on creates interference,” says to deliver care, he said.
“Formerly, physicians were iterant, right?”
Dr. Mate adds. “They would come in and
out of institutions and didn’t really have a
stake in the game, on some level, of institutional quality. That’s totally different now.”
But, while the individual hospitalist has a
responsibility to embrace safety initiatives,
employers and industry groups have a duty
to provide the proper resources to make that
connection easier.
“The individual’s responsibility is to try
to access that information to carry on in the
face of busy schedules and busy lives,” Dr.
Mate says. “SHM, IHI, and others have a
responsibility to try to make those that are
inclined able to continue and able to build
and move their efforts forward in an even
more productive way.”
Inclined docs like Dr. Lee, who know that
their hospitals collect reams of data that can
be useful for patient safety projects, many
times have no idea how to extract said data.
He has learned that partnering with “gatekeepers” is a way to help others help him.
“We are collecting data every second,
every minute,” Dr. Lee says. “It’s amazing
how much data we have, but to actually sift
through it and make it meaningful is very
difficult. ... You have to know what questions
to ask and you have to get buy-in from the
[gatekeepers], because they get thousands of
requests for data extraction.”
Q&A
QUESTION: Quality improvement guru Peter Pronovost, MD, PhD, senior vice president for patient safety and
quality at Johns Hopkins Medicine in Baltimore, challenged attendees at HM15 to finish this sentence about how
they will make healthcare safer: “I will…” The Hospitalist talked to a few doctors who accepted the challenge.
“I will let them
know that
everything is
possible. If
you’re really
negative and
you feel like you
are not going
to get your goal, nothing will
be done and nothing will be
accomplished for the patient.”
–Hospitalist Salah Mohageb, MD
Virtua Medical Group, Marlton, N.J.
“Spending more time
with the patients, listening to their stories in life
and trying to incorporate
that into daily rounds and
your overall coordination
of care for the patient is
really important. … My
job is to make sure the patient is heard.
The patients and families—their stories
and their requests of care really need to
be heard.”
–Hospitalist Moncy Varughese, MD
Highland Park Hospital, NorthShore University
Health System, Chicago
“I’m always a guy
that sits down
in the patient’s
room, looks them
in the eye, and
doesn’t leave
until all the questions are asked.
So I really applaud those types of
initiatives. … That hits home and
makes you want to keep teaching and telling less experienced
doctors how to do that.”
–Timothy Farmer, MD, locums tenens
hospitalist in North Carolina
HM15 CONTINUES ON PAGE 18
CONTINUED FROM PAGE 17
Hill Day, c. 2015
Hospitalists march on the Capitol, put a face and a voice
to three major healthcare issues
NATIONAL HARBOR, Md.—Armed
with blue folders chockablock with agendas, talking points, and fact sheets, about
100 hospitalists boarded three charter buses
and descended on Capitol Hill last month
like a swarm of erudite high schoolers on a
class trip.
Clad in state-themed ties, suits, and
dresses, the group’s goal was singular: Introduce the concept of hospital medicine to
every senator, representative, and Congressional staffer who would take the time to
meet them, and let those folks know that
SHM and its members stand at the ready to
serve as a resource for politicians.
“We don’t go to Washington and say, ‘You
need to pay hospitalists more money,’” says
SHM CEO Larry Wellikson, MD, MHM.
“We go and we say, ‘You have a problem.
We have a solution. Why don’t we work
together to create the future?’ This is what
people need to hear. This is a breath of fresh
air, and that’s why we get invited back and
we’re part of the discussion.”
This year’s discussion was formally titled
Hospitalists on the Hill, version 2015. The
turnout always improves when the annual
meeting is just across the Potomac River at
the Gaylord National Resort & Convention
Center, as it has been for three of the past
six years. The society ferried hospitalists to
the offices of Washington power players with
three goals this year:
• Push for support for the Improving
Access to Medicare Coverage Act of 2015
(H.R. 1571 and S. 843), as it would
adjust Medicare rules to allow observation status to be counted toward the
three-day inpatient rule for coverage of
care in skilled nursing facilities.
• Ask for support for the Personalize Your
Care Act, a soon-to-be-reintroduced
bill from U.S. Rep. Earl Blumenauer
(D-Ore.) authorizing Medicare to pay for
end-of-life care discussions and building
in opportunities for patients to participate
in their long-term care planning.
• Push for Congress to repeal the sustainable growth rate (SGR) formula and
create a “pathway towards payment
models that reward quality and efficiency.” This legislative “ask,” to use lobbying
parlance, is an evergreen that has been an
SHM priority for years.
Jodi Strong, director of operations at
18
whether it be a representative or senator, you
talk to the people that actually directly influence and impact not only the work that we
do, but the work that we do for our patients,”
he says. “In that regard, we represent a voice
for them, to explain to them who we are and
what we do and what our patients’ needs are.
“They depend on us.”
That’s the message that Stephanie Vance,
who founded Washington-based Advocacy
Associates LLC, pushed as she prepped the
laymen lobbyists for more than an hour
before sending them off to their meetings.
Vance, a 25-year veteran of
the political scene, reminded
“Any time you get
hospitalists during the
to have face-to-face breakfast prep session that
those in Congress are elected
time with one of
serve—and that means
your Congressional to
they’re elected to listen.
leaders, whether it
Hospitalist Gordon Johnson, MD, FACP, FHM, got
be a representative
the message. He’s presior senator, you talk
dent of the SHM’s Oregon
to the people that actually directly Chapter, but he had never
done a lobbying trip like
influence and impact not only the this before. The appeal was
simple and effective to him.
work that we do, but the work
“The more of us that are
that we do for our patients.”
involved, the more mean—H.E. “Chip” Walpole, Jr., MS, MD ingful it is,” he says. “When
[members of Congress and
their staffs] have people
The trick of lobbying is getting those in coming from their constituency, that carries
power to see the world as those in practice a message. It does carry a stronger message.”
But, as with patient discharge, the
do. It helps when the two are friends. H.E.
“Chip” Walpole Jr., MS, MD, regional message is always strongest with good
medical director of Select Medical of Green- follow-up. Vance, known to many as
ville, S.C., has known U.S. Rep. Trey Gowdy “the advocacy guru,” urged hospitalists to
(R-S.C.) for years. When they talk about follow up after their meetings—an occamedical issues, it helps the congressman get sional phone call or e-mail to let the person
know that, should they have any questions,
a stethoscope-on-the-ground view.
“He’ll say, ‘I know I can trust Chip and a hospitalist is standing by to provide
he’ll give me a straight answer for a prob- answers. To Dr. Walpole, a connection like
lem,’” Dr. Walpole says. “Then it’s about that can be worth more than hiring a whiteinviting them, to say ‘Hey, come and see. shoed lobbying firm.
“When you put a face with someone—
You want to learn a little bit more about
what we do in the hospital? Come and see ‘Oh, I know Chip, I know Richard from
back home,’—they make a connection with
our facility.’”
And, while many first-time Hill Day someone that is real and personal to them,”
attendees get nervous about trying to impress he says. “And, ultimately, that can probably
the Beltway, Dr. Walpole views it from the make a bigger difference in influencing how
they represent us than anything else.”
flip side.
“Any time you get to have face-to-face
time with one of your Congressional leaders, Richard Quinn is a freelance writer in New Jersey.
Novant Health, a 12-hospital group based
in Charlotte, N.C., says that she joined this
year’s advocacy pilgrimage for the first time
because, in a time of generational upheaval
in the American healthcare system, every
voice should be heard.
“One vote does make a difference, and I
want to be a part of that process,” she says,
adding, “Hospitalists are very instrumental in the patient, the care that they receive,
where they go after they’ve had a hospital
visit, how they connect with the patient’s
primary care physician.”
National Gala
Stars of the Show
SHM’s annual RIV poster competition attracts the
best, brightest from all corners of the country
NATIONAL HARBOR, Md.—On one
end of the cavernous exhibit hall space at
HM15 stood Brendan Sullivan, OMS-II,
a second-year medical student, practically
grinning as he showcased his poster on the
effects of bedside rounds with nurses. On
the other side stood Donald Tashkin, MD, a
pulmonologist who began his training in the
1960s and was talking like a younger man
about his poster on drug therapies for exacerbated cases of COPD.
Both men were first-time presenters at
SHM’s annual Research, Innovations, and
Clinical Vignettes (RIV) poster competition.
The contest has become one of the meeting’s most popular rites, growing so big it
now spans two of the conference’s four days.
This year’s competition drew a record 1,297
abstracts, topping the prior record of 1,132
and fully double the 634 abstracts submitted
for HM10, according to SHM.
What makes the contest popular is that its
posters are as varied as the presenters’ motives.
Take Sullivan, a student at Midwestern University Chicago College of Osteopathic Medicine in Downers Grove, Ill. His
poster, “Examining the Future of Hospitalist Medicine: Impact of Bedside Rounding
with Nurses on Patient Care,” served as his
introduction to the specialty.
“You can see the tangible results [hospitalists] have,” he says. “Working with the
nurses, the nurses recognize [hospitalists]
as a continuous part of hospital life. It just
seems like, as a field, there’s definitely a lot
of opportunity for medical students like me,
Brendan Sullivan,
a second-year
medical student
at Midwestern
University Chicago
College of Osteopathic Medicine in
Downers Grove, Ill.,
(right) discusses
his poster, “Examining the Future
of Hospitalist
Medicine: Impact
of Bedside Rounding with Nurses on
Patient Care,” at
HM15 with Mihai
Gravis, MD, FHM,
of ApolloMD in
Richmond, Va.
2015 RIV WINNERS
Research
OVERALL: Standardizing Attending
Rounds to Improve the Patient
Experience: A Cluster Randomized
Controlled Trial
Bradley Monash, MD; Nader Najafi,
MD; Dimiter Milev, MPH; Marcia Glass,
MD; Yile Ding, MD; Alvin R. Rajkomar,
MD; Michelle Mourad, MD; Sumant
Ranji, MD; Bradley A. Sharpe, MD and
James D Harrison, MPH, PhD
TRAINEE: Prevalence and
Appropriateness of Fasting Orders
in the Hospital: “Doctor, When Can
I Eat?”
Atsushi Sorita, MD, MPH; Charat
Thongprayoon, MD; Adil Ahmed, MD;
Ruth E. Bates, MD; John T. Ratelle,
MD; Katie M. Rieck, MD; Aditya
P. Devalapalli, MD; Meltiady Issa,
MD; Riddhi M. Shah, MD; Miguel A.
Lalama, MD; Wang Zeng, PhD; M.
Hassan Murad, MD, MPH, and
Deanne T. Kashiwagi, MD
Innovation
who want to go into internal medicine but
[are] not really sure what aspect of internal
medicine. Hospital medicine is definitely a
very viable career option.”
Sullivan’s project came about because of
work with his faculty mentor, a second-year
hospitalist. At HM15, with the titans of the
field walking around him, Sullivan showed
his work off proudly but respectfully.
“It’s definitely a learning experience for
me,” he says. “I’m just taking a backseat
and soaking it all in. I realize that being
one of the youngest and more inexperienced members here, I have a lot to learn
.… I spent eight weeks in a field they’ve
been doing for 20 years.”
Donald Tashkin, MD, of Pacific Palisades,
Calif., talks about his poster in the RIV poster
competition.
But experience doesn’t mean a poster
presenter has been here before. Dr. Tashkin,
a veteran pulmonologist at UCLA’s David
Geffen School of Medicine in Los Angeles,
had never been to an SHM annual meeting.
He presented two related posters on COPD
drug therapies.
Where Sullivan was awed by the experience, Dr. Tashkin was in it for the academic
stimulation that comes with bouncing medical ideas off of medical minds.
CONTINUED ON PAGE 20
OVERALL: Developing Frontline
Teams to Drive Health System
Transformation
Jeffrey J. Glasheen, MD; Ethan
Cumbler, MD; Patrick P. Kneeland,
MD; Jennifer L. Wiler, MD, MBA;
Daniel Hyman, MD; Gail Armstrong,
DNP, PhD, ACNS-BC, CNE; Sarah
J. Caffrey, MBA; Zachary Robison,
MBA; Bryan Gomez, BA; Molly Lane,
BS; Michelle Rove, BS; Heather J.
Bennett, MS, MBA, and Read G.
Pierce, MD
TRAINEE AWARD: Enhancing
Patient Engagement in Stroke Care:
Developing Patient Centered Tools
David Medrano; Megan Ross, MPH;
Stephen Groves, MBA; Melanie
Muszelik; Madeline Rovira; Rachel
de Andrade Pereira, MS; Joseph R
Sweigart, MD; Read G. Pierce, MD,
and Darlene Tad-y, MD
Vignettes
OVERALL: Leave No Stone
Unturned
Dr. John Stephens, MD, and Davis
Viprakasit, MD
TRAINEE: Discharge Against
Medical Advice: A Challenge in
Patient-Centered Care
Parker Richards Hill, MD, and
Jennifer Pascoe, MD
PEDIATRIC HOSPITAL MEDICINE:
When a Fever Gets Cross-Eyed
Ana G. Cristancho, MD, PhD, and
Tara Wedin, MD
PATIENT EXPERIENCE: Building a
Patient-Centered Hospitalist Culture
Suparna Dutta, MD, MPH; Francis
Fullam, MA; Jisu Kim, MD, MSc, FHM;
Jill Wener, MD; Margaret McLaughlin,
MD, and Amir K Jaffer, MD, MBA
“It’s an intellectual enjoyment,” he says.
“You can learn things when you talk to
people, because they give you certain insights
that you never thought of before. It’s not
about ego; I’ll tell you that.”
Poster presenters say that a lot. The sharing of projects isn’t about adulation, they say.
It’s about finding fellow hospitalists who are
dealing with the kinds of issues that plague
all hospital medicine groups. That’s why
Greta Boynton, MD, SFHM, enjoys the
RIV sessions.
“When you walk around and see all the
great work that other people have done, most
people are working on very similar things,
like readmission rates or quality or [patient]
satisfaction,” says Dr. Boynton, division chief
of hospital medicine for Baystate Health in
Springfield, Mass. “You get a lot of practical
suggestions for things that you could implement in your own group.”
Dr. Boynton, regional medical director
for the Northeast for Sound Physicians, has
“I’ve done a lot of practice management and process
improvement initiatives over the years, and I have not
brought them forward here. Then when you see other
people working on similar things, you kind of kick
yourself for not showing how you did it.”
—Greta Boynton, MD, SFHM
thought that for years, but this year she took
the added step of presenting her first two
posters. While showcasing one titled “Unit
Medical Director as Career Development for
Young Hospitalist,” she said years of seeing
work similar to her own left her wondering
why she didn’t present.
“I’ve done a lot of practice management
and process improvement initiatives over the
years, and I have not brought them forward
here,” she says. “Then when you see other
people working on similar things, you kind of
kick yourself for not showing how you did it.”
THE ACADEMIC
HOSPITALIST ACADEMY
October 7-10, 2015
The Inverness Hotel and Conference Center
Englewood, Colorado
The Academy provides junior academic hospitalists
with the educational, scholarly and professional
development skills needed to advance their careers.
Register Before
July 6, 2015 and Save $300.
So she did it. And now she’s glad she did.
“I feel proud of my hospitalist team,”
Dr. Boynton says. “The fact that people
are interested in it, the fact that they’re
asking questions—practical questions on
how it might look on a smaller team—very
rewarding.”
Rehan Qayyum, MBBS, medical director of the academic hospitalist program at
University of Tennessee College of Medicine in Chattanooga, Tenn., has found one
reward particularly useful: peer review.
Over the course of roughly 10 posters
presented over the years, he has used the
comments of passersby to hone his writing
skills. He is now transforming his poster,
“Effect of HCAHPS Reporting Patient
Satisfaction with Physicians,” into a paper
he plans to publish.
The RIV session is free editing.
“They’re talking about what they think
about how I should be looking at things
that are not very clear, or things they may
have interest in,” Dr. Qayyum says. “When
I’m writing the discussion part or when I’m
writing the methods and results part, I may
focus on those [comments], add those parts,
maybe. Or highlight those things in discussion where people show interest.
“I may be more focused in what I’m doing
and may lose what may be important for
other people. But being here and letting
other people see my work and discuss it with
me … that helps a lot.”
SHM’s eLEARNING INITIATIVES
TOGETHER IN ONE LOCATION
Stay updated with new content:
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• shmConsults is moving to SHM’s
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Don’t miss the opportunity to easily
capture and track CME credits.
www.academichospitalist.org/earlybird
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20
National Gala
The Playbook
HM15 offers hospitalist leaders equal parts training, encouragement
“Make sure that no
matter what conflict
might be up front,
that everybody is
looking at the goals
downstream and
saying, ‘Yes, that is
a goal we want to
achieve. We want to
have better patient
safety metrics.
We want to have
decreased readmissions. We want to
have better transitions of care.’”
—David Weidig, MD
NATIONAL HARBOR, Md.—Patient
satisfaction, physician engagement, and
administrator buy-in, oh my.
So went the thoughts of Jaidev Bhoopal, MD, last month at HM15. He’d been
a hospitalist for about eight years, but he
was named section chair about a month
before he arrived at the annual meeting. His
calculated first stop was the daylong practice management pre-course titled “Where
the Rubber Meets the Road: Managing in
the Era of Healthcare Reform.”
The timing couldn’t have been better.
“I’m starting a new role and I wanted
to get input and ideas,” said Dr. Bhoopal,
section chair of the hospitalist department
at St. Mary’s Medical Center in Duluth,
Minn. “This gives you a playbook of where
you want to be and where you want to go.”
A playbook for where to go could just
as well be the slogan for practice management’s role at SHM’s annual meeting. An
educational track, a dedicated—and everpopular—pre-course, and a chance to ask
the field’s founding fathers their best practices were among the highlights of this
spring’s four-day confab.
The need for practice management and
leadership training is greater in the past
few years as hospitalists have been more
confounded than ever with how to best
run their practices under a myriad of new
rules and regulations tied to the Affordable
Care Act and the digitization of healthcare. At their core, the changes are shifting
hospital-based care from fee-for-service to
value-based payments.
“The tipping point is really here for us,” said
Win Whitcomb, MD, MHM, chief medical
officer of Remedy Partners of Darien, Conn.
Dr. Whitcomb, a founder of SHM and
regular columnist for The Hospitalist, said
that HM group (HMG) leaders have to be
well versed in how to navigate a landscape
of alternative payment models to excel in
the new paradigm. Particularly after the
announcement earlier this year that the
federal government has set a goal of tying
85% of Medicare hospital fee-for-service
payments to quality or value by 2016, and
that percentage could increase to 90% by
2018. The January announcement was the
first time in Medicare’s history that explicit
goals for alternative payment models and
value-based payments were set, according
to an announcement from the U.S. Department of Health and Human Services.
“Strategically, these things are essential to
work into the plan of what the hospital medicine group is doing in the coming three to five
years,” Dr. Whitcomb said. “Hospitalists can’t
Tracy Cardin,
ACNP-BC, FHM,
chair of SHM’s
NP-PA Committee,
answers questions during the
“Role of NPs and
PAs in Hospitalist
Medicine” precourse at HM15.
do this alone. They have to do it with teams.
It’s not only teams of other professionals in
the hospital and around the hospital, but it’s
other physicians.”
Dr. Whitcomb said key to the new
paradigm is shared financial and clinical
responsibilities. He says hospitalists have to
“change our thinking…to a mindset where
we’re in this together.”
Part of that shared responsibility extends to
the post-acute care setting, where SHM senior
vice president for practice management Joseph
Miller said that some 30% of HMGs are practicing. To help those practitioners, SHM and
IPC Healthcare of North Hollywood, Calif.,
debuted the “Primer for Hospitalists on
Skilled Nursing Facilities” at HM15.
The educational program, housed at
SHM’s Learning Portal (www.shmlearning
portal.org), has 32 lessons meant to differentiate the traditional acute-care hospital
from post-acute care facilities. It is grouped
in five sections and two modules, with a focus
on skilled-nursing facilities (SNFs), which are
the most common post-acute care settings.
“The types of resources that are available
are different, and that’s not only in terms of
staff, but the availability of specialists, the
LISTEN NOW
SHM founder Win
Whitcomb, MD, MHM,
chief medical officer of
Remedy Partners of Darien,
Conn., talks about the
annual practice management
pre-course in an ever-changing healthcare landscape.
availability of testing capabilities,” Miller
said. “If you need to work with a cardiologist for a particular patient...how do you
engage them? You’re not going to be able
to have them come and see that patient
frequently. How do you communicate with
them to get the feedback you need as the
attending physician?”
Another communication hassle involves the
growing number of HMGs spread over multiple sites. For Sara Shraibman, MD, an assistant
program director at Syosset Hospital in Syosset,
N.Y., those sites are two hospitals covered by
the North Shore LIJ Medical Group.
“It’s actually a new program, so we are
trying to look at our compensation, models
comparing them across two hospitals…and
how we manage,” she said. “Not every hospitalist will go back and forth. Some will, some
won’t. Some will work nights to help cover,
some won’t. It’s very interesting trying to
come up with a schedule.”
The best way to address conflict at multisite groups is communicating and focusing
on shared goals, said David Weidig, MD,
director of hospital medicine for Aurora
Medical Group in West Allis, Wis., and a
new member of Team Hospitalist.
“Make sure that no matter what conflict
might be up front, that everybody is looking at the goals downstream and saying, ‘Yes,
that is a goal we want to achieve. We want to
have better patient safety metrics. We want to
have decreased readmissions. We want to have
better transitions of care,’” Dr. Weidig said.
“The common goal all the way from hospital
administrators all the way down to hospital
physicians is going to be the key.”
Team Hospitalist Analyzes
HM15’s Clinical Session
HM15’s contributing writers
Julianna Lindsey,
MD, MBA, FHM,
is a hospitalist and
physician leader
based in the
Dallas-Fort Worth
Metroplex. Her
focus is patient
safety/quality and
physician leadership. She has
been a member of
Team Hospitalist
since 2013.
David M. Pressel,
MD, PhD, is
medical director of inpatient
care at A.I.
duPont Hospital
for Children in
Wilmington, Del.
He joined the
team in 2014.
Palliative Care
and Last-Minute
Heroics
By Julianna Lindsey, MD, MBA
HM15 Session: Last-Minute
Heroics and Palliative Care – Do
They Meet in the Middle?
HM15 Presenter: Tammie Quest, MD
Summation: Heroics - a set of medical
actions that attempts to prolong life with a
low likelihood of success.
Palliative care - an approach of care
provided to patients and families suffering
from serious and/or life-limiting illness;
focus on physical, spiritual, psychological,
and social aspects of distress.
Hospice care - intense palliative care
provided when the patient has terminal
illness with a prognosis of six months or less
if the disease runs its usual course.
We underutilize palliative and hospice care
in the U.S.; fewer than 50% of all patients
receive hospice care at end of life, and of
those who receive hospice care, more than
22
Nancy K.
Zeitoun, MD,
FHM, is assistant
professor of medicine at Hofstra
North ShoreLIJ School of
Medicine in New
Hyde Park, N.Y.
She joined the
team in 2014.
Sowmya
Kanikkannan,
MD, SFHM, is
hospitalist medical director and
assistant professor of medicine at
Rowan University
School of Medicine
in Stratford, N.J.
She joined the
team in 2014.
Follow her on
twitter
@skanikkannan.
half receive care for fewer than 20 days, while
one in five patients dies in an ICU. Palliative care can and should co-exist with lifeprolonging care following the diagnosis of
serious illness.
Common therapies/interventions to be
contemplated and discussed with patient at
end of life: CPR, mechanical ventilation,
central venous/arterial access, renal replacement therapy, surgical procedures, valve
therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental
oxygen, artificial nutrition, antimicrobials,
blood products, cancer-directed therapy,
antithrombotics, anticoagulation.
Practical Elements of Palliative Care: pain and
symptom management, advance care planning, communication/goals of care, truth
telling, social support, spiritual support,
psychological support, risk/burden assessment of treatments.
Key Points/HM Takeaways:
1. Palliative care bedside talking points• Cardiac arrest is the moment of death;
very few people survive an attempt at
reversing death.
• If you are one of the few who survive
to discharge, you may do well, but few
will survive to discharge.
• Antibiotics DO improve survival; antibiotics DO NOT improve comfort.
• No evidence to show that dying from
pneumonia, or any other infection, is
painful.
•
A llowing natural death includes
permitting the body to shut itself down
through natural mechanisms, including infection.
• Dialysis may extend life, but there will
be progressive functional decline.
2. Goals of care: Define what therapies are
indicated. Balance prolongation of life with
the illness experience.
Hospital
Management of
Patients Presenting
with ALTE: An
Evidence-Based
Approach
By David M. Pressel, MD, PhD
HM15 Presenter: Jack Percelay,
MD, MPH
Summation: In a presentation on guidelines for apparent life-threatening events
(ALTE), Jack Percelay, MD, MPH, SHM
representative to the American Academy of
Pediatrics (AAP) Subcommittee, provided
further insight into the work that has been
done for the clinical entity known as ALTE
since a consensus statement was put forward
by the NIH in 1986. The original statement
emphasized four possible features to constitute ALTE: apnea, color change, change in
tone, and gagging. The imprecise nature of
the definition, along with both provider and
caretaker anxiety related to the diagnosis,
have led to a cascade of diagnostic testing and treatments for what is a symptom
complex, not a disease.
Subsequent work in the field has clarified that an ALTE is not a risk factor for
sudden infant death syndrome (SIDS). Of
the myriad of etiologies that can cause an
ALTE, many will have a readily identifiable
etiology that a good history and physical
exam will diagnose. Most other diseases, if
not diagnosed at initial presentation, will
become apparent subsequently, without
any significant consequences (e.g. epilepsy).
Two diagnoses that may have significant
consequences if missed include child abuse
and a cardiac arrhythmia.
In an effort to synthesize new data with
expert opinion, the AAP has convened a
subcommittee on the guideline for ALTE,
led by Joel Tieder, MD, MPH, to develop a
new practice guideline. This guideline is still
in development, with certain areas not ready
for broad dissemination. The highlight of
the new guideline will be a proposal for a
name change for ALTE. Dr. Percelay reports
the proposed new name would be BRUE
(pronounced “brew”), which stands for brief
resolved unexplained event. He anticipates
further information that will offer a framework to specify which infants to consider at
low risk of recurrence and which to consider
at higher risk for significant pathology. For
those infants identified as low risk, the
guideline will offer specific evaluation and
treatment recommendations. An anticipated key point of the new guideline will
be that a careful history and physical is the
cornerstone of the initial evaluation and that
in the absence of specific historical or exam
findings, diagnostic testing of well-appearing infants is of low value.
Assessing,
Managing Delirium
in Hospitalized
Patients
By Julianna Lindsey, MD, MBA
HM15 Presenter: Ethan Cumbler,
MD, FHM, FACP
Summation: Delirium, a common problem in hospitalized patients, is all too often
iatrogenic. Delirium is associated with poor
outcomes such as prolonged hospitalization
and functional decline, and it increases the
risk of nursing home admission. The tool
most commonly used to assess the presence of
delirium is the Confusion Assessment Method (CAM). Dr. Cumbler educated the audience on a more refined tool, the 3D-CAM,
and provided the algorithm for diagnosis and
evaluation of hospital-onset delirium.
National Gala
Where delirium is concerned, as with
most conditions, “an ounce of prevention
is worth a pound of cure.” Namely, avoid
prescribing problem medications such as
anticholinergics, sedative/hypnotics (except
benzodiazepines for treatment of alcohol
withdrawal), and antihistamines, and minimize narcotics, but don’t undertreat pain,
because uncontrolled pain is a more potent
delirium trigger than narcotics.
Avoid sleep deprivation. Do we really
need vital signs and phlebotomy between
midnight and 6 a.m.? Make sure patients
have their glasses and hearing aids, and keep
them up and moving during daylight hours.
Sleep and sensory deprivation are effective
forms of human torture and are known to
be rather disorienting.
Finally, antipsychotics are associated with
increased mortality in dementia. Patients
with agitated delirium may benefit from a
low dose of haloperidol. When prescribing
haloperidol, remember that IV administration requires EKG monitoring (FDA black
box warning), and a reasonable starting dose
is 0.5 mg, not 5 mg.
•U
se CAM, 3D-CAM to diagnose delirium;
•
Avoid anticholinergic medications
(promethazine, cyclobenzaprine, oxybutynin, amitriptyline, prednisolone, theophylline, dixogin, furosemide);
• Minimize, but do not avoid, narcotics
in patients with both pain and delirium;
• Use low-dose antipsychotics, not benzodiazepines, for agitated delirium; and
•Stop antipsychotics ASAP, ideally prior
to discharge; if this is not possible,
then include discontinuation date on
discharge medication list.
Bedside
Procedures and
Ultrasound:
Evidence and Cost
of Doing Business
By Nancy K. Zeitoun, MD, FHM
HM15 Presenters: Joshua D.
Lenchus, DO, RPh, FACP, SFHM,
and Nilam Soni, MD, FHM
Summation: Drs. Lenchus and Soni
focused on the forces that are driving the
value and success of established procedure
teams in hospital medicine groups (HMGs).
These stem from a need to rapidly address
the growing shortage of skilled internists
who can perform diagnostic and therapeutic procedures, which leads to a subset of
hospitalists who are willing to provide these
services, particularly with the assistance of
bedside ultrasonography.
They stressed the importance of providing a platform that is preemptive, proprietary, and scalable. With a defined set of
the exam at normal speed without
commentary.
• Deconstruction. The teacher performs
the exam while describing the steps.
• Comprehension. The teacher performs
the exam while the learner describes the
steps.
• Performance. The learner performs the
exam while also describing the steps.
This approach can be abbreviated for
more advanced learners, with the middle
two steps combined in a discussion between
the teacher and learner to highlight any
differences or changes in technique.
Update in Hospital
Medicine 2015
HM15 procedures pre-course faculty trainer Karen Hust (center) has a hands-on discussion
with Christine Lucarelli, MD, a hospitalist at Mid Coast Hospital in Brunswick, Maine (right) and
Alberto Soyano, MD, of Winchester Hospital in Winchester, Mass.
value-creating metrics, such as faster turnaround times, a reduction in complication
rates, and, ultimately, a reduction in cost,
length of stay, and utilization, data must be
collected to adequately measure the impact
of these services on the institution.
They also discussed the key components
necessary to create a procedure service, starting with the logistics of adequate training
and demonstration of competence, proper
staffing, supplies and equipment, ultrasound image archiving, and the use of
documentation templates. The process is
followed by the development of pre-procedure and post-procedure guidelines, as well
as standardized procedural techniques.
The session also reviewed billing practices and professional fees. An analysis was
made comparing Medicare reimbursement
and work RVUs for each procedure service
with and without a full procedure consultation. A complete consultation significantly
increases the allowable fee and associated
work relative value units (wRVU). The
caveat is that billing for consults is limited
to services rendered for patients who are not
cared for by the same hospitalist group.
Furthermore, subspecialists historically
perform these procedures. The argument
can be made that hospitalists will reduce an
unnecessary burden on interventional radiologists, thereby enabling them to focus on
more complex invasive and highly technical
procedures.
The key to success is the ability to find
a strategic partner in the C-suite who will
directly or indirectly provide the financial
and political support. Other sources of
funding include private foundations, medical schools, the U.S. Department of Veterans Affairs, and such patient safety organizations as the Agency for Healthcare Research
and Quality, the Institute of Medicine, and
the Institute for Healthcare Improvement.
HMG leaders also should consider scalability across other hospitalist groups.
“If you build it, they will come.”
• Create a business plan;
• Find institutional financial and political support;
• Start small and selective;
• Plan for standardization and training
of colleagues;
• Create a credentialing/privileging
process;
• Bill for services and consider billing for
full consults; and
•Gather baseline and follow-up data.
Enhancing Physical
Exam Skills, and
Strategies to Teach
Them
By David M. Pressel, MD, PhD
HM15 Presenters: Verity Schaye,
MD, Michael Janjigian, MD, Frank
Volpicelli, MD, Susan Hunt.
Summation: Physical exam is the standard of care for evaluating patients. It has
been shown to have higher diagnostic
utility than many technology-based tests.
The physical exam is the gold standard for
dermatological and mental status assessment, for which technological tests are not
readily available. The traditional “laying
on of hands” has important benefits for the
physician-patient relationship.
The teaching of physical exam skills is
increasingly problematic, however. Barriers
include attending time, comfort, and skill
level, as well as challenges of patient comfort
and potential isolation issues.
The Peyton Model provides a better
means of teaching physical exam skills than
the traditional “See one, do one, teach one”
model. The Peyton Model has four steps:
• Demonstration. The teacher performs
By Sowmya Kanikkannan, MD,
FACP, SFHM
HM15 Presenters: Kathleen
Finn, MD, MPhil, FHM, FACP, and
Jeffrey Greenwald, MD, SFHM
Summation: Drs. Finn and Greenwald
engaged the audience with playful banter
while reviewing medical literature of clinical significance for the hospitalist in their
hospital medicine update. The studies
presented were high quality and practical and addressed questions that arise in
our day-to-day practice. A wide variety of
topics was addressed, and key points are
summarized below.
HM Takeaways:
In the PARADIGM-HF study, angiotensin
receptor blocker (ARB) + neprilysin inhibitor decreased cardiovascular mortality and
reduced congestive heart failure hospitalization by 20% when compared to enalapril alone in heart failure patients. The
combination drug is an alternative choice
to angiotensin-converting enzyme (ACE)
inhibitors. FDA approval is forthcoming.
Is the risk of contrast-induced nephrotoxicity really as great as we have come to
believe? Review of propensity-matched
studies suggests that acute kidney injury
(AKI), 30-day need for emergent hemodialysis, and death are unrelated to contrast. If
CT with contrast makes a difference to the
patient, consider using it if glomerular filtration rate is greater than 30 ml/min.
SAGES trial and Project Recovery developed a delirium screening method in hospitalized patients. The CAM (Confusion
Assessment Method) scoring system assesses
delirium severity in elderly patients (70+).
Hospital and post-hospital outcomes in
delirious vs. non-delirious patients showed
that the more severe the delirium was, the
longer the patient stayed in the hospital. Further, the rate of new skilled nursing facility placement and 90-day mortality was higher in the delirious group. The
CAM score correlates with prognosis in
CONTINUED ON PAGE 24
medical patients. Addressing long-term
goals of care in this patient population may
be warranted.
A randomized, placebo-controlled trial
looked at the preventive effects of ramelteon, a melatonin receptor agonist, on delirium. Ramelteon (8 mg) was given to patients
at 9 p.m. for seven days (or d/c). Although
this was a small and short study, ramelteon
appears to reduce incident delirium in medical and non-intubated ICU patients.
The HELP randomized clinical trial
compared lactulose with polyethylene glycol
(PEG) electrolyte solution for treatment
of overt hepatic encephalopathy. Patients
received either PEG (4 L in four hours)
or lactulose (20 to 30-g 3+doses/24 hrs).
Primary outcome was an improvement in
hepatic encephalopathy scoring algorithm
(HESA) score by one at 24 hours. HESA
score improved and patients had a shorter
length of stay in the PEG group. In addition, patients requested PEG at discharge
because it tasted better.
A retrospective study looked at nonselective beta blockers (NSBB) in patients with
spontaneous bacterial peritonitis (SBP).
Results suggest that the use of NSBB after
SBP onset increases the risk of AKI, hepatorenal syndrome, and mortality by 58%.
NSBB appear beneficial before SBP onset,
suggesting that as cirrhosis becomes more
severe, NSBB may not be effective.
A retrospective cohort trial (Michigan
Hospital Medicine Safety Consortium)
assessed hospital performance of VTE
prophylaxis. The rate of clinically evident,
confirmed VTE was measured. There was no
difference in VTE occurrence during hospitalization, 90-day VTE rates, and pulmonary
embolism vs. DVT rates. No clear benefit
was evident from VTE prophylaxis for medical patients. This could indicate the need to
risk stratify patients’ VTE risk.
Direct oral anticoagulants (DOACs)
were compared with vitamin K antagonists (VKA) for treatment of acute VTE in
a meta-analysis reviewed by the speakers.
Death, safety, and bleeding were assessed.
DOACs seem to work as well as VKA for
VTE. They also had a better safety profile.
In cancer patients, a study comparing
DOACs with low molecular weight heparin
(LMWH) is still needed. In patients with
atrial fibrillation (AF), DOACs prevent
AF-associated strokes better than VKA.
They also reduce hemorrhagic stroke and
intracranial hemorrhage.
In the elderly patients (75 or older),
DOACs are as safe as VKAs and LMWH
for AF and VTE treatment.
Randomized controlled trials compared
once-weekly dalbavancin or single-dose
oritavancin with daily conventional therapy
for acute bacterial skin infections (celluli-
24
Travis McClure, MD, of St Bernard’s Healthcare in Jonesboro, Ark., reviews protocols for lumbar
puncture during the “Medical Procedures for the Hospitalist” pre-course at HM15.
tis, major abscess, wound infection, 75-cm²
erythema). Outcomes measured were cessation of spread of erythema and no fever over
three readings in 48-72 hours. Dalbavancin
once weekly was noninferior to vancomycin in safety profile and outcome measures. Direct cost of dalbavancin was higher,
although patients on this drug had shorter
length of stays, which is cost effective. Dalbavancin is FDA approved for skin infections.
The presence of family during CPR
decreased post-traumatic stress disorder,
anxiety, and depression symptoms in family
members. Outcomes were similar when
participants were assessed at 90 days and
one year. While this study was conducted in
an out-of-hospital setting, it may be worthwhile to assess its applicability to patients
who code in the hospital.
Striving For
Optimal Care:
Updates in Quality,
Value, and Patient
Satisfaction
By Sowmya Kanikkannan, MD,
FACP, SFHM
HM15 Presenters: Michelle
Mourad, MD, and Christopher
Moriates, MD
Summation: Drs. Mourad and Moriates took a systematic approach to answering quality questions that we commonly
encounter in our hospitalist practices. They
reviewed current evidence, including metaanalyses and systematic reviews, to arrive
at answers for various quality-related questions. These are summarized below:
• What are the common features of
interventions that have successfully
reduced re-admissions? Effective interventions that enhance patient capacity to
reliably access and engage in post-discharge
care have been associated with success in
decreasing readmissions.
• Does patient engagement correlate with
decreased resource use or readmissions?
Patient activation is defined as knowledge,
skills, confidence, and inclination to assume
responsibility for managing one’s own health.
A higher patient activation score reduced the
risk of 30-day hospital reutilization.
• Do patients’ reports of their healthcare experience reflect quality of care?
Patient satisfaction scores may be a reflection of their desires (e.g. to get pain medications) regardless of clinical benefit. In
these situations, quality should be based on
achieving a mutual understanding of patient
situation and treatment plan between the
provider and patient.
• Is there any relationship between
quality of care and health outcomes? Positive associations were found between patient
experience and safety/effectiveness. Including patient experience in quality improve-
ment, therefore, may lead to improvements
in safety and effectiveness. Reducing the
trauma of hospitalization could improve
patient satisfaction and outcomes. Efforts
such as personalizing, providing rest and
nourishment, reducing stress disruption and
surprises, and providing a post-discharge
safety net are strategies to reduce the trauma
of hospitalization and improve satisfaction
and patient outcomes.
• Is there anything we can do to make
hand-offs safer? The I-PASS hand-off
bundle for a systematic hand-off process was
reviewed (Illness severity, Patient summary,
Action list, Situation awareness and contingency planning, Synthesis by receiver)
as a means of reducing medical errors.
When used in conjunction with training,
faculty development, and a culture change
campaign, this process was associated with
improved patient safety without negatively
affecting workflow.
• How can hospitalists deflate medical bills? Patient expectations of the benefits and harms of clinical interventions
influence physician decision making and
contribute to overuse and increased healthcare costs. Harm of excessive testing was
underestimated in such situations. Conversations with patients, colleagues, and the
public are crucial to decreasing low-value
care. Physicians should discuss potential benefits and risks to address patient
expectations. In addition, they should seek
opportunities to better understand healthcare costs.
• How big is the problem of antibiotic overuse in hospitals, and can we do
better? In a national database review, more
than half of all patients (55.7%) discharged
from a hospital received antibiotics during
their stay. There is a wide variation in antibiotic use across hospital wards. Reducing
this exposure to broad-spectrum antibiotics
would lead to a 26% reduction in C. diff
infections and reduce antibiotic resistance.
To improve this overutilization, stewardship programs should actively engage and
educate clinicians, encourage clear antibiotic documentation in daily progress notes,
and use 72-hour antibiotic time-out during
multidisciplinary rounds.
LISTEN NOW
Team Hospitalist member
David Weidig, MD,
director of hospital medicine for Aurora Medical
Group in West Allis, Wis.,
talks about best practices
for multi-site hospital medicine.
National Gala
Looking for a Hero?
Vineet Arora, MD, SFHM, provides early-career hospitalists tips
for identifying—and working well with—a mentor
NATIONAL HARBOR, Md.—What do
Harry Potter, Luke Skywalker, and Frodo
Baggins have in common?
Vineet Arora, MD, MAPP, SFHM, said
each of the big screen superstars had a great
mentor. Dr. Arora’s HM15 session, “Making
the Most of Your Mentoring Relationships,”
looked at the qualities young hospitalists
should seek out in a mentor. She also outlined
skills and behaviors mentees should look to
improve in themselves, in terms of connecting with a mentor and building relationships.
“You need to know yourself, your goals,
your priorities,” said Dr. Arora, associate
professor of medicine, assistant dean for
scholarship and discovery, and director of
the GME clinical learning environment
innovation at the University of Chicago.
“Mentorship is a partnership. If your
mentor is always busy and traveling, and
you need a lot of hand holding, that is not
a great fit.”
Dr. Arora’s pep talk was part of a new
educational track focused on young hospitalists that debuted at this year’s annual
meeting. The track, coordinated by
members of SHM’s Physicians in Training Committee, also included sessions on
“How to Stand Out: Being the Best Applicant You Can Be,” “Getting to the Top of
the Pile: Writing Your CV,” and “Quality
and Safety for Residents and Students.”
The majority of the 100 or so in attendance at Dr. Arora’s talk were residents and
academic hospitalists in the first few years of
their career, but the crowd also included a few
fellows and a handful of program directors.
You Need a Hero
Using video clips featuring three of the
most popular fictional characters of all
time, Dr. Arora outlined some of the key
characteristics young physicians should
look for in mentors.
Yoda, for example, provided inspiration
in “The Empire Strikes Back” by showing young Skywalker the impossible is
possible. Yoda, the 500-year-old mentor,
“used the Force” to lift Skywalker’s X-Wing
Fighter from the swamp. “He showed him
that ‘this is doable,’” said Dr. Arora, a selfproclaimed movie buff. “That’s really half
the battle, and it’s something you really
want to think about.”
In a scene from “Harry Potter and the
Prisoner of Azkaban,” veteran wizard
Remus Lupin comforts the young sorcerer
when he struggles to learn a new spell, the
powerful Patronus charm. “I didn’t expect
you to do it the first time,” Lupin told
Outgoing SHM President Burke Kealey, MD, SFHM, (far left) recognizes SHM chapter leaders at HM15: (l-r) Myra Rubio, MD, St. Louis Chapter;
Kenneth Simone, DO, SFHM, Maine; Carrie Herzke, MD, SFHM, Maryland; Sowmya Kanikkannan, MD, SFHM, Philadelphia Tri-State; Rupesh
Prasad, MD, MPH, SFHM, Wisconsin; Robert Gould, MD, Pacific Northwest; and Chi-Cheng Huang, MD, FHM, Boston.
Potter. “That would have been remarkable.”
The teaching moment, Dr. Arora said,
was that it is “OK to fail” and that good
mentors are “going to pick you back up and
help you.”
Mentors’ words—and how they say
them—are important, too. At the end of the
first “The Lord of the Rings” movie, little
Frodo stood at the shore of a lake wondering
if he could continue on his journey—“I wish
the ring had never come to me; I wish none
of this had happened,” he said. The next
scene showed Frodo recalling the encouraging words of his friend and mentor, Gandalf:
“So do all who have lived to see such times,
“I learned the errors of
how I’ve approached my
mentors in the past. I
think I have been guilty
of every one of the
points she made. Maybe
not as much the drop-in
meetings, but definitely
the last-minute, ‘Hey,
I have this poster due
tomorrow. Can you help
me edit it?’”
—Brandon Mauldin, MD,
resident, Tulane University School
of Medicine, New Orleans
but that is not for them to decide. All you
will have to decide is what to do with the
time that is given to you.”
“You thought your quality improvement project was bad? Talk to Frodo!” Dr.
Arora quipped. “Support, empathy, easing
the pain; these are very different mentoring
functions than the technical quality of doing
a project, or being capable.”
Comparing mentors to superheroes utilizing the acronym CAPE, Dr. Arora boiled it
down to the qualities mentees should look
for in their mentors:
• Capable: “If the mentor is not capable,
they are not going to be a good mentor,”
she said. “This is important; not everyone
is capable of being a good mentor.”
• Available: “It’s easy to walk away from a
project. A good mentor stays with you,
show you how it works, and inspires you
to work harder.”
• Project (or Passion): “You want to have
a mentor who is going to teach you something you are interested in; otherwise you
are not going to want to learn, and there
is no inspiration.”
• Empathetic: “They must be empathetic,
easy to get along with, able to ease the
pain.”
Mentee Self-Assessment
Dr. Arora and her colleague, Valerie Press,
MD, MPH, role-played a number of scenarios in which young hospitalists and trainees
err in their relationships with mentors. These
ranged from the dreaded “pop-in meeting”
to e-mail etiquette to last-minute requests to
review a CV or poster.
The scenarios rang true with Brandon
Mauldin, MD, a third-year resident at
Tulane University School of Medicine in
New Orleans.
“I learned the errors of how I’ve
approached my mentors in the past. I think
I have been guilty of every one of the points
she made,” said Dr. Mauldin, who attended
the session to glean tips as he prepares for a
career as an academic hospitalist. “Maybe not
as much the drop-in meetings, but definitely
the last-minute, ‘Hey, I have this poster due
tomorrow. Can you help me edit it?’”
Dr. Mauldin’s mentor at Tulane, Deepa
Bhatnagar, MD, also attended the session.
In her fourth year as an academic hospitalist, Dr. Bhatnagar said she gleaned the most
practical information from Dr. Arora’s final
scenario, which focused on mentees doing
their homework before selecting a mentor
or joining a research project.
“Do not sign on the dotted line without consultation. Right? Do not buy a car
without doing your homework,” Dr. Arora
said. “Mentors want free labor, so beware.”
Dr. Arora said mentees should set
reasonable expectations and focus broadly
in selecting projects, as they “have their
whole career to do the project you love;
right now, do the project that works.” It
was a tip that stuck.
“The successful project is a good takeaway: Find your interest, find a good mentor,
but find a good project,” Dr. Bhatnagar said.
“It’s better to zone in on a successful project,
instead of taking on a project that might not
be successful for you.”
What’s App?
Instructor
Sophia Rodgers, ACNP,
(right) works
with HM15
attendee David
Quach during
the “Medical
Procedures for
the Hospitalist”
pre-course.
Tech-minded hospitalists know mobile
technology is the next frontier
NATIONAL HARBOR, Md.—The
conversation about hospitalists and technology can be pretty big. Rigmarole with
rollout of an electronic health records
(EHR) system is as much a rite of physician
passage as Match Day. Administrators and
C-suiters agonize over sprawling national
initiatives (i.e., the Health Information
Technology for Economic and Clinical
Health [HITECH] Act of 2009) and the
delayed implementation of the 10th revision of the International Statistical Classifi-
cation of Diseases coding system (ICD-10).
And there’s not an informatics officer in the
country who doesn’t struggle with the term
“meaningful use.”
Yet at HM15, one of the most interesting technology discussions wasn’t about the
biggest of the big. In fact, it was about the
smallest of the small: mobile applications,
better known as apps. App usage on the evermore-ubiquitous smartphones and tablets,
used by patients and physicians alike, is a
topic in its infancy. But hospitalist Roger Yu,
MD, of Mayo Clinic in Rochester, Minn.,
says that hospitalists need to get ahead of
the issue. He knows patients will soon start
asking them more and more questions.
“Some of the older generation may not
be savvy enough to utilize these apps themselves, but the next generation, who are
these older patients’ caregivers, are savvy
enough, and they are very facile with their
use of mobile technology,” says Dr. Yu, who
helped lead one of the annual meeting’s best
attended workshops, “Dr. Hi Tech Hospi-
talist: Improving Quality and Value of Care
Using Mobile Apps.”
“So we need to be able to advise them,
because they will come to us as physicians
thinking that we have expertise in this.”
Anuj Dalal, MD, FHM, a hospitalist at
Brigham and Women’s Hospital in Boston,
says that one of the impediments to knowing
the best apps is the pure size of the marketplace. There are some 44,000 applications
related to healthcare. Although the bulk
of those are consumer-related applications
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26
National Gala
focused on diet, fitness, and personal health,
many can be resources for hospitalists. But
first, medical professionals need the marketplace to develop a reliable app certification
process, Dr. Dalal says.
“They will provide [physicians’ board]
certification, and patients will start relying
To Battle Burnout, Jerome C. Siy, MD, SFHM, Instructs
Hospitalist Leaders to Engage, Communicate, and
Create a “Culture”
MAKE IT OFFICIAL
H
ospitalists work at the leading edge of technology in the
inpatient setting, so taking charge makes sense, says Kendall
Rogers, MD, CPE, FACP, SFHM, chief of the division of
hospital medicine at the University of New Mexico Health Sciences
Center in Albuquerque and chair of SHM’s Information Technology
(IT) Committee.
Board certification for clinical informatics is one way to formalize
that leadership role. Board certification in medical informatics was
created in 2013, utilizing an exam crafted by the American Board of
Medical Specialties (ABMS).
Dr. Rogers says that hospitalists, more than any other
specialists, are involved in informatics. So SHM’s IT Committee is
urging those who would likely qualify to take the exam.
“There is no hospitalist group out there that doesn’t have
someone … that everyone else in their group looks to to try to start
fixing issues with IT,” he says. “Our goal is if we’re going to be put
in that role, we need members who are going to be educated in that,
who are going to be effective in those roles.
“[Certification] is just the most obvious avenue for us to achieve
that goal. No. 1, it directs the information and the skills that we think
that people need to have to be effective in those roles and, No. 2, it
gives external validity.” —RQ
Part of the difficulty of vetting apps is
what Cheng-Kai Kao, MD, medical director
of informatics at the University of Chicago
Medicine, calls the “hype cycle.”
“When it first shows up, there’s a lot of
hype, there’s a lot of hope for the technology, and you [drill] down, and eventually
you find what’s real,” he says. “We are looking for what are the things that we hope
mobile apps can really do.”
Hospitalist Lisa Bonwell, MD, of Colorado Health Medical Group in Colorado
Springs, sees discharge as one useful time
to work with patients via applications. She
believes many patients would find elec-
tronic instructions delivered through their
smartphone or tablet more useful than the
deluge of paperwork many now receive.
“When I discharge a patient from our
system, they get a stack of papers,” she
says. “I was recently a patient in the ER.
I looked at that [stack of paperwork] and
said, ‘There is nothing useful here. This
is ridiculous.’
“I mean, it’s all this medical, legal stuff
[patients] have to have, so I think that
really turns off people. This would be
much more usable to them.”
QUESTION: SHM CEO Larry Wellikson, MD, MHM, calls the country’s roughly 48,000 hospitalists “agents
of change.” The Hospitalist asked HM15 why is it important that hospitalists be those people?
Q&A
READ
MORE
Mark Ault, MD (above)
demonstrates live vascular
scanning during the “Medical Procedures for the Hospitalist” pre-course at HM15.
Right: Tochi Iroku-Maloize,
MD, MPH, MBA, SFHM, of
Hofstra North Shore-LIJ
School of Medicine in Islip,
N.Y., participates in the
technology special interest
forum at HM15.
on them for advice just as you would rely
on Consumer Reports,” he says. “I think that
will help individual providers and patients
decide what is a good app and what is an
effective app, which apps they should use
and which apps they shouldn’t use.”
Of course, some physicians frustrated
with regulation prefer
to see the government
stay out of technology
in healthcare. The
FDA currently reviews
apps with direct ties
to medical devices,
but the remainder of
the app marketplace
is wide open for some
entity to fill the certification void.
“I think there are a
lot of people who are
fearful of overregulation, but right now
I think we’re at the
point of underregulation,” Dr. Yu says.
“There’s a sweet spot.
I think if there is a
standard that people
can meet, companies
can meet, technologies
can meet, that’ll give a
lot of structure and
guidance to people
who want to make
their own apps.”
“Because
our healthcare system
is broken
in a lot of
ways, and
a lot of
patients
fall through the cracks or
they don’t get good followup. Part of helping that and
helping to fix our system
is being willing to make
changes and think of innovative ways, new ways to
do things.”
“We have
to stay
dynamic,
and change
is the nature
of things.
We have
to change
what we do to adapt to new
environments and new
circumstances. … We have
to keep an eye on the goals,
which are cutting costs,
length of stay, decreased
rates of mortality, and
patient satisfaction.”
–Lorrie Saville, NP, assistant
medical director,
Carilion Roanoke Memorial
Hospital, Roanoke, Va.
–Hospitalist Ahmed Farag, MD
Rex Hospital, Raleigh, N.C.
“For me, for
patients’ sake,
we always need
to be in good
practice. We
should always
be up to date.
When we don’t
actually go through quality
improvement projects or we
don’t try to obtain or achieve
certain milestones, then we’ll
always be behind. We could
actually be harming a lot of
patients without necessarily
knowing. … It’s important from
a patient perspective; that’s why
it’s important to me and should
be important to every physician.”
–Hospitalist Zahra’a Salah, MD
St. Mary Mercy Livonia Hospital,
Livonia, Mich.
“Because
nobody else
is doing it.
In my opinion, hospital
medicine
over the
years has
become the operational
machinery for the health
systems and hospitals
around the country. By all
means, I think the hospitalist should be at the forefront
to leading the change, or
whatever we call the new
evolution of medicine in the
country.”
–Ajay Kumar, MD, MECP, FACP,
SFHM, chief, Department of
Medicine, Hartford Hospital,
Hartford, Conn.
T
N
E
PATI
E
C
N
E
I
R
E
P
X
E
rom
ued f
contin
page
1
The survey must be administered to a
random sample of hospital inpatients 48 hours
to six weeks after discharge, and it is offered
in multiple languages, either by phone or
mail. Twenty-one core questions cover seven
composites (communication with doctors,
communication with nurses, responsiveness
of hospital staff, pain control, communication
about new medications, discharge information and planning, and cleanliness/quietness)
and two global items
(patients’ overall
The more satisfied patients are with the
rating of the hospicare they receive, the more likely they are
tal and likelihood
to recommend it to
to continue to seek care from the same
and friends).
provider, hospital, and/or clinic. Improved family
There are several
continuity can help increase adherence,
additional questions adjusting for
improve patient safety, and decrease
patient mix between
healthcare costs. Positive healthcare expehospitals, as well as
riences are also correlated with improved
any supplementary
questions desired by
patient compliance with treatment regiindividual hospitals.1
mens and medical advice, which will lead
With the exception of the two
to better outcomes.
global items, all core
HCAHPS questions ask “how often” a patient
experienced a particular aspect of hospital
care. Possible answers are “Always,” “Usually,”
“Sometimes,” or “Never”; credit is given to the
hospital only for a “top box” score of “Always.”
The three questions that are most applicable
to hospitalists make up the “communication
with doctors” composite; they focus on the
28
quality of physician-patient communication:
• During this hospital stay, how often
did doctors treat you with courtesy and
respect?
• During this hospital stay, how often did
doctors listen carefully to you?
• During this hospital stay, how often did
doctors explain things in a way you could
understand?
Importance to Hospitalists
A tremendous amount is tied to HCAHPS
scores: hospital reimbursement from CMS
(through value-based purchasing), hospital rating and “brand,” patients’ choice of
hospital, and, in some cases, hospitalist
performance bonuses. Hospitals and health
systems therefore emphasize HCAHPS
heavily. This emphasis has sparked some
controversy, particularly surrounding the
risk that inappropriate medical decisions
(e.g. prescribing antimicrobials or pain
medications when not indicated) will be
made in order to generate higher patient
satisfaction scores. Given the evidence that
physicians’ biomedical skill and interpersonal qualities are equally important in
determining patient satisfaction, however,
we can remain optimistic that time spent
explaining the rationale for appropriate
medical care is highly valued by patients.2,3
We must also recognize that both the
patient experience and physician-patient
communication impact clinical care. First,
a positive patient experience is linked to
higher continuity of care.4 The more satisfied patients are with the care they receive,
the more likely they are to continue to seek
care from the same provider, hospital, and/
or clinic. Improved continuity can help
increase adherence, improve patient safety,
and decrease healthcare costs. Positive
healthcare experiences are also correlated
with improved patient compliance with
treatment regimens and medical advice,
which will lead to better outcomes.5,6
Additionally, higher patient satisfaction
is associated with decreased readmission
rates. An analysis of more than 2,500 hospitals demonstrated a statistically significant
correlation between lower 30-day riskstandardized readmission rates, higher
patient satisfaction with discharge planning, and higher overall patient satisfaction with care.7
Furthermore, high quality physicianpatient communication has been linked to
improved health outcomes. A meta-analysis
of 21 separate studies evaluating the effect
of communication on health outcomes
demonstrated a direct positive correlation
with five outcome measures—emotional
health, symptom resolution, functional
status, physiologic measures (blood pressure
and glycemic control), and pain control.8
Finally, higher patient satisfaction and
improved physician-patient communication are inversely correlated with medical
malpractice risk.9,10
Current data regarding the effect of
patient satisfaction on mortality and
healthcare utilization/expenditures are
conflicting. Jaipaul and Rosenthal found
that higher patient satisfaction was associated with decreased mortality.11 Conversely,
Fenton and colleagues found an association
References
between high patient satisfaction and both
increased mortality and higher healthcare
utilization/costs.12 More long-term data will
be helpful in clarifying this question.
For hospitalists, the importance of patient
satisfaction might reach beyond its clinical
impact. Both new residency graduates and
more seasoned hospitalists will find that
their personal HCAHPS scores can either
be highlighted as a strength or work to their
detriment when they apply for new positions. Many physicians find that they are
asked about their patient satisfaction scores
during job interviews. Being knowledgeable about both the patient experience and
whether your patients perceive you positively can be an asset.
What Influences Patient
Satisfaction, and How Do We
Promote It?
Studies show that excellent medical care and
strong interpersonal qualities are equally
important influences on patients’ satisfaction with physicians.2,3 Having a high
quality interaction with their doctor—
during which patients feel that they are
valued and listened to, that their opinions
are taken into consideration, and that they
have received a clear explanation—is more
important to patients than having a lengthy
visit with their provider.13
Consequently, interventions that focus on
improving the humanistic aspects of our care
and enhancing the quality of our communication will be the most effective strategies for
improving patient satisfaction. Remembering
to practice empathy for our patients in the
midst of our very busy and stressful workdays is an excellent start. We can also utilize
the following proven practices for enhancing
physician-patient communication:
• Sit down at the bedside;
• Use patient-centered communication
techniques, such as asking open-ended
questions, using the teach-back method
and shared decision-making, and avoiding jargon;
• Clearly outline the plan for the day and
explain how it fits into the overall goal
of the hospitalization;
• Invite questions; and
• Utilize patient whiteboards.
In addition, demonstrating to patients
that we collaborate and effectively communicate with the rest of the healthcare team
can also enhance their experience.
Final Thoughts
Ultimately, patient satisfaction should not
be regarded as an extraneous amenity for
our patients or as a necessary evil to placate
!
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hospital administrators. Instead, improving
our patients’ hospital experience can help
improve their overall care and health.
Strong physician-patient partnerships
and high patient satisfaction increase
continuity of care and adherence to treatment, while also resulting in better health
outcomes and decreased hospital readmission rates. Furthermore, if hospitalists
emphasize a positive patient experience
by fostering effective communication and
positive relationships, they can also decrease
their malpractice risk.
We must therefore find ways to foster
patient satisfaction while maintaining
safe, effective, quality-driven patient care.
Emphasizing humanism and communication, while providing safe and high quality
care, is the optimal way to promote patient
satisfaction. In this way, we can improve not
only the patient experience but also health
outcomes.
Dr. Bergin is an academic hospitalist for the internal medicine
residency program at Banner-University Medical Center
Phoenix in Arizona and a clinical assistant professor at the
University of Arizona College of Medicine. Dr. O’Malley is
the internal medicine residency program director at Banner
and an assistant professor of medicine at the University
of Arizona College of Medicine. She currently serves as
SHM’s representative on the Alliance for Academic Internal
Medicine’s Internal Medicine Education Redesign Advisory
Board. Dr. Donahue is assistant professor of medicine at the
University of Massachusetts Medical School in Worcester.
1. Agency for Healthcare Research and Quality. HCAHPS
Fact Sheet (CAHPS Hospital Survey) – August 2013.
Available at: http://www.hcahpsonline.org/files/
August_2013_HCAHPS_Fact_Sheet3.pdf. Accessed
April 9, 2015.
2. Matthews DA, Sledge WH, Lieberman PB. Evaluation
of intern performance by medical inpatients. Am J Med.
1987;83(5):938-944.
3. Matthews DA, Feinstein AR. A new instrument for patients’ ratings of physician performance in the hospital
setting. J Gen Intern Med. 1989;4(1):14-22.
4. Safran DG, Montgomery JE, Change H, Murphy J,
Rogers WH. Switching doctors: Predictors of voluntary
disenrollment from a primary physician’s practice.
J Fam Pract. 2001;50(2):130-136.
5. DeMatteo MR. Enhancing patient adherence to medical
recommendations. JAMA. 1994:271(1):79, 83.
6. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware
JE, Tarlov AR. Linking primary care performance to
outcomes of care. J Fam Pract. 1998;47(3):213-220.
7. Boulding W, Glickman SW, Manary MP, Schulman KA,
Staelin R. Relationship between patient satisfaction
with inpatient care and hospital readmission within 30
days. Am J Manag Care. 2011;17(1):41-48.
8. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ.
1995;152(9):1423-1433.
9. Tan SY. Issues in medical malpractice IX. Doctors most
prone to lawsuits. Hawaii Med J. 2007;66(3):78-79.
10. Beckman HB, Markakis KM, Suchman AL, Frankel
RM. The doctor-patient relationship and malpractice:
Lessons from plaintiff depositions. Arch Intern Med.
1994;154(12):1365-1370.
11. Jaipaul CK, Rosenthal GE. Do hospitals with lower
mortality have higher patient satisfaction? A regional
analysis of patients with medical diagnoses. Am J Med
Qual. 2003;18(2):59-65.
12. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost
of satisfaction: a national study of patient satisfaction,
health care utilization, expenditures, and mortality. Arch
Intern Med. 2012;172(5):405-411.
13. Blanden AR, Rohr RE. Cognitive interview techniques
reveal specific behaviors and issues that could affect
patient satisfaction relative to hospitalists. J Hosp Med.
2009;4(9):E1-6.
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W
NE
I THE PRESIDENT’S DESK I By Robert Harrington Jr., MD, SFHM
Increased Diversity
Strengthens HM
The mix of training, experience, settings, and cultures makes our specialty special
M
Dr. Harrington is chief medical officer
at Reliant Post-Acute Care Solutions in
Atlanta, Ga., and president of SHM.
y path to the SHM presidency
has been a long and winding one.
After paying back some student
loans courtesy of the U.S. Air Force, I joined
a busy traditional family medicine practice.
Routinely, we would have a census of 20-25
patients in our local community hospital on
any given day, and we shared the hospital
duties as the “hospital doc” for a week at
a time. I truly enjoyed the hospital-based
portion of my practice, and this eventually led me to start and build a hospitalist
program at our small community hospital.
I’ve been a hospitalist ever since and have
never looked back.
My story is similar to the experiences of
thousands of hospitalists across the country
today. Many physicians who entered medical
school with the intention of working in an
office-based or traditional practice have been
drawn into the fast-growing hospital medicine field—where they’ve happily stayed.
Today, according to our best estimates,
there are more than 44,000 hospitalists
practicing in the U.S. Most have come to
the specialty from the internal medicine
field, but that is rapidly changing. As the
first hospitalist trained in family medicine
to serve as SHM president, I couldn’t be
more excited or encouraged by the increasing diversity in the types of healthcare practitioners who call themselves hospitalists.
A Changing Profession
Joint Statement on
Hospitalists Trained
in Family Medicine
Including more physicians and clinicians in the
hospital medicine movement makes it stronger.
To learn more about
the Joint Statement on
Hospitalists Trained in
Family Medicine from
SHM and AAFP, see this
month’s Society Pages
on page 8.
38
Today’s hospitalists come from diverse training environments. In addition to internal
medicine, hospitalists are trained in family
medicine, pediatrics, intensive care, obstetrics and gynecology, surgery, orthopedics,
neurology, oncology, and a variety of other
specialties and subspecialties. The specialty
hospitalist movement has grown on the back
of the same forces that gave a dramatic push
to the hospitalist movement over the past
15 years—in-house provider availability,
the need for greater inpatient efficiency, the
aging physician workforce, and the enormous difficulty of staying competent in both
an ambulatory and inpatient setting, just to
name a few. Needless to say, it’s become a
well-established dynamic with evidence
pointing to its long-term benefits for both
patients and healthcare delivery systems.
In addition, as demand for hospitalist
services continues to grow, hospitals and
hospital medicine groups are increasingly
adding nurse practitioners (NPs), physician
assistants (PAs), and other advanced practice providers to their ranks. According to
the 2014 State of Hospital Medicine Report,
the use of NPs and PAs in hospital medicine
SHM is stronger when we can draw upon
a membership of varying types of training,
opinions, and expertise in developing
initiatives and educational programs in
support of our mission...
programs serving adults has risen nearly 12%
since 2012. Today, more than 65% of hospital medicine groups employ NPs or PAs.
Within SHM, we’re seeing these changes
begin to play out in our membership
makeup, as well. Though the vast majority of
our 14,000 members are internal medicine
physicians, more than 10% are hospitalists
trained in family medicine (HTFMs), 3%
are trained in pediatrics, and 3% are internal medicine/pediatrics. Our fastest growing
segments are family medicine and NPs/PAs.
Strength in Diversity
The expansion of the hospitalist field to
include so many different kinds of providers
is beneficial to both SHM and the broader
profession.
On a macro level, the increasing diversity of the field has the potential to improve
care for hospitalized patients. For example,
when more hospital providers are based
within the facility, there’s an opportunity for
providers to develop improved relationships
and communication, which leads to better
patient handoffs and expedited care across
the inpatient care continuum. Studies have
shown that hospitalist practices have a positive impact on patient lengths of stay, readmission rates, and patient satisfaction scores.
Among our peers in healthcare, this diversity opens up opportunities for even more
physicians and clinicians to work as hospitalists and improve care delivery in America’s hospitals. For instance, the American
Academy of Family Physicians (AAFP)
and SHM recently endorsed the growing
contribution of hospitalists trained in family
medicine. Together, our two organizations
stated that “the opportunity to participate as
a hospitalist should be granted to all physicians commensurate with their documented
training and/or experience, demonstrated
abilities and current competencies.”
SHM is stronger when we can draw upon
a membership of varying types of training,
opinions, and expertise in developing initiatives and educational programs in support of
our mission to promote exceptional care for
hospitalized patients. Diverse membership
also provides an additional level of authority
to our organization and is one of the reasons
we are often invited to Washington, D.C.,
to testify in front of Congress about various
medical topics. Because we represent many
constituencies among physicians and maintain close working relationships with clinical
and business leaders throughout the hospital,
we can provide unique insight into healthcare reform, quality initiatives, and other
issues shaping the healthcare industry today.
Expanding Membership
Although we are seeing the increasing
diversity in the hospital medicine field play
out in SHM membership, many specialty
hospitalists, advanced practice providers,
and even family medicine and pediatric
physicians don’t yet consider SHM a professional “home.” And our membership ranks
represent only a fraction of the hospitalists
practicing across the country.
One of the goals for my presidency is to
help spread the word that SHM isn’t just
for internal medicine hospitalists—though
they certainly make up a majority of our
membership and we owe them a debt of
gratitude for getting us to where we are
today—but for all providers involved in
the hospital-based care of patients. We are
an organization that truly represents all of
the professionals across the continuum of
hospital-based medicine. We can be a valuable professional resource for the growing
number of physicians, advanced practice
providers, administrators, and other care
providers who choose to focus their careers
on the care of hospitalized patients.
Looking Ahead
Though I happened into the hospital medicine field by chance, making my career in the
field was no accident. I’m proud to work in
a specialty that is so uniquely positioned to
enhance the care and experience for hospitalized patients. I’m excited to see so many
providers from various fields of medicine
choosing hospital-based practice.
I hope the trend will continue and that
our organization will have the opportunity
to welcome many of them in the months
ahead.
I PEDIATRIC HM I By Weijen Chang, MD, SFHM, FAAP
‘Best Movie Ever’
My name is Dr. Inigo Montoya. You killed albuterol … prepare to die!
R
Dr. Chang is pediatric editor of
The Hospitalist. He is associate clinical
professor of medicine and pediatrics
at the University of California at
San Diego (UCSD) School of Medicine,
and a hospitalist at both UCSD
Medical Center and Rady Children’s
Hospital. Send comments and
questions to wwch@ucsd.edu.
As Dr. Inigo
Montoya might
say, doctors have
been in the thinking-independently
business so long
that, now that it’s
over, they don’t
know what to do
with the rest of
their lives.
eading posts from multiple listservs is much like Cold War-era
CIA monitoring of Russian phone
calls—you have to scan through a lot of
unrewarding material to find a nugget of
interesting material. But that nugget, once
found, can be a revelation.
Recently, the American Academy of Pediatrics (AAP) released an update to its clinical
practice guideline (CPG) for bronchiolitis
in Pediatrics. The 2011 incarnation had
made concessions to the “do something”
crowd, allowing for a “carefully monitored”
trial of either albuterol or epinephrine, but
the 2014 version quashed all hopes of pharmacologic intervention by eradicating that
possibility.1 The AAPHOSPMED listserv,
which goes out to the members of the AAP
Section on Hospital Medicine, predictably
bloomed with a flurry of entries opining
about the 2014 guidelines, many of them
from academic leaders in pediatric hospital
medicine (PHM). But one entry, submitted
by Scott Krugman, MD, chairman of pediatrics at MedStar Franklin Square Medical
Center in Baltimore, caught my eye:
While the hospitalist medicine group celebrates, I’d thought I’d let you all in on the
reaction from the Peds EM list serve (2 emails
follow with redacted names….):
-----Original Message----Date: Thu, 30 Oct 2014 15:17:57 -0700
Subject: My name is Dr. Indigo Montoya, You
Killed Albuterol…
To: PED-EM-L@LISTSERV.BROWN.EDU
… prepare to die.
In face of the recent AAP Guideline on the
management of bronchiolitis, I am recruiting
other Peds ED centers who will be endorsing
this set of practices to serve as the treatment
group in my non-randomized observational
study. Our center will serve as the ‘out-ofcontrol’ group and we will be initiating a new
clinical pathway entitled... ‘Empiric therapy
for the treatment of undifferentiated respiratory distress in infants.’
It is my hypothesis that our group’s admission
and bounce-back rates will
be the same as last year.
I anxiously await the data from the centers
who adopt the AAP approach!
-----Original Message----Subject: Re: My name is Dr. Indigo Montoya,
You Killed Albuterol…
From:
Reply-To:
Date: Thu, 30 Oct 2014 20:07:51 -0400
I am pretty sure it is Inigo Montoya.
Best movie ever.
How about this:
Trial of Duoneb
If you see a positive clinical response, great,
if not...well...don’t give it anymore. If a very
strong positive clinical response, consider steroids in addition. Can you believe I said that? I
understand the studies for “traditional” bron-
chiolitis, I also understand there is a subset
of these patients that I see that have a very
favorable response to this treatment. I also see
some variation to the response year by year.
Have also heard and (think I have, as we have
no rapid test for this) seen very good response
with EV D68 to Albuterol + steroids.
Just Sayin...
At first read, I was surprised by the evident
mastery of satirical humor manifested by our
peds ED physician colleagues. Then it began
to dawn on me that perhaps these comments
were not purely in jest. But, then again, this
is not so terribly inconceivable to any pediatric hospitalist—the ED is the last great
bastion of nonstandardized medical practice
(or maybe that’s the ICU). If any group of
physicians were to thumb their noses at the
AAP bronchiolitis CPGs, clearly they would
be ED docs.
As I was vacillating between horror and
indignant vexation, I began to realize that
our peds ED colleagues are perhaps more
intelligent than we give them credit for.
Just the prior month, in the September
2014 issue of Journal of Pediatrics, a group
of researchers, led by Vineeta Mittal, MD,
associate professor of pediatrics at UT Southwestern in Dallas, had found that, despite
the scholarly, evidence-based implementation of bronchiolitis guidelines across 28
U.S. children’s hospitals, these CPGs had not
significantly moved the needle on ordering
nonrecommended therapies and diagnostics.2 My only comfort was that Dr. Mittal
had at least been able to lower the ordering of
chest radiographs, bronchodilators, and steroids through the use of a bronchiolitis CPG
at her own institution, Children’s Medical
Center in Dallas, as described in the March
2014 issue of Pediatrics.3 Truly, Dr. Mittal,
“you have a dizzying intellect!”
But the fact remains that PHM thought
leaders, despite their best intentions and
dedicated pursuit of research to improve
bronchiolitis outcomes, have begun to
alienate peds ED physicians and likely many
pediatric hospitalists as well. In the Country of (Todd) Florin, MD, MSCE, otherwise
known as Cincinnati Children’s Hospital
ED, researchers led by Dr. Florin found that
the release of the AAP bronchiolitis CPG
in 2006 had not significantly changed the
utilization of nonrecommended resources
in bronchiolitis, despite the fact that use
of these nonrecommended resources only
increased length of stay without reducing
readmission rates.4 Once again, we find that
simply releasing high-minded CPGs without appropriate local multidisciplinary active
implementation is as ill-fated as a land war
in Asia.
Perhaps we shouldn’t be surprised that
individuals trained for years to trust their gut
feelings about the patient in front of them
would begin to buck the tidal wave of regulation, oversight, and standardization that has
begun to define how medicine is practiced
in the 21st century. Many pediatric hospitalists and pediatric ED physicians would
take issue with the outcomes cited by CPGs
as not taking into account the therapeutic
benefit of even short-term symptomatic
improvements achieved through bronchodilators use. As Dr. Inigo Montoya might
say, doctors have been in the thinking-independently business so long that, now that it’s
over, they don’t know what to do with the
rest of their lives.
Yet, is that really true? Have clinical pathways, practice guidelines, and high-minded
academic pediatric hospitalists snuffed the
life out of our quick-thinking, sword-wielding heroic physician?
Perhaps, but mostly dead is slightly alive.
I would posit, however, that our heroic
physician, instead of viewing the local hospital’s creator of CPGs and clinical pathways
as a condescending Prince Humperdinck,
should consider him more of a Fezzik,
who would do their heavy lifting for more
mundane tasks, leading the charge against
more worthy adversaries. Who wants to
enter all those orders anyway?
For who could resist storming the castle
of Kawasaki Disease? Hand-to-hand combat
with metabolic defects? The Fire Swamp
of PHM is still lurking with Diseases of
Unusual Size that haven’t been tamed by
AAP CPGs. Even our old nemesis, sepsis,
has been found to be less susceptible to
the arrows of early goal-directed therapy
(EGDT) than we thought.5 By reporting in
the October 16, 2014, issue of New England
Journal of Medicine that EGDT may not
reduce mortality in sepsis after all, fearless
Aussie and Kiwi ARISE investigators may
have opened a path for pediatric hospitalists
and intensivists to follow in the battle against
pediatric sepsis.
So, fear not, brave PHM warrior. There
are still dragons to slay, ogres to battle, ED
docs to debate as to whether to admit the kid
with iocane poisoning. Do not worry about
CPGs, and have fun storming the castle!
I would like to thank Drs. Scott Krugman, Jay
Fisher, and Todd Zimmerman for giving their
permission to reproduce their listserv posts, which
inspired this column.
References
1. Ralston SL, Lieberthal AS, Meissner HC, et al.
Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics.
2014;134(5):e1474-e1502.
2. Mittal V, Hall M, Morse R, et al. Impact of inpatient bronchiolitis clinical practice guideline implementation on testing
and treatment. J Pediatrics. 2014;165(3):570-576.e3.
3. Mittal V, Darnell C, Walsh B, et al. Inpatient bronchiolitis
guideline implementation and resource utilization.
Pediatrics. 2014;133(3):e730-737.
4. Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test
M, Shah SS. Variation in the management of infants
hospitalized for bronchiolitis persists after the 2006
American Academy of Pediatrics bronchiolitis guidelines. J Pediatrics. 2014;165(4):786-792.e1.
5. ARISE Investigators, ANZICS Clinical Trials Group,
Peake SL, et al. Goal-directed resuscitation for
patients with early septic shock. New Engl J Med.
2014;371(16):1496-1506.
ELIQUIS® (apixaban) tablets for oral use
Brief Summary of Prescribing Information. For complete prescribing information
consult official package insert.
WARNING: (A) PREMATURE DISCONTINUATION OF ELIQUIS INCREASES THE RISK
OF THROMBOTIC EVENTS
(B) SPINAL/EPIDURAL HEMATOMA
(A) PREMATURE DISCONTINUATION OF ELIQUIS INCREASES THE RISK OF
THROMBOTIC EVENTS
Premature discontinuation of any oral anticoagulant, including ELIQUIS,
increases the risk of thrombotic events. If anticoagulation with ELIQUIS is
discontinued for a reason other than pathological bleeding or completion of a
course of therapy, consider coverage with another anticoagulant [see Dosage
and Administration, Warnings and Precautions, and Clinical Studies (14.1) in
full Prescribing Information].
Epidural or spinal hematomas may occur in patients treated with ELIQUIS
who are receiving neuraxial anesthesia or undergoing spinal puncture. These
hematomas may result in long-term or permanent paralysis. Consider these
risks when scheduling patients for spinal procedures. Factors that can increase
the risk of developing epidural or spinal hematomas in these patients include:
• use of indwelling epidural catheters
• concomitant use of other drugs that affect hemostasis, such as nonsteroidal
anti-inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants
• a history of traumatic or repeated epidural or spinal punctures
• a history of spinal deformity or spinal surgery
• optimal timing between the administration of ELIQUIS and neuraxial
procedures is not known
[see Warnings and Precautions]
Monitor patients frequently for signs and symptoms of neurological impairment.
If neurological compromise is noted, urgent treatment is necessary [see
Warnings and Precautions].
Consider the benefits and risks before neuraxial intervention in patients
anticoagulated or to be anticoagulated [see Warnings and Precautions].
ADVERSE REACTIONS
The following serious adverse reactions are discussed in greater detail in other sections of
the prescribing information.
•
Increased risk of thrombotic events after premature discontinuation [see Warnings
and Precautions]
•
Bleeding [see Warnings and Precautions]
•
Spinal/epidural anesthesia or puncture [see Warnings and Precautions]
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates
observed in the clinical trials of a drug cannot be directly compared to rates in the clinical
trials of another drug and may not reflect the rates observed in practice.
Reduction of Risk of Stroke and Systemic Embolism in Nonvalvular Atrial Fibrillation
The safety of ELIQUIS (apixaban) was evaluated in the ARISTOTLE and AVERROES studies
[see Clinical Studies (14) in full Prescribing Information], including 11,284 patients exposed
to ELIQUIS 5 mg twice daily and 602 patients exposed to ELIQUIS 2.5 mg twice daily.
The duration of ELIQUIS exposure was ≥12 months for 9375 patients and ≥24 months
for 3369 patients in the two studies. In ARISTOTLE, the mean duration of exposure was
89 weeks (>15,000 patient-years). In AVERROES, the mean duration of exposure was
approximately 59 weeks (>3000 patient-years).
The most common reason for treatment discontinuation in both studies was for bleedingrelated adverse reactions; in ARISTOTLE this occurred in 1.7% and 2.5% of patients treated
with ELIQUIS and warfarin, respectively, and in AVERROES, in 1.5% and 1.3% on ELIQUIS
and aspirin, respectively.
Bleeding in Patients with Nonvalvular Atrial Fibrillation in ARISTOTLE and AVERROES
Tables 1 and 2 show the number of patients experiencing major bleeding during the
treatment period and the bleeding rate (percentage of subjects with at least one bleeding
event per year) in ARISTOTLE and AVERROES.
Major bleeding was defined as clinically overt bleeding that was accompanied by one or more
of the following: a decrease in hemoglobin of 2 g/dL or more; a transfusion of 2 or more
units of packed red blood cells; bleeding that occurred in at least one of the following critical
sites: intracranial, intraspinal, intraocular, pericardial, intra-articular, intramuscular with
compartment syndrome, retroperitoneal; or bleeding that was fatal. Intracranial hemorrhage
included intracerebral (hemorrhagic stroke), subarachnoid, and subdural bleeds.
Table 1:
Reduction of Risk of Stroke and Systemic Embolism in Nonvalvular Atrial Fibrillation
Prophylaxis of Deep Vein Thrombosis Following Hip or Knee Replacement Surgery
ELIQUIS is indicated for the prophylaxis of deep vein thrombosis (DVT), which may lead to
pulmonary embolism (PE), in patients who have undergone hip or knee replacement surgery.
Treatment of Deep Vein Thrombosis
Major†
ELIQUIS
N=9088
n (%/year)
Warfarin
N=9052
n (%/year)
Hazard Ratio
(95% CI*)
P-value
327 (2.13)
462 (3.09)
0.69 (0.60, 0.80)
<0.0001
Gastrointestinal (GI)‡
128 (0.83)
141 (0.93)
0.89 (0.70, 1.14)
-
Intracranial
52 (0.33)
125 (0.82)
0.41 (0.30, 0.57)
-
Intraocular§
32 (0.21)
22 (0.14)
1.42 (0.83, 2.45)
-
Fatal¶
10 (0.06)
37 (0.24)
0.27 (0.13, 0.53)
-
318 (2.08)
444 (3.00)
0.70 (0.60, 0.80)
<0.0001
ELIQUIS is indicated for the treatment of DVT.
CRNM**
Treatment of Pulmonary Embolism
* Confidence interval.
† International Society on Thrombosis and Hemostasis (ISTH) major bleed assessed by sequential
testing strategy for superiority designed to control the overall type I error in the trial.
‡ GI bleed includes upper GI, lower GI, and rectal bleeding.
§ Intraocular bleed is within the corpus of the eye (a conjunctival bleed is not an intraocular bleed).
¶ Fatal bleed is an adjudicated death because of bleeding during the treatment period and includes
both fatal extracranial bleeds and fatal hemorrhagic stroke.
** CRNM = clinically relevant nonmajor bleeding.
Events associated with each endpoint were counted once per subject, but subjects may have
contributed events to multiple endpoints.
ELIQUIS is indicated for the treatment of PE.
Reduction in the Risk of Recurrence of DVT and PE
ELIQUIS is indicated to reduce the risk of recurrent DVT and PE following initial therapy.
DOSAGE AND ADMINISTRATION (Selected information)
Temporary Interruption for Surgery and Other Interventions
ELIQUIS should be discontinued at least 48 hours prior to elective surgery or invasive
procedures with a moderate or high risk of unacceptable or clinically significant bleeding.
ELIQUIS should be discontinued at least 24 hours prior to elective surgery or invasive
procedures with a low risk of bleeding or where the bleeding would be noncritical in location
and easily controlled. Bridging anticoagulation during the 24 to 48 hours after stopping
ELIQUIS and prior to the intervention is not generally required. ELIQUIS should be restarted
after the surgical or other procedures as soon as adequate hemostasis has been established.
(For complete Dosage and Administration section, see full Prescribing Information.)
CONTRAINDICATIONS
ELIQUIS is contraindicated in patients with the following conditions:
•
Active pathological bleeding [see Warnings and Precautions and Adverse Reactions]
•
Severe hypersensitivity reaction to ELIQUIS (e.g., anaphylactic reactions) [see
Adverse Reactions]
WARNINGS AND PRECAUTIONS
Increased Risk of Thrombotic Events after Premature Discontinuation
Premature discontinuation of any oral anticoagulant, including ELIQUIS, in the absence of
adequate alternative anticoagulation increases the risk of thrombotic events. An increased
rate of stroke was observed during the transition from ELIQUIS to warfarin in clinical trials
in atrial fibrillation patients. If ELIQUIS is discontinued for a reason other than pathological
bleeding or completion of a course of therapy, consider coverage with another anticoagulant
[see Dosage and Administration (2.5) and Clinical Studies (14.1) in full Prescribing Information].
In ARISTOTLE, the results for major bleeding were generally consistent across most major
subgroups including age, weight, CHADS2 score (a scale from 0 to 6 used to estimate risk
of stroke, with higher scores predicting greater risk), prior warfarin use, geographic region,
ELIQUIS dose, type of atrial fibrillation (AF), and aspirin use at randomization (Figure 1).
Subjects treated with apixaban with diabetes bled more (3.0% per year) than did subjects
without diabetes (1.9% per year).
Figure 1:
Bleeding Events in Patients with Nonvalvular Atrial Fibrillation in AVERROES
Major Bleeding Hazard Ratios by Baseline Characteristics – ARISTOTLE
Study
ELIQUIS (apixaban)
N=2798
n (%/year)
Aspirin
N=2780
n (%/year)
Hazard Ratio
(95% CI)
P-value
45 (1.41)
29 (0.92)
1.54 (0.96, 2.45)
0.07
Major
Fatal
5 (0.16)
5 (0.16)
0.99 (0.23, 4.29)
-
Intracranial
11 (0.34)
11 (0.35)
0.99 (0.39, 2.51)
-
Other Adverse Reactions
Hypersensitivity reactions (including drug hypersensitivity, such as skin rash, and
anaphylactic reactions, such as allergic edema) and syncope were reported in <1% of
patients receiving ELIQUIS.
Prophylaxis of Deep Vein Thrombosis Following Hip or Knee Replacement Surgery
The safety of ELIQUIS has been evaluated in 1 Phase II and 3 Phase III studies including
5924 patients exposed to ELIQUIS 2.5 mg twice daily undergoing major orthopedic surgery
of the lower limbs (elective hip replacement or elective knee replacement) treated for up to
38 days.
In total, 11% of the patients treated with ELIQUIS 2.5 mg twice daily experienced adverse
reactions.
Bleeding results during the treatment period in the Phase III studies are shown in Table 3.
Bleeding was assessed in each study beginning with the first dose of double-blind study drug.
Table 3:
Bleeding During the Treatment Period in Patients Undergoing Elective Hip
or Knee Replacement Surgery
ADVANCE-3
Hip Replacement
Surgery
Bleeding
Endpoint*
Concomitant use of drugs affecting hemostasis increases the risk of bleeding. These include
aspirin and other antiplatelet agents, other anticoagulants, heparin, thrombolytic agents,
selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and
nonsteroidal anti-inflammatory drugs (NSAIDs) [see Drug Interactions].
ADVANCE-1
Knee Replacement
Surgery
Enoxaparin
40 mg
sc qd
35±3 days
ELIQUIS
2.5 mg
po bid
12±2 days
Enoxaparin
40 mg
sc qd
12±2 days
ELIQUIS
2.5 mg
po bid
12±2 days
Enoxaparin
30 mg
sc q12h
12±2 days
First dose
12 to 24
hours post
surgery
First dose
9 to 15
hours prior
to surgery
First dose
12 to 24
hours post
surgery
First dose
9 to 15
hours prior
to surgery
First dose
12 to 24
hours post
surgery
First dose
12 to 24
hours post
surgery
N=2673
22
(0.82%)†
N=2659
18
(0.68%)
N=1501
9
(0.60%)‡
N=1508
14
(0.93%)
N=1596
11
(0.69%)
N=1588
22
(1.39%)
0
0
0
0
0
1
(0.06%)
13
(0.49%)
10
(0.38%)
8
(0.53%)
9
(0.60%)
10
(0.63%)
16
(1.01%)
Transfusion of
≥2 units RBC
16
(0.60%)
14
(0.53%)
5
(0.33%)
9
(0.60%)
9
(0.56%)
18
(1.13%)
Bleed at
critical site§
1
(0.04%)
1
(0.04%)
1
(0.07%)
2
(0.13%)
1
(0.06%)
4
(0.25%)
Major
+ CRNM¶
129
(4.83%)
134
(5.04%)
53
(3.53%)
72
(4.77%)
46
(2.88%)
68
(4.28%)
All
313
(11.71%)
334
(12.56%)
104
(6.93%)
126
(8.36%)
85
(5.33%)
108
(6.80%)
All treated
Major
(including
surgical site)
Fatal
Hgb decrease
≥2 g/dL
* All bleeding criteria included surgical site bleeding.
Includes 13 subjects with major bleeding events that occurred before the first dose of apixaban
(administered 12 to 24 hours post surgery).
‡ Includes 5 subjects with major bleeding events that occurred before the first dose of apixaban
(administered 12 to 24 hours post surgery).
§ Intracranial, intraspinal, intraocular, pericardial, an operated joint requiring re-operation or intervention,
intramuscular with compartment syndrome, or retroperitoneal. Bleeding into an operated joint requiring
re-operation or intervention was present in all patients with this category of bleeding. Events and event
rates include one enoxaparin-treated patient in ADVANCE-1 who also had intracranial hemorrhage.
¶ CRNM = clinically relevant nonmajor.
†
Adverse reactions occurring in ≥1% of patients undergoing hip or knee replacement surgery
in the 1 Phase II study and the 3 Phase III studies are listed in Table 4.
Table 4:
Adverse Reactions Occurring in ≥1% of Patients in Either Group Undergoing
Hip or Knee Replacement Surgery
ELIQUIS, n (%)
2.5 mg po bid
N=5924
Enoxaparin, n (%)
40 mg sc qd or
30 mg sc q12h
N=5904
Nausea
153 (2.6)
159 (2.7)
Anemia (including postoperative and
hemorrhagic anemia, and respective
laboratory parameters)
153 (2.6)
178 (3.0)
Bleeding
ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding
[see Dosage and Administration (2.2) in full Prescribing Information and Adverse Reactions].
ADVANCE-2
Knee Replacement
Surgery
ELIQUIS
2.5 mg
po bid
35±3 days
Bleeding Events in Patients with Nonvalvular Atrial Fibrillation in ARISTOTLE
INDICATIONS AND USAGE
ELIQUIS ® (apixaban) is indicated to reduce the risk of stroke and systemic embolism in
patients with nonvalvular atrial fibrillation.
Table 2:
Contusion
83 (1.4)
115 (1.9)
Advise patients of signs and symptoms of blood loss and to report them immediately or go to
an emergency room. Discontinue ELIQUIS in patients with active pathological hemorrhage.
Hemorrhage (including hematoma, and
vaginal and urethral hemorrhage)
67 (1.1)
81 (1.4)
There is no established way to reverse the anticoagulant effect of apixaban, which can be
expected to persist for at least 24 hours after the last dose, i.e., for about two drug half-lives.
A specific antidote for ELIQUIS is not available. Hemodialysis does not appear to have a
substantial impact on apixaban exposure [see Clinical Pharmacology (12.3) in full Prescribing
Information]. Protamine sulfate and vitamin K are not expected to affect the anticoagulant
activity of apixaban. There is no experience with antifibrinolytic agents (tranexamic acid,
aminocaproic acid) in individuals receiving apixaban. There is neither scientific rationale
for reversal nor experience with systemic hemostatics (desmopressin and aprotinin) in
individuals receiving apixaban. Use of procoagulant reversal agents such as prothrombin
complex concentrate, activated prothrombin complex concentrate, or recombinant factor
VIIa may be considered but has not been evaluated in clinical studies. Activated oral
charcoal reduces absorption of apixaban, thereby lowering apixaban plasma concentration
[see Overdosage].
Postprocedural hemorrhage (including
postprocedural hematoma, wound
hemorrhage, vessel puncture site
hematoma and catheter site hemorrhage)
54 (0.9)
60 (1.0)
Transaminases increased (including alanine
aminotransferase increased and alanine
aminotransferase abnormal)
50 (0.8)
71 (1.2)
Aspartate aminotransferase increased
47 (0.8)
69 (1.2)
Gamma-glutamyltransferase increased
38 (0.6)
65 (1.1)
Spinal/Epidural Anesthesia or Puncture
Less common adverse reactions in apixaban-treated patients undergoing hip or knee
replacement surgery occurring at a frequency of ≥0.1% to <1%:
When neuraxial anesthesia (spinal/epidural anesthesia) or spinal/epidural puncture is
employed, patients treated with antithrombotic agents for prevention of thromboembolic
complications are at risk of developing an epidural or spinal hematoma which can result in
long-term or permanent paralysis.
Blood and lymphatic system disorders: thrombocytopenia (including platelet count
decreases)
The risk of these events may be increased by the postoperative use of indwelling epidural
catheters or the concomitant use of medicinal products affecting hemostasis. Indwelling
epidural or intrathecal catheters should not be removed earlier than 24 hours after the last
administration of ELIQUIS. The next dose of ELIQUIS should not be administered earlier than
5 hours after the removal of the catheter. The risk may also be increased by traumatic or
repeated epidural or spinal puncture. If traumatic puncture occurs, delay the administration
of ELIQUIS for 48 hours.
Respiratory, thoracic, and mediastinal disorders: epistaxis
Monitor patients frequently for signs and symptoms of neurological impairment (e.g.,
numbness or weakness of the legs, bowel, or bladder dysfunction). If neurological
compromise is noted, urgent diagnosis and treatment is necessary. Prior to neuraxial
intervention the physician should consider the potential benefit versus the risk in
anticoagulated patients or in patients to be anticoagulated for thromboprophylaxis.
Injury, poisoning, and procedural complications: wound secretion, incision-site hemorrhage
(including incision-site hematoma), operative hemorrhage
Patients with Prosthetic Heart Valves
Gingival bleeding, hemoptysis, hypersensitivity, muscle hemorrhage, ocular hemorrhage
(including conjunctival hemorrhage), rectal hemorrhage
The safety and efficacy of ELIQUIS have not been studied in patients with prosthetic heart
valves. Therefore, use of ELIQUIS is not recommended in these patients.
Acute PE in Hemodynamically Unstable Patients or Patients who Require Thrombolysis
or Pulmonary Embolectomy
Initiation of ELIQUIS is not recommended as an alternative to unfractionated heparin for the
initial treatment of patients with PE who present with hemodynamic instability or who may
receive thrombolysis or pulmonary embolectomy.
Vascular disorders: hypotension (including procedural hypotension)
Gastrointestinal disorders: gastrointestinal hemorrhage (including hematemesis and
melena), hematochezia
Hepatobiliary disorders: liver function test abnormal, blood alkaline phosphatase increased,
blood bilirubin increased
Renal and urinary disorders: hematuria (including respective laboratory parameters)
Less common adverse reactions in apixaban-treated patients undergoing hip or knee
replacement surgery occurring at a frequency of <0.1%:
Treatment of DVT and PE and Reduction in the Risk of Recurrence of DVT or PE
The safety of ELIQUIS has been evaluated in the AMPLIFY and AMPLIFY-EXT studies,
including 2676 patients exposed to ELIQUIS 10 mg twice daily, 3359 patients exposed to
ELIQUIS 5 mg twice daily, and 840 patients exposed to ELIQUIS 2.5 mg twice daily.
Common adverse reactions (≥1%) were gingival bleeding, epistaxis, contusion, hematuria,
rectal hemorrhage, hematoma, menorrhagia, and hemoptysis.
AMPLIFY Study
The mean duration of exposure to ELIQUIS (apixaban) was 154 days and to enoxaparin/
warfarin was 152 days in the AMPLIFY study. Adverse reactions related to bleeding
occurred in 417 (15.6%) ELIQUIS-treated patients compared to 661 (24.6%) enoxaparin/
warfarin-treated patients. The discontinuation rate due to bleeding events was 0.7% in the
ELIQUIS-treated patients compared to 1.7% in enoxaparin/warfarin-treated patients in the
AMPLIFY study.
For patients receiving ELIQUIS (apixaban) at a dose of 2.5 mg twice daily, avoid
coadministration with strong dual inhibitors of CYP3A4 and P-gp [see Dosage and
Administration (2.2) and Clinical Pharmacology (12.3) in full Prescribing Information].
Strong Dual Inducers of CYP3A4 and P-gp
Avoid concomitant use of ELIQUIS with strong dual inducers of CYP3A4 and P-gp
(e.g., rifampin, carbamazepine, phenytoin, St. John’s wort) because such drugs will decrease
exposure to apixaban [see Clinical Pharmacology (12.3) in full Prescribing Information].
In the AMPLIFY study, ELIQUIS was statistically superior to enoxaparin/warfarin in the
primary safety endpoint of major bleeding (relative risk 0.31, 95% CI [0.17, 0.55], P-value
<0.0001).
Anticoagulants and Antiplatelet Agents
Bleeding results from the AMPLIFY study are summarized in Table 5.
APPRAISE-2, a placebo-controlled clinical trial of apixaban in high-risk, post-acute coronary
syndrome patients treated with aspirin or the combination of aspirin and clopidogrel, was
terminated early due to a higher rate of bleeding with apixaban compared to placebo.
The rate of ISTH major bleeding was 2.77% per year with apixaban versus 0.62% per year
with placebo in patients receiving single antiplatelet therapy and was 5.91% per year with
apixaban versus 2.50% per year with placebo in those receiving dual antiplatelet therapy.
Table 5:
Bleeding Results in the AMPLIFY Study
Major
CRNM*
Major + CRNM
Minor
All
ELIQUIS
N=2676
n (%)
Enoxaparin/
Warfarin
N=2689
n (%)
15 (0.6)
49 (1.8)
103 (3.9)
115 (4.3)
313 (11.7)
402 (15.0)
215 (8.0)
261 (9.7)
505 (18.8)
676 (25.1)
Relative Risk
(95% CI)
0.31 (0.17, 0.55)
p<0.0001
Pregnancy
Pregnancy Category B
Adverse reactions occurring in ≥1% of patients in the AMPLIFY study are listed in Table 6.
Adverse Reactions Occurring in ≥1% of Patients Treated for DVT and PE in
the AMPLIFY Study
Epistaxis
Contusion
Hematuria
Menorrhagia
Hematoma
Hemoptysis
Rectal hemorrhage
Gingival bleeding
ELIQUIS
N=2676
n (%)
Enoxaparin/Warfarin
N=2689
n (%)
77 (2.9)
49 (1.8)
46 (1.7)
38 (1.4)
35 (1.3)
32 (1.2)
26 (1.0)
26 (1.0)
146 (5.4)
97 (3.6)
102 (3.8)
30 (1.1)
76 (2.8)
31 (1.2)
39 (1.5)
50 (1.9)
AMPLIFY-EXT Study
The mean duration of exposure to ELIQUIS was approximately 330 days and to placebo was
312 days in the AMPLIFY-EXT study. Adverse reactions related to bleeding occurred in 219
(13.3%) ELIQUIS-treated patients compared to 72 (8.7%) placebo-treated patients. The
discontinuation rate due to bleeding events was approximately 1% in the ELIQUIS-treated
patients compared to 0.4% in those patients in the placebo group in the AMPLIFY-EXT study.
Bleeding Results in the AMPLIFY-EXT Study
Major
CRNM*
Major + CRNM
Minor
All
There are no adequate and well-controlled studies of ELIQUIS in pregnant women. Treatment
is likely to increase the risk of hemorrhage during pregnancy and delivery. ELIQUIS should
be used during pregnancy only if the potential benefit outweighs the potential risk to the
mother and fetus.
Treatment of pregnant rats, rabbits, and mice after implantation until the end of gestation
resulted in fetal exposure to apixaban, but was not associated with increased risk for fetal
malformations or toxicity. No maternal or fetal deaths were attributed to bleeding. Increased
incidence of maternal bleeding was observed in mice, rats, and rabbits at maternal
exposures that were 19, 4, and 1 times, respectively, the human exposure of unbound drug,
based on area under plasma-concentration time curve (AUC) comparisons at the maximum
recommended human dose (MRHD) of 10 mg (5 mg twice daily).
Labor and Delivery
Safety and effectiveness of ELIQUIS during labor and delivery have not been studied in
clinical trials. Consider the risks of bleeding and of stroke in using ELIQUIS in this setting [see
Treatment of pregnant rats from implantation (gestation Day 7) to weaning (lactation Day
21) with apixaban at a dose of 1000 mg/kg (about 5 times the human exposure based on
unbound apixaban) did not result in death of offspring or death of mother rats during labor
in association with uterine bleeding. However, increased incidence of maternal bleeding,
primarily during gestation, occurred at apixaban doses of ≥25 mg/kg, a dose corresponding
to ≥1.3 times the human exposure.
Nursing Mothers
It is unknown whether apixaban or its metabolites are excreted in human milk. Rats excrete
apixaban in milk (12% of the maternal dose).
Women should be instructed either to discontinue breastfeeding or to discontinue ELIQUIS
therapy, taking into account the importance of the drug to the mother.
Pediatric Use
Safety and effectiveness in pediatric patients have not been established.
Geriatric Use
Bleeding results from the AMPLIFY-EXT study are summarized in Table 7.
Table 7:
In ARISTOTLE, concomitant use of aspirin increased the bleeding risk on ELIQUIS from
1.8% per year to 3.4% per year and the bleeding risk on warfarin from 2.7% per year to
4.6% per year. In this clinical trial, there was limited (2.3%) use of dual antiplatelet therapy
with ELIQUIS.
USE IN SPECIFIC POPULATIONS
* CRNM = clinically relevant nonmajor bleeding.
Table 6:
Coadministration of antiplatelet agents, fibrinolytics, heparin, aspirin, and chronic NSAID
use increases the risk of bleeding.
ELIQUIS
2.5 mg
N=840
n (%)
ELIQUIS
5 mg
N=811
n (%)
Placebo
2 (0.2)
25 (3.0)
27 (3.2)
75 (8.9)
94 (11.2)
1 (0.1)
34 (4.2)
35 (4.3)
98 (12.1)
121 (14.9)
4 (0.5)
19 (2.3)
22 (2.7)
58 (7.0)
74 (9.0)
N=826
n (%)
* CRNM = clinically relevant nonmajor bleeding.
Of the total subjects in the ARISTOTLE and AVERROES clinical studies, >69% were 65 and
older, and >31% were 75 and older. In the ADVANCE-1, ADVANCE-2, and ADVANCE-3 clinical
studies, 50% of subjects were 65 and older, while 16% were 75 and older. In the AMPLIFY
and AMPLIFY-EXT clinical studies, >32% of subjects were 65 and older and >13% were 75
and older. No clinically significant differences in safety or effectiveness were observed when
comparing subjects in different age groups.
End-Stage Renal Disease Patients Maintained with Hemodialysis
Patients with ESRD with or without hemodialysis were not studied in clinical efficacy
and safety studies with ELIQUIS; therefore, the dosing recommendation for patients with
nonvalvular atrial fibrillation is based on pharmacokinetic and pharmacodynamic (antiFactor Xa activity) data in subjects with ESRD maintained on dialysis. The recommended
dose for ESRD patients maintained with hemodialysis is 5 mg orally twice daily. For ESRD
patients maintained with hemodialysis with one of the following patient characteristics,
age ≥80 years or body weight ≤60 kg, reduce dose to 2.5 mg twice daily [see Dosage and
Administration (2.7) and Clinical Pharmacology (12.2, 12.3) in full Prescribing Information].
OVERDOSAGE
Adverse reactions occurring in ≥1% of patients in the AMPLIFY-EXT study are listed in Table 8.
There is no antidote to ELIQUIS. Overdose of ELIQUIS increases the risk of bleeding [see
Table 8:
In controlled clinical trials, orally administered apixaban in healthy subjects at doses up to
50 mg daily for 3 to 7 days (25 mg twice daily for 7 days or 50 mg once daily for 3 days) had
no clinically relevant adverse effects.
Adverse Reactions Occurring in ≥1% of Patients Undergoing Extended
Treatment for DVT and PE in the AMPLIFY-EXT Study
Epistaxis
Hematuria
Hematoma
Contusion
Gingival bleeding
ELIQUIS
2.5 mg
N=840
n (%)
ELIQUIS
5 mg
N=811
n (%)
Placebo
13 (1.5)
12 (1.4)
13 (1.5)
18 (2.1)
12 (1.4)
29 (3.6)
17 (2.1)
16 (2.0)
18 (2.2)
9 (1.1)
9 (1.1)
9 (1.1)
10 (1.2)
18 (2.2)
3 (0.4)
N=826
n (%)
In healthy subjects, administration of activated charcoal 2 and 6 hours after ingestion of a
20-mg dose of apixaban reduced mean apixaban AUC by 50% and 27%, respectively. Thus,
administration of activated charcoal may be useful in the management of apixaban overdose
or accidental ingestion.
PATIENT COUNSELING INFORMATION
See FDA-approved patient labeling (Medication Guide).
Advise patients of the following:
•
They should not discontinue ELIQUIS without talking to their physician first.
•
They should be informed that it might take longer than usual for bleeding to stop,
and they may bruise or bleed more easily when treated with ELIQUIS. Advise
patients about how to recognize bleeding or symptoms of hypovolemia and of the
urgent need to report any unusual bleeding to their physician.
•
They should tell their physicians and dentists they are taking ELIQUIS, and/or
any other product known to affect bleeding (including nonprescription products,
such as aspirin or NSAIDs), before any surgery or medical or dental procedure is
scheduled and before any new drug is taken.
•
If the patient is having neuraxial anesthesia or spinal puncture, inform the patient
to watch for signs and symptoms of spinal or epidural hematomas, such as
numbness or weakness of the legs, or bowel or bladder dysfunction [see Warnings
and Precautions]. If any of these symptoms occur, the patient should contact his or
her physician immediately.
•
They should tell their physicians if they are pregnant or plan to become pregnant or
are breastfeeding or intend to breastfeed during treatment with ELIQUIS [see Use
in Specific Populations].
•
If a dose is missed, the dose should be taken as soon as possible on the same
day and twice-daily administration should be resumed. The dose should not be
doubled to make up for a missed dose.
Other Adverse Reactions
Less common adverse reactions in ELIQUIS-treated patients in the AMPLIFY or AMPLIFYEXT studies occurring at a frequency of ≥0.1% to <1%:
Blood and lymphatic system disorders: hemorrhagic anemia
Gastrointestinal disorders: hematochezia, hemorrhoidal hemorrhage, gastrointestinal
hemorrhage, hematemesis, melena, anal hemorrhage
Injury, poisoning, and procedural complications: wound hemorrhage, postprocedural
hemorrhage, traumatic hematoma, periorbital hematoma
Musculoskeletal and connective tissue disorders: muscle hemorrhage
Reproductive system and breast disorders: vaginal hemorrhage, metrorrhagia,
menometrorrhagia, genital hemorrhage
Vascular disorders: hemorrhage
Skin and subcutaneous tissue disorders: ecchymosis, skin hemorrhage, petechiae
Eye disorders: conjunctival hemorrhage, retinal hemorrhage, eye hemorrhage
Investigations: blood urine present, occult blood positive, occult blood, red blood cells urine
positive
General disorders and administration-site conditions: injection-site hematoma, vessel
puncture-site hematoma
DRUG INTERACTIONS
Apixaban is a substrate of both CYP3A4 and P-gp. Inhibitors of CYP3A4 and P-gp increase
exposure to apixaban and increase the risk of bleeding. Inducers of CYP3A4 and P-gp
decrease exposure to apixaban and increase the risk of stroke and other thromboembolic
events.
Strong Dual Inhibitors of CYP3A4 and P-gp
For patients receiving ELIQUIS doses greater than 2.5 mg twice daily, the dose of ELIQUIS
should be decreased by 50% when it is coadministered with drugs that are strong dual
inhibitors of CYP3A4 and P-gp (e.g., ketoconazole, itraconazole, ritonavir, or clarithromycin)
[see Dosage and Administration (2.2) and Clinical Pharmacology (12.3) in full Prescribing
Information].
Manufactured by:
Bristol-Myers Squibb Company
Princeton, New Jersey 08543 USA
Marketed by:
Bristol-Myers Squibb Company
Princeton, New Jersey 08543 USA
and
Pfizer Inc
New York, New York 10017 USA
1289808A1 / 1289807A1 / 1298500A1
Rev August 2014
432US14BR00804-05-01
For patients with nonvalvular atrial fibrillation (NVAF),
ONLY ELIQUIS
DELIVERS BOTH
The ONLY anticoagulant that demonstrated
superiority in BOTH stroke/systemic
embolism and major bleeding vs warfarin.1
SUPERIOR
SUPERIOR
Based on
fewer major
bleeding* events
vs warfarin1
Risk reduction in
stroke/systemic
embolism
vs warfarin1
1.27%/year vs 1.60%/year; P=0.01
HR†=0.79 (95% CI,‡ 0.66, 0.95); 21% RRR§
PRIMARY EFFICACY OUTCOME
2.13%/year vs 3.09%/year; P<0.0001
HR=0.69 (95% CI, 0.60, 0.80); 31% RRR
PRIMARY SAFETY OUTCOME
Superiority to
warfarin was
primarily
attributable to
a reduction in
hemorrhagic stroke
and ischemic strokes
with hemorrhagic
conversion compared
to warfarin. Purely
ischemic strokes
occurred with similar
rates on both drugs.1
In another clinical
trial, AVERROES®,
ELIQUIS was
associated
with an increase
in major bleeding
compared to
aspirin that was not
statistically significant
(1.41%/year vs O.92%/
year, HR=1.54 [95% CI,
0.96, 2.45]; P=0.07).1
The most common reason for treatment discontinuation in both studies was for bleeding-related adverse reactions; in ARISTOTLE, this occurred in
1.7% and 2.5% of patients treated with ELIQUIS and warfarin, respectively, and in AVERROES, in 1.5% and 1.3% on ELIQUIS and aspirin, respectively.
*Major bleeding was defined as clinically overt bleeding accompanied by one or more of the
following: bleeding that was fatal; bleeding that occurred in at least one critical site (critical
hcp.eliquis.com
sites included intracranial, intraspinal, intraocular, pericardial, intra-articular, intramuscular
with compartment syndrome, retroperitoneal); a transfusion of 2 or more units of packed red
blood cells; or a decrease in hemoglobin of 2 g/dL or more.
Connect with us to learn more about
†
HR=hazard ratio; ‡CI=confidence interval; §RRR=relative risk reduction.
ELIQUIS and our NVAF clinical trial program.
ELIQUIS® and the ELIQUIS logo are trademarks of Bristol-Myers Squibb Company.
© 2015 Bristol-Myers Squibb Company. All rights reserved. 432US15BR00031-01-01 1/15
ARISTOTLE® was a Phase III, double-blind, randomized trial designed to determine whether ELIQUIS (5 mg twice daily||) was effective [noninferior to] warfarin
(target INR range: 2.0-3.0) in reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation and ≥1 additional risk factor for
stroke: prior stroke or transient ischemic attack (TIA), prior systemic embolism, age ≥75 years, arterial hypertension requiring treatment, diabetes mellitus, heart
failure ≥New York Heart Association (NYHA) Class 2, or left ventricular ejection fraction (LVEF) ≤40%. A total of 18,201 patients were randomized to ELIQUIS
(n=9120) or warfarin (n=9081), and followed for a median of ≈1.7 years. The 2 treatment groups were well balanced with respect to baseline characteristics,
including age, stroke risk at entry as measured by CHADS2 score,¶ and prior vitamin K antagonist (VKA) experience.1,2
AVERROES® was a Phase III, double-blind, randomized trial designed to compare the effects of ELIQUIS (5 mg twice daily||), n=2807, and aspirin (81 mg–324
mg once daily), n=2791, in reducing the risk of stroke and systemic embolism in 5598 patients with nonvalvular atrial fibrillation thought not to be candidates
for warfarin therapy, and with ≥1 additional risk factor for stroke: prior stroke or TIA, age ≥75 years, arterial hypertension (receiving treatment), diabetes mellitus
(receiving treatment), heart failure (≥NYHA Class 2 at the time of enrollment), LVEF ≤35%, or documented peripheral artery disease. Patients could not be
receiving VKA therapy (eg, warfarin), either because it had already been demonstrated to be or because it was expected to be unsuitable for them. The 2
treatment groups were well balanced with respect to baseline characteristics, including age, stroke risk at entry as measured by CHADS2 score, and prior use of a
VKA within 30 days before screening. The mean follow-up period was approximately 1.1 years.1,3
||
A dose of 2.5 mg twice daily was assigned to patients with at least 2 of the following characteristics: age ≥80 years, body weight ≤60 kg, or
serum creatinine ≥1.5 mg/dL.
¶
Scale from 0 to 6 to estimate stroke risk; higher scores predict greater risk.
SELECTED IMPORTANT SAFETY INFORMATION
B:15.25”
T:15”
S:14.5”
WARNINGS AND PRECAUTIONS (contd)
• Bleeding Risk: ELIQUIS increases the risk of bleeding, and can cause serious, potentially fatal bleeding.
– Concomitant use of drugs affecting hemostasis increases the risk of bleeding, including aspirin and other antiplatelet agents, other anticoagulants,
heparin, thrombolytic agents, SSRIs, SNRIs, and NSAIDs.
– Advise patients of signs and symptoms of blood loss and to report them immediately or go to an emergency room. Discontinue ELIQUIS in patients
with active pathological hemorrhage.
– There is no established way to reverse the anticoagulant effect of apixaban, which can be expected to persist for at least 24 hours after the last dose
(i.e., about two half-lives). A specific antidote for ELIQUIS is not available.
• Spinal/Epidural Anesthesia or Puncture: Patients treated with ELIQUIS undergoing spinal/epidural anesthesia or puncture may develop an epidural or
spinal hematoma which can result in long-term or permanent paralysis.
The risk of these events may be increased by the postoperative use of indwelling epidural catheters or the concomitant use of medicinal products
affecting hemostasis. Indwelling epidural or intrathecal catheters should not be removed earlier than 24 hours after the last administration of ELIQUIS.
The next dose of ELIQUIS should not be administered earlier than 5 hours after the removal of the catheter. The risk may also be increased by traumatic
or repeated epidural or spinal puncture. If traumatic puncture occurs, delay the administration of ELIQUIS for 48 hours.
Monitor patients frequently and if neurological compromise is noted, urgent diagnosis and treatment is necessary. Physicians should consider the
potential benefit versus the risk of neuraxial intervention in ELIQUIS patients.
• Prosthetic Heart Valves: The safety and efficacy of ELIQUIS have not been studied in patients with prosthetic heart valves and is not recommended in
these patients.
• Acute PE in Hemodynamically Unstable Patients or Patients who Require Thrombolysis or Pulmonary Embolectomy: Initiation of ELIQUIS is not
recommended as an alternative to unfractionated heparin for the initial treatment of patients with PE who present with hemodynamic instability or who
may receive thrombolysis or pulmonary embolectomy.
ADVERSE REACTIONS
• The most common and most serious adverse reactions reported with ELIQUIS were related to bleeding.
TEMPORARY INTERRUPTION FOR SURGERY AND OTHER INTERVENTIONS
• ELIQUIS should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically
significant bleeding. ELIQUIS should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the
bleeding would be noncritical in location and easily controlled. Bridging anticoagulation during the 24 to 48 hours after stopping ELIQUIS and prior to the
intervention is not generally required. ELIQUIS should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.
DRUG INTERACTIONS
• Strong Dual Inhibitors of CYP3A4 and P-gp: Inhibitors of CYP3A4 and P-gp increase exposure to apixaban and increase the risk of bleeding. For patients
receiving ELIQUIS doses greater than 2.5 mg twice daily, the dose of ELIQUIS should be decreased by 50% when it is coadministered with drugs that are
strong dual inhibitors of CYP3A4 and P-gp (e.g., ketoconazole, itraconazole, ritonavir, or clarithromycin). For patients receiving ELIQUIS at a dose of 2.5 mg
twice daily, avoid coadministration with strong dual inhibitors of CYP3A4 and P-gp.
• Strong Dual Inducers of CYP3A4 and P-gp: Avoid concomitant use of ELIQUIS with strong dual inducers of CYP3A4 and P-gp (e.g., rifampin,
carbamazepine, phenytoin, St. John’s wort) because such drugs will decrease exposure to apixaban and increase the risk of stroke and other
thromboembolic events.
• Anticoagulants and Antiplatelet Agents: Coadministration of antiplatelet agents, fibrinolytics, heparin, aspirin, and chronic NSAID use increases the risk
of bleeding. APPRAISE-2, a placebo-controlled clinical trial of apixaban in high-risk post-acute coronary syndrome patients treated with aspirin or the
combination of aspirin and clopidogrel, was terminated early due to a higher rate of bleeding with apixaban compared to placebo.
PREGNANCY CATEGORY B
• There are no adequate and well-controlled studies of ELIQUIS in pregnant women. Treatment is likely to increase the risk of hemorrhage during pregnancy
and delivery. ELIQUIS should be used during pregnancy only if the potential benefit outweighs the potential risk to the mother and fetus.
Please see Brief Summary of Full Prescribing Information, including Boxed WARNINGS, on following pages.
References: 1. ELIQUIS® (apixaban) Package Insert. Bristol-Myers Squibb Company, Princeton, NJ, and Pfizer Inc, New York, NY; August 2014. 2. Granger CB, Alexander JH, McMurray JJV, et al; for
the ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981-992. 3. Connolly SJ, Eikelboom J, Joyner C, et al; for the
AVERROES Steering Committee and Investigators. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011;364(9):806-817.
Approved for 6 indications
Treatment
of PE
Reduction in risk
of stroke/systemic
embolism in NVAF
Prophylaxis of DVT, which
may lead to PE, after hip
replacement surgery
Treatment
of DVT
Reduction in the
risk of recurrent
DVT and PE
following initial
therapy
Prophylaxis of DVT, which
may lead to PE, after knee
replacement surgery
NVAF=nonvalvular atrial fibrillation; DVT=deep vein thrombosis; PE=pulmonary embolism.
SELECTED IMPORTANT SAFETY INFORMATION
WARNING: (A) PREMATURE DISCONTINUATION OF ELIQUIS INCREASES THE RISK OF THROMBOTIC EVENTS,
(A) Premature discontinuation of any oral anticoagulant, including ELIQUIS, increases the risk of thrombotic events. If
anticoagulation with ELIQUIS is discontinued for a reason other than pathological bleeding or completion of a course of therapy,
consider coverage with another anticoagulant.
(B) Epidural or spinal hematomas may occur in patients treated with ELIQUIS who are receiving neuraxial anesthesia or undergoing
spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients
for spinal procedures. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include:
• use of indwelling epidural catheters
• concomitant use of other drugs that affect hemostasis, such as nonsteroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors,
other anticoagulants
• a history of traumatic or repeated epidural or spinal punctures
• a history of spinal deformity or spinal surgery
• optimal timing between the administration of ELIQUIS and neuraxial procedures is not known
Monitor patients frequently for signs and symptoms of neurological impairment. If neurological compromise is noted, urgent
treatment is necessary.
Consider the benefits and risks before neuraxial intervention in patients anticoagulated or to be anticoagulated.
CONTRAINDICATIONS
• Active pathological bleeding
• Severe hypersensitivity reaction to ELIQUIS (e.g., anaphylactic reactions)
WARNINGS AND PRECAUTIONS
• Increased Risk of Thrombotic Events after Premature Discontinuation: Premature discontinuation of any oral anticoagulant, including ELIQUIS,
in the absence of adequate alternative anticoagulation increases the risk of thrombotic events. An increased rate of stroke was observed during the
transition from ELIQUIS to warfarin in clinical trials in atrial fibrillation patients. If ELIQUIS is discontinued for a reason other than pathological
bleeding or completion of a course of therapy, consider coverage with another anticoagulant.
Please see additional Important Safety Information and Brief Summary of Full Prescribing Information, including Boxed WARNINGS, on following pages.

patient - The Hospitalist

Transcription

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