Caitlin Foxley, MD, FHM

Daniel Brotman, MD, FACP, FHM, of Johns Hopkins Hospital in Baltimore, addressed questions all hospitalists wonder about:

1. Is warfarin still the best anticoagulant in afib? 2. Should DVT prevention extend beyond hospitalization? 3. What is the best evidence for LMWH bridging in valve patients? 4. When should anticoagulation be started in stroke patients with afib?

Warfarin, Dr. Brotman explained, has many disadvantages, and new oral anticoagulants (dabigatran, apixaban, rivaoxaban) offer many advantages with lower side-effect profiles. All of the new agents appear to have either better efficacy or trend toward better efficacy, none require monitoring, and all have lower rate of ICH.

Prices are higher for new agents, but are competitive with other drugs currently on market for other diseases. Use dabigatran with caution in patients with renal failure, and realize that there is no antidote for any of these drugs. Dabigatran is acidic and causes GI upset, thus a higher rate of GI bleeding. Stop any of these 5 days prior to planned proceduers; longer if patients are at high risk of bleeding.

Evidence from RCTs in hospitalized surgical patients suggest that VTE prophylaxis should be continued in patients undergoing hip surgery and surgery for abdominal or pelvic malignancy. Patients admitted for acute medical illness do not benefit from VTE prophylaxis beyond acute hospitlaization, even if immobilized, unless they have solid tumors with additional risk factors (hormone use, prior VTE, etc.) and are at low risk for bleeding. Chronically immobilized patients do not benefit from VTE prophylaxis beyond the acute hospitalization.

Bridging-aortic valves have an equivalent CHAD2 score of about 2, so there really is no need to bridge pre-op. Mitral valves have a CHADS2 score of about 4-5, so they always need to be bridged. No head-to-head trials of bridging with LMWH exist, but it's still worth considering if no contraindications because it is much more cost-effective than inpatient admission for IV UFH.

Oral anticoag can be started within 1-2 weeks of stroke onset. The larger the stroke, the greater the risk of hemorrhagic transformation with early anticoagulation, so the smaller the stroke, the safer to start early. VTE prophylaxis important regardless.

Key Takeaways:

• We'll be using the new oral anticoagulants in place of warfarin in the coming years, although there is no safe anticoagulant. Be cautious and aware of the side effect profiles of each.
• Don't sweat VTE prophylaxis in chronically immobilized patients unless they are acutely hospitalized.
• VTE prophylaxis is critical in stroke patients, but the larger the stroke in afib patients, the longer the wait to start oral anticoagulation.

Dr. Foxley is medical director of Inpatient Management, Inc., at the The Nebraska Medical Center Hospitals in Omaha

Daniel Brotman, MD, FACP, FHM, of Johns Hopkins Hospital in Baltimore, addressed questions all hospitalists wonder about:

1. Is warfarin still the best anticoagulant in afib? 2. Should DVT prevention extend beyond hospitalization? 3. What is the best evidence for LMWH bridging in valve patients? 4. When should anticoagulation be started in stroke patients with afib?

Warfarin, Dr. Brotman explained, has many disadvantages, and new oral anticoagulants (dabigatran, apixaban, rivaoxaban) offer many advantages with lower side-effect profiles. All of the new agents appear to have either better efficacy or trend toward better efficacy, none require monitoring, and all have lower rate of ICH.

Prices are higher for new agents, but are competitive with other drugs currently on market for other diseases. Use dabigatran with caution in patients with renal failure, and realize that there is no antidote for any of these drugs. Dabigatran is acidic and causes GI upset, thus a higher rate of GI bleeding. Stop any of these 5 days prior to planned proceduers; longer if patients are at high risk of bleeding.

Evidence from RCTs in hospitalized surgical patients suggest that VTE prophylaxis should be continued in patients undergoing hip surgery and surgery for abdominal or pelvic malignancy. Patients admitted for acute medical illness do not benefit from VTE prophylaxis beyond acute hospitlaization, even if immobilized, unless they have solid tumors with additional risk factors (hormone use, prior VTE, etc.) and are at low risk for bleeding. Chronically immobilized patients do not benefit from VTE prophylaxis beyond the acute hospitalization.

Bridging-aortic valves have an equivalent CHAD2 score of about 2, so there really is no need to bridge pre-op. Mitral valves have a CHADS2 score of about 4-5, so they always need to be bridged. No head-to-head trials of bridging with LMWH exist, but it's still worth considering if no contraindications because it is much more cost-effective than inpatient admission for IV UFH.

Oral anticoag can be started within 1-2 weeks of stroke onset. The larger the stroke, the greater the risk of hemorrhagic transformation with early anticoagulation, so the smaller the stroke, the safer to start early. VTE prophylaxis important regardless.

Key Takeaways:

• We'll be using the new oral anticoagulants in place of warfarin in the coming years, although there is no safe anticoagulant. Be cautious and aware of the side effect profiles of each.
• Don't sweat VTE prophylaxis in chronically immobilized patients unless they are acutely hospitalized.
• VTE prophylaxis is critical in stroke patients, but the larger the stroke in afib patients, the longer the wait to start oral anticoagulation.

Dr. Foxley is medical director of Inpatient Management, Inc., at the The Nebraska Medical Center Hospitals in Omaha

Daniel Brotman, MD, FACP, FHM, of Johns Hopkins Hospital in Baltimore, addressed questions all hospitalists wonder about:

1. Is warfarin still the best anticoagulant in afib? 2. Should DVT prevention extend beyond hospitalization? 3. What is the best evidence for LMWH bridging in valve patients? 4. When should anticoagulation be started in stroke patients with afib?

Warfarin, Dr. Brotman explained, has many disadvantages, and new oral anticoagulants (dabigatran, apixaban, rivaoxaban) offer many advantages with lower side-effect profiles. All of the new agents appear to have either better efficacy or trend toward better efficacy, none require monitoring, and all have lower rate of ICH.

Prices are higher for new agents, but are competitive with other drugs currently on market for other diseases. Use dabigatran with caution in patients with renal failure, and realize that there is no antidote for any of these drugs. Dabigatran is acidic and causes GI upset, thus a higher rate of GI bleeding. Stop any of these 5 days prior to planned proceduers; longer if patients are at high risk of bleeding.

Evidence from RCTs in hospitalized surgical patients suggest that VTE prophylaxis should be continued in patients undergoing hip surgery and surgery for abdominal or pelvic malignancy. Patients admitted for acute medical illness do not benefit from VTE prophylaxis beyond acute hospitlaization, even if immobilized, unless they have solid tumors with additional risk factors (hormone use, prior VTE, etc.) and are at low risk for bleeding. Chronically immobilized patients do not benefit from VTE prophylaxis beyond the acute hospitalization.

Bridging-aortic valves have an equivalent CHAD2 score of about 2, so there really is no need to bridge pre-op. Mitral valves have a CHADS2 score of about 4-5, so they always need to be bridged. No head-to-head trials of bridging with LMWH exist, but it's still worth considering if no contraindications because it is much more cost-effective than inpatient admission for IV UFH.

Oral anticoag can be started within 1-2 weeks of stroke onset. The larger the stroke, the greater the risk of hemorrhagic transformation with early anticoagulation, so the smaller the stroke, the safer to start early. VTE prophylaxis important regardless.

Key Takeaways:

• We'll be using the new oral anticoagulants in place of warfarin in the coming years, although there is no safe anticoagulant. Be cautious and aware of the side effect profiles of each.
• Don't sweat VTE prophylaxis in chronically immobilized patients unless they are acutely hospitalized.
• VTE prophylaxis is critical in stroke patients, but the larger the stroke in afib patients, the longer the wait to start oral anticoagulation.

Dr. Foxley is medical director of Inpatient Management, Inc., at the The Nebraska Medical Center Hospitals in Omaha

Patrick Torcson explained the history behind the ABCs of CMS during a Monday-morning session at HM12.

Medicare Part A currently spends $200 billion annually, and Part B spends $120 billion annually. These costs are unsustainable, said Dr. Torcson, and a 2003 Rand study found the quality of care provided by Medicare to be "untrustworthy." Fee for service is volume-based, not quality-based, said Dr. Torcson. Out of this was born the idea of pay for performance (P4P). The structure of P4P is such that performance is measured, reported, and rewarded. Whether or not P4P actually works is controversial, said Dr. Torcson. Studies are limited, results are conflicting, and nothing suggests better outcomes for patients.

The 3 Stages of P4P

1. Physician Quality Reporting System (PQRS): voluntary reporting system whereby physicians report to CMS on a variety of metrics. There are 10 metrics that hospitalists can report on, such as ACE/ARB for HF, and BB for AMI. PQRS provides a potential percentage increase in medicare payments through 2014. In 2015, failure to participate will result in reductions in payments from Medicare.
2. Physician Feedback Program: A three-phase program that began in 2007, it provides confidential reports to physicians called quality resource use reports (QRUR). These reports will be used to generate physicians' scores for the next:
3. Value-Based Payment Modifier: Each physician will receive a two-digit score assigned to his or her NPI. This will cause reimbursement of E&M scores to be weighted according to quality. Whereas currently a 99233 is reimbursed at $186.19, the range will be from $166.19 to $206.19, depending on a physician's VBP modifier. This will take effect in 2013 in Iowa, Nebraska, Kansas, and Missouri.

Bottom Line

• Value-based purchasing is designed to be budget-neutral; some will earn more, some less.
• Get used to being measured.
• Learn new skills and competencies.
• Embrace it; don't be lulled into complacency.

Patrick Torcson explained the history behind the ABCs of CMS during a Monday-morning session at HM12.

Medicare Part A currently spends $200 billion annually, and Part B spends $120 billion annually. These costs are unsustainable, said Dr. Torcson, and a 2003 Rand study found the quality of care provided by Medicare to be "untrustworthy." Fee for service is volume-based, not quality-based, said Dr. Torcson. Out of this was born the idea of pay for performance (P4P). The structure of P4P is such that performance is measured, reported, and rewarded. Whether or not P4P actually works is controversial, said Dr. Torcson. Studies are limited, results are conflicting, and nothing suggests better outcomes for patients.

The 3 Stages of P4P

1. Physician Quality Reporting System (PQRS): voluntary reporting system whereby physicians report to CMS on a variety of metrics. There are 10 metrics that hospitalists can report on, such as ACE/ARB for HF, and BB for AMI. PQRS provides a potential percentage increase in medicare payments through 2014. In 2015, failure to participate will result in reductions in payments from Medicare.
2. Physician Feedback Program: A three-phase program that began in 2007, it provides confidential reports to physicians called quality resource use reports (QRUR). These reports will be used to generate physicians' scores for the next:
3. Value-Based Payment Modifier: Each physician will receive a two-digit score assigned to his or her NPI. This will cause reimbursement of E&M scores to be weighted according to quality. Whereas currently a 99233 is reimbursed at $186.19, the range will be from $166.19 to $206.19, depending on a physician's VBP modifier. This will take effect in 2013 in Iowa, Nebraska, Kansas, and Missouri.

Bottom Line

• Value-based purchasing is designed to be budget-neutral; some will earn more, some less.
• Get used to being measured.
• Learn new skills and competencies.
• Embrace it; don't be lulled into complacency.

Patrick Torcson explained the history behind the ABCs of CMS during a Monday-morning session at HM12.

Medicare Part A currently spends $200 billion annually, and Part B spends $120 billion annually. These costs are unsustainable, said Dr. Torcson, and a 2003 Rand study found the quality of care provided by Medicare to be "untrustworthy." Fee for service is volume-based, not quality-based, said Dr. Torcson. Out of this was born the idea of pay for performance (P4P). The structure of P4P is such that performance is measured, reported, and rewarded. Whether or not P4P actually works is controversial, said Dr. Torcson. Studies are limited, results are conflicting, and nothing suggests better outcomes for patients.

The 3 Stages of P4P

1. Physician Quality Reporting System (PQRS): voluntary reporting system whereby physicians report to CMS on a variety of metrics. There are 10 metrics that hospitalists can report on, such as ACE/ARB for HF, and BB for AMI. PQRS provides a potential percentage increase in medicare payments through 2014. In 2015, failure to participate will result in reductions in payments from Medicare.
2. Physician Feedback Program: A three-phase program that began in 2007, it provides confidential reports to physicians called quality resource use reports (QRUR). These reports will be used to generate physicians' scores for the next:
3. Value-Based Payment Modifier: Each physician will receive a two-digit score assigned to his or her NPI. This will cause reimbursement of E&M scores to be weighted according to quality. Whereas currently a 99233 is reimbursed at $186.19, the range will be from $166.19 to $206.19, depending on a physician's VBP modifier. This will take effect in 2013 in Iowa, Nebraska, Kansas, and Missouri.

Bottom Line

• Value-based purchasing is designed to be budget-neutral; some will earn more, some less.
• Get used to being measured.
• Learn new skills and competencies.
• Embrace it; don't be lulled into complacency.