Take-Home Points

• The Flesch-Kincaid Readability Scale is a useful tool in evaluating the readability of PEMs.
• Only 1 article analyzed in our study was below a sixth-grade readability level.
• Coauthorship of PEMs with other subspecialty groups had no effect on readability.
• Poor health literacy has been associated with poor health outcomes.
• Efforts must be undertaken to make PEMs more readable across medical subspecialties.

Patients increasingly turn to the Internet to self-educate about orthopedic conditions.^1,2 Accordingly, the Internet has become a valuable tool in maintaining effective physician-patient communication.^3-5 Given the Internet’s importance as a medium for conveying patient information, it is important that orthopedic patient education materials (PEMs) on the Internet provide high-quality information that is easily read by the target patient population. Unfortunately, studies have found that many of the Internet’s orthopedic PEMs have been neither of high quality^6-8 nor presented such that they are easy for patients to read and comprehend.^1,9-12

Readability, which is the reading comprehension level (school grade level) a person must have to understand written materials, is determined by systematic formulae¹²; readability levels correlate with the ability to comprehend written information.² Studies have consistently found that orthopedic PEMs are written at readability levels too high for the average patient to understand.^1,9,13 The readability of PEMs in orthopedics as a whole⁹ and within the orthopedic subspecialties of arthroplasty,¹ foot and ankle surgery,² sports medicine,¹² and spine surgery¹³ has been evaluated, but so far there has been no evaluation of PEMs in orthopedic trauma (OT).

We conducted a study to assess the readability of OT-PEMs available online from the American Academy of Orthopaedic Surgeons (AAOS) in conjunction with the Orthopaedic Trauma Association (OTA) and other orthopedic subspecialty societies. We hypothesized the readability levels of these OT-PEMs would be above the level (sixth to eighth grade) recommended by several healthcare organizations, including the Centers for Disease Control and Prevention.^9,11,14 We also assessed the effect that orthopedic subspecialty coauthorship has on PEM readability.

Methods

In July 2014, we searched the AAOS online patient education library (Broken Bones & Injuries section, http://orthoinfo.aaos.org/menus/injury.cfm) and the AAOS OrthoPortal website (Trauma section, http://pubsearch.aaos.org/search?q=trauma&client=OrthoInfo&site=PATIENT&output=xml_no_dtd&proxystylesheet=OrthoInfo&filter=0) for all relevant OT-PEMs. Although OTA does not publish its own PEMs on its website, it coauthored several of the articles in the AAOS patient education library. Other subspecialty organizations, including the American Orthopaedic Society for Sports Medicine (AOSSM), the American Society for Surgery of the Hand (ASSH), the Pediatric Orthopaedic Society of North America (POSNA), the American Shoulder and Elbow Surgeons (ASES), the American Association of Hip and Knee Surgeons (AAHKS), and the American Orthopaedic Foot and Ankle Society (AOFAS), coauthored several of these online OT-PEMs as well.

Using the technique described by Badarudeen and Sabharwal,¹⁰ we saved all articles to be included in the study as separate Microsoft Word 2011 files. We saved them in plain-text format to remove any HTML tags and any other hidden formatting that might affect readability results. Then we edited them to remove elements that might affect readability result accuracy—deleted article topic–unrelated information (eg, copyright notice, disclaimers, author information) and all numerals, decimal points, bullets, abbreviations, paragraph breaks, colons, semicolons, and dashes.¹⁰Mr. Mohan used the Flesch-Kincaid (FK) Readability Scale to calculate grade level for each article. Microsoft Word 2011 was used as described in other investigations of orthopedic PEM readability^2,10,12,13: Its readability function is enabled by going to the Tools tab and then to the Spelling & Grammar tool, where the “Show readability statistics” option is selected.¹⁰ Readability scores are calculated with the Spelling & Grammar tool; the readability score is displayed after completion of the spelling-and-grammar check. The formula used to calculate FK grade level is¹⁵: (0.39 × average number of words per sentence) + (11.8 × average number of syllables per word) – 15.59.

Statistical Analysis

Descriptive statistics, including means and 95% confidence intervals (CIs), were calculated for the FK grade levels. Student t tests were used to compare average FK grade levels of articles written exclusively by AAOS with those of articles coauthored by AAOS and other orthopedic subspecialty societies. A 2-sample unequal-variance t test was used, and significance was set at P < .05. Total number of articles written at or below the sixth- and eighth-grade levels, the reading levels recommended for PEMs, were tabulated.^1,9-12 Intraobserver and interobserver reliabilities were calculated with intraclass correlation coefficients (ICCs): Mr. Mohan, who calculated the FK scores earlier, now 1 week later calculated the readability levels of 15 randomly selected articles^10,11; in addition, Mr. Mohan and Dr. Yi independently calculated the readability levels of 30 randomly selected articles.^10,11 The same method described earlier—edit plain-text files, then use Microsoft Word to obtain FK scores—was again used. ICCs of 0 to 0.24 correspond to poor correlation; 0.25 to 0.49, low correlation; 0.5 to 0.69, fair correlation; 0.7 to 0.89, good correlation; and 0.9 to 1.0, excellent correlation.^10,11 All statistical analyses were performed with Microsoft Excel 2011 and VassarStats (http://vassarstats.net/tu.html).

Results

Of the 115 AAOS website articles included in the study and reviewed, 18 were coauthored by OTA, 10 by AOSSM, 14 by POSNA, 2 by ASSH, 2 by ASES, 1 by AAHKS, 3 by AOFAS, 1 by AOSSM and ASES, and 1 by AOFAS and AOSSM.

Mean FK grade level was 9.1 (range, 6.2-12; 95% CI, 8.9-9.3) for all articles reviewed and 9.1 (range, 6.2-12; 95% CI, 8.8-9.4) for articles exclusively written by AAOS. For coauthored articles, mean FK grade level was 9.3 (range, 7.6-11.3; 95% CI, 8.8-9.8) for AAOS-OTA; 8.9 (range, 7.4-10.4; 95% CI, 8.4-9.6) for AAOS-AOSSM; 9.4 (range, 7-11.8; 95% CI, 8.9-10.1) for AAOS-POSNA; 7.8 (range, 7.8-9.1; 95% CI, 7.2-9.8) for AAOS-ASSH; 9 (range, 8.2-9.6; 95% CI, 7.6-10.2) for AAOS-ASES; 9 (range, 7.9-9; 95% CI, 7.9-9.3) for AAOS-AOFAS; 8.1 for the 1 AAOS-AAHKS article; 8.5 for the 1 AAOS-AOSSM-ASES article; and 8 for the 1 AAOS-AOFAS-AOSSM article (Figure).

Discussion

Although increasing numbers of patients are using information from the Internet to inform their healthcare decisions,¹² studies have shown that online PEMs are written at a readability level above that of the average patient.^1,9,13 In the present study, we also found that OT-PEMs from AAOS are written at a level considerably higher than the recommended sixth-grade reading level,¹⁶ potentially impairing patient comprehension and leading to poorer health outcomes.¹⁷

The pervasiveness of too-high PEM readability levels has been found across orthopedic subspecialties.^2,9,12,13 Following this trend, the OT articles we reviewed had a ninth-grade reading level on average, and only 1 of 115 articles was below the recommended sixth-grade level.¹⁰ The issue of too-high PEM readability levels is thus a problem both in OT and in orthopedics in general. Accordingly, efforts to address this problem are warranted, especially as orthopedic PEM readability has not substantially improved over the past several years.¹⁸In this study, we also tried to identify any readability differences between articles coauthored by orthopedic societies and articles that were not coauthored by orthopedic societies. We hypothesized that multidisciplinary authorship could improve PEM readability; for example, orthopedic societies could collaborate with other medical specialties (eg, family medicine) that have produced appropriately readable PEMs. One study found that the majority of PEMs from the American Academy of Family Physicians (AAFP) were written below the sixth-grade reading level because of strict organizational regulation of the production of such materials.¹⁹ By noting and adopting successful PEM development methods used by groups such as AAFP,^19,20 we might be able to improve OT-PEM readability. However, this was not the case in our study, though our observations may have been limited by the small sample of reviewable articles.

One factor contributing to the poor readability of orthopedic PEMs is that orthopedics terminology is complex and includes words that are often difficult to translate into simpler terms without losing their meaning.¹⁰ When PEMs are written at a level that is too complex, patients cannot fully comprehend them, which may lead to poor health literacy. This problem may be even more harmful when considering the poor literacy levels of patients at baseline. Kadakia and colleagues¹⁶ found that OT patients had poor health literacy; for example, fewer than half knew which bone they fractured. As health literacy is associated with poorer health outcomes and reduced use of healthcare services,²¹ optimizing patients’ health literacy is of crucial importance to both their education and their outcomes.

Our study should be viewed in light of some important limitations. As OTA does not publish its own PEMs, we assessed only OT-related articles that were available on the AAOS website and were exclusively written by AAOS, or coauthored by AAOS and by OTA and/or another orthopedic subspecialty organization. As these articles represent only a subset of the full spectrum of OT-PEMs available on the Internet, our results may not be generalizable to the entire scope of such materials. However, as AAOS and OTA represent the most authoritative OT organizations, we think these PEMs would be among those most likely to be recommended to patients by their surgeons. In addition, although we used a well-established tool for examining readability—the FK readability scale^10-13—this tool has its own inherent limitations, as FK readability grade level is calculated purely on the basis of words per sentence and total syllables per word, and does not take into account other article elements, such as images, which also provide information.^1,10 Nevertheless, the FK scale is an inexpensive, easily accessed readability tool that provides a reproducible readability value that is easily comparable to results from earlier studies.¹⁰ The final limitation is that we excluded from the study AAOS website articles written in a language other than English. Such articles, however, are important, as a large portion of the patient population speaks English as a second language. Indeed, the readability of Spanish PEMs has been investigated—albeit using a readability measure other than the FK scale—and may be a topic pertinent to orthopedic PEMs.²²Most of the literature on the readability of orthopedic PEMs has found their reading levels too high for the average patient to comprehend.^1,9-12 The trend continues with our study findings regarding OT-PEMs available online from AAOS. Although the literature on the inadequacies of orthopedic PEMs is vast,^1,9-12 more work is needed to improve the quality, accuracy, and readability of these materials. There has been some success in improving PEM readability and producing appropriately readable materials within the medical profession,^19,23 so we know that appropriately readable orthopedic PEMs are feasible.

Am J Orthop. 2017;46(3):E190-E194. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• The Flesch-Kincaid Readability Scale is a useful tool in evaluating the readability of PEMs.
• Only 1 article analyzed in our study was below a sixth-grade readability level.
• Coauthorship of PEMs with other subspecialty groups had no effect on readability.
• Poor health literacy has been associated with poor health outcomes.
• Efforts must be undertaken to make PEMs more readable across medical subspecialties.

Patients increasingly turn to the Internet to self-educate about orthopedic conditions.^1,2 Accordingly, the Internet has become a valuable tool in maintaining effective physician-patient communication.^3-5 Given the Internet’s importance as a medium for conveying patient information, it is important that orthopedic patient education materials (PEMs) on the Internet provide high-quality information that is easily read by the target patient population. Unfortunately, studies have found that many of the Internet’s orthopedic PEMs have been neither of high quality^6-8 nor presented such that they are easy for patients to read and comprehend.^1,9-12

Readability, which is the reading comprehension level (school grade level) a person must have to understand written materials, is determined by systematic formulae¹²; readability levels correlate with the ability to comprehend written information.² Studies have consistently found that orthopedic PEMs are written at readability levels too high for the average patient to understand.^1,9,13 The readability of PEMs in orthopedics as a whole⁹ and within the orthopedic subspecialties of arthroplasty,¹ foot and ankle surgery,² sports medicine,¹² and spine surgery¹³ has been evaluated, but so far there has been no evaluation of PEMs in orthopedic trauma (OT).

We conducted a study to assess the readability of OT-PEMs available online from the American Academy of Orthopaedic Surgeons (AAOS) in conjunction with the Orthopaedic Trauma Association (OTA) and other orthopedic subspecialty societies. We hypothesized the readability levels of these OT-PEMs would be above the level (sixth to eighth grade) recommended by several healthcare organizations, including the Centers for Disease Control and Prevention.^9,11,14 We also assessed the effect that orthopedic subspecialty coauthorship has on PEM readability.

Methods

In July 2014, we searched the AAOS online patient education library (Broken Bones & Injuries section, http://orthoinfo.aaos.org/menus/injury.cfm) and the AAOS OrthoPortal website (Trauma section, http://pubsearch.aaos.org/search?q=trauma&client=OrthoInfo&site=PATIENT&output=xml_no_dtd&proxystylesheet=OrthoInfo&filter=0) for all relevant OT-PEMs. Although OTA does not publish its own PEMs on its website, it coauthored several of the articles in the AAOS patient education library. Other subspecialty organizations, including the American Orthopaedic Society for Sports Medicine (AOSSM), the American Society for Surgery of the Hand (ASSH), the Pediatric Orthopaedic Society of North America (POSNA), the American Shoulder and Elbow Surgeons (ASES), the American Association of Hip and Knee Surgeons (AAHKS), and the American Orthopaedic Foot and Ankle Society (AOFAS), coauthored several of these online OT-PEMs as well.

Using the technique described by Badarudeen and Sabharwal,¹⁰ we saved all articles to be included in the study as separate Microsoft Word 2011 files. We saved them in plain-text format to remove any HTML tags and any other hidden formatting that might affect readability results. Then we edited them to remove elements that might affect readability result accuracy—deleted article topic–unrelated information (eg, copyright notice, disclaimers, author information) and all numerals, decimal points, bullets, abbreviations, paragraph breaks, colons, semicolons, and dashes.¹⁰Mr. Mohan used the Flesch-Kincaid (FK) Readability Scale to calculate grade level for each article. Microsoft Word 2011 was used as described in other investigations of orthopedic PEM readability^2,10,12,13: Its readability function is enabled by going to the Tools tab and then to the Spelling & Grammar tool, where the “Show readability statistics” option is selected.¹⁰ Readability scores are calculated with the Spelling & Grammar tool; the readability score is displayed after completion of the spelling-and-grammar check. The formula used to calculate FK grade level is¹⁵: (0.39 × average number of words per sentence) + (11.8 × average number of syllables per word) – 15.59.

Statistical Analysis

Descriptive statistics, including means and 95% confidence intervals (CIs), were calculated for the FK grade levels. Student t tests were used to compare average FK grade levels of articles written exclusively by AAOS with those of articles coauthored by AAOS and other orthopedic subspecialty societies. A 2-sample unequal-variance t test was used, and significance was set at P < .05. Total number of articles written at or below the sixth- and eighth-grade levels, the reading levels recommended for PEMs, were tabulated.^1,9-12 Intraobserver and interobserver reliabilities were calculated with intraclass correlation coefficients (ICCs): Mr. Mohan, who calculated the FK scores earlier, now 1 week later calculated the readability levels of 15 randomly selected articles^10,11; in addition, Mr. Mohan and Dr. Yi independently calculated the readability levels of 30 randomly selected articles.^10,11 The same method described earlier—edit plain-text files, then use Microsoft Word to obtain FK scores—was again used. ICCs of 0 to 0.24 correspond to poor correlation; 0.25 to 0.49, low correlation; 0.5 to 0.69, fair correlation; 0.7 to 0.89, good correlation; and 0.9 to 1.0, excellent correlation.^10,11 All statistical analyses were performed with Microsoft Excel 2011 and VassarStats (http://vassarstats.net/tu.html).

Results

Of the 115 AAOS website articles included in the study and reviewed, 18 were coauthored by OTA, 10 by AOSSM, 14 by POSNA, 2 by ASSH, 2 by ASES, 1 by AAHKS, 3 by AOFAS, 1 by AOSSM and ASES, and 1 by AOFAS and AOSSM.

Mean FK grade level was 9.1 (range, 6.2-12; 95% CI, 8.9-9.3) for all articles reviewed and 9.1 (range, 6.2-12; 95% CI, 8.8-9.4) for articles exclusively written by AAOS. For coauthored articles, mean FK grade level was 9.3 (range, 7.6-11.3; 95% CI, 8.8-9.8) for AAOS-OTA; 8.9 (range, 7.4-10.4; 95% CI, 8.4-9.6) for AAOS-AOSSM; 9.4 (range, 7-11.8; 95% CI, 8.9-10.1) for AAOS-POSNA; 7.8 (range, 7.8-9.1; 95% CI, 7.2-9.8) for AAOS-ASSH; 9 (range, 8.2-9.6; 95% CI, 7.6-10.2) for AAOS-ASES; 9 (range, 7.9-9; 95% CI, 7.9-9.3) for AAOS-AOFAS; 8.1 for the 1 AAOS-AAHKS article; 8.5 for the 1 AAOS-AOSSM-ASES article; and 8 for the 1 AAOS-AOFAS-AOSSM article (Figure).

Discussion

Although increasing numbers of patients are using information from the Internet to inform their healthcare decisions,¹² studies have shown that online PEMs are written at a readability level above that of the average patient.^1,9,13 In the present study, we also found that OT-PEMs from AAOS are written at a level considerably higher than the recommended sixth-grade reading level,¹⁶ potentially impairing patient comprehension and leading to poorer health outcomes.¹⁷

The pervasiveness of too-high PEM readability levels has been found across orthopedic subspecialties.^2,9,12,13 Following this trend, the OT articles we reviewed had a ninth-grade reading level on average, and only 1 of 115 articles was below the recommended sixth-grade level.¹⁰ The issue of too-high PEM readability levels is thus a problem both in OT and in orthopedics in general. Accordingly, efforts to address this problem are warranted, especially as orthopedic PEM readability has not substantially improved over the past several years.¹⁸In this study, we also tried to identify any readability differences between articles coauthored by orthopedic societies and articles that were not coauthored by orthopedic societies. We hypothesized that multidisciplinary authorship could improve PEM readability; for example, orthopedic societies could collaborate with other medical specialties (eg, family medicine) that have produced appropriately readable PEMs. One study found that the majority of PEMs from the American Academy of Family Physicians (AAFP) were written below the sixth-grade reading level because of strict organizational regulation of the production of such materials.¹⁹ By noting and adopting successful PEM development methods used by groups such as AAFP,^19,20 we might be able to improve OT-PEM readability. However, this was not the case in our study, though our observations may have been limited by the small sample of reviewable articles.

One factor contributing to the poor readability of orthopedic PEMs is that orthopedics terminology is complex and includes words that are often difficult to translate into simpler terms without losing their meaning.¹⁰ When PEMs are written at a level that is too complex, patients cannot fully comprehend them, which may lead to poor health literacy. This problem may be even more harmful when considering the poor literacy levels of patients at baseline. Kadakia and colleagues¹⁶ found that OT patients had poor health literacy; for example, fewer than half knew which bone they fractured. As health literacy is associated with poorer health outcomes and reduced use of healthcare services,²¹ optimizing patients’ health literacy is of crucial importance to both their education and their outcomes.

Our study should be viewed in light of some important limitations. As OTA does not publish its own PEMs, we assessed only OT-related articles that were available on the AAOS website and were exclusively written by AAOS, or coauthored by AAOS and by OTA and/or another orthopedic subspecialty organization. As these articles represent only a subset of the full spectrum of OT-PEMs available on the Internet, our results may not be generalizable to the entire scope of such materials. However, as AAOS and OTA represent the most authoritative OT organizations, we think these PEMs would be among those most likely to be recommended to patients by their surgeons. In addition, although we used a well-established tool for examining readability—the FK readability scale^10-13—this tool has its own inherent limitations, as FK readability grade level is calculated purely on the basis of words per sentence and total syllables per word, and does not take into account other article elements, such as images, which also provide information.^1,10 Nevertheless, the FK scale is an inexpensive, easily accessed readability tool that provides a reproducible readability value that is easily comparable to results from earlier studies.¹⁰ The final limitation is that we excluded from the study AAOS website articles written in a language other than English. Such articles, however, are important, as a large portion of the patient population speaks English as a second language. Indeed, the readability of Spanish PEMs has been investigated—albeit using a readability measure other than the FK scale—and may be a topic pertinent to orthopedic PEMs.²²Most of the literature on the readability of orthopedic PEMs has found their reading levels too high for the average patient to comprehend.^1,9-12 The trend continues with our study findings regarding OT-PEMs available online from AAOS. Although the literature on the inadequacies of orthopedic PEMs is vast,^1,9-12 more work is needed to improve the quality, accuracy, and readability of these materials. There has been some success in improving PEM readability and producing appropriately readable materials within the medical profession,^19,23 so we know that appropriately readable orthopedic PEMs are feasible.

Am J Orthop. 2017;46(3):E190-E194. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• The Flesch-Kincaid Readability Scale is a useful tool in evaluating the readability of PEMs.
• Only 1 article analyzed in our study was below a sixth-grade readability level.
• Coauthorship of PEMs with other subspecialty groups had no effect on readability.
• Poor health literacy has been associated with poor health outcomes.
• Efforts must be undertaken to make PEMs more readable across medical subspecialties.

Patients increasingly turn to the Internet to self-educate about orthopedic conditions.^1,2 Accordingly, the Internet has become a valuable tool in maintaining effective physician-patient communication.^3-5 Given the Internet’s importance as a medium for conveying patient information, it is important that orthopedic patient education materials (PEMs) on the Internet provide high-quality information that is easily read by the target patient population. Unfortunately, studies have found that many of the Internet’s orthopedic PEMs have been neither of high quality^6-8 nor presented such that they are easy for patients to read and comprehend.^1,9-12

Readability, which is the reading comprehension level (school grade level) a person must have to understand written materials, is determined by systematic formulae¹²; readability levels correlate with the ability to comprehend written information.² Studies have consistently found that orthopedic PEMs are written at readability levels too high for the average patient to understand.^1,9,13 The readability of PEMs in orthopedics as a whole⁹ and within the orthopedic subspecialties of arthroplasty,¹ foot and ankle surgery,² sports medicine,¹² and spine surgery¹³ has been evaluated, but so far there has been no evaluation of PEMs in orthopedic trauma (OT).

We conducted a study to assess the readability of OT-PEMs available online from the American Academy of Orthopaedic Surgeons (AAOS) in conjunction with the Orthopaedic Trauma Association (OTA) and other orthopedic subspecialty societies. We hypothesized the readability levels of these OT-PEMs would be above the level (sixth to eighth grade) recommended by several healthcare organizations, including the Centers for Disease Control and Prevention.^9,11,14 We also assessed the effect that orthopedic subspecialty coauthorship has on PEM readability.

Methods

In July 2014, we searched the AAOS online patient education library (Broken Bones & Injuries section, http://orthoinfo.aaos.org/menus/injury.cfm) and the AAOS OrthoPortal website (Trauma section, http://pubsearch.aaos.org/search?q=trauma&client=OrthoInfo&site=PATIENT&output=xml_no_dtd&proxystylesheet=OrthoInfo&filter=0) for all relevant OT-PEMs. Although OTA does not publish its own PEMs on its website, it coauthored several of the articles in the AAOS patient education library. Other subspecialty organizations, including the American Orthopaedic Society for Sports Medicine (AOSSM), the American Society for Surgery of the Hand (ASSH), the Pediatric Orthopaedic Society of North America (POSNA), the American Shoulder and Elbow Surgeons (ASES), the American Association of Hip and Knee Surgeons (AAHKS), and the American Orthopaedic Foot and Ankle Society (AOFAS), coauthored several of these online OT-PEMs as well.

Using the technique described by Badarudeen and Sabharwal,¹⁰ we saved all articles to be included in the study as separate Microsoft Word 2011 files. We saved them in plain-text format to remove any HTML tags and any other hidden formatting that might affect readability results. Then we edited them to remove elements that might affect readability result accuracy—deleted article topic–unrelated information (eg, copyright notice, disclaimers, author information) and all numerals, decimal points, bullets, abbreviations, paragraph breaks, colons, semicolons, and dashes.¹⁰Mr. Mohan used the Flesch-Kincaid (FK) Readability Scale to calculate grade level for each article. Microsoft Word 2011 was used as described in other investigations of orthopedic PEM readability^2,10,12,13: Its readability function is enabled by going to the Tools tab and then to the Spelling & Grammar tool, where the “Show readability statistics” option is selected.¹⁰ Readability scores are calculated with the Spelling & Grammar tool; the readability score is displayed after completion of the spelling-and-grammar check. The formula used to calculate FK grade level is¹⁵: (0.39 × average number of words per sentence) + (11.8 × average number of syllables per word) – 15.59.

Statistical Analysis

Descriptive statistics, including means and 95% confidence intervals (CIs), were calculated for the FK grade levels. Student t tests were used to compare average FK grade levels of articles written exclusively by AAOS with those of articles coauthored by AAOS and other orthopedic subspecialty societies. A 2-sample unequal-variance t test was used, and significance was set at P < .05. Total number of articles written at or below the sixth- and eighth-grade levels, the reading levels recommended for PEMs, were tabulated.^1,9-12 Intraobserver and interobserver reliabilities were calculated with intraclass correlation coefficients (ICCs): Mr. Mohan, who calculated the FK scores earlier, now 1 week later calculated the readability levels of 15 randomly selected articles^10,11; in addition, Mr. Mohan and Dr. Yi independently calculated the readability levels of 30 randomly selected articles.^10,11 The same method described earlier—edit plain-text files, then use Microsoft Word to obtain FK scores—was again used. ICCs of 0 to 0.24 correspond to poor correlation; 0.25 to 0.49, low correlation; 0.5 to 0.69, fair correlation; 0.7 to 0.89, good correlation; and 0.9 to 1.0, excellent correlation.^10,11 All statistical analyses were performed with Microsoft Excel 2011 and VassarStats (http://vassarstats.net/tu.html).

Results

Of the 115 AAOS website articles included in the study and reviewed, 18 were coauthored by OTA, 10 by AOSSM, 14 by POSNA, 2 by ASSH, 2 by ASES, 1 by AAHKS, 3 by AOFAS, 1 by AOSSM and ASES, and 1 by AOFAS and AOSSM.

Mean FK grade level was 9.1 (range, 6.2-12; 95% CI, 8.9-9.3) for all articles reviewed and 9.1 (range, 6.2-12; 95% CI, 8.8-9.4) for articles exclusively written by AAOS. For coauthored articles, mean FK grade level was 9.3 (range, 7.6-11.3; 95% CI, 8.8-9.8) for AAOS-OTA; 8.9 (range, 7.4-10.4; 95% CI, 8.4-9.6) for AAOS-AOSSM; 9.4 (range, 7-11.8; 95% CI, 8.9-10.1) for AAOS-POSNA; 7.8 (range, 7.8-9.1; 95% CI, 7.2-9.8) for AAOS-ASSH; 9 (range, 8.2-9.6; 95% CI, 7.6-10.2) for AAOS-ASES; 9 (range, 7.9-9; 95% CI, 7.9-9.3) for AAOS-AOFAS; 8.1 for the 1 AAOS-AAHKS article; 8.5 for the 1 AAOS-AOSSM-ASES article; and 8 for the 1 AAOS-AOFAS-AOSSM article (Figure).

Discussion

Although increasing numbers of patients are using information from the Internet to inform their healthcare decisions,¹² studies have shown that online PEMs are written at a readability level above that of the average patient.^1,9,13 In the present study, we also found that OT-PEMs from AAOS are written at a level considerably higher than the recommended sixth-grade reading level,¹⁶ potentially impairing patient comprehension and leading to poorer health outcomes.¹⁷

The pervasiveness of too-high PEM readability levels has been found across orthopedic subspecialties.^2,9,12,13 Following this trend, the OT articles we reviewed had a ninth-grade reading level on average, and only 1 of 115 articles was below the recommended sixth-grade level.¹⁰ The issue of too-high PEM readability levels is thus a problem both in OT and in orthopedics in general. Accordingly, efforts to address this problem are warranted, especially as orthopedic PEM readability has not substantially improved over the past several years.¹⁸In this study, we also tried to identify any readability differences between articles coauthored by orthopedic societies and articles that were not coauthored by orthopedic societies. We hypothesized that multidisciplinary authorship could improve PEM readability; for example, orthopedic societies could collaborate with other medical specialties (eg, family medicine) that have produced appropriately readable PEMs. One study found that the majority of PEMs from the American Academy of Family Physicians (AAFP) were written below the sixth-grade reading level because of strict organizational regulation of the production of such materials.¹⁹ By noting and adopting successful PEM development methods used by groups such as AAFP,^19,20 we might be able to improve OT-PEM readability. However, this was not the case in our study, though our observations may have been limited by the small sample of reviewable articles.

One factor contributing to the poor readability of orthopedic PEMs is that orthopedics terminology is complex and includes words that are often difficult to translate into simpler terms without losing their meaning.¹⁰ When PEMs are written at a level that is too complex, patients cannot fully comprehend them, which may lead to poor health literacy. This problem may be even more harmful when considering the poor literacy levels of patients at baseline. Kadakia and colleagues¹⁶ found that OT patients had poor health literacy; for example, fewer than half knew which bone they fractured. As health literacy is associated with poorer health outcomes and reduced use of healthcare services,²¹ optimizing patients’ health literacy is of crucial importance to both their education and their outcomes.

Our study should be viewed in light of some important limitations. As OTA does not publish its own PEMs, we assessed only OT-related articles that were available on the AAOS website and were exclusively written by AAOS, or coauthored by AAOS and by OTA and/or another orthopedic subspecialty organization. As these articles represent only a subset of the full spectrum of OT-PEMs available on the Internet, our results may not be generalizable to the entire scope of such materials. However, as AAOS and OTA represent the most authoritative OT organizations, we think these PEMs would be among those most likely to be recommended to patients by their surgeons. In addition, although we used a well-established tool for examining readability—the FK readability scale^10-13—this tool has its own inherent limitations, as FK readability grade level is calculated purely on the basis of words per sentence and total syllables per word, and does not take into account other article elements, such as images, which also provide information.^1,10 Nevertheless, the FK scale is an inexpensive, easily accessed readability tool that provides a reproducible readability value that is easily comparable to results from earlier studies.¹⁰ The final limitation is that we excluded from the study AAOS website articles written in a language other than English. Such articles, however, are important, as a large portion of the patient population speaks English as a second language. Indeed, the readability of Spanish PEMs has been investigated—albeit using a readability measure other than the FK scale—and may be a topic pertinent to orthopedic PEMs.²²Most of the literature on the readability of orthopedic PEMs has found their reading levels too high for the average patient to comprehend.^1,9-12 The trend continues with our study findings regarding OT-PEMs available online from AAOS. Although the literature on the inadequacies of orthopedic PEMs is vast,^1,9-12 more work is needed to improve the quality, accuracy, and readability of these materials. There has been some success in improving PEM readability and producing appropriately readable materials within the medical profession,^19,23 so we know that appropriately readable orthopedic PEMs are feasible.

Am J Orthop. 2017;46(3):E190-E194. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

NEW YORK – Allogeneic hematopoietic stem cell transplantation (alloHCT) using HLA-compatible donors results in excellent long-term progression-free survival in younger high-risk chronic lymphocytic leukemia (CLL) patients, an analysis of data from a European Society for Blood and Marrow Transplantation registry cohort suggests.

AlloHCT may, in some patients, be preferable to sequential targeted therapy, according to Michel van Gelder, MD.

Sharon Worcester/Frontline Medical News

[email protected]

NEW YORK – Allogeneic hematopoietic stem cell transplantation (alloHCT) using HLA-compatible donors results in excellent long-term progression-free survival in younger high-risk chronic lymphocytic leukemia (CLL) patients, an analysis of data from a European Society for Blood and Marrow Transplantation registry cohort suggests.

AlloHCT may, in some patients, be preferable to sequential targeted therapy, according to Michel van Gelder, MD.

Sharon Worcester/Frontline Medical News

[email protected]

NEW YORK – Allogeneic hematopoietic stem cell transplantation (alloHCT) using HLA-compatible donors results in excellent long-term progression-free survival in younger high-risk chronic lymphocytic leukemia (CLL) patients, an analysis of data from a European Society for Blood and Marrow Transplantation registry cohort suggests.

AlloHCT may, in some patients, be preferable to sequential targeted therapy, according to Michel van Gelder, MD.

Sharon Worcester/Frontline Medical News

[email protected]

SAN DIEGO – Cognitive-behavioral therapy (CPT) interventions delivered online are effective in reducing symptoms of mild to moderate depression in adults, according to results presented at the annual meeting of the American Psychiatric Association.

The findings, presented by Charles Koransky, MD, of the University of Maryland, Baltimore, derive from a meta-analysis of 14 randomized studies, conducted between 2005 and 2015, that enrolled more than 1,600 patients aged 18 years and older in Europe and Australia.

Patients in the studies were not receiving any other form of therapy, though some studies allowed concurrent use of antidepressant medications.

Results from patients assigned to the web-based interventions, which lasted 1 month or more, were compared with those who remained on waiting lists for treatment. Most of the interventions included brief clinician contact as part of their designs. Others were entirely self-guided.

Dr. Koransky and his colleagues found that completion rates were high, with between 55% and 93% of patients finishing the assigned interventions. The intervention groups saw significant improvement in symptoms after the online CBT interventions, with a standard mean difference of 0.74 (95% confidence interval, 0.63-0.86; P less than 0.001), compared with patients randomized to wait lists.

For the 11 studies that included between 3- and 6-months’ follow-up, improvement in depressive symptoms was seen to be durable, with a large SMD of 0.85 (95% CI, 0.79-0.90; P less than 0.001). “This shows that the effects last,” Dr. Koransky told conference attendees.

Dr. Koransky noted that statistically significant difference was seen between the studies with interventions that included clinician contact and those that did not. “This is probably because the clinician contact in the studies was brief, 10-minute chats or emails,” he said.

“Internet-based CBT leads to immediate and sustained reduction of depressive symptoms, which is consistent with analyses in the past,” Dr. Koransky said. “We also found that iCBT may be a good option for patients not able to access traditional face-to-face therapy,” he said, noting that several of the interventions in the study were designed to help address access issues in rural Australia.

Dr. Koransky noted that the results might not be generalizable because of the large portion of female patients across studies – more than 75% – and the fact that all patients were recruited through advertisements, suggesting that these were “highly motivated participants seeking some alleviation of their symptoms.” Another limitation of the study was a lack of uniformity across iCBT interfaces.

Nonetheless, he said, the findings have implications for U.S. practitioners, particularly primary care doctors in regions with poor access to mental health specialists.

Internet-delivered CBT may be “great for people in rural settings, especially if prescribed by primary care providers who don’t have the training to provide CBT,” he said.

Dr. Koransky said his group aimed to study these interventions in a U.S. population and among patients referred to iCBT by their primary care doctors. The researchers disclosed no conflicts of interest related to their findings.

SAN DIEGO – Cognitive-behavioral therapy (CPT) interventions delivered online are effective in reducing symptoms of mild to moderate depression in adults, according to results presented at the annual meeting of the American Psychiatric Association.

The findings, presented by Charles Koransky, MD, of the University of Maryland, Baltimore, derive from a meta-analysis of 14 randomized studies, conducted between 2005 and 2015, that enrolled more than 1,600 patients aged 18 years and older in Europe and Australia.

Patients in the studies were not receiving any other form of therapy, though some studies allowed concurrent use of antidepressant medications.

Results from patients assigned to the web-based interventions, which lasted 1 month or more, were compared with those who remained on waiting lists for treatment. Most of the interventions included brief clinician contact as part of their designs. Others were entirely self-guided.

Dr. Koransky and his colleagues found that completion rates were high, with between 55% and 93% of patients finishing the assigned interventions. The intervention groups saw significant improvement in symptoms after the online CBT interventions, with a standard mean difference of 0.74 (95% confidence interval, 0.63-0.86; P less than 0.001), compared with patients randomized to wait lists.

For the 11 studies that included between 3- and 6-months’ follow-up, improvement in depressive symptoms was seen to be durable, with a large SMD of 0.85 (95% CI, 0.79-0.90; P less than 0.001). “This shows that the effects last,” Dr. Koransky told conference attendees.

Dr. Koransky noted that statistically significant difference was seen between the studies with interventions that included clinician contact and those that did not. “This is probably because the clinician contact in the studies was brief, 10-minute chats or emails,” he said.

“Internet-based CBT leads to immediate and sustained reduction of depressive symptoms, which is consistent with analyses in the past,” Dr. Koransky said. “We also found that iCBT may be a good option for patients not able to access traditional face-to-face therapy,” he said, noting that several of the interventions in the study were designed to help address access issues in rural Australia.

Dr. Koransky noted that the results might not be generalizable because of the large portion of female patients across studies – more than 75% – and the fact that all patients were recruited through advertisements, suggesting that these were “highly motivated participants seeking some alleviation of their symptoms.” Another limitation of the study was a lack of uniformity across iCBT interfaces.

Nonetheless, he said, the findings have implications for U.S. practitioners, particularly primary care doctors in regions with poor access to mental health specialists.

Internet-delivered CBT may be “great for people in rural settings, especially if prescribed by primary care providers who don’t have the training to provide CBT,” he said.

Dr. Koransky said his group aimed to study these interventions in a U.S. population and among patients referred to iCBT by their primary care doctors. The researchers disclosed no conflicts of interest related to their findings.

SAN DIEGO – Cognitive-behavioral therapy (CPT) interventions delivered online are effective in reducing symptoms of mild to moderate depression in adults, according to results presented at the annual meeting of the American Psychiatric Association.

The findings, presented by Charles Koransky, MD, of the University of Maryland, Baltimore, derive from a meta-analysis of 14 randomized studies, conducted between 2005 and 2015, that enrolled more than 1,600 patients aged 18 years and older in Europe and Australia.

Patients in the studies were not receiving any other form of therapy, though some studies allowed concurrent use of antidepressant medications.

Results from patients assigned to the web-based interventions, which lasted 1 month or more, were compared with those who remained on waiting lists for treatment. Most of the interventions included brief clinician contact as part of their designs. Others were entirely self-guided.

Dr. Koransky and his colleagues found that completion rates were high, with between 55% and 93% of patients finishing the assigned interventions. The intervention groups saw significant improvement in symptoms after the online CBT interventions, with a standard mean difference of 0.74 (95% confidence interval, 0.63-0.86; P less than 0.001), compared with patients randomized to wait lists.

For the 11 studies that included between 3- and 6-months’ follow-up, improvement in depressive symptoms was seen to be durable, with a large SMD of 0.85 (95% CI, 0.79-0.90; P less than 0.001). “This shows that the effects last,” Dr. Koransky told conference attendees.

Dr. Koransky noted that statistically significant difference was seen between the studies with interventions that included clinician contact and those that did not. “This is probably because the clinician contact in the studies was brief, 10-minute chats or emails,” he said.

“Internet-based CBT leads to immediate and sustained reduction of depressive symptoms, which is consistent with analyses in the past,” Dr. Koransky said. “We also found that iCBT may be a good option for patients not able to access traditional face-to-face therapy,” he said, noting that several of the interventions in the study were designed to help address access issues in rural Australia.

Dr. Koransky noted that the results might not be generalizable because of the large portion of female patients across studies – more than 75% – and the fact that all patients were recruited through advertisements, suggesting that these were “highly motivated participants seeking some alleviation of their symptoms.” Another limitation of the study was a lack of uniformity across iCBT interfaces.

Nonetheless, he said, the findings have implications for U.S. practitioners, particularly primary care doctors in regions with poor access to mental health specialists.

Internet-delivered CBT may be “great for people in rural settings, especially if prescribed by primary care providers who don’t have the training to provide CBT,” he said.

Dr. Koransky said his group aimed to study these interventions in a U.S. population and among patients referred to iCBT by their primary care doctors. The researchers disclosed no conflicts of interest related to their findings.

BOSTON – Body weight over 100 kg in acute ischemic stroke patients does not reduce the clinical benefit derived from a 90-mg fixed dose of intravenous recombinant tissue plasminogen activator, according to a pooled analysis of data from three randomized clinical trials.

Prior small studies have suggested that the magnitude of benefit with intravenous recombinant tissue plasminogen activator (IV rtPA) is reduced in patients with body weight over 100 kg who receive less than 0.9 mg/kg of IV rtPA under current guidelines. However, in the current study, the rate of favorable outcomes at 90 days – defined as modified Rankin scale score of 0-2 – did not differ significantly between 872 patients with weight at or below 100 kg and 105 with body weight over 100 kg (and up to 190 kg) after adjustment for patient demographics, stroke severity, and 90-day modified Rankin scale score (adjusted odds ratio, 0.99), Shahram Majidi, MD, said at the annual meeting of the American Academy of Neurology.

Copyright American Stroke Association

[email protected]

BOSTON – Body weight over 100 kg in acute ischemic stroke patients does not reduce the clinical benefit derived from a 90-mg fixed dose of intravenous recombinant tissue plasminogen activator, according to a pooled analysis of data from three randomized clinical trials.

Prior small studies have suggested that the magnitude of benefit with intravenous recombinant tissue plasminogen activator (IV rtPA) is reduced in patients with body weight over 100 kg who receive less than 0.9 mg/kg of IV rtPA under current guidelines. However, in the current study, the rate of favorable outcomes at 90 days – defined as modified Rankin scale score of 0-2 – did not differ significantly between 872 patients with weight at or below 100 kg and 105 with body weight over 100 kg (and up to 190 kg) after adjustment for patient demographics, stroke severity, and 90-day modified Rankin scale score (adjusted odds ratio, 0.99), Shahram Majidi, MD, said at the annual meeting of the American Academy of Neurology.

Copyright American Stroke Association

[email protected]

BOSTON – Body weight over 100 kg in acute ischemic stroke patients does not reduce the clinical benefit derived from a 90-mg fixed dose of intravenous recombinant tissue plasminogen activator, according to a pooled analysis of data from three randomized clinical trials.

Prior small studies have suggested that the magnitude of benefit with intravenous recombinant tissue plasminogen activator (IV rtPA) is reduced in patients with body weight over 100 kg who receive less than 0.9 mg/kg of IV rtPA under current guidelines. However, in the current study, the rate of favorable outcomes at 90 days – defined as modified Rankin scale score of 0-2 – did not differ significantly between 872 patients with weight at or below 100 kg and 105 with body weight over 100 kg (and up to 190 kg) after adjustment for patient demographics, stroke severity, and 90-day modified Rankin scale score (adjusted odds ratio, 0.99), Shahram Majidi, MD, said at the annual meeting of the American Academy of Neurology.

Copyright American Stroke Association

[email protected]

The effect of 10-valent pneumococcal conjugate vaccine (PCV10) after 4 years of routine childhood vaccination in Brazil was near elimination of PCV10 serotypes in a study of over 500 children, said Felipe P.G. Neves, PhD, of the University of California, Berkeley, and his associates.

The emergence of multidrug-resistant (MDR) serotype 6C isolates, however, is of concern, they said.

Of the 284 children who attended a public clinic and 238 children who went to two private clinics in the greater Rio de Janeiro metropolitan area between Sept. 29 and Dec. 5, 2014, 118 (23%) were pneumococcal carriers. Their median age was 2 years and all were under age 6 years. All 118 isolates were susceptible to levofloxacin, rifampicin, and vancomycin; 26 (22%) isolates were MDR, and 14 of the 18 serotype 6C isolates were MDR.

CDC/Dr. Mike Miller

[email protected]

The effect of 10-valent pneumococcal conjugate vaccine (PCV10) after 4 years of routine childhood vaccination in Brazil was near elimination of PCV10 serotypes in a study of over 500 children, said Felipe P.G. Neves, PhD, of the University of California, Berkeley, and his associates.

The emergence of multidrug-resistant (MDR) serotype 6C isolates, however, is of concern, they said.

Of the 284 children who attended a public clinic and 238 children who went to two private clinics in the greater Rio de Janeiro metropolitan area between Sept. 29 and Dec. 5, 2014, 118 (23%) were pneumococcal carriers. Their median age was 2 years and all were under age 6 years. All 118 isolates were susceptible to levofloxacin, rifampicin, and vancomycin; 26 (22%) isolates were MDR, and 14 of the 18 serotype 6C isolates were MDR.

CDC/Dr. Mike Miller

[email protected]

The effect of 10-valent pneumococcal conjugate vaccine (PCV10) after 4 years of routine childhood vaccination in Brazil was near elimination of PCV10 serotypes in a study of over 500 children, said Felipe P.G. Neves, PhD, of the University of California, Berkeley, and his associates.

The emergence of multidrug-resistant (MDR) serotype 6C isolates, however, is of concern, they said.

Of the 284 children who attended a public clinic and 238 children who went to two private clinics in the greater Rio de Janeiro metropolitan area between Sept. 29 and Dec. 5, 2014, 118 (23%) were pneumococcal carriers. Their median age was 2 years and all were under age 6 years. All 118 isolates were susceptible to levofloxacin, rifampicin, and vancomycin; 26 (22%) isolates were MDR, and 14 of the 18 serotype 6C isolates were MDR.

CDC/Dr. Mike Miller

[email protected]

Streptococcus pneumoniae did not grow more resistant to penicillin after the introduction of 13-valent pneumococcal conjugate vaccine, though geographic differences remained, according to Cheryl P. Andam, Ph.D., and her associates.

Data from the Active Bacterial Core surveillance system on 285 patients before introduction of PCV13 and from 339 patients after PCV13 introduction were used in the study. Patients were from California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. New Mexico, Maryland, and Georgia saw the largest increases in penicillin-nonsusceptible pneumococcus (PNSP) rates, while Colorado, New York, and Connecticut saw decreases. No change was seen in the nationwide PNSP rate.

Preintroduction of PCV13, geographic heterogeneity in serotype distribution, and serotype-specific differences in penicillin resistance were equally responsible for geographic variation in PNSP rates. Although no significant change was seen after introduction, influence of serotype-specific differences did decrease slightly while geographic heterogeneity of PSNP serotypes increased.

“Further long-term nationwide surveillance of serotype dynamics is required to assess the multiple ecologic factors that influence antibiotic resistance in the pneumococcus in the conjugate vaccine era,” the investigators concluded.

Find the full research letter in Emerging Infectious Diseases (doi: 10.3201/eid2306.161331).

[email protected]

Streptococcus pneumoniae did not grow more resistant to penicillin after the introduction of 13-valent pneumococcal conjugate vaccine, though geographic differences remained, according to Cheryl P. Andam, Ph.D., and her associates.

Data from the Active Bacterial Core surveillance system on 285 patients before introduction of PCV13 and from 339 patients after PCV13 introduction were used in the study. Patients were from California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. New Mexico, Maryland, and Georgia saw the largest increases in penicillin-nonsusceptible pneumococcus (PNSP) rates, while Colorado, New York, and Connecticut saw decreases. No change was seen in the nationwide PNSP rate.

Preintroduction of PCV13, geographic heterogeneity in serotype distribution, and serotype-specific differences in penicillin resistance were equally responsible for geographic variation in PNSP rates. Although no significant change was seen after introduction, influence of serotype-specific differences did decrease slightly while geographic heterogeneity of PSNP serotypes increased.

“Further long-term nationwide surveillance of serotype dynamics is required to assess the multiple ecologic factors that influence antibiotic resistance in the pneumococcus in the conjugate vaccine era,” the investigators concluded.

Find the full research letter in Emerging Infectious Diseases (doi: 10.3201/eid2306.161331).

[email protected]

Streptococcus pneumoniae did not grow more resistant to penicillin after the introduction of 13-valent pneumococcal conjugate vaccine, though geographic differences remained, according to Cheryl P. Andam, Ph.D., and her associates.

Data from the Active Bacterial Core surveillance system on 285 patients before introduction of PCV13 and from 339 patients after PCV13 introduction were used in the study. Patients were from California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. New Mexico, Maryland, and Georgia saw the largest increases in penicillin-nonsusceptible pneumococcus (PNSP) rates, while Colorado, New York, and Connecticut saw decreases. No change was seen in the nationwide PNSP rate.

Preintroduction of PCV13, geographic heterogeneity in serotype distribution, and serotype-specific differences in penicillin resistance were equally responsible for geographic variation in PNSP rates. Although no significant change was seen after introduction, influence of serotype-specific differences did decrease slightly while geographic heterogeneity of PSNP serotypes increased.

“Further long-term nationwide surveillance of serotype dynamics is required to assess the multiple ecologic factors that influence antibiotic resistance in the pneumococcus in the conjugate vaccine era,” the investigators concluded.

Find the full research letter in Emerging Infectious Diseases (doi: 10.3201/eid2306.161331).

[email protected]

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

Presenters

Roberta Himebaugh MBA, SHM; John Nelson, MD, FACP, MHM; Jerome Siy, MD, SFHM

Session summary

Creating a “culture of ownership” by recruiting the right people, promoting physician leadership, and improving structural elements such as compensation model and schedule were topics discussed in this practice management precourse at HM17.

The presenters said leaders must reduce hierarchy and promote shared decision making among the group, while instilling a “thank you culture” that recognizes motivations such as autonomy, mastery, and purpose.

Key takeaways for HM

• Create a culture of ownership to promote engagement and job satisfaction.

• Make adjustments to schedule and workflow to improve efficiency.

• Prepare for evolving pay-for-performance programs.

• Demonstrate the value of the group by setting expectations with key stakeholders, developing a practice score, and providing effective feedback to providers.
 

Dr. Villagra is a chief hospitalist in Batesville, Ark., and an editorial board member of The Hospitalist.

Despite a 30% decline in heart disease mortality from 2001 to 2011, heart disease prevalence is on the rise, responsible for 1 of every 3 deaths in the U.S.¹ Cardiac rehabilitation (CR) is an evidence-based, secondary prevention strategy that has been proven effective in preventing future cardiovascular events and decreasing heart disease mortality.^2-4 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is the leading authority on CR and provides guidelines for CR programs. The AACVPR and the American Heart Association (AHA) published core components for CR programs deemed essential for all CR/secondary prevention programs, including evaluations, interventions, and expected outcomes.⁵ These core components are aimed at promoting a healthy lifestyle and increasing function and well-being while reducing injury, death, and the reoccurrence of disease.⁶

In a meta-analysis of 47 trials with 10,794 participants, CR reduced cardiovascular disease (CVD) mortality and hospital admissions by 26% and 18%, respectively.² Performance measures (Class 1, Level A) recommend the following types of patients should be referred from the inpatient setting: “all patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina, or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation.”⁷ However, despite overwhelming evidence and widespread endorsement (Class 1, Level A), service utilization, uptake, and patient adherence to CR programs remain suboptimal. In a U.S. study of claims from > 250,000 Medicare beneficiaries, < 30% of eligible patients participated in some type of CR program.⁸ In response to poor participation, a presidential advisory from the AHA in 2011 stated, “the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.”⁹

This treatment gap is echoed throughout the VHA. Schopfer and colleagues found that only 28% of the 124 VAMCs that provide inpatient care also offer a supervised, facility-based CR program.¹⁰ Furthermore, only 10.3% of eligible veterans participated in at least 1 CR session (VA or non-VA). On a systemic level, low patient referral rates and inadequate third-party reimbursement were the most common barriers to participation in CR.^10,11 On a patient level, distance was by far the largest barrier to veterans receiving CR. Currently, 74% of the 9.3 million VA-enrolled veterans live at least 1 hour by car from a VA facility that offers CR.⁹ Within some regions of the VHA, there are no VA facility-based CR programs. For example, VISN 21 has no facility-based CR programs. At the same time, referral of eligible veterans to facility-based CR outside the VA remains low. Prior to April 2013, < 2% of qualified patients residing in VISN 21 were being referred to Non-VA CR programs, making it the VISN with the lowest participation rate for CR.

One potential solution that addresses both systemic and patient barriers to CR utilization is home-based CR. Veterans within the wide geographic area of VISN 21 are referred to San Francisco VAMC (SFVAMC) for ischemic heart disease, cardiovascular revascularization, and cardiac valve surgeries. In 2013, a comprehensive home-based CR program named The Healthy Heart Program was developed based on a successful evidence-based CVD secondary prevention program. The Healthy Heart Program is designed to be a physician-directed, nurse case-managed, customized exercise and lifestyle program that provides a safe and convenient way for veterans to participate in CR. Exercise and disease self-management education are the cornerstones of the Healthy Heart Program. The program’s multidisciplinary team includes physicians, nurses, a dietician, an exercise physiologist, and a health behavior psychologist.

An Alternative Approach

DeBusk and colleagues demonstrated that a physician-directed, nurse-managed, home-based cardiac risk-factor modification program improved smoking cessation, reduced low-density lipoprotein cholesterol, and increased exercise capacity compared with usual care.¹² The results of this study helped pave the way for one of the first CR programs with a strong home-based element. The MULTIFIT program was jointly developed by the Stanford Coronary Rehabilitation Program and Kaiser Permanente (Oakland, CA) in 1995. MULTIFIT is a nurse-based care model for CVD prevention.

Further research that evaluated other home-based programs showed similar promise. A Cochrane review demonstrated that home- and facility-based CR programs were equal in cardiac risk factor reduction, reduced hospital readmissions and mortality rates, and improved quality of life (QOL).¹³ Cost-effectiveness also seemed to be similar in both home- and hospital-based CR programs.¹⁴ A meta-analysis of telephone support interventions for coronary artery disease demonstrated a 38% decrease in rehospitalizations and a 32% increase in the number of participants who stopped smoking.¹⁵ In addition, patients with time constraints (eg, work, family obligations) preferred home-based CR programs for the convenience and accessibility that these programs offer.¹⁶ Home-based CR programs may have better completion rates compared with that of facility-based programs.¹⁷ The American College of Cardiology and AHA updated guidelines for CR include home-based CR as a substitute for facility-based CR for low-risk patients (Class 1, Level A).¹⁸

Referrals

To address the problems with referrals that plague other CR programs, staff of the Healthy Heart Program worked closely with interventional cardiology and the cardiothoracic team, including the clinical informatics coordinators, to develop an automatic referral system for CR evaluation. Consults for CR evaluation were embedded within the post-CABG and PCI order sets in the electronic health record. Laboratory troponin alerts were created to alert CR staff of patients with elevated troponins, which identified patients admitted for acute MI. Healthy Heart Program staff members received the referrals once a patient was admitted to the unit following their heart procedure. Early referrals for evaluation allowed staff to begin a chart review of all eligible patients and to follow the patient’s course of recovery. Most consults were generated during hospitalization for one of the indications; however, a minority of consults come from both the cardiology and primary care clinics.

Three Phases of CR

The AACVPR describes the challenges and opportunities found throughout the CR continuum.⁵ Over the past several decades, the continuum of care was more program centered and service utilization was more isolated. Today, CR is viewed as more process oriented and coordinates care across many professionals and services. Phase 1 inpatient CR begins in the hospital and is a shared responsibility between several services. Shortened hospital stays have led to innovative solutions for early ambulation, risk factor education, and discharge planning, including enrollment into phase 2 CR. Phase 2, also known as early outpatient, should begin within 1 to 2 weeks postevent in healthier patients and can last between 6 and 12 weeks postdischarge. Phase 3 (maintenance phase) should begin immediately at the conclusion of phase 2.

Phase 1

Prior to the advent of the Healthy Heart Program, secondary prevention education was not done at the bedside for SFVAMC patients following cardiac revascularization. The AACVPR recommends patient assessment, mobilization, risk-factor identification and education, and facilitation into outpatient CR as essential components of phase 1 CR.⁵ The Healthy Heart Program clinician initiates phase 1 CR by examining cardiac risk factor management for all referred patients. Physical and cardiac risk factor assessments are accomplished by completing a detailed chart review and interview with the patient. During this interview with the patient, the clinician evaluates cognitive function and readiness to learn. Staff will interview the patient further to assess the overall patient needs, including availability of social support, resources to maintain optimal health, and the need for secondary preventive education. For the PCI patient, the interview may occur in the hours following their procedure; for the surgical patient, this bedside visit typically occurs postoperative day 3 or 4.

A standardized cardiac risk factor evaluation tool was designed, which also serves as an education form to help guide the conversation on risk factor management. The interactive, patient-centered form includes opportunities to review risk, discuss current laboratory values (eg, lipids and hemoglobin A_1c), and establish individualized goals based on patient preference and recommended guidelines. Healthy Heart Program staff assist the patient in formulating achievable goals using the SMART (specific, measurable, attainable, realistic, and time-related) criteria.¹⁹ Immediately after a heart event or procedure, patients often feel highly motivated to initiate lifestyle changes.²⁰ However, PCI patients may have a short window of opportunity for learning between their readiness to learn state and before the activities of discharge. Staff use these opportunities as a teachable moment and to increase enrollment into outpatient CR (phase 2).

The provider performs a thorough chart review and bedside consultation to determine whether home-based CR is indicated, feasible, and appropriate. Not every patient that is referred will be enrolled in CR. Patients have the option to opt out. In addition, clinical staff adhere to the program protocol’s exclusion criteria.

Absolute contraindications for home enrollment include unstable angina, staged cardiac procedure (PCI and surgery), complex ventricular arrhythmias, severe or symptomatic aortic stenosis, decompensated heart failure, and uncontrolled hypertension (Table). Patients deemed high risk for home-based CR may be referred to a non-VA facility-based CR program. Risk stratification, using the Canadian Cardiovascular Society Grading of Angina Pectoris, is a continuous process that is used to identify patients who may move from moderate to high risk, both before and during the program.^21,22

Phases 2 and 3

Phase 2 of the Healthy Heart Program CR includes physical activity, risk-factor modification, nutritional guidance, psychosocial modification, a return to previous activities, and an improved QOL. Prior to entry into the program, a submaximal exercise test, the 6-minute walk test (6MWT), is used as both a qualifying test and for developing the initial exercise prescription.²² The minimum 6MWT distance needed to qualify is 75 m for postoperative and 150 m for nonsurgical patients. The 6MWT is performed in-hospital for patients who were admitted for stable angina, PCI, and are > 4 days following acute MI.²³ Cardiothoracic surgery patients are tested at their first follow-up clinic visit (typically 2-3 weeks postoperatively). The clinician monitors the heart rate with either a wearable device or via inpatient telemetry monitors. This exercise testing also serves as a motivational tool for patients to gain confidence in their ability to begin to exercise at home.

Each participant receives a workbook and a DVD titled An Active Partnership for the Health of Your Heart. A personal health journal is provided for documenting vital signs, activity, and dietary intake. In addition, each participant receives equipment on an as-needed basis, including resistance bands, a weight scale, a blood pressure cuff, a pedometer/heart rate monitoring device, an exercise peddler or stationary bike, and a dietary video. Baseline assessments include the General Anxiety Disorder (GAD-7), Personal Health Questionnaire (PHQ-9) and a nutrition (Rate Your Plate) questionnaire. A cognitive function test (Montreal Cognitive Assessment) is used on an as-needed basis.

Nine 30-minute telephone follow-up sessions are scheduled within a 12-week period (weekly for the first 6 weeks, then biweekly). Topics covered are customized and include exercise; nutrition; medications; smoking cessation; and diabetes, hypertension, and weight management. Via a telephone follow-up session, the program nurses and patients codevelop an electronic individualized treatment plan that is tailored to the patient’s diagnosis, individual goals, and preferences. Clinicians teach participants how to self-monitor exercise, using a continuous heart rate monitoring device (Mio Alpha II or Fuse) and the 6-20 Borg dyspnea rating scale.²⁴ Initially, moderate intensity exercise is prescribed with a target heart rate that is 60% to 75% of the 6MWT peak heart rate and an initial Borg scale target (11-14 on 20 point scale). The program physicians approve the treatment plan at the first patient visit and every 30 days until phase 2 is complete.

Patients who have completed early outpatient phase 2 CR can benefit from continuing to a phase 3 CR program.²⁵ Participants of the Healthy Heart Program automatically are enrolled in phase 3, which is a long-term maintenance program that includes monthly or bimonthly phone calls for up to 1-year posthospital discharge. The goal is to support each veteran’s transition to a long-term healthy lifestyle that includes regular exercise.

Client-Clinician Partnership

The Healthy Heart Program establishes the client-clinician partnership prior to discharge for hospitalized patients. The nurse who initiates phase 1 at the bedside is the primary clinician throughout phases 2 and 3 with the exception of a dietician, psychologist, and/or exercise physiologist who provide follow-up calls as needed. Throughout these weekly follow-up phone sessions, the clinician gains an appreciation of the patient’s understanding of his or her disease, patterns of behavior, desire to change, confidence in being able to change, potential barriers, and responses to obstacles. Clinicians in this setting are empathetic, supportive, and nonjudgmental. They encourage positive changes no matter how small and express concern when the patient is having difficulty.

Tailored Behavioral Change

The clinician’s responsibility is to listen to the patient’s concerns, assess their level of commitment for changing health behaviors, and provide guidance and support at the patient’s current level. The clinician applies the Transtheoretical Model founded on the Stages of Change principals to help understand and provide guidance based on the patient’s feelings about health behavior change.²⁶ People are actively open to changing behaviors by only 20% at any given time.²⁷ Therefore, action-oriented guidance for patients who are in the contemplative stage would not be helpful. This patient-centered approach promotes patients’ self-awareness, participation, and understanding of their decision-making role in their health management. Ultimately, individuals must take ownership of their health care maintenance for sustained behavioral change and medication management, and clinicians should facilitate that process.

Discussion

Secondary prevention strategies for heart disease continue to be underutilized. The Healthy Heart Program aims to improve participation in CR, improve QOL, help patients understand their heart disease, and support these patients psychologically. An advantage of this program is that it begins inpatient CR immediately following the heart event, when many patients often are more receptive to behavioral change support and guidance. Another advantage is that the program breaks down barriers to access, which is especially important in the veteran population. The Healthy Heart Program provides support and guidance for exercise and cardiac risk factor management to patients who otherwise would have not participated in any type of CR program.

A home-based CR program can be adopted independently or in conjunction with a facility-based program to which patients lack access. Furthermore, home-based CR programs function well as a phase 3 maintenance program at the completion of a traditional CR program. Since its inception, the Healthy Heart Program has increased the number of veterans enrolled in cardiac rehabilitation at the SFVAMC dramatically, from < 1% in FY 2012 to > 40% in FY 2015.

Program Limitations

One potential disadvantage of a home-based CR program is patients’ fear of returning to an exercise routine following a cardiac event. In addition, a lack of in-person supervision in home-based CR can lead patients to engage in less intensive activity than in facility-based CR. Other disadvantages include a lack of social support, less patient accountability, and safety concerns for sicker patients. Staff have consulted on several patients who expressed a lack of confidence in their ability to do well in this type of program, where accountability for exercising is self-reported. Staff referred these patients, who had the means to travel, to a non-VA facility-based CR program of their choice. Ideally, patients would have the choice between facility- or home-based programs or be able to choose a hybrid program that would best meet their needs.

Another identified limitation of this program was the lack of group support and in-person interactions with rehabilitation staff. Finally, although this program uses mobile devices with heart rate monitoring technology, these devices currently lack the capability to remotely share data with clinicians. Clinicians are reliant on the patient’s use of a personal health journal and memory. Subjective patient reporting has been found to be overestimated; therefore, more objective methods to measure important clinical outcomes are necessary^.28

Conclusion

Facility-based CR is effective but underutilized. Alternative secondary programs are needed to help meet patient needs and overcome patient barriers. One promising approach to increase participation is home-based CR. Home-based CR programs have the potential to increase CR uptake and adherence. Home-based CR optimizes enrollment through evidence-based alternative models due to improved access. The future of CR will become highly individualized and multifaceted as a result of available mobile technologies and Internet-based tools, which will help increase the number of participants and expand the reach of cardiac risk factor management programs beyond the facility-based setting. A home-based program will be a valuable addition to facility-based programs as a stand-alone program or adopted into a hybrid program.

Acknowledgments
This work was funded by the VA Quality Enhancement Research Initiative.

Despite a 30% decline in heart disease mortality from 2001 to 2011, heart disease prevalence is on the rise, responsible for 1 of every 3 deaths in the U.S.¹ Cardiac rehabilitation (CR) is an evidence-based, secondary prevention strategy that has been proven effective in preventing future cardiovascular events and decreasing heart disease mortality.^2-4 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is the leading authority on CR and provides guidelines for CR programs. The AACVPR and the American Heart Association (AHA) published core components for CR programs deemed essential for all CR/secondary prevention programs, including evaluations, interventions, and expected outcomes.⁵ These core components are aimed at promoting a healthy lifestyle and increasing function and well-being while reducing injury, death, and the reoccurrence of disease.⁶

In a meta-analysis of 47 trials with 10,794 participants, CR reduced cardiovascular disease (CVD) mortality and hospital admissions by 26% and 18%, respectively.² Performance measures (Class 1, Level A) recommend the following types of patients should be referred from the inpatient setting: “all patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina, or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation.”⁷ However, despite overwhelming evidence and widespread endorsement (Class 1, Level A), service utilization, uptake, and patient adherence to CR programs remain suboptimal. In a U.S. study of claims from > 250,000 Medicare beneficiaries, < 30% of eligible patients participated in some type of CR program.⁸ In response to poor participation, a presidential advisory from the AHA in 2011 stated, “the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.”⁹

This treatment gap is echoed throughout the VHA. Schopfer and colleagues found that only 28% of the 124 VAMCs that provide inpatient care also offer a supervised, facility-based CR program.¹⁰ Furthermore, only 10.3% of eligible veterans participated in at least 1 CR session (VA or non-VA). On a systemic level, low patient referral rates and inadequate third-party reimbursement were the most common barriers to participation in CR.^10,11 On a patient level, distance was by far the largest barrier to veterans receiving CR. Currently, 74% of the 9.3 million VA-enrolled veterans live at least 1 hour by car from a VA facility that offers CR.⁹ Within some regions of the VHA, there are no VA facility-based CR programs. For example, VISN 21 has no facility-based CR programs. At the same time, referral of eligible veterans to facility-based CR outside the VA remains low. Prior to April 2013, < 2% of qualified patients residing in VISN 21 were being referred to Non-VA CR programs, making it the VISN with the lowest participation rate for CR.

One potential solution that addresses both systemic and patient barriers to CR utilization is home-based CR. Veterans within the wide geographic area of VISN 21 are referred to San Francisco VAMC (SFVAMC) for ischemic heart disease, cardiovascular revascularization, and cardiac valve surgeries. In 2013, a comprehensive home-based CR program named The Healthy Heart Program was developed based on a successful evidence-based CVD secondary prevention program. The Healthy Heart Program is designed to be a physician-directed, nurse case-managed, customized exercise and lifestyle program that provides a safe and convenient way for veterans to participate in CR. Exercise and disease self-management education are the cornerstones of the Healthy Heart Program. The program’s multidisciplinary team includes physicians, nurses, a dietician, an exercise physiologist, and a health behavior psychologist.

An Alternative Approach

DeBusk and colleagues demonstrated that a physician-directed, nurse-managed, home-based cardiac risk-factor modification program improved smoking cessation, reduced low-density lipoprotein cholesterol, and increased exercise capacity compared with usual care.¹² The results of this study helped pave the way for one of the first CR programs with a strong home-based element. The MULTIFIT program was jointly developed by the Stanford Coronary Rehabilitation Program and Kaiser Permanente (Oakland, CA) in 1995. MULTIFIT is a nurse-based care model for CVD prevention.

Further research that evaluated other home-based programs showed similar promise. A Cochrane review demonstrated that home- and facility-based CR programs were equal in cardiac risk factor reduction, reduced hospital readmissions and mortality rates, and improved quality of life (QOL).¹³ Cost-effectiveness also seemed to be similar in both home- and hospital-based CR programs.¹⁴ A meta-analysis of telephone support interventions for coronary artery disease demonstrated a 38% decrease in rehospitalizations and a 32% increase in the number of participants who stopped smoking.¹⁵ In addition, patients with time constraints (eg, work, family obligations) preferred home-based CR programs for the convenience and accessibility that these programs offer.¹⁶ Home-based CR programs may have better completion rates compared with that of facility-based programs.¹⁷ The American College of Cardiology and AHA updated guidelines for CR include home-based CR as a substitute for facility-based CR for low-risk patients (Class 1, Level A).¹⁸

Referrals

To address the problems with referrals that plague other CR programs, staff of the Healthy Heart Program worked closely with interventional cardiology and the cardiothoracic team, including the clinical informatics coordinators, to develop an automatic referral system for CR evaluation. Consults for CR evaluation were embedded within the post-CABG and PCI order sets in the electronic health record. Laboratory troponin alerts were created to alert CR staff of patients with elevated troponins, which identified patients admitted for acute MI. Healthy Heart Program staff members received the referrals once a patient was admitted to the unit following their heart procedure. Early referrals for evaluation allowed staff to begin a chart review of all eligible patients and to follow the patient’s course of recovery. Most consults were generated during hospitalization for one of the indications; however, a minority of consults come from both the cardiology and primary care clinics.

Three Phases of CR

The AACVPR describes the challenges and opportunities found throughout the CR continuum.⁵ Over the past several decades, the continuum of care was more program centered and service utilization was more isolated. Today, CR is viewed as more process oriented and coordinates care across many professionals and services. Phase 1 inpatient CR begins in the hospital and is a shared responsibility between several services. Shortened hospital stays have led to innovative solutions for early ambulation, risk factor education, and discharge planning, including enrollment into phase 2 CR. Phase 2, also known as early outpatient, should begin within 1 to 2 weeks postevent in healthier patients and can last between 6 and 12 weeks postdischarge. Phase 3 (maintenance phase) should begin immediately at the conclusion of phase 2.

Phase 1

Prior to the advent of the Healthy Heart Program, secondary prevention education was not done at the bedside for SFVAMC patients following cardiac revascularization. The AACVPR recommends patient assessment, mobilization, risk-factor identification and education, and facilitation into outpatient CR as essential components of phase 1 CR.⁵ The Healthy Heart Program clinician initiates phase 1 CR by examining cardiac risk factor management for all referred patients. Physical and cardiac risk factor assessments are accomplished by completing a detailed chart review and interview with the patient. During this interview with the patient, the clinician evaluates cognitive function and readiness to learn. Staff will interview the patient further to assess the overall patient needs, including availability of social support, resources to maintain optimal health, and the need for secondary preventive education. For the PCI patient, the interview may occur in the hours following their procedure; for the surgical patient, this bedside visit typically occurs postoperative day 3 or 4.

A standardized cardiac risk factor evaluation tool was designed, which also serves as an education form to help guide the conversation on risk factor management. The interactive, patient-centered form includes opportunities to review risk, discuss current laboratory values (eg, lipids and hemoglobin A_1c), and establish individualized goals based on patient preference and recommended guidelines. Healthy Heart Program staff assist the patient in formulating achievable goals using the SMART (specific, measurable, attainable, realistic, and time-related) criteria.¹⁹ Immediately after a heart event or procedure, patients often feel highly motivated to initiate lifestyle changes.²⁰ However, PCI patients may have a short window of opportunity for learning between their readiness to learn state and before the activities of discharge. Staff use these opportunities as a teachable moment and to increase enrollment into outpatient CR (phase 2).

The provider performs a thorough chart review and bedside consultation to determine whether home-based CR is indicated, feasible, and appropriate. Not every patient that is referred will be enrolled in CR. Patients have the option to opt out. In addition, clinical staff adhere to the program protocol’s exclusion criteria.

Absolute contraindications for home enrollment include unstable angina, staged cardiac procedure (PCI and surgery), complex ventricular arrhythmias, severe or symptomatic aortic stenosis, decompensated heart failure, and uncontrolled hypertension (Table). Patients deemed high risk for home-based CR may be referred to a non-VA facility-based CR program. Risk stratification, using the Canadian Cardiovascular Society Grading of Angina Pectoris, is a continuous process that is used to identify patients who may move from moderate to high risk, both before and during the program.^21,22

Phases 2 and 3

Phase 2 of the Healthy Heart Program CR includes physical activity, risk-factor modification, nutritional guidance, psychosocial modification, a return to previous activities, and an improved QOL. Prior to entry into the program, a submaximal exercise test, the 6-minute walk test (6MWT), is used as both a qualifying test and for developing the initial exercise prescription.²² The minimum 6MWT distance needed to qualify is 75 m for postoperative and 150 m for nonsurgical patients. The 6MWT is performed in-hospital for patients who were admitted for stable angina, PCI, and are > 4 days following acute MI.²³ Cardiothoracic surgery patients are tested at their first follow-up clinic visit (typically 2-3 weeks postoperatively). The clinician monitors the heart rate with either a wearable device or via inpatient telemetry monitors. This exercise testing also serves as a motivational tool for patients to gain confidence in their ability to begin to exercise at home.

Each participant receives a workbook and a DVD titled An Active Partnership for the Health of Your Heart. A personal health journal is provided for documenting vital signs, activity, and dietary intake. In addition, each participant receives equipment on an as-needed basis, including resistance bands, a weight scale, a blood pressure cuff, a pedometer/heart rate monitoring device, an exercise peddler or stationary bike, and a dietary video. Baseline assessments include the General Anxiety Disorder (GAD-7), Personal Health Questionnaire (PHQ-9) and a nutrition (Rate Your Plate) questionnaire. A cognitive function test (Montreal Cognitive Assessment) is used on an as-needed basis.

Nine 30-minute telephone follow-up sessions are scheduled within a 12-week period (weekly for the first 6 weeks, then biweekly). Topics covered are customized and include exercise; nutrition; medications; smoking cessation; and diabetes, hypertension, and weight management. Via a telephone follow-up session, the program nurses and patients codevelop an electronic individualized treatment plan that is tailored to the patient’s diagnosis, individual goals, and preferences. Clinicians teach participants how to self-monitor exercise, using a continuous heart rate monitoring device (Mio Alpha II or Fuse) and the 6-20 Borg dyspnea rating scale.²⁴ Initially, moderate intensity exercise is prescribed with a target heart rate that is 60% to 75% of the 6MWT peak heart rate and an initial Borg scale target (11-14 on 20 point scale). The program physicians approve the treatment plan at the first patient visit and every 30 days until phase 2 is complete.

Patients who have completed early outpatient phase 2 CR can benefit from continuing to a phase 3 CR program.²⁵ Participants of the Healthy Heart Program automatically are enrolled in phase 3, which is a long-term maintenance program that includes monthly or bimonthly phone calls for up to 1-year posthospital discharge. The goal is to support each veteran’s transition to a long-term healthy lifestyle that includes regular exercise.

Client-Clinician Partnership

The Healthy Heart Program establishes the client-clinician partnership prior to discharge for hospitalized patients. The nurse who initiates phase 1 at the bedside is the primary clinician throughout phases 2 and 3 with the exception of a dietician, psychologist, and/or exercise physiologist who provide follow-up calls as needed. Throughout these weekly follow-up phone sessions, the clinician gains an appreciation of the patient’s understanding of his or her disease, patterns of behavior, desire to change, confidence in being able to change, potential barriers, and responses to obstacles. Clinicians in this setting are empathetic, supportive, and nonjudgmental. They encourage positive changes no matter how small and express concern when the patient is having difficulty.

Tailored Behavioral Change

The clinician’s responsibility is to listen to the patient’s concerns, assess their level of commitment for changing health behaviors, and provide guidance and support at the patient’s current level. The clinician applies the Transtheoretical Model founded on the Stages of Change principals to help understand and provide guidance based on the patient’s feelings about health behavior change.²⁶ People are actively open to changing behaviors by only 20% at any given time.²⁷ Therefore, action-oriented guidance for patients who are in the contemplative stage would not be helpful. This patient-centered approach promotes patients’ self-awareness, participation, and understanding of their decision-making role in their health management. Ultimately, individuals must take ownership of their health care maintenance for sustained behavioral change and medication management, and clinicians should facilitate that process.

Discussion

Secondary prevention strategies for heart disease continue to be underutilized. The Healthy Heart Program aims to improve participation in CR, improve QOL, help patients understand their heart disease, and support these patients psychologically. An advantage of this program is that it begins inpatient CR immediately following the heart event, when many patients often are more receptive to behavioral change support and guidance. Another advantage is that the program breaks down barriers to access, which is especially important in the veteran population. The Healthy Heart Program provides support and guidance for exercise and cardiac risk factor management to patients who otherwise would have not participated in any type of CR program.

A home-based CR program can be adopted independently or in conjunction with a facility-based program to which patients lack access. Furthermore, home-based CR programs function well as a phase 3 maintenance program at the completion of a traditional CR program. Since its inception, the Healthy Heart Program has increased the number of veterans enrolled in cardiac rehabilitation at the SFVAMC dramatically, from < 1% in FY 2012 to > 40% in FY 2015.

Program Limitations

One potential disadvantage of a home-based CR program is patients’ fear of returning to an exercise routine following a cardiac event. In addition, a lack of in-person supervision in home-based CR can lead patients to engage in less intensive activity than in facility-based CR. Other disadvantages include a lack of social support, less patient accountability, and safety concerns for sicker patients. Staff have consulted on several patients who expressed a lack of confidence in their ability to do well in this type of program, where accountability for exercising is self-reported. Staff referred these patients, who had the means to travel, to a non-VA facility-based CR program of their choice. Ideally, patients would have the choice between facility- or home-based programs or be able to choose a hybrid program that would best meet their needs.

Another identified limitation of this program was the lack of group support and in-person interactions with rehabilitation staff. Finally, although this program uses mobile devices with heart rate monitoring technology, these devices currently lack the capability to remotely share data with clinicians. Clinicians are reliant on the patient’s use of a personal health journal and memory. Subjective patient reporting has been found to be overestimated; therefore, more objective methods to measure important clinical outcomes are necessary^.28

Conclusion

Facility-based CR is effective but underutilized. Alternative secondary programs are needed to help meet patient needs and overcome patient barriers. One promising approach to increase participation is home-based CR. Home-based CR programs have the potential to increase CR uptake and adherence. Home-based CR optimizes enrollment through evidence-based alternative models due to improved access. The future of CR will become highly individualized and multifaceted as a result of available mobile technologies and Internet-based tools, which will help increase the number of participants and expand the reach of cardiac risk factor management programs beyond the facility-based setting. A home-based program will be a valuable addition to facility-based programs as a stand-alone program or adopted into a hybrid program.

Acknowledgments
This work was funded by the VA Quality Enhancement Research Initiative.

Despite a 30% decline in heart disease mortality from 2001 to 2011, heart disease prevalence is on the rise, responsible for 1 of every 3 deaths in the U.S.¹ Cardiac rehabilitation (CR) is an evidence-based, secondary prevention strategy that has been proven effective in preventing future cardiovascular events and decreasing heart disease mortality.^2-4 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) is the leading authority on CR and provides guidelines for CR programs. The AACVPR and the American Heart Association (AHA) published core components for CR programs deemed essential for all CR/secondary prevention programs, including evaluations, interventions, and expected outcomes.⁵ These core components are aimed at promoting a healthy lifestyle and increasing function and well-being while reducing injury, death, and the reoccurrence of disease.⁶

In a meta-analysis of 47 trials with 10,794 participants, CR reduced cardiovascular disease (CVD) mortality and hospital admissions by 26% and 18%, respectively.² Performance measures (Class 1, Level A) recommend the following types of patients should be referred from the inpatient setting: “all patients hospitalized with a primary diagnosis of an acute myocardial infarction (MI) or chronic stable angina, or who during hospitalization have undergone coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation.”⁷ However, despite overwhelming evidence and widespread endorsement (Class 1, Level A), service utilization, uptake, and patient adherence to CR programs remain suboptimal. In a U.S. study of claims from > 250,000 Medicare beneficiaries, < 30% of eligible patients participated in some type of CR program.⁸ In response to poor participation, a presidential advisory from the AHA in 2011 stated, “the remarkably wide treatment gap between scientific evidence of the benefits of cardiac rehabilitation and clinical implementation of rehabilitation programs is unacceptable.”⁹

This treatment gap is echoed throughout the VHA. Schopfer and colleagues found that only 28% of the 124 VAMCs that provide inpatient care also offer a supervised, facility-based CR program.¹⁰ Furthermore, only 10.3% of eligible veterans participated in at least 1 CR session (VA or non-VA). On a systemic level, low patient referral rates and inadequate third-party reimbursement were the most common barriers to participation in CR.^10,11 On a patient level, distance was by far the largest barrier to veterans receiving CR. Currently, 74% of the 9.3 million VA-enrolled veterans live at least 1 hour by car from a VA facility that offers CR.⁹ Within some regions of the VHA, there are no VA facility-based CR programs. For example, VISN 21 has no facility-based CR programs. At the same time, referral of eligible veterans to facility-based CR outside the VA remains low. Prior to April 2013, < 2% of qualified patients residing in VISN 21 were being referred to Non-VA CR programs, making it the VISN with the lowest participation rate for CR.

One potential solution that addresses both systemic and patient barriers to CR utilization is home-based CR. Veterans within the wide geographic area of VISN 21 are referred to San Francisco VAMC (SFVAMC) for ischemic heart disease, cardiovascular revascularization, and cardiac valve surgeries. In 2013, a comprehensive home-based CR program named The Healthy Heart Program was developed based on a successful evidence-based CVD secondary prevention program. The Healthy Heart Program is designed to be a physician-directed, nurse case-managed, customized exercise and lifestyle program that provides a safe and convenient way for veterans to participate in CR. Exercise and disease self-management education are the cornerstones of the Healthy Heart Program. The program’s multidisciplinary team includes physicians, nurses, a dietician, an exercise physiologist, and a health behavior psychologist.

An Alternative Approach

DeBusk and colleagues demonstrated that a physician-directed, nurse-managed, home-based cardiac risk-factor modification program improved smoking cessation, reduced low-density lipoprotein cholesterol, and increased exercise capacity compared with usual care.¹² The results of this study helped pave the way for one of the first CR programs with a strong home-based element. The MULTIFIT program was jointly developed by the Stanford Coronary Rehabilitation Program and Kaiser Permanente (Oakland, CA) in 1995. MULTIFIT is a nurse-based care model for CVD prevention.

Further research that evaluated other home-based programs showed similar promise. A Cochrane review demonstrated that home- and facility-based CR programs were equal in cardiac risk factor reduction, reduced hospital readmissions and mortality rates, and improved quality of life (QOL).¹³ Cost-effectiveness also seemed to be similar in both home- and hospital-based CR programs.¹⁴ A meta-analysis of telephone support interventions for coronary artery disease demonstrated a 38% decrease in rehospitalizations and a 32% increase in the number of participants who stopped smoking.¹⁵ In addition, patients with time constraints (eg, work, family obligations) preferred home-based CR programs for the convenience and accessibility that these programs offer.¹⁶ Home-based CR programs may have better completion rates compared with that of facility-based programs.¹⁷ The American College of Cardiology and AHA updated guidelines for CR include home-based CR as a substitute for facility-based CR for low-risk patients (Class 1, Level A).¹⁸

Referrals

To address the problems with referrals that plague other CR programs, staff of the Healthy Heart Program worked closely with interventional cardiology and the cardiothoracic team, including the clinical informatics coordinators, to develop an automatic referral system for CR evaluation. Consults for CR evaluation were embedded within the post-CABG and PCI order sets in the electronic health record. Laboratory troponin alerts were created to alert CR staff of patients with elevated troponins, which identified patients admitted for acute MI. Healthy Heart Program staff members received the referrals once a patient was admitted to the unit following their heart procedure. Early referrals for evaluation allowed staff to begin a chart review of all eligible patients and to follow the patient’s course of recovery. Most consults were generated during hospitalization for one of the indications; however, a minority of consults come from both the cardiology and primary care clinics.

Three Phases of CR

The AACVPR describes the challenges and opportunities found throughout the CR continuum.⁵ Over the past several decades, the continuum of care was more program centered and service utilization was more isolated. Today, CR is viewed as more process oriented and coordinates care across many professionals and services. Phase 1 inpatient CR begins in the hospital and is a shared responsibility between several services. Shortened hospital stays have led to innovative solutions for early ambulation, risk factor education, and discharge planning, including enrollment into phase 2 CR. Phase 2, also known as early outpatient, should begin within 1 to 2 weeks postevent in healthier patients and can last between 6 and 12 weeks postdischarge. Phase 3 (maintenance phase) should begin immediately at the conclusion of phase 2.

Phase 1

Prior to the advent of the Healthy Heart Program, secondary prevention education was not done at the bedside for SFVAMC patients following cardiac revascularization. The AACVPR recommends patient assessment, mobilization, risk-factor identification and education, and facilitation into outpatient CR as essential components of phase 1 CR.⁵ The Healthy Heart Program clinician initiates phase 1 CR by examining cardiac risk factor management for all referred patients. Physical and cardiac risk factor assessments are accomplished by completing a detailed chart review and interview with the patient. During this interview with the patient, the clinician evaluates cognitive function and readiness to learn. Staff will interview the patient further to assess the overall patient needs, including availability of social support, resources to maintain optimal health, and the need for secondary preventive education. For the PCI patient, the interview may occur in the hours following their procedure; for the surgical patient, this bedside visit typically occurs postoperative day 3 or 4.

A standardized cardiac risk factor evaluation tool was designed, which also serves as an education form to help guide the conversation on risk factor management. The interactive, patient-centered form includes opportunities to review risk, discuss current laboratory values (eg, lipids and hemoglobin A_1c), and establish individualized goals based on patient preference and recommended guidelines. Healthy Heart Program staff assist the patient in formulating achievable goals using the SMART (specific, measurable, attainable, realistic, and time-related) criteria.¹⁹ Immediately after a heart event or procedure, patients often feel highly motivated to initiate lifestyle changes.²⁰ However, PCI patients may have a short window of opportunity for learning between their readiness to learn state and before the activities of discharge. Staff use these opportunities as a teachable moment and to increase enrollment into outpatient CR (phase 2).

The provider performs a thorough chart review and bedside consultation to determine whether home-based CR is indicated, feasible, and appropriate. Not every patient that is referred will be enrolled in CR. Patients have the option to opt out. In addition, clinical staff adhere to the program protocol’s exclusion criteria.

Absolute contraindications for home enrollment include unstable angina, staged cardiac procedure (PCI and surgery), complex ventricular arrhythmias, severe or symptomatic aortic stenosis, decompensated heart failure, and uncontrolled hypertension (Table). Patients deemed high risk for home-based CR may be referred to a non-VA facility-based CR program. Risk stratification, using the Canadian Cardiovascular Society Grading of Angina Pectoris, is a continuous process that is used to identify patients who may move from moderate to high risk, both before and during the program.^21,22

Phases 2 and 3

Phase 2 of the Healthy Heart Program CR includes physical activity, risk-factor modification, nutritional guidance, psychosocial modification, a return to previous activities, and an improved QOL. Prior to entry into the program, a submaximal exercise test, the 6-minute walk test (6MWT), is used as both a qualifying test and for developing the initial exercise prescription.²² The minimum 6MWT distance needed to qualify is 75 m for postoperative and 150 m for nonsurgical patients. The 6MWT is performed in-hospital for patients who were admitted for stable angina, PCI, and are > 4 days following acute MI.²³ Cardiothoracic surgery patients are tested at their first follow-up clinic visit (typically 2-3 weeks postoperatively). The clinician monitors the heart rate with either a wearable device or via inpatient telemetry monitors. This exercise testing also serves as a motivational tool for patients to gain confidence in their ability to begin to exercise at home.

Each participant receives a workbook and a DVD titled An Active Partnership for the Health of Your Heart. A personal health journal is provided for documenting vital signs, activity, and dietary intake. In addition, each participant receives equipment on an as-needed basis, including resistance bands, a weight scale, a blood pressure cuff, a pedometer/heart rate monitoring device, an exercise peddler or stationary bike, and a dietary video. Baseline assessments include the General Anxiety Disorder (GAD-7), Personal Health Questionnaire (PHQ-9) and a nutrition (Rate Your Plate) questionnaire. A cognitive function test (Montreal Cognitive Assessment) is used on an as-needed basis.

Nine 30-minute telephone follow-up sessions are scheduled within a 12-week period (weekly for the first 6 weeks, then biweekly). Topics covered are customized and include exercise; nutrition; medications; smoking cessation; and diabetes, hypertension, and weight management. Via a telephone follow-up session, the program nurses and patients codevelop an electronic individualized treatment plan that is tailored to the patient’s diagnosis, individual goals, and preferences. Clinicians teach participants how to self-monitor exercise, using a continuous heart rate monitoring device (Mio Alpha II or Fuse) and the 6-20 Borg dyspnea rating scale.²⁴ Initially, moderate intensity exercise is prescribed with a target heart rate that is 60% to 75% of the 6MWT peak heart rate and an initial Borg scale target (11-14 on 20 point scale). The program physicians approve the treatment plan at the first patient visit and every 30 days until phase 2 is complete.

Patients who have completed early outpatient phase 2 CR can benefit from continuing to a phase 3 CR program.²⁵ Participants of the Healthy Heart Program automatically are enrolled in phase 3, which is a long-term maintenance program that includes monthly or bimonthly phone calls for up to 1-year posthospital discharge. The goal is to support each veteran’s transition to a long-term healthy lifestyle that includes regular exercise.

Client-Clinician Partnership

The Healthy Heart Program establishes the client-clinician partnership prior to discharge for hospitalized patients. The nurse who initiates phase 1 at the bedside is the primary clinician throughout phases 2 and 3 with the exception of a dietician, psychologist, and/or exercise physiologist who provide follow-up calls as needed. Throughout these weekly follow-up phone sessions, the clinician gains an appreciation of the patient’s understanding of his or her disease, patterns of behavior, desire to change, confidence in being able to change, potential barriers, and responses to obstacles. Clinicians in this setting are empathetic, supportive, and nonjudgmental. They encourage positive changes no matter how small and express concern when the patient is having difficulty.

Tailored Behavioral Change

The clinician’s responsibility is to listen to the patient’s concerns, assess their level of commitment for changing health behaviors, and provide guidance and support at the patient’s current level. The clinician applies the Transtheoretical Model founded on the Stages of Change principals to help understand and provide guidance based on the patient’s feelings about health behavior change.²⁶ People are actively open to changing behaviors by only 20% at any given time.²⁷ Therefore, action-oriented guidance for patients who are in the contemplative stage would not be helpful. This patient-centered approach promotes patients’ self-awareness, participation, and understanding of their decision-making role in their health management. Ultimately, individuals must take ownership of their health care maintenance for sustained behavioral change and medication management, and clinicians should facilitate that process.

Discussion

Secondary prevention strategies for heart disease continue to be underutilized. The Healthy Heart Program aims to improve participation in CR, improve QOL, help patients understand their heart disease, and support these patients psychologically. An advantage of this program is that it begins inpatient CR immediately following the heart event, when many patients often are more receptive to behavioral change support and guidance. Another advantage is that the program breaks down barriers to access, which is especially important in the veteran population. The Healthy Heart Program provides support and guidance for exercise and cardiac risk factor management to patients who otherwise would have not participated in any type of CR program.

A home-based CR program can be adopted independently or in conjunction with a facility-based program to which patients lack access. Furthermore, home-based CR programs function well as a phase 3 maintenance program at the completion of a traditional CR program. Since its inception, the Healthy Heart Program has increased the number of veterans enrolled in cardiac rehabilitation at the SFVAMC dramatically, from < 1% in FY 2012 to > 40% in FY 2015.

Program Limitations

One potential disadvantage of a home-based CR program is patients’ fear of returning to an exercise routine following a cardiac event. In addition, a lack of in-person supervision in home-based CR can lead patients to engage in less intensive activity than in facility-based CR. Other disadvantages include a lack of social support, less patient accountability, and safety concerns for sicker patients. Staff have consulted on several patients who expressed a lack of confidence in their ability to do well in this type of program, where accountability for exercising is self-reported. Staff referred these patients, who had the means to travel, to a non-VA facility-based CR program of their choice. Ideally, patients would have the choice between facility- or home-based programs or be able to choose a hybrid program that would best meet their needs.

Another identified limitation of this program was the lack of group support and in-person interactions with rehabilitation staff. Finally, although this program uses mobile devices with heart rate monitoring technology, these devices currently lack the capability to remotely share data with clinicians. Clinicians are reliant on the patient’s use of a personal health journal and memory. Subjective patient reporting has been found to be overestimated; therefore, more objective methods to measure important clinical outcomes are necessary^.28

Conclusion

Facility-based CR is effective but underutilized. Alternative secondary programs are needed to help meet patient needs and overcome patient barriers. One promising approach to increase participation is home-based CR. Home-based CR programs have the potential to increase CR uptake and adherence. Home-based CR optimizes enrollment through evidence-based alternative models due to improved access. The future of CR will become highly individualized and multifaceted as a result of available mobile technologies and Internet-based tools, which will help increase the number of participants and expand the reach of cardiac risk factor management programs beyond the facility-based setting. A home-based program will be a valuable addition to facility-based programs as a stand-alone program or adopted into a hybrid program.

Acknowledgments
This work was funded by the VA Quality Enhancement Research Initiative.

Photo courtesy of CDC

Severe hospital-acquired anemia (HAA) may increase a person’s risk of hospital readmission and death, a new study suggests.

Researchers studied more than 11,000 patients admitted to 6 Texas hospitals and found that a third of the patients developed HAA.

The team also found that severe HAA was associated with a higher risk of death or readmission, even after the researchers adjusted for other factors.

They reported these findings in the Journal of Hospital Medicine.

“This study shines a spotlight on a very common but underappreciated risk of hospitalization, hospital-acquired anemia, which has traditionally been viewed as an incidental change in the red blood count of no significance,” said study author Ethan Halm, MD, of the University of Texas Southwestern Medical Center in Dallas.

“However, our results showed that hospital-acquired anemia was associated with worse clinical outcomes after leaving the hospital, so it needs to be taken more seriously.”

Dr Halm and his colleagues looked at consecutive medicine discharges between November 1, 2009, and October 30, 2010, from 6 hospitals in Texas (safety-net, teaching, and nonteaching).

Of the 11,309 patients studied, 33.1% developed HAA. Most (21.6%) had mild HAA, followed by moderate HAA (10.1%), and severe HAA (1.4%).

The study’s primary outcome was a composite of 30-day mortality and nonelective readmission. This occurred in 9.7% of patients without HAA and 16.4% of those with severe HAA.

The researchers found that severe HAA was independently associated with a 39% increase in the odds of meeting the primary outcome (readmission or 30-day mortality).

The team noted that 85% of patients with severe HAA underwent a major procedure, had a discharge diagnosis of hemorrhage, and/or a discharge diagnosis of hemorrhagic disorder.

The researchers identified 2 potentially modifiable predictors of moderate or severe HAA. These were length of hospital stay (adjusted odds ratio=1.26 per day) and undergoing a major procedure (adjusted odds ratio=5.09).

“Our findings suggest that reducing blood loss during major surgeries and reducing unnecessary testing during hospital stays may lower a patient’s risk of developing severe hospital-acquired anemia, and potentially improve their recovery,” said Anil N. Makam, MD, of the University of Texas Southwestern Medical Center.

In the future, the researchers hope to examine other patient-centered outcomes that may be related to HAA, such as fatigue, functional impairment, and the trajectory of post-hospital recovery. 

Photo courtesy of CDC

Severe hospital-acquired anemia (HAA) may increase a person’s risk of hospital readmission and death, a new study suggests.

Researchers studied more than 11,000 patients admitted to 6 Texas hospitals and found that a third of the patients developed HAA.

The team also found that severe HAA was associated with a higher risk of death or readmission, even after the researchers adjusted for other factors.

They reported these findings in the Journal of Hospital Medicine.

“This study shines a spotlight on a very common but underappreciated risk of hospitalization, hospital-acquired anemia, which has traditionally been viewed as an incidental change in the red blood count of no significance,” said study author Ethan Halm, MD, of the University of Texas Southwestern Medical Center in Dallas.

“However, our results showed that hospital-acquired anemia was associated with worse clinical outcomes after leaving the hospital, so it needs to be taken more seriously.”

Dr Halm and his colleagues looked at consecutive medicine discharges between November 1, 2009, and October 30, 2010, from 6 hospitals in Texas (safety-net, teaching, and nonteaching).

Of the 11,309 patients studied, 33.1% developed HAA. Most (21.6%) had mild HAA, followed by moderate HAA (10.1%), and severe HAA (1.4%).

The study’s primary outcome was a composite of 30-day mortality and nonelective readmission. This occurred in 9.7% of patients without HAA and 16.4% of those with severe HAA.

The researchers found that severe HAA was independently associated with a 39% increase in the odds of meeting the primary outcome (readmission or 30-day mortality).

The team noted that 85% of patients with severe HAA underwent a major procedure, had a discharge diagnosis of hemorrhage, and/or a discharge diagnosis of hemorrhagic disorder.

The researchers identified 2 potentially modifiable predictors of moderate or severe HAA. These were length of hospital stay (adjusted odds ratio=1.26 per day) and undergoing a major procedure (adjusted odds ratio=5.09).

“Our findings suggest that reducing blood loss during major surgeries and reducing unnecessary testing during hospital stays may lower a patient’s risk of developing severe hospital-acquired anemia, and potentially improve their recovery,” said Anil N. Makam, MD, of the University of Texas Southwestern Medical Center.

In the future, the researchers hope to examine other patient-centered outcomes that may be related to HAA, such as fatigue, functional impairment, and the trajectory of post-hospital recovery. 

Photo courtesy of CDC

Severe hospital-acquired anemia (HAA) may increase a person’s risk of hospital readmission and death, a new study suggests.

Researchers studied more than 11,000 patients admitted to 6 Texas hospitals and found that a third of the patients developed HAA.

The team also found that severe HAA was associated with a higher risk of death or readmission, even after the researchers adjusted for other factors.

They reported these findings in the Journal of Hospital Medicine.

“This study shines a spotlight on a very common but underappreciated risk of hospitalization, hospital-acquired anemia, which has traditionally been viewed as an incidental change in the red blood count of no significance,” said study author Ethan Halm, MD, of the University of Texas Southwestern Medical Center in Dallas.

“However, our results showed that hospital-acquired anemia was associated with worse clinical outcomes after leaving the hospital, so it needs to be taken more seriously.”

Dr Halm and his colleagues looked at consecutive medicine discharges between November 1, 2009, and October 30, 2010, from 6 hospitals in Texas (safety-net, teaching, and nonteaching).

Of the 11,309 patients studied, 33.1% developed HAA. Most (21.6%) had mild HAA, followed by moderate HAA (10.1%), and severe HAA (1.4%).

The study’s primary outcome was a composite of 30-day mortality and nonelective readmission. This occurred in 9.7% of patients without HAA and 16.4% of those with severe HAA.

The researchers found that severe HAA was independently associated with a 39% increase in the odds of meeting the primary outcome (readmission or 30-day mortality).

The team noted that 85% of patients with severe HAA underwent a major procedure, had a discharge diagnosis of hemorrhage, and/or a discharge diagnosis of hemorrhagic disorder.

The researchers identified 2 potentially modifiable predictors of moderate or severe HAA. These were length of hospital stay (adjusted odds ratio=1.26 per day) and undergoing a major procedure (adjusted odds ratio=5.09).

“Our findings suggest that reducing blood loss during major surgeries and reducing unnecessary testing during hospital stays may lower a patient’s risk of developing severe hospital-acquired anemia, and potentially improve their recovery,” said Anil N. Makam, MD, of the University of Texas Southwestern Medical Center.

In the future, the researchers hope to examine other patient-centered outcomes that may be related to HAA, such as fatigue, functional impairment, and the trajectory of post-hospital recovery. 

The drop in frequent binge drinking (FBD) among adolescents can be attributed to age, period, and cohort effects, but there are variations in certain subgroups of teens, said Joy Bohyun Jang, PhD, and her associates.

The decline in FBD is not as great in teen girls, African American youth, and youth from low socioeconomic backgrounds, so those groups deserve close attention by researchers and clinicians, they said.

Galina Barskaya/Fotolia

The drop in frequent binge drinking (FBD) among adolescents can be attributed to age, period, and cohort effects, but there are variations in certain subgroups of teens, said Joy Bohyun Jang, PhD, and her associates.

The decline in FBD is not as great in teen girls, African American youth, and youth from low socioeconomic backgrounds, so those groups deserve close attention by researchers and clinicians, they said.

Galina Barskaya/Fotolia

The drop in frequent binge drinking (FBD) among adolescents can be attributed to age, period, and cohort effects, but there are variations in certain subgroups of teens, said Joy Bohyun Jang, PhD, and her associates.

The decline in FBD is not as great in teen girls, African American youth, and youth from low socioeconomic backgrounds, so those groups deserve close attention by researchers and clinicians, they said.

Galina Barskaya/Fotolia