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Higher Risk of Cataracts After Percutaneous Coronary Intervention
NEW YORK (Reuters Health) - The risk of cataracts increases after percutaneous coronary intervention (PCI), suggesting the need for eye protection in patients undergoing these procedures, researchers from Taiwan report.
Although previous studies have identified a link between occupational radiation exposure and excess risk of cataract formation, the research in patients has been more limited. Lead eyeglasses are currently recommended for interventionists, but there are no guidelines for patient eye protection.
Dr. Yu-Tung Huang, from Kaohsiung Medical University,Kaohsiung, Taiwan, and colleagues used data from Taiwan's National Health Insurance research database to evaluate the risk of cataract surgery in 13,807 patients exposed to PCI and 27,614 patients not exposed to PCI.
Patients who underwent PCI were 25% more likely than those not exposed to PCI to have cataract surgery, according to the April 4 JAMA Internal Medicine online report.
The risk of cataract surgery increased with increasing numbers of PCI procedures, from 23% increased risk with one procedure to 29% increased risk with two to four procedures to 43% increased risk with five or more procedures.
"Because this was an observational study," they note, "we cannot establish causation, and there may be unmeasured confounders."
Nevertheless, the researchers conclude, "providing lead eyeglasses to protect patients' eyes, as is already done during cosmetic laser procedures, during the PCI procedures is recommended."
Dr. Huang did not respond to a request for comments.The authors reported no funding or disclosures.
NEW YORK (Reuters Health) - The risk of cataracts increases after percutaneous coronary intervention (PCI), suggesting the need for eye protection in patients undergoing these procedures, researchers from Taiwan report.
Although previous studies have identified a link between occupational radiation exposure and excess risk of cataract formation, the research in patients has been more limited. Lead eyeglasses are currently recommended for interventionists, but there are no guidelines for patient eye protection.
Dr. Yu-Tung Huang, from Kaohsiung Medical University,Kaohsiung, Taiwan, and colleagues used data from Taiwan's National Health Insurance research database to evaluate the risk of cataract surgery in 13,807 patients exposed to PCI and 27,614 patients not exposed to PCI.
Patients who underwent PCI were 25% more likely than those not exposed to PCI to have cataract surgery, according to the April 4 JAMA Internal Medicine online report.
The risk of cataract surgery increased with increasing numbers of PCI procedures, from 23% increased risk with one procedure to 29% increased risk with two to four procedures to 43% increased risk with five or more procedures.
"Because this was an observational study," they note, "we cannot establish causation, and there may be unmeasured confounders."
Nevertheless, the researchers conclude, "providing lead eyeglasses to protect patients' eyes, as is already done during cosmetic laser procedures, during the PCI procedures is recommended."
Dr. Huang did not respond to a request for comments.The authors reported no funding or disclosures.
NEW YORK (Reuters Health) - The risk of cataracts increases after percutaneous coronary intervention (PCI), suggesting the need for eye protection in patients undergoing these procedures, researchers from Taiwan report.
Although previous studies have identified a link between occupational radiation exposure and excess risk of cataract formation, the research in patients has been more limited. Lead eyeglasses are currently recommended for interventionists, but there are no guidelines for patient eye protection.
Dr. Yu-Tung Huang, from Kaohsiung Medical University,Kaohsiung, Taiwan, and colleagues used data from Taiwan's National Health Insurance research database to evaluate the risk of cataract surgery in 13,807 patients exposed to PCI and 27,614 patients not exposed to PCI.
Patients who underwent PCI were 25% more likely than those not exposed to PCI to have cataract surgery, according to the April 4 JAMA Internal Medicine online report.
The risk of cataract surgery increased with increasing numbers of PCI procedures, from 23% increased risk with one procedure to 29% increased risk with two to four procedures to 43% increased risk with five or more procedures.
"Because this was an observational study," they note, "we cannot establish causation, and there may be unmeasured confounders."
Nevertheless, the researchers conclude, "providing lead eyeglasses to protect patients' eyes, as is already done during cosmetic laser procedures, during the PCI procedures is recommended."
Dr. Huang did not respond to a request for comments.The authors reported no funding or disclosures.
Antimalarial resistance can’t be passed on, team says
in mosquito gut
Image by Antoine Nicot
and Jacques Denoyelle
Parasites that develop resistance to the antimalarial drug atovaquone cannot pass this resistance on to their offspring, a new study suggests.
Researchers found that malaria parasites develop resistance to atovaquone via mutations in the mitochondrial cytochrome b complex.
However, these mutations also prevent female parasites from reproducing, so the resistance cannot be passed on to future generations.
Geoff McFadden, PhD, of the University of Melbourne in Victoria, Australia, and his colleagues reported these findings in Science.
“These results are very exciting because the spread of drug resistance is currently destroying our ability to control malaria,” Dr McFadden said.
“We now understand the particular genetic mutation that gave rise to drug resistance in some malaria parasite populations and how it eventually kills them in the mosquito, providing new targets for the development of drugs. So the development of drug resistance may not be a major problem if the resistance cannot spread, meaning the drug atovaquone could be more widely used in malaria control.”
To conduct this study, Dr McFadden and his colleagues analyzed 3 atovaquone-resistant strains of Plasmodium berghei, a malaria parasite that infects rodents. Each strain contained a different mutation in cytochrome b.
The researchers found that 2 of the mutations resulted in developmental defects in the parasite zygotes, and the third mutation resulted in complete infertility in the parasites due to severely impaired female germ cells.
Cross breeding parasites with and without these mutations showed that the mutations are not passed on to offspring. From 44 separate transmission attempts involving 750 mosquito bites, transmission of atovaquone resistance was only observed once, and this mutant was unable to transmit further, despite 7 attempts.
The researchers said it appears that atovaquone-resistant mutations severely impair the lifecycle of the parasites when they are living in mosquito hosts, so these mutations cannot be passed on.
In the human malaria parasite Plasmodium falciparum, the researchers identified similar mutations that impaired the ability of the parasites to infect mosquitos, as well as the number of oocysts produced when infection did occur. 
in mosquito gut
Image by Antoine Nicot
and Jacques Denoyelle
Parasites that develop resistance to the antimalarial drug atovaquone cannot pass this resistance on to their offspring, a new study suggests.
Researchers found that malaria parasites develop resistance to atovaquone via mutations in the mitochondrial cytochrome b complex.
However, these mutations also prevent female parasites from reproducing, so the resistance cannot be passed on to future generations.
Geoff McFadden, PhD, of the University of Melbourne in Victoria, Australia, and his colleagues reported these findings in Science.
“These results are very exciting because the spread of drug resistance is currently destroying our ability to control malaria,” Dr McFadden said.
“We now understand the particular genetic mutation that gave rise to drug resistance in some malaria parasite populations and how it eventually kills them in the mosquito, providing new targets for the development of drugs. So the development of drug resistance may not be a major problem if the resistance cannot spread, meaning the drug atovaquone could be more widely used in malaria control.”
To conduct this study, Dr McFadden and his colleagues analyzed 3 atovaquone-resistant strains of Plasmodium berghei, a malaria parasite that infects rodents. Each strain contained a different mutation in cytochrome b.
The researchers found that 2 of the mutations resulted in developmental defects in the parasite zygotes, and the third mutation resulted in complete infertility in the parasites due to severely impaired female germ cells.
Cross breeding parasites with and without these mutations showed that the mutations are not passed on to offspring. From 44 separate transmission attempts involving 750 mosquito bites, transmission of atovaquone resistance was only observed once, and this mutant was unable to transmit further, despite 7 attempts.
The researchers said it appears that atovaquone-resistant mutations severely impair the lifecycle of the parasites when they are living in mosquito hosts, so these mutations cannot be passed on.
In the human malaria parasite Plasmodium falciparum, the researchers identified similar mutations that impaired the ability of the parasites to infect mosquitos, as well as the number of oocysts produced when infection did occur.
in mosquito gut
Image by Antoine Nicot
and Jacques Denoyelle
Parasites that develop resistance to the antimalarial drug atovaquone cannot pass this resistance on to their offspring, a new study suggests.
Researchers found that malaria parasites develop resistance to atovaquone via mutations in the mitochondrial cytochrome b complex.
However, these mutations also prevent female parasites from reproducing, so the resistance cannot be passed on to future generations.
Geoff McFadden, PhD, of the University of Melbourne in Victoria, Australia, and his colleagues reported these findings in Science.
“These results are very exciting because the spread of drug resistance is currently destroying our ability to control malaria,” Dr McFadden said.
“We now understand the particular genetic mutation that gave rise to drug resistance in some malaria parasite populations and how it eventually kills them in the mosquito, providing new targets for the development of drugs. So the development of drug resistance may not be a major problem if the resistance cannot spread, meaning the drug atovaquone could be more widely used in malaria control.”
To conduct this study, Dr McFadden and his colleagues analyzed 3 atovaquone-resistant strains of Plasmodium berghei, a malaria parasite that infects rodents. Each strain contained a different mutation in cytochrome b.
The researchers found that 2 of the mutations resulted in developmental defects in the parasite zygotes, and the third mutation resulted in complete infertility in the parasites due to severely impaired female germ cells.
Cross breeding parasites with and without these mutations showed that the mutations are not passed on to offspring. From 44 separate transmission attempts involving 750 mosquito bites, transmission of atovaquone resistance was only observed once, and this mutant was unable to transmit further, despite 7 attempts.
The researchers said it appears that atovaquone-resistant mutations severely impair the lifecycle of the parasites when they are living in mosquito hosts, so these mutations cannot be passed on.
In the human malaria parasite Plasmodium falciparum, the researchers identified similar mutations that impaired the ability of the parasites to infect mosquitos, as well as the number of oocysts produced when infection did occur.
Gut bacteria could help prevent lymphoma, other cancers
New research published in PLOS ONE suggests certain intestinal bacteria could potentially be used to reduce the risk of lymphomas and other cancers.
Researchers believe doctors might be able to reduce a person’s risk of these cancers by analyzing the levels and types of intestinal bacteria in the body and then prescribing probiotics to replace or bolster the amount of bacteria with anti-inflammatory properties.
“It is not invasive and rather easy to do,” said study author Robert Schiestl, PhD, of the University of California, Los Angeles.
Dr Schiestl and his colleagues isolated a bacterium called Lactobacillus johnsonii 456, which is the most abundant of the beneficial bacteria.
The team found this bacterium reduced gene damage and inflammation, which, as they pointed out, plays a key role in cancers and other diseases.
Previous research led by Dr Schiestl presented the first evidence of a relationship between intestinal microbiota and the onset of lymphoma.
The new study explains how this microbiota might delay the onset of cancer and suggests that probiotic supplements could help keep cancer from forming.
For both studies, Dr Schiestl and his team used mice that had mutations in the gene ATM, which made them susceptible to a neurologic disorder called ataxia telangiectasia. The disorder is associated with a high incidence of leukemias, lymphomas, and other cancers.
The mice were divided into two groups—one that was given only anti-inflammatory bacteria and another that received a mix of inflammatory and anti-inflammatory microbes that typically co-exist in the intestines.
With their previous study, Dr Schiestl and his team showed that, in the mice with more of the beneficial bacteria, the lymphoma took significantly longer to form.
For the new study, the researchers analyzed metabolites in the mice’s urine and feces and found the mice that were receiving only the beneficial microbiota produced metabolites that are known to prevent cancer.
Those mice also had more efficient fat and oxidative metabolism, which the researchers believe might also lower the risk for cancer.
Among the other results, in the mice receiving only the good bacteria, lymphoma formed only half as quickly as it did in the other mice. In addition, mice with the good bacteria lived 4 times longer and had less DNA damage and inflammation.
The researchers said these findings lend credence to the idea that manipulating microbial composition could be used to prevent or alleviate cancer susceptibility. They hope that, in the future, probiotic supplements could be chemopreventive for the average person and decrease tumor incidence in cancer-susceptible populations.
The University of California, Los Angeles has a patent pending on the use of Lactobacillus johnsonii 456 as an anti-inflammatory agent.
New research published in PLOS ONE suggests certain intestinal bacteria could potentially be used to reduce the risk of lymphomas and other cancers.
Researchers believe doctors might be able to reduce a person’s risk of these cancers by analyzing the levels and types of intestinal bacteria in the body and then prescribing probiotics to replace or bolster the amount of bacteria with anti-inflammatory properties.
“It is not invasive and rather easy to do,” said study author Robert Schiestl, PhD, of the University of California, Los Angeles.
Dr Schiestl and his colleagues isolated a bacterium called Lactobacillus johnsonii 456, which is the most abundant of the beneficial bacteria.
The team found this bacterium reduced gene damage and inflammation, which, as they pointed out, plays a key role in cancers and other diseases.
Previous research led by Dr Schiestl presented the first evidence of a relationship between intestinal microbiota and the onset of lymphoma.
The new study explains how this microbiota might delay the onset of cancer and suggests that probiotic supplements could help keep cancer from forming.
For both studies, Dr Schiestl and his team used mice that had mutations in the gene ATM, which made them susceptible to a neurologic disorder called ataxia telangiectasia. The disorder is associated with a high incidence of leukemias, lymphomas, and other cancers.
The mice were divided into two groups—one that was given only anti-inflammatory bacteria and another that received a mix of inflammatory and anti-inflammatory microbes that typically co-exist in the intestines.
With their previous study, Dr Schiestl and his team showed that, in the mice with more of the beneficial bacteria, the lymphoma took significantly longer to form.
For the new study, the researchers analyzed metabolites in the mice’s urine and feces and found the mice that were receiving only the beneficial microbiota produced metabolites that are known to prevent cancer.
Those mice also had more efficient fat and oxidative metabolism, which the researchers believe might also lower the risk for cancer.
Among the other results, in the mice receiving only the good bacteria, lymphoma formed only half as quickly as it did in the other mice. In addition, mice with the good bacteria lived 4 times longer and had less DNA damage and inflammation.
The researchers said these findings lend credence to the idea that manipulating microbial composition could be used to prevent or alleviate cancer susceptibility. They hope that, in the future, probiotic supplements could be chemopreventive for the average person and decrease tumor incidence in cancer-susceptible populations.
The University of California, Los Angeles has a patent pending on the use of Lactobacillus johnsonii 456 as an anti-inflammatory agent.
New research published in PLOS ONE suggests certain intestinal bacteria could potentially be used to reduce the risk of lymphomas and other cancers.
Researchers believe doctors might be able to reduce a person’s risk of these cancers by analyzing the levels and types of intestinal bacteria in the body and then prescribing probiotics to replace or bolster the amount of bacteria with anti-inflammatory properties.
“It is not invasive and rather easy to do,” said study author Robert Schiestl, PhD, of the University of California, Los Angeles.
Dr Schiestl and his colleagues isolated a bacterium called Lactobacillus johnsonii 456, which is the most abundant of the beneficial bacteria.
The team found this bacterium reduced gene damage and inflammation, which, as they pointed out, plays a key role in cancers and other diseases.
Previous research led by Dr Schiestl presented the first evidence of a relationship between intestinal microbiota and the onset of lymphoma.
The new study explains how this microbiota might delay the onset of cancer and suggests that probiotic supplements could help keep cancer from forming.
For both studies, Dr Schiestl and his team used mice that had mutations in the gene ATM, which made them susceptible to a neurologic disorder called ataxia telangiectasia. The disorder is associated with a high incidence of leukemias, lymphomas, and other cancers.
The mice were divided into two groups—one that was given only anti-inflammatory bacteria and another that received a mix of inflammatory and anti-inflammatory microbes that typically co-exist in the intestines.
With their previous study, Dr Schiestl and his team showed that, in the mice with more of the beneficial bacteria, the lymphoma took significantly longer to form.
For the new study, the researchers analyzed metabolites in the mice’s urine and feces and found the mice that were receiving only the beneficial microbiota produced metabolites that are known to prevent cancer.
Those mice also had more efficient fat and oxidative metabolism, which the researchers believe might also lower the risk for cancer.
Among the other results, in the mice receiving only the good bacteria, lymphoma formed only half as quickly as it did in the other mice. In addition, mice with the good bacteria lived 4 times longer and had less DNA damage and inflammation.
The researchers said these findings lend credence to the idea that manipulating microbial composition could be used to prevent or alleviate cancer susceptibility. They hope that, in the future, probiotic supplements could be chemopreventive for the average person and decrease tumor incidence in cancer-susceptible populations.
The University of California, Los Angeles has a patent pending on the use of Lactobacillus johnsonii 456 as an anti-inflammatory agent.
PD-1 inhibitor granted priority review for cHL
Photo courtesy of Business Wire
The US Food and Drug Administration (FDA) has granted priority review to a supplemental biologics license application seeking to expand use of the PD-1 inhibitor nivolumab (Opdivo) to patients with previously treated classical Hodgkin lymphoma (cHL).
A priority review designation means the FDA’s goal is to take action on an application within 6 months, rather than the 10 months typically taken for a standard review.
To grant an application priority review, the FDA must believe the drug would provide a significant improvement in the treatment, diagnosis, or prevention of a serious condition.
About nivolumab
Nivolumab is an inhibitor that binds to the checkpoint receptor PD-1, which is expressed on activated T cells. The drug prevents PD-L1 and PD-L2 from binding, thereby preventing the PD-1 pathway’s suppressive signaling on the immune system, including interference with an anti-tumor immune response.
Nivolumab is being developed by Bristol-Myers Squibb. The drug currently has regulatory approval in 48 countries.
In the US, nivolumab is approved—both as a single agent and in combination—to treat certain patients with melanoma, non-small-cell lung cancer, or advanced renal cell carcinoma.
According to Bristol-Myers Squibb, nivolumab has the potential to become first PD-1 inhibitor approved for a hematologic malignancy in the US.
The supplemental biologics license application for nivolumab included data from the phase 2 trial CheckMate 205. In this ongoing trial, researchers are evaluating nivolumab in patients with relapsed or refractory cHL who have received an autologous stem cell transplant and brentuximab vedotin.
Data from this trial are expected to be presented at a medical meeting later this year.
The FDA previously granted nivolumab breakthrough therapy designation for cHL. The FDA’s breakthrough therapy designation is intended to expedite the development and review of drugs for serious or life-threatening conditions.
Photo courtesy of Business Wire
The US Food and Drug Administration (FDA) has granted priority review to a supplemental biologics license application seeking to expand use of the PD-1 inhibitor nivolumab (Opdivo) to patients with previously treated classical Hodgkin lymphoma (cHL).
A priority review designation means the FDA’s goal is to take action on an application within 6 months, rather than the 10 months typically taken for a standard review.
To grant an application priority review, the FDA must believe the drug would provide a significant improvement in the treatment, diagnosis, or prevention of a serious condition.
About nivolumab
Nivolumab is an inhibitor that binds to the checkpoint receptor PD-1, which is expressed on activated T cells. The drug prevents PD-L1 and PD-L2 from binding, thereby preventing the PD-1 pathway’s suppressive signaling on the immune system, including interference with an anti-tumor immune response.
Nivolumab is being developed by Bristol-Myers Squibb. The drug currently has regulatory approval in 48 countries.
In the US, nivolumab is approved—both as a single agent and in combination—to treat certain patients with melanoma, non-small-cell lung cancer, or advanced renal cell carcinoma.
According to Bristol-Myers Squibb, nivolumab has the potential to become first PD-1 inhibitor approved for a hematologic malignancy in the US.
The supplemental biologics license application for nivolumab included data from the phase 2 trial CheckMate 205. In this ongoing trial, researchers are evaluating nivolumab in patients with relapsed or refractory cHL who have received an autologous stem cell transplant and brentuximab vedotin.
Data from this trial are expected to be presented at a medical meeting later this year.
The FDA previously granted nivolumab breakthrough therapy designation for cHL. The FDA’s breakthrough therapy designation is intended to expedite the development and review of drugs for serious or life-threatening conditions.
Photo courtesy of Business Wire
The US Food and Drug Administration (FDA) has granted priority review to a supplemental biologics license application seeking to expand use of the PD-1 inhibitor nivolumab (Opdivo) to patients with previously treated classical Hodgkin lymphoma (cHL).
A priority review designation means the FDA’s goal is to take action on an application within 6 months, rather than the 10 months typically taken for a standard review.
To grant an application priority review, the FDA must believe the drug would provide a significant improvement in the treatment, diagnosis, or prevention of a serious condition.
About nivolumab
Nivolumab is an inhibitor that binds to the checkpoint receptor PD-1, which is expressed on activated T cells. The drug prevents PD-L1 and PD-L2 from binding, thereby preventing the PD-1 pathway’s suppressive signaling on the immune system, including interference with an anti-tumor immune response.
Nivolumab is being developed by Bristol-Myers Squibb. The drug currently has regulatory approval in 48 countries.
In the US, nivolumab is approved—both as a single agent and in combination—to treat certain patients with melanoma, non-small-cell lung cancer, or advanced renal cell carcinoma.
According to Bristol-Myers Squibb, nivolumab has the potential to become first PD-1 inhibitor approved for a hematologic malignancy in the US.
The supplemental biologics license application for nivolumab included data from the phase 2 trial CheckMate 205. In this ongoing trial, researchers are evaluating nivolumab in patients with relapsed or refractory cHL who have received an autologous stem cell transplant and brentuximab vedotin.
Data from this trial are expected to be presented at a medical meeting later this year.
The FDA previously granted nivolumab breakthrough therapy designation for cHL. The FDA’s breakthrough therapy designation is intended to expedite the development and review of drugs for serious or life-threatening conditions.
Study provides new insight into malaria transmission
infecting a red blood cell
Image courtesy of St. Jude
Children’s Research Hospital
Research published in PNAS helps explain how the malaria parasite Plasmodium falciparum undergoes the changes that enable transmission of the parasite from humans to mosquitoes.
Investigators determined how the parasite transforms its own structure and the structure of a host red blood cell so the parasite can hide from the body’s normal defenses and later re-enter the bloodstream for transmission via mosquito bite.
The team believes that, by understanding this process, it may be possible to inhibit the blood cell’s transformation.
“Once you understand the molecular mechanisms, it becomes easier to find drugs to target them,” said Sulin Zhang, PhD, of Pennsylvania State University in University Park.
Dr Zhang developed the computational methods used to understand the physical transformations in the infected red blood cells that allow them to avoid removal in the spleen and prepare for transmission to a mosquito host.
He and his colleagues knew that healthy red blood cells are able to squeeze through small slits in the spleen, but damaged and aging red blood cells cannot and are filtered out and removed from the circulation.
To avoid this fate, the sexual stage malaria parasite first makes the red blood cell rigid and hides out in deep tissue. Then, when the parasite is mature, the infected red blood cells become flexible and elastic, ready to be picked up by a mosquito for disease transmission.
To understand these changes, the investigators prepared samples of parasites at each stage and studied the changing microstructure using atomic force microscopy.
This revealed changes in the organization of a meshwork of tiny spring-like proteins in the blood cell membrane. When the parasite is ready for transmission, it reverses the structural changes.
The team then turned to Dr Zhang, who developed a model to explain how subtle changes to the molecular structure of the spring-like proteins were sufficient to make the red blood cell either rigid or flexible.
The investigators are continuing to use Dr Zhang’s model to simulate the overall shapes and the flow dynamics of infected red blood cells in the bloodstream, providing information that could aid researchers looking to inhibit the malaria parasite’s spread.
infecting a red blood cell
Image courtesy of St. Jude
Children’s Research Hospital
Research published in PNAS helps explain how the malaria parasite Plasmodium falciparum undergoes the changes that enable transmission of the parasite from humans to mosquitoes.
Investigators determined how the parasite transforms its own structure and the structure of a host red blood cell so the parasite can hide from the body’s normal defenses and later re-enter the bloodstream for transmission via mosquito bite.
The team believes that, by understanding this process, it may be possible to inhibit the blood cell’s transformation.
“Once you understand the molecular mechanisms, it becomes easier to find drugs to target them,” said Sulin Zhang, PhD, of Pennsylvania State University in University Park.
Dr Zhang developed the computational methods used to understand the physical transformations in the infected red blood cells that allow them to avoid removal in the spleen and prepare for transmission to a mosquito host.
He and his colleagues knew that healthy red blood cells are able to squeeze through small slits in the spleen, but damaged and aging red blood cells cannot and are filtered out and removed from the circulation.
To avoid this fate, the sexual stage malaria parasite first makes the red blood cell rigid and hides out in deep tissue. Then, when the parasite is mature, the infected red blood cells become flexible and elastic, ready to be picked up by a mosquito for disease transmission.
To understand these changes, the investigators prepared samples of parasites at each stage and studied the changing microstructure using atomic force microscopy.
This revealed changes in the organization of a meshwork of tiny spring-like proteins in the blood cell membrane. When the parasite is ready for transmission, it reverses the structural changes.
The team then turned to Dr Zhang, who developed a model to explain how subtle changes to the molecular structure of the spring-like proteins were sufficient to make the red blood cell either rigid or flexible.
The investigators are continuing to use Dr Zhang’s model to simulate the overall shapes and the flow dynamics of infected red blood cells in the bloodstream, providing information that could aid researchers looking to inhibit the malaria parasite’s spread.
infecting a red blood cell
Image courtesy of St. Jude
Children’s Research Hospital
Research published in PNAS helps explain how the malaria parasite Plasmodium falciparum undergoes the changes that enable transmission of the parasite from humans to mosquitoes.
Investigators determined how the parasite transforms its own structure and the structure of a host red blood cell so the parasite can hide from the body’s normal defenses and later re-enter the bloodstream for transmission via mosquito bite.
The team believes that, by understanding this process, it may be possible to inhibit the blood cell’s transformation.
“Once you understand the molecular mechanisms, it becomes easier to find drugs to target them,” said Sulin Zhang, PhD, of Pennsylvania State University in University Park.
Dr Zhang developed the computational methods used to understand the physical transformations in the infected red blood cells that allow them to avoid removal in the spleen and prepare for transmission to a mosquito host.
He and his colleagues knew that healthy red blood cells are able to squeeze through small slits in the spleen, but damaged and aging red blood cells cannot and are filtered out and removed from the circulation.
To avoid this fate, the sexual stage malaria parasite first makes the red blood cell rigid and hides out in deep tissue. Then, when the parasite is mature, the infected red blood cells become flexible and elastic, ready to be picked up by a mosquito for disease transmission.
To understand these changes, the investigators prepared samples of parasites at each stage and studied the changing microstructure using atomic force microscopy.
This revealed changes in the organization of a meshwork of tiny spring-like proteins in the blood cell membrane. When the parasite is ready for transmission, it reverses the structural changes.
The team then turned to Dr Zhang, who developed a model to explain how subtle changes to the molecular structure of the spring-like proteins were sufficient to make the red blood cell either rigid or flexible.
The investigators are continuing to use Dr Zhang’s model to simulate the overall shapes and the flow dynamics of infected red blood cells in the bloodstream, providing information that could aid researchers looking to inhibit the malaria parasite’s spread.
Resident‐Created Hospitalist Curriculum
Hospital medicine has grown tremendously since its inception in the 1990s.[1, 2] This expansion has led to the firm establishment of hospitalists in medical education, quality improvement (QI), research, subspecialty comanagement, and administration.[3, 4, 5]
This growth has also created new challenges. The training needs for the next generation of hospitalists are changing given the expanded clinical duties expected of hospitalists.[6, 7, 8] Prior surveys have suggested that some graduates employed as hospitalists have reported feeling underprepared in the areas of surgical comanagement, neurology, geriatrics, palliative care, and navigating the interdisciplinary care system.[9, 10]
In keeping with national trends, the number of residents interested in hospital medicine at our institution has dramatically increased. As internal medicine residents interested in careers in hospitalist medicine, we felt that improving hospitalist training at our institution was imperative given the increasing scope of practice and job competitiveness.[11, 12] We therefore sought to design and implement a hospitalist curriculum within our residency. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents.
METHODS
Needs Assessment
To improve hospitalist training at our institution, we first performed a needs assessment. We contacted recent hospitalist graduates and current faculty to identify aspects of their clinical duties that may have been underemphasized during their training. Next, we performed a literature search in PubMed using the combined terms of hospitalist, hospital medicine, residency, education, training gaps, or curriculum. Based on these efforts, we developed a resident survey that assessed their attitudes toward various components of a potential curriculum. The survey was sent to all categorical internal medicine residents at our institution in December 2014. The survey specified that the respondents only include those who were interested in careers in hospital medicine. Responses were measured using a 5‐point Likert scale (1 = least important to 5 = most important).
Curriculum Development
Our intention was to develop a well‐rounded program that utilized mentorship, research, and clinical experience to augment our learner's knowledge and skills for a successful, long‐term career in the increasingly competitive field of hospital medicine. When designing our curriculum, we accounted for our program's current rotational requirements and local culture. Several previously identified underemphasized areas within hospital medicine, such as palliative care and neurology, were already required rotations at our program.[3, 4, 5] Therefore, any proposed curricular changes would need to mold into program requirements while still providing a preparatory experience in hospital medicine beyond what our current rotations offered. We felt this could be accomplished by including rotations that could provide specific skills pertinent to hospital medicine, such as ultrasound diagnostics or QI.
| Rotation | Non‐SHAPE | SHAPE |
|---|---|---|
| ||
| ICU | At least 12 weeks | At least 16 weeks |
| Medical wards | At least 16 weeks | At least 16 weeks |
| Ultrasound diagnostics | Elective | Required |
| Quality improvement | Elective | Required |
| Surgical comanagement | Elective | Required |
| Medicine consult | Elective | Required |
| Neurology | Required | Required |
| Palliative care | Required | Required |
Meeting With Stakeholders
We presented our curriculum proposal to the chief of the Stanford Hospital Medicine Program. We identified her early in the process to be our primary mentor, and she proved instrumental in being an advocate. After several meetings with the hospitalist group to further develop our program, we presented it to the residency program leadership who helped us to finalize our program.
RESULTS
Needs Assessment
Twenty‐two out of 111 categorical residents in our program (19.8%) identified themselves as interested in hospital medicine and responded to the survey. There were several areas of a potential hospitalist curriculum that the residents identified as important (defined as 4 or 5 on a 5‐point Likert scale). These areas included mentorship (90.9% of residents; mean 4.6, standard deviation [SD] 0.7), opportunities to teach (86.3%; mean 4.4, SD 0.9), and the establishment of a formal hospitalist curriculum (85.7%; mean 4.2, SD 0.8). The residents also identified several rotations that would be beneficial (defined as a 4 or 5 on a 5‐point Likert scale). These included medicine consult/procedures team (95.5% of residents; mean 4.7, SD 0.6), point‐of‐care ultrasound diagnostics (90.8%; mean 4.7, SD 0.8), and a community hospitalist preceptorship (86.4%; mean 4.4, SD 1.0). The residents also identified several rotations deemed to be of lesser benefit. These rotations included inpatient neurology (only 27.3% of residents; mean 3.2, SD 0.8) and palliative care (50.0%; mean 3.5, SD 1.0).
The Final Product: A Hospitalist Training Curriculum
Based on the needs assessment and meetings with program leadership, we designed a hospitalist program and named it the Stanford Hospitalist Advanced Practice and Education (SHAPE) program. The program was based on 3 core principles: (1) clinical excellence: by training in hospitalist‐relevant clinical areas, (2) academic development: with required research, QI, and teaching, and (3) career mentorship.
Clinical Excellence By Training in Hospitalist‐Relevant Clinical Areas
The SHAPE curriculum builds off of our institution's current curriculum with additional required rotations to improve the resident's skillsets. These included ultrasound diagnostics, surgical comanagement, and QI (Box 1). Given that some hospitalists work in an open intensive care unit (ICU), we increased the amount of required ICU time to provide expanded procedural and critical care experiences. The residents also receive 10 seminars focused on hospital medicine, including patient safety, QI, and career development (Box 1).
Box
The Stanford Hospitalist Advanced Practice and Education (SHAPE) program curriculum. Members of the program are required to complete the requirements listed before the end of their third year. Note that the clinical rotations are spread over the 3 years of residency.
Stanford Hospitalist Advanced Practice and Education Required Clinical Rotations
- Medicine Consult (24 weeks)
- Critical Care (16 weeks)
- Ultrasound Diagnostics (2 weeks)
- Quality Improvement (4 weeks)
- Inpatient Neurology (2 weeks)
- Palliative Care (2 weeks)
- Surgical Comanagement (2 weeks)
Required Nonclinical Work
- Quality improvement, clinical or educational project with a presentation at an academic conference or manuscript submission in a peer‐reviewed journal
- Enrollment in the Stanford Faculty Development Center workshop on effective clinical teaching
- Attendance at the hospitalist lecture series (10 lectures): patient safety, hospital efficiency, fundamentals of perioperative medicine, healthcare structure and changing reimbursement patterns, patient handoff, career development, prevention of burnout, inpatient nutrition, hospitalist research, and lean modeling in the hospital setting
Mentorship
- Each participant is matched with 3 hospitalist mentors in order to provide comprehensive career and personal mentorship
Academic Development With Required Research and Teaching
SHAPE program residents are required to develop a QI, education, or clinical research project before graduation. They are required to present their work at a hospitalist conference or submit to a peer‐reviewed journal. They are also encouraged to attend the Society of Hospital Medicine annual meeting for their own career development.
SHAPE program residents also have increased opportunities to improve their teaching skills. The residents are enrolled in a clinical teaching workshop. Furthermore, the residents are responsible for leading regular lectures regarding common inpatient conditions for first‐ and second‐year medical students enrolled in a transitions‐of‐care elective.
Career Mentorship
Each resident is paired with 3 faculty hospitalists who have different areas of expertise (ie, clinical teaching, surgical comanagement, QI). They individually meet on a quarterly basis to discuss their career development and research projects. The SHAPE program will also host an annual resume‐development and career workshop.
SHAPE Resident Characteristics
In its first year, 13 of 25 residents (52%) interested in hospital medicine enrolled in the program. The SHAPE residents were predominantly second‐year residents (11 residents, 84.6%).
Among the 12 residents who did not enroll, there were 7 seniors (58.3%) who would soon be graduating and would not be eligible.
DISCUSSION
The training needs of aspiring hospitalists are changing as the scope of hospital medicine has expanded.[6] Residency programs can facilitate this by implementing a hospitalist curriculum that augments training and provides focused mentorship.[13, 14] An emphasis on resident leadership within these programs ensures positive housestaff buy‐in and satisfaction.
There were several key lessons we learned while designing our curriculum because of our unique role as residents and curriculum founders. This included the early engagement of departmental leadership as mentors. They assisted us in integrating our program within the existing internal medicine residency and the selection of electives. It was also imperative to secure adequate buy‐in from the academic hospitalists at our institution, as they would be our primary source of faculty mentors and lecturers.
A second challenge was balancing curriculum requirements and ensuring adequate buy‐in from our residents. The residents had fewer electives over their second and third years. However, this was balanced by the fact that the residents were given first preference on historically desirable rotations at our institution (including ultrasound, medicine consult, and QI). Furthermore, we purposefully included current resident opinions when performing our needs assessment to ensure adequate buy‐in. Surprisingly, the residents found several key rotations to be of low importance in our needs assessment, such as palliative care and inpatient neurology. Although this may seem confounding, several of these rotations (ie, neurology and palliative care) are already required of all residents at our program. It may be that some residents feel comfortable in these areas based on their previous experiences. Alternatively, this result may represent a lack of knowledge on the residents' part of what skill sets are imperative for career hospitalists. [4, 6]
Finally, we recognize that our program was based on our local needs assessment. Other residency programs may already have similar curricula built into their rotation schedule. In those instances, a hospitalist curriculum that emphasizes scholarly advancement and mentorship may be more appropriate.
CONCLUSIONS AND FUTURE DIRECTIONS
At out institution, we have created a hospitalist program designed to train the next generation of hospitalists with improved clinical, research, and teaching skills. Our cohort of residents will be observed over the next year, and we will administer a follow‐up study to assess the effectiveness of the program.
Acknowledgements
The authors acknowledge Karina Delgado, program manager at Stanford's internal medicine residency, for providing data on recent graduate plans.
Disclosures: Andre Kumar, MD, and Andrea Smeraglio, MD, are cofirst authors. The authors report no conflicts of interest.
- . The hospitalist field turns 15: new opportunities and challenges. J Hosp Med. 2011;6(4):10–13.
- , , , , . The spectrum of community based hospitalist practice: A call to tailor internal medicine residency training. Arch Intern Med. 2007;167:727–729.
- , , , . Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20(2):101–107.
- , , , . Survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999:343–349.
- , . Hospitalist educators: future of inpatient internal medicine training. Mt Sinai J Med. 2008;75(5):430–435.
- , , , , . Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs. J Gen Intern Med. 2008;23(7):1110–1115.
- , , , , . Closing the gap between internal medicine training and practice: recommendations from recent graduates. Am J Med. 2005;118(6):680–685
- , , , et al. Curricular content of internal medicine residency programs: a nationwide report. Am J Med. 2014;127(12):1247–1254.
- , , , . Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247–254.
- , , , et al. Reforming internal medicine residency training: a report from the Society of General Internal Medicine's Task Force for Residency Reform. J Gen Intern Med. 2005;20(12):1165–1172.
- , . Clinical hospital medicine fellowships: perspectives of employers, hospitalists, and medicine residents. J Hosp Med. 2008;3(1):28–34.
- , , , , , . Challenges and opportunities in academic hospital medicine: report from the Academic hospital medicine Summit. J Hosp Med. 2009;4(4):240–246.
- , , . Achieving hospital medicine's promise through internal medicine residency redesign. Mt Sinai J Med. 2008;75(5):436–441.
- , , , , . Training Future Hospitalists. Cult Med. 1999;171(12):367–370.
Hospital medicine has grown tremendously since its inception in the 1990s.[1, 2] This expansion has led to the firm establishment of hospitalists in medical education, quality improvement (QI), research, subspecialty comanagement, and administration.[3, 4, 5]
This growth has also created new challenges. The training needs for the next generation of hospitalists are changing given the expanded clinical duties expected of hospitalists.[6, 7, 8] Prior surveys have suggested that some graduates employed as hospitalists have reported feeling underprepared in the areas of surgical comanagement, neurology, geriatrics, palliative care, and navigating the interdisciplinary care system.[9, 10]
In keeping with national trends, the number of residents interested in hospital medicine at our institution has dramatically increased. As internal medicine residents interested in careers in hospitalist medicine, we felt that improving hospitalist training at our institution was imperative given the increasing scope of practice and job competitiveness.[11, 12] We therefore sought to design and implement a hospitalist curriculum within our residency. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents.
METHODS
Needs Assessment
To improve hospitalist training at our institution, we first performed a needs assessment. We contacted recent hospitalist graduates and current faculty to identify aspects of their clinical duties that may have been underemphasized during their training. Next, we performed a literature search in PubMed using the combined terms of hospitalist, hospital medicine, residency, education, training gaps, or curriculum. Based on these efforts, we developed a resident survey that assessed their attitudes toward various components of a potential curriculum. The survey was sent to all categorical internal medicine residents at our institution in December 2014. The survey specified that the respondents only include those who were interested in careers in hospital medicine. Responses were measured using a 5‐point Likert scale (1 = least important to 5 = most important).
Curriculum Development
Our intention was to develop a well‐rounded program that utilized mentorship, research, and clinical experience to augment our learner's knowledge and skills for a successful, long‐term career in the increasingly competitive field of hospital medicine. When designing our curriculum, we accounted for our program's current rotational requirements and local culture. Several previously identified underemphasized areas within hospital medicine, such as palliative care and neurology, were already required rotations at our program.[3, 4, 5] Therefore, any proposed curricular changes would need to mold into program requirements while still providing a preparatory experience in hospital medicine beyond what our current rotations offered. We felt this could be accomplished by including rotations that could provide specific skills pertinent to hospital medicine, such as ultrasound diagnostics or QI.
| Rotation | Non‐SHAPE | SHAPE |
|---|---|---|
| ||
| ICU | At least 12 weeks | At least 16 weeks |
| Medical wards | At least 16 weeks | At least 16 weeks |
| Ultrasound diagnostics | Elective | Required |
| Quality improvement | Elective | Required |
| Surgical comanagement | Elective | Required |
| Medicine consult | Elective | Required |
| Neurology | Required | Required |
| Palliative care | Required | Required |
Meeting With Stakeholders
We presented our curriculum proposal to the chief of the Stanford Hospital Medicine Program. We identified her early in the process to be our primary mentor, and she proved instrumental in being an advocate. After several meetings with the hospitalist group to further develop our program, we presented it to the residency program leadership who helped us to finalize our program.
RESULTS
Needs Assessment
Twenty‐two out of 111 categorical residents in our program (19.8%) identified themselves as interested in hospital medicine and responded to the survey. There were several areas of a potential hospitalist curriculum that the residents identified as important (defined as 4 or 5 on a 5‐point Likert scale). These areas included mentorship (90.9% of residents; mean 4.6, standard deviation [SD] 0.7), opportunities to teach (86.3%; mean 4.4, SD 0.9), and the establishment of a formal hospitalist curriculum (85.7%; mean 4.2, SD 0.8). The residents also identified several rotations that would be beneficial (defined as a 4 or 5 on a 5‐point Likert scale). These included medicine consult/procedures team (95.5% of residents; mean 4.7, SD 0.6), point‐of‐care ultrasound diagnostics (90.8%; mean 4.7, SD 0.8), and a community hospitalist preceptorship (86.4%; mean 4.4, SD 1.0). The residents also identified several rotations deemed to be of lesser benefit. These rotations included inpatient neurology (only 27.3% of residents; mean 3.2, SD 0.8) and palliative care (50.0%; mean 3.5, SD 1.0).
The Final Product: A Hospitalist Training Curriculum
Based on the needs assessment and meetings with program leadership, we designed a hospitalist program and named it the Stanford Hospitalist Advanced Practice and Education (SHAPE) program. The program was based on 3 core principles: (1) clinical excellence: by training in hospitalist‐relevant clinical areas, (2) academic development: with required research, QI, and teaching, and (3) career mentorship.
Clinical Excellence By Training in Hospitalist‐Relevant Clinical Areas
The SHAPE curriculum builds off of our institution's current curriculum with additional required rotations to improve the resident's skillsets. These included ultrasound diagnostics, surgical comanagement, and QI (Box 1). Given that some hospitalists work in an open intensive care unit (ICU), we increased the amount of required ICU time to provide expanded procedural and critical care experiences. The residents also receive 10 seminars focused on hospital medicine, including patient safety, QI, and career development (Box 1).
Box
The Stanford Hospitalist Advanced Practice and Education (SHAPE) program curriculum. Members of the program are required to complete the requirements listed before the end of their third year. Note that the clinical rotations are spread over the 3 years of residency.
Stanford Hospitalist Advanced Practice and Education Required Clinical Rotations
- Medicine Consult (24 weeks)
- Critical Care (16 weeks)
- Ultrasound Diagnostics (2 weeks)
- Quality Improvement (4 weeks)
- Inpatient Neurology (2 weeks)
- Palliative Care (2 weeks)
- Surgical Comanagement (2 weeks)
Required Nonclinical Work
- Quality improvement, clinical or educational project with a presentation at an academic conference or manuscript submission in a peer‐reviewed journal
- Enrollment in the Stanford Faculty Development Center workshop on effective clinical teaching
- Attendance at the hospitalist lecture series (10 lectures): patient safety, hospital efficiency, fundamentals of perioperative medicine, healthcare structure and changing reimbursement patterns, patient handoff, career development, prevention of burnout, inpatient nutrition, hospitalist research, and lean modeling in the hospital setting
Mentorship
- Each participant is matched with 3 hospitalist mentors in order to provide comprehensive career and personal mentorship
Academic Development With Required Research and Teaching
SHAPE program residents are required to develop a QI, education, or clinical research project before graduation. They are required to present their work at a hospitalist conference or submit to a peer‐reviewed journal. They are also encouraged to attend the Society of Hospital Medicine annual meeting for their own career development.
SHAPE program residents also have increased opportunities to improve their teaching skills. The residents are enrolled in a clinical teaching workshop. Furthermore, the residents are responsible for leading regular lectures regarding common inpatient conditions for first‐ and second‐year medical students enrolled in a transitions‐of‐care elective.
Career Mentorship
Each resident is paired with 3 faculty hospitalists who have different areas of expertise (ie, clinical teaching, surgical comanagement, QI). They individually meet on a quarterly basis to discuss their career development and research projects. The SHAPE program will also host an annual resume‐development and career workshop.
SHAPE Resident Characteristics
In its first year, 13 of 25 residents (52%) interested in hospital medicine enrolled in the program. The SHAPE residents were predominantly second‐year residents (11 residents, 84.6%).
Among the 12 residents who did not enroll, there were 7 seniors (58.3%) who would soon be graduating and would not be eligible.
DISCUSSION
The training needs of aspiring hospitalists are changing as the scope of hospital medicine has expanded.[6] Residency programs can facilitate this by implementing a hospitalist curriculum that augments training and provides focused mentorship.[13, 14] An emphasis on resident leadership within these programs ensures positive housestaff buy‐in and satisfaction.
There were several key lessons we learned while designing our curriculum because of our unique role as residents and curriculum founders. This included the early engagement of departmental leadership as mentors. They assisted us in integrating our program within the existing internal medicine residency and the selection of electives. It was also imperative to secure adequate buy‐in from the academic hospitalists at our institution, as they would be our primary source of faculty mentors and lecturers.
A second challenge was balancing curriculum requirements and ensuring adequate buy‐in from our residents. The residents had fewer electives over their second and third years. However, this was balanced by the fact that the residents were given first preference on historically desirable rotations at our institution (including ultrasound, medicine consult, and QI). Furthermore, we purposefully included current resident opinions when performing our needs assessment to ensure adequate buy‐in. Surprisingly, the residents found several key rotations to be of low importance in our needs assessment, such as palliative care and inpatient neurology. Although this may seem confounding, several of these rotations (ie, neurology and palliative care) are already required of all residents at our program. It may be that some residents feel comfortable in these areas based on their previous experiences. Alternatively, this result may represent a lack of knowledge on the residents' part of what skill sets are imperative for career hospitalists. [4, 6]
Finally, we recognize that our program was based on our local needs assessment. Other residency programs may already have similar curricula built into their rotation schedule. In those instances, a hospitalist curriculum that emphasizes scholarly advancement and mentorship may be more appropriate.
CONCLUSIONS AND FUTURE DIRECTIONS
At out institution, we have created a hospitalist program designed to train the next generation of hospitalists with improved clinical, research, and teaching skills. Our cohort of residents will be observed over the next year, and we will administer a follow‐up study to assess the effectiveness of the program.
Acknowledgements
The authors acknowledge Karina Delgado, program manager at Stanford's internal medicine residency, for providing data on recent graduate plans.
Disclosures: Andre Kumar, MD, and Andrea Smeraglio, MD, are cofirst authors. The authors report no conflicts of interest.
Hospital medicine has grown tremendously since its inception in the 1990s.[1, 2] This expansion has led to the firm establishment of hospitalists in medical education, quality improvement (QI), research, subspecialty comanagement, and administration.[3, 4, 5]
This growth has also created new challenges. The training needs for the next generation of hospitalists are changing given the expanded clinical duties expected of hospitalists.[6, 7, 8] Prior surveys have suggested that some graduates employed as hospitalists have reported feeling underprepared in the areas of surgical comanagement, neurology, geriatrics, palliative care, and navigating the interdisciplinary care system.[9, 10]
In keeping with national trends, the number of residents interested in hospital medicine at our institution has dramatically increased. As internal medicine residents interested in careers in hospitalist medicine, we felt that improving hospitalist training at our institution was imperative given the increasing scope of practice and job competitiveness.[11, 12] We therefore sought to design and implement a hospitalist curriculum within our residency. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents.
METHODS
Needs Assessment
To improve hospitalist training at our institution, we first performed a needs assessment. We contacted recent hospitalist graduates and current faculty to identify aspects of their clinical duties that may have been underemphasized during their training. Next, we performed a literature search in PubMed using the combined terms of hospitalist, hospital medicine, residency, education, training gaps, or curriculum. Based on these efforts, we developed a resident survey that assessed their attitudes toward various components of a potential curriculum. The survey was sent to all categorical internal medicine residents at our institution in December 2014. The survey specified that the respondents only include those who were interested in careers in hospital medicine. Responses were measured using a 5‐point Likert scale (1 = least important to 5 = most important).
Curriculum Development
Our intention was to develop a well‐rounded program that utilized mentorship, research, and clinical experience to augment our learner's knowledge and skills for a successful, long‐term career in the increasingly competitive field of hospital medicine. When designing our curriculum, we accounted for our program's current rotational requirements and local culture. Several previously identified underemphasized areas within hospital medicine, such as palliative care and neurology, were already required rotations at our program.[3, 4, 5] Therefore, any proposed curricular changes would need to mold into program requirements while still providing a preparatory experience in hospital medicine beyond what our current rotations offered. We felt this could be accomplished by including rotations that could provide specific skills pertinent to hospital medicine, such as ultrasound diagnostics or QI.
| Rotation | Non‐SHAPE | SHAPE |
|---|---|---|
| ||
| ICU | At least 12 weeks | At least 16 weeks |
| Medical wards | At least 16 weeks | At least 16 weeks |
| Ultrasound diagnostics | Elective | Required |
| Quality improvement | Elective | Required |
| Surgical comanagement | Elective | Required |
| Medicine consult | Elective | Required |
| Neurology | Required | Required |
| Palliative care | Required | Required |
Meeting With Stakeholders
We presented our curriculum proposal to the chief of the Stanford Hospital Medicine Program. We identified her early in the process to be our primary mentor, and she proved instrumental in being an advocate. After several meetings with the hospitalist group to further develop our program, we presented it to the residency program leadership who helped us to finalize our program.
RESULTS
Needs Assessment
Twenty‐two out of 111 categorical residents in our program (19.8%) identified themselves as interested in hospital medicine and responded to the survey. There were several areas of a potential hospitalist curriculum that the residents identified as important (defined as 4 or 5 on a 5‐point Likert scale). These areas included mentorship (90.9% of residents; mean 4.6, standard deviation [SD] 0.7), opportunities to teach (86.3%; mean 4.4, SD 0.9), and the establishment of a formal hospitalist curriculum (85.7%; mean 4.2, SD 0.8). The residents also identified several rotations that would be beneficial (defined as a 4 or 5 on a 5‐point Likert scale). These included medicine consult/procedures team (95.5% of residents; mean 4.7, SD 0.6), point‐of‐care ultrasound diagnostics (90.8%; mean 4.7, SD 0.8), and a community hospitalist preceptorship (86.4%; mean 4.4, SD 1.0). The residents also identified several rotations deemed to be of lesser benefit. These rotations included inpatient neurology (only 27.3% of residents; mean 3.2, SD 0.8) and palliative care (50.0%; mean 3.5, SD 1.0).
The Final Product: A Hospitalist Training Curriculum
Based on the needs assessment and meetings with program leadership, we designed a hospitalist program and named it the Stanford Hospitalist Advanced Practice and Education (SHAPE) program. The program was based on 3 core principles: (1) clinical excellence: by training in hospitalist‐relevant clinical areas, (2) academic development: with required research, QI, and teaching, and (3) career mentorship.
Clinical Excellence By Training in Hospitalist‐Relevant Clinical Areas
The SHAPE curriculum builds off of our institution's current curriculum with additional required rotations to improve the resident's skillsets. These included ultrasound diagnostics, surgical comanagement, and QI (Box 1). Given that some hospitalists work in an open intensive care unit (ICU), we increased the amount of required ICU time to provide expanded procedural and critical care experiences. The residents also receive 10 seminars focused on hospital medicine, including patient safety, QI, and career development (Box 1).
Box
The Stanford Hospitalist Advanced Practice and Education (SHAPE) program curriculum. Members of the program are required to complete the requirements listed before the end of their third year. Note that the clinical rotations are spread over the 3 years of residency.
Stanford Hospitalist Advanced Practice and Education Required Clinical Rotations
- Medicine Consult (24 weeks)
- Critical Care (16 weeks)
- Ultrasound Diagnostics (2 weeks)
- Quality Improvement (4 weeks)
- Inpatient Neurology (2 weeks)
- Palliative Care (2 weeks)
- Surgical Comanagement (2 weeks)
Required Nonclinical Work
- Quality improvement, clinical or educational project with a presentation at an academic conference or manuscript submission in a peer‐reviewed journal
- Enrollment in the Stanford Faculty Development Center workshop on effective clinical teaching
- Attendance at the hospitalist lecture series (10 lectures): patient safety, hospital efficiency, fundamentals of perioperative medicine, healthcare structure and changing reimbursement patterns, patient handoff, career development, prevention of burnout, inpatient nutrition, hospitalist research, and lean modeling in the hospital setting
Mentorship
- Each participant is matched with 3 hospitalist mentors in order to provide comprehensive career and personal mentorship
Academic Development With Required Research and Teaching
SHAPE program residents are required to develop a QI, education, or clinical research project before graduation. They are required to present their work at a hospitalist conference or submit to a peer‐reviewed journal. They are also encouraged to attend the Society of Hospital Medicine annual meeting for their own career development.
SHAPE program residents also have increased opportunities to improve their teaching skills. The residents are enrolled in a clinical teaching workshop. Furthermore, the residents are responsible for leading regular lectures regarding common inpatient conditions for first‐ and second‐year medical students enrolled in a transitions‐of‐care elective.
Career Mentorship
Each resident is paired with 3 faculty hospitalists who have different areas of expertise (ie, clinical teaching, surgical comanagement, QI). They individually meet on a quarterly basis to discuss their career development and research projects. The SHAPE program will also host an annual resume‐development and career workshop.
SHAPE Resident Characteristics
In its first year, 13 of 25 residents (52%) interested in hospital medicine enrolled in the program. The SHAPE residents were predominantly second‐year residents (11 residents, 84.6%).
Among the 12 residents who did not enroll, there were 7 seniors (58.3%) who would soon be graduating and would not be eligible.
DISCUSSION
The training needs of aspiring hospitalists are changing as the scope of hospital medicine has expanded.[6] Residency programs can facilitate this by implementing a hospitalist curriculum that augments training and provides focused mentorship.[13, 14] An emphasis on resident leadership within these programs ensures positive housestaff buy‐in and satisfaction.
There were several key lessons we learned while designing our curriculum because of our unique role as residents and curriculum founders. This included the early engagement of departmental leadership as mentors. They assisted us in integrating our program within the existing internal medicine residency and the selection of electives. It was also imperative to secure adequate buy‐in from the academic hospitalists at our institution, as they would be our primary source of faculty mentors and lecturers.
A second challenge was balancing curriculum requirements and ensuring adequate buy‐in from our residents. The residents had fewer electives over their second and third years. However, this was balanced by the fact that the residents were given first preference on historically desirable rotations at our institution (including ultrasound, medicine consult, and QI). Furthermore, we purposefully included current resident opinions when performing our needs assessment to ensure adequate buy‐in. Surprisingly, the residents found several key rotations to be of low importance in our needs assessment, such as palliative care and inpatient neurology. Although this may seem confounding, several of these rotations (ie, neurology and palliative care) are already required of all residents at our program. It may be that some residents feel comfortable in these areas based on their previous experiences. Alternatively, this result may represent a lack of knowledge on the residents' part of what skill sets are imperative for career hospitalists. [4, 6]
Finally, we recognize that our program was based on our local needs assessment. Other residency programs may already have similar curricula built into their rotation schedule. In those instances, a hospitalist curriculum that emphasizes scholarly advancement and mentorship may be more appropriate.
CONCLUSIONS AND FUTURE DIRECTIONS
At out institution, we have created a hospitalist program designed to train the next generation of hospitalists with improved clinical, research, and teaching skills. Our cohort of residents will be observed over the next year, and we will administer a follow‐up study to assess the effectiveness of the program.
Acknowledgements
The authors acknowledge Karina Delgado, program manager at Stanford's internal medicine residency, for providing data on recent graduate plans.
Disclosures: Andre Kumar, MD, and Andrea Smeraglio, MD, are cofirst authors. The authors report no conflicts of interest.
- . The hospitalist field turns 15: new opportunities and challenges. J Hosp Med. 2011;6(4):10–13.
- , , , , . The spectrum of community based hospitalist practice: A call to tailor internal medicine residency training. Arch Intern Med. 2007;167:727–729.
- , , , . Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20(2):101–107.
- , , , . Survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999:343–349.
- , . Hospitalist educators: future of inpatient internal medicine training. Mt Sinai J Med. 2008;75(5):430–435.
- , , , , . Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs. J Gen Intern Med. 2008;23(7):1110–1115.
- , , , , . Closing the gap between internal medicine training and practice: recommendations from recent graduates. Am J Med. 2005;118(6):680–685
- , , , et al. Curricular content of internal medicine residency programs: a nationwide report. Am J Med. 2014;127(12):1247–1254.
- , , , . Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247–254.
- , , , et al. Reforming internal medicine residency training: a report from the Society of General Internal Medicine's Task Force for Residency Reform. J Gen Intern Med. 2005;20(12):1165–1172.
- , . Clinical hospital medicine fellowships: perspectives of employers, hospitalists, and medicine residents. J Hosp Med. 2008;3(1):28–34.
- , , , , , . Challenges and opportunities in academic hospital medicine: report from the Academic hospital medicine Summit. J Hosp Med. 2009;4(4):240–246.
- , , . Achieving hospital medicine's promise through internal medicine residency redesign. Mt Sinai J Med. 2008;75(5):436–441.
- , , , , . Training Future Hospitalists. Cult Med. 1999;171(12):367–370.
- . The hospitalist field turns 15: new opportunities and challenges. J Hosp Med. 2011;6(4):10–13.
- , , , , . The spectrum of community based hospitalist practice: A call to tailor internal medicine residency training. Arch Intern Med. 2007;167:727–729.
- , , , . Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005;20(2):101–107.
- , , , . Survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999:343–349.
- , . Hospitalist educators: future of inpatient internal medicine training. Mt Sinai J Med. 2008;75(5):430–435.
- , , , , . Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs. J Gen Intern Med. 2008;23(7):1110–1115.
- , , , , . Closing the gap between internal medicine training and practice: recommendations from recent graduates. Am J Med. 2005;118(6):680–685
- , , , et al. Curricular content of internal medicine residency programs: a nationwide report. Am J Med. 2014;127(12):1247–1254.
- , , , . Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247–254.
- , , , et al. Reforming internal medicine residency training: a report from the Society of General Internal Medicine's Task Force for Residency Reform. J Gen Intern Med. 2005;20(12):1165–1172.
- , . Clinical hospital medicine fellowships: perspectives of employers, hospitalists, and medicine residents. J Hosp Med. 2008;3(1):28–34.
- , , , , , . Challenges and opportunities in academic hospital medicine: report from the Academic hospital medicine Summit. J Hosp Med. 2009;4(4):240–246.
- , , . Achieving hospital medicine's promise through internal medicine residency redesign. Mt Sinai J Med. 2008;75(5):436–441.
- , , , , . Training Future Hospitalists. Cult Med. 1999;171(12):367–370.
Patient‐Reported Barriers to Discharge
Thirty‐six million adults were discharged from US hospitals in 2012, with approximately 45% from medicine service lines.[1, 2] Discharge planning, a key aspect of care for hospitalized patients,[3] should involve the development of a plan to enable the patient to be discharged at the appropriate time and with provision of sufficient postdischarge support and services.[4]
Central to the discharge planning process is an assessment of a patient's readiness for discharge. Readiness is often a provider‐driven process, based on specific clinical and health system benchmarks.[5] However, providers' perception of readiness for discharge does not always correlate with patients' self‐assessments or objective measures of understanding.[6] For example, nurses overestimate patients' readiness for discharge compared to patients' own self‐report.[7] As a result, the need to include the patient perspective is increasingly recognized as an important contributing factor in the discharge planning process.[8, 9]
Current approaches to assessing discharge readiness are typically single assessments. However, these assessments do not take into account the complexity of discharge planning or patients' understanding, or their ability to carry out postacute care tasks.[8] In addition, few models have included assessments of physical stability and functional ability along with measures such as ability to manage self‐care activities at home, coping and social support, or access to health system and community resources.[10, 11]
To address these gaps in the existing literature, we carried out a prospective observational study of daily, patient‐reported, assessments of discharge readiness to better understand patients' perspectives on issues that could impede the transition to home. Using these data, we then sought to determine the prevalence of patient‐reported discharge barriers and the frequency with which they were resolved prior to the day of discharge. We also explored whether problems identified at discharge were associated with 30‐day readmission.
METHODS
Study Design, Setting, and Participants
We carried out a prospective observational study at the University of California San Francisco (UCSF) Medical Center, a 600‐bed tertiary care academic hospital in San Francisco, California. The UCSF Committee on Human Research approved this study. We recruited patients between November 2013 and April 2014. Patients were eligible to participate if they were admitted to the General Medicine Service; over 18 years old; English speaking; cognitively able to provide informed consent; and not under contact, droplet, airborne, or radiation isolation. Patients were eligible to participate regardless of where they were admitted from or expected to be discharged (eg, home, skilled nursing facility). Patients were excluded if they were acutely unwell or symptomatic resulting in them being unable to complete the surveys. Caregivers were not able to participate in the study on behalf of patients. We screened daily admission charts for eligibility and approached consecutive patients to consent them into the study on their first or second day of hospitalization. An enrollment tracker was used to documented reasons for patients' exclusion or refusal.
Survey Development
We adapted an existing and validated Readiness for Hospital Discharge Survey (RHDS) previously used in obstetric, surgical, and medicine patients for our study.[10, 11, 12] This initial list was culled from 23 to 12 items, based on input from patients and physicians. This feedback step also prompted a change in the response scale from a 0 to 10 scale to a simpler yes, no, or I would like to talk with someone about this scale intended to encourage discussion between patients and providers. After this revision step, we further pretested the survey among physicians and a small set of general medical patients to assess comprehension. Thus, our final question set included 12 items in 4 domains; personal status (ie, pain, mobility), knowledge (ie, medications, problems to watch for, recovery plan), coping ability (ie, emotional support, who to call with problems), and expected support (ie, related to activities and instrumental activities of daily living).
Data Collection
We collected data from interviews of patients as well as chart abstraction. Trained research assistants approached patients to complete our revised RHDS at admission, which was either on their first or second day of hospitalization. We collected data via an intake admission survey, which asked patients about their readiness for discharge, followed by a daily readiness for discharge survey until the day of discharge. A research assistant read the survey items to patients and recorded responses on a paper version of the survey. We abstracted demographic, clinical, and 30‐day readmission information from each participant's electronic medical record.
Analytic Approach
A barrier to discharge readiness was confirmed when a patient responded no' to an item (except for presence of catheter and pain or discomfort where yes was used) and/or they stated they wanted to talk to someone about the issue. We then used descriptive statistics to summarize patients' responses by survey administration number. Multilevel mixed effect regression was used to investigate any patterns in barriers to discharge over the course of hospitalization. We described the frequency of identified barriers to discharge on the intake admission and final (48 hours of discharge) surveys. McNemar's tests compared the proportion of patients reporting each barrier, and paired t tests the mean number of barriers at these 2 survey time points. We also assessed whether persistent barriers to discharge readiness on the final survey were associated with readmission to our hospital within 30‐days using t tests, 2, or Fisher exact test. Analysis was conducted in SPSS 22.0 (IBM Corp., Armonk, NY) and Stata (StataCorp, College Station, TX).
RESULTS
Patients
There were 2045 patients admitted to the general medicine service during the study period. Medical record screening resulted in 1350 exclusions. Of the remaining 695 patients, 113 refused and 419 were further found to be unable to participate. After all exclusions were applied and following direct screening, 163 patients agreed to participate in our study (Table 1). Mean length of stay among our cohort was 5.42 days (standard deviation [SD], 11.49) and the majority of patients were admitted from and discharged to home (Table 1).
| |
| Mean age, y (SD) | 56.4 (17) |
| Female gender, no. (%) | 86 (53) |
| Race, no. (%) | |
| Asian | 13 (8) |
| African American | 27 (16) |
| White | 96 (59) |
| Other | 24 (25) |
| Declined to say | 3 (1) |
| Married, no. (%) | 78 (48) |
| Insurance, no. (%) | |
| Medicare | 59 (36) |
| Medicaid | 22 (14) |
| Private | 73 (45) |
| Self‐pay | 2 (1) |
| Other | 7 (4) |
| Patient admitted from, no. (%) | |
| Home | 118 (72) |
| Outpatient clinic | 17 (10) |
| Procedural area | 6 (4) |
| Another facility | 12 (7) |
| Other | 9 (6) |
| Patient discharged to, no. (%) | |
| Home without services | 107 (66) |
| Home with services | 40 (25) |
| Home hospice | 2 (1) |
| Skilled nursing facility | 8 (5) |
| Patient deceased | 3 (2) |
| Other | 3 (2) |
Barriers to Discharge Readiness
Patients completed on average 1.82 surveys (SD 1.10; range, 18), and in total 296 surveys were administered. Only 5% of patients were captured on their admission day, whereas 77% of patients were surveyed on their second hospital day (Table 2). Between the first and second survey administration, 51% of patients were lost to follow‐up, and then by the third survey administration a further 37% were lost to follow‐up (Table 3). Patients were unable to be reinterviewed most often because they had been (1) discharged, (2) were unavailable or having a procedure at time of recruitment, or (3) became too sick and symptomatic.
| Hospital Day | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
| No. of eligible patients hospitalized | 163 | 161 | 138 | 102 | 70 | 50 | 35 | 24 | 19 | 17 |
| No. of patients surveyed | 8 | 124 | 70 | 30 | 22 | 13 | 7 | 6 | 2 | 0 |
| % of eligible patients surveyed | 4.9 | 77.0 | 50.7 | 29.4 | 31.4 | 26.0 | 20.0 | 25.0 | 10.5 | 0 |
| Survey No. | ||||||
|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6+ | |
| ||||||
| No. of patients surveyed | 163 | 83 | 31 | 11 | 3 | 5 |
| Total barriers (all patients) | 533 | 235 | 84 | 22 | 7 | 8 |
| No. of barriers per patient, mean (SD) | 3.27(2.35) | 2.83 (2.11) | 2.71 (2.49) | 2.00 (1.73) | 2.33 (2.51) | 1.60 (2.30) |
| Median no. of barriers per patient | 3.0 | 3.0 | 2.0 | 1.0 | 2.0 | 0 |
| Median hospital day of survey administration | 2.0 | 3.0 | 5.0 | 6.0 | 8.0 | 13.0 |
| Initial admission survey, no. (%) | 163 (100.0) | 0 | 0 | 0 | 0 | 0 |
| Follow‐up survey, no. (%) | 0 | 38 (45.8) | 16 (51.6) | 4 (36.4) | 0 | 1 (20.0) |
| Survey 48 hours before discharge, no. (%) | 59 (36.2) | 45 (54.2) | 15 (48.4) | 7 (63.6) | 3 (100.0) | 4 (80.0) |
In total, over 889 individual barriers to discharge readiness were reported across all surveys. The total and mean numbers of barriers were highest on the admission intake survey, and numbers continued to decrease until the fourth survey. On average, the total number of barriers to discharge patients reported decreased by 0.15 (95% confidence interval: 0.01‐0.30) per day (P = 0.047).
Change in Barriers to Discharge
Sixty‐eight patients (42%) completed an admission intake survey as well as final survey 48 hours before discharge (Table 4). We observed a significant reduction in mean number of barriers reported between admission and discharge surveys (3.19 vs 2.53, P = 0.01). Sixty‐one patients (90%) left the hospital with 1 or more persistent barrier to a safe discharge. However, the 3 most common barriers to discharge readiness on the admission and final survey remained the same: unresolved pain, lack of understanding of plan for recovery, and daily living activities (eg, cooking, cleaning, and shopping). The number of patients with unresolved pain appeared to increase slightly, though this rise was not statistically significant. In contrast, there were significant reductions in patients reporting they were unaware of problems to watch out for postdischarge (28% vs 16%; P = 0.04) or did not understand their recovery plan (52% vs 40%; P = 0.03).
| Barrier to Discharge | Survey | |
|---|---|---|
| Admission, No. (%) | Final Survey, No. (%) | |
| ||
| Catheter is present? | 6 (7.2) | 6 (7.2) |
| Not out of bed, sitting in a chair, or walking? | 17 (20.5) | 13 (15.7) |
| Pain or discomfort? | 50 (60.2) | 52 (62.7) |
| Unable to get to the bathroom for toilet or to shower? | 15 (18.1) | 12 (14.5) |
| Unable to self‐care without help from others? | 27 (32.5) | 23 (27.7) |
| Unable to get your own medications? | 11 (13.3) | 14 (16.9) |
| Know what problems to watch for?* | 23 (27.7) | 13 (15.7) |
| Know where to call if you had problems? | 10 (12.0) | 8 (9.6) |
| Inability for personal care such as bathing, toileting, and eating? | 8 (9.6) | 11 (13.3) |
| Lack of support for emotional needs? | 16 (19.3) | 9 (10.8) |
| Unable to cook, clean, or do shopping? | 33 (39.8) | 25 (30.1) |
| Do not understand the overall plan for your recovery?* | 43 (51.8) | 33 (39.8) |
DISCUSSION
Assessing discharge readiness highlights an opportunity to engage patients directly in their discharge planning process. However, our prospective study of 163 hospitalized adults revealed that unresolved discharge barriers were common; 90% of patients were discharged with at least 1 issue that might inhibit an effective transition home. The majority of these patients were also discharged home without any support services. In addition, many of the major barriers patients reportedpain, lack of understanding around plans, and ability to provide self‐carewere consistent from admission to discharge, suggesting a missed opportunity to address problems present early in a patient's stay.
Some of the issues our patients described, such as pain; lack of understanding of a recovery plan; and functional, social, and environmental vulnerabilities that impede recovery, have been described in studies using data collected in the postacute time period.[13, 14, 15] Focus on postacute barriers is likely to be of limited clinical utility to assist in any real‐time discharge planning, particularly planning that assesses individual patients' needs and tailors programs and education appropriately. Having said this, consistency between our results and data collected from postdischarge patients again supports broad areas of improvement for health systems.
Persistent gaps in care at discharge may be a result of limited standardization of discharge processes and a lack of engagement in obtaining patient‐reported concerns. Lack of a framework for preparing individual patients for discharge has been recognized as a significant obstacle to effective discharge planning. For example, Hesselink et al.'s qualitative study with almost 200 patients and providers across multiple institutions described how lack of a standard approach to providing discharge planning resulted in gaps in information provision.[16] Similarly, Horwitz et al. described wide variation in discharge practices at a US academic medical center, suggesting lack of a standard approach to identifying patient needs.[14]
Although many transitions of care programs have supported implementation of specific care interventions at a hospital or health system level, there have been surprisingly few studies describing efforts to standardize the assessment of discharge barriers and prospectively engage individual patients.[17] One emblematic study used stakeholder interviews and process mapping to develop a readiness report within their electronic medical record (EMR).[17] Aggregate data from the EMR including orders and discharge plans were coded, extracted, and summarized into a report. The overall goal of the report was to identify progress toward completion of discharge tasks; however, a limitation was that it did not explicitly include patient self‐assessments. Another study by Grimmer et al. describes the development of a patient‐centered discharge checklist that incorporated patients and care concerns.[18] The themes incorporated into this checklist cover many transitional issues; however, outside of the checklist's development, few publications or Web resources describe it in actual use.
Our approach may represent an advance in approaches to engaging patients in discharge planning and preparing patients for leaving the hospital. Although our data do not support efficacy of our daily surveys in terms of improving discharge planning, this initial evaluation provides the framework upon which providers can develop discharge plans that are both standardized in terms of using a structured multidomain communication tool to elicit barriers, as well as patient‐centered and patient‐directed, by using the information collected in the survey tool to initiate tailored discharge planning earlier in the hospital stay. However, our program points out an important limitation of an entirely patient‐initiated program, which is difficulty obtaining truly daily assessments. During this study, we had a single research assistant visit patients as frequently as possible during hospitalization, but even daily visits did not yield complete information on all patients. Although this limitation may in part be due to the fact that our study was a focused pilot of an approach we hope to expand, it also represents the complexity of patient experience in the hospital, where patients are often out of their room for tests, are unable to complete a survey because of problematic symptoms, or simply are unwilling or unable to participate in regular surveys.
Our study has a number of limitations. First, the number of patients in our study overall, and the number who completed at least 2 surveys, was relatively small, limiting the generalizability of the study and our ability to determine the true prevalence of unresolved barriers at discharge. In addition, our selection criteria and response rates have limited our sample in that our final group may not be representative of all patients admitted to our medicine service. The broad exclusion of patients who had physical or psychosocial barriers, and those who were acutely unwell and symptomatic, has the potential to introduce selection bias given the excluded populations are those most at risk of readmission. We also acknowledge that some of the issues that patients' are reporting may be chronic ones. However, given the fact that patients feel these issues, even if chronic, are unaddressed or that they want to talk with their doctor about them, is still a very large potential gap in care and patient engagement.
However, despite these limitations, which seem most likely to produce a cohort that is more likely to be able to participate in our survey, and in turn more likely to participate in their care more broadly, we still observed disappointing resolution of discharge barriers. In addition, our adapted survey instrument, though based on well‐supported conceptual frameworks,[19] has not been extensively tested outside of our hospital setting. Finally, as a single‐center study, our results cannot be generalized to other settings.
Assessing discharge readiness highlights an opportunity to obtain patient self‐reported barriers to discharge. This can facilitate discharge planning that targets individual patient needs. This information also emphasizes potentially fruitful opportunities for improved communication and education activities, potentially if these data are fed back to providers in real time, potentially as part of team‐based dashboards or the context of interdisciplinary team models.
Acknowledgements
The authors thank all of the patients who participated in this project, and Yimdriuska Magan Gigi for her assistance with chart abstractions. The authors also acknowledge and thank John Boscardin for his statistical and analytic support.
Disclosures: James D. Harrison, and Drs. Ryan S. Greysen and Andrew D. Auerbach contributed to the concept, design, analysis, interpretation of data, drafting of the manuscript, critical revisions to the manuscript, and final approval of manuscript. Ronald Jacolbia and Alice Nguyen contributed to the acquisition of data, drafting and final approval of manuscript and project, and administrative and technical support. Dr. Auerbach was supported by National Heart, Lung, and Blood Institute grant K24 K24HL098372. Dr. Greysen is supported by the National Institutes of Health (NIH), National Institute of Aging (NIA) through the Claude D. Pepper Older Americans Independence Center (P30AG021342 NIH/NIA and K23AG045338‐01). The authors have no financial or other conflicts of interest to declare.
- , , . Trends and projections in inpatient hospital costs and utilization 2003–2013. HCUP statistical brief #175. July 2014. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
- , . Overview of hospital stays in the United States 2012. HCUP statistical brief #180. October 2014. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
- Joint Commision. The Joint Commission Comprehensive Accreditation Manual for Hospitals. Oak Brook, IL: The Joint Commission; 2015.
- , , . Hospital discharge and readmission. In: Post TW, ed. UpToDate website: Available at: http://www.uptodate.com/contents/hospital‐discharge‐and‐readmission. Accessed August 14, 2015.
- , . A patient centered model of care for hospital discharge. Clin Nurse Res. 2004;13:117–136.
- , , , , , . Which reasons do doctors, nurses and patients have for hospital discharge? A mixed methods study. PLoS One. 2014;9:e91333.
- , , . Nurse and patient perceptions of discharge readiness in relation to postdischarge utilization. Med Care. 2010;48:482–486.
- , . Older people's perception of their readiness for discharge and postdischarge use of community support and services. Int J Older People Nurs. 2013;8:104–115.
- , , , . The care transitions intervention: Results of a randomized controlled trial. Arch Intern Med. 2006;166:1822–1828.
- , . Psychometric properties of the Readiness for Hospital Discharge Scale. J Nurs Meas. 2006;14:163–180.
- , , , et al. Perceived readiness for hospital discharge in adult medical‐surgical patients. Clin Nurse Spec. 2007;21:31–42.
- , , , . Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital. Health Serv Res. 2014;49:304–317.
- , , , et al. “Missing Pieces”—functional, social and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. J Am Geriatr Soc. 2014;62:1556–1561.
- , , , et al. Quality of discharge practices and patient understanding at an academic medical center. JAMA Intern Med. 2013;173:1715–1722.
- , , . Brief scale measuring patient prepardeness for hospital discharge to home: Psychometric properties. J Hosp Med. 2008;3:446–454.
- , , , et al. Improving patient discharge and reducing hospital readmission by using intervention mapping. BMC Health Serv Res. 2014;14:389.
- , , , , , . Development of a discharge readiness report within the electronic health record: a discharge planning tool. J Hosp Med. 2014;9:533–539.
- , , , . Incorporating Patient and Carer Concerns in Discharge Plans: The Development of a Practical Patient‐Centred Checklist. The Internet Journal of Allied Health Sciences and Practice. 2006;4: Article 5.
- , , , . Identifying keys to success in reducing readmissions using the ideal transitions in care framework. BMC Health Serv Res. 2014;14:423.
Thirty‐six million adults were discharged from US hospitals in 2012, with approximately 45% from medicine service lines.[1, 2] Discharge planning, a key aspect of care for hospitalized patients,[3] should involve the development of a plan to enable the patient to be discharged at the appropriate time and with provision of sufficient postdischarge support and services.[4]
Central to the discharge planning process is an assessment of a patient's readiness for discharge. Readiness is often a provider‐driven process, based on specific clinical and health system benchmarks.[5] However, providers' perception of readiness for discharge does not always correlate with patients' self‐assessments or objective measures of understanding.[6] For example, nurses overestimate patients' readiness for discharge compared to patients' own self‐report.[7] As a result, the need to include the patient perspective is increasingly recognized as an important contributing factor in the discharge planning process.[8, 9]
Current approaches to assessing discharge readiness are typically single assessments. However, these assessments do not take into account the complexity of discharge planning or patients' understanding, or their ability to carry out postacute care tasks.[8] In addition, few models have included assessments of physical stability and functional ability along with measures such as ability to manage self‐care activities at home, coping and social support, or access to health system and community resources.[10, 11]
To address these gaps in the existing literature, we carried out a prospective observational study of daily, patient‐reported, assessments of discharge readiness to better understand patients' perspectives on issues that could impede the transition to home. Using these data, we then sought to determine the prevalence of patient‐reported discharge barriers and the frequency with which they were resolved prior to the day of discharge. We also explored whether problems identified at discharge were associated with 30‐day readmission.
METHODS
Study Design, Setting, and Participants
We carried out a prospective observational study at the University of California San Francisco (UCSF) Medical Center, a 600‐bed tertiary care academic hospital in San Francisco, California. The UCSF Committee on Human Research approved this study. We recruited patients between November 2013 and April 2014. Patients were eligible to participate if they were admitted to the General Medicine Service; over 18 years old; English speaking; cognitively able to provide informed consent; and not under contact, droplet, airborne, or radiation isolation. Patients were eligible to participate regardless of where they were admitted from or expected to be discharged (eg, home, skilled nursing facility). Patients were excluded if they were acutely unwell or symptomatic resulting in them being unable to complete the surveys. Caregivers were not able to participate in the study on behalf of patients. We screened daily admission charts for eligibility and approached consecutive patients to consent them into the study on their first or second day of hospitalization. An enrollment tracker was used to documented reasons for patients' exclusion or refusal.
Survey Development
We adapted an existing and validated Readiness for Hospital Discharge Survey (RHDS) previously used in obstetric, surgical, and medicine patients for our study.[10, 11, 12] This initial list was culled from 23 to 12 items, based on input from patients and physicians. This feedback step also prompted a change in the response scale from a 0 to 10 scale to a simpler yes, no, or I would like to talk with someone about this scale intended to encourage discussion between patients and providers. After this revision step, we further pretested the survey among physicians and a small set of general medical patients to assess comprehension. Thus, our final question set included 12 items in 4 domains; personal status (ie, pain, mobility), knowledge (ie, medications, problems to watch for, recovery plan), coping ability (ie, emotional support, who to call with problems), and expected support (ie, related to activities and instrumental activities of daily living).
Data Collection
We collected data from interviews of patients as well as chart abstraction. Trained research assistants approached patients to complete our revised RHDS at admission, which was either on their first or second day of hospitalization. We collected data via an intake admission survey, which asked patients about their readiness for discharge, followed by a daily readiness for discharge survey until the day of discharge. A research assistant read the survey items to patients and recorded responses on a paper version of the survey. We abstracted demographic, clinical, and 30‐day readmission information from each participant's electronic medical record.
Analytic Approach
A barrier to discharge readiness was confirmed when a patient responded no' to an item (except for presence of catheter and pain or discomfort where yes was used) and/or they stated they wanted to talk to someone about the issue. We then used descriptive statistics to summarize patients' responses by survey administration number. Multilevel mixed effect regression was used to investigate any patterns in barriers to discharge over the course of hospitalization. We described the frequency of identified barriers to discharge on the intake admission and final (48 hours of discharge) surveys. McNemar's tests compared the proportion of patients reporting each barrier, and paired t tests the mean number of barriers at these 2 survey time points. We also assessed whether persistent barriers to discharge readiness on the final survey were associated with readmission to our hospital within 30‐days using t tests, 2, or Fisher exact test. Analysis was conducted in SPSS 22.0 (IBM Corp., Armonk, NY) and Stata (StataCorp, College Station, TX).
RESULTS
Patients
There were 2045 patients admitted to the general medicine service during the study period. Medical record screening resulted in 1350 exclusions. Of the remaining 695 patients, 113 refused and 419 were further found to be unable to participate. After all exclusions were applied and following direct screening, 163 patients agreed to participate in our study (Table 1). Mean length of stay among our cohort was 5.42 days (standard deviation [SD], 11.49) and the majority of patients were admitted from and discharged to home (Table 1).
| |
| Mean age, y (SD) | 56.4 (17) |
| Female gender, no. (%) | 86 (53) |
| Race, no. (%) | |
| Asian | 13 (8) |
| African American | 27 (16) |
| White | 96 (59) |
| Other | 24 (25) |
| Declined to say | 3 (1) |
| Married, no. (%) | 78 (48) |
| Insurance, no. (%) | |
| Medicare | 59 (36) |
| Medicaid | 22 (14) |
| Private | 73 (45) |
| Self‐pay | 2 (1) |
| Other | 7 (4) |
| Patient admitted from, no. (%) | |
| Home | 118 (72) |
| Outpatient clinic | 17 (10) |
| Procedural area | 6 (4) |
| Another facility | 12 (7) |
| Other | 9 (6) |
| Patient discharged to, no. (%) | |
| Home without services | 107 (66) |
| Home with services | 40 (25) |
| Home hospice | 2 (1) |
| Skilled nursing facility | 8 (5) |
| Patient deceased | 3 (2) |
| Other | 3 (2) |
Barriers to Discharge Readiness
Patients completed on average 1.82 surveys (SD 1.10; range, 18), and in total 296 surveys were administered. Only 5% of patients were captured on their admission day, whereas 77% of patients were surveyed on their second hospital day (Table 2). Between the first and second survey administration, 51% of patients were lost to follow‐up, and then by the third survey administration a further 37% were lost to follow‐up (Table 3). Patients were unable to be reinterviewed most often because they had been (1) discharged, (2) were unavailable or having a procedure at time of recruitment, or (3) became too sick and symptomatic.
| Hospital Day | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
| No. of eligible patients hospitalized | 163 | 161 | 138 | 102 | 70 | 50 | 35 | 24 | 19 | 17 |
| No. of patients surveyed | 8 | 124 | 70 | 30 | 22 | 13 | 7 | 6 | 2 | 0 |
| % of eligible patients surveyed | 4.9 | 77.0 | 50.7 | 29.4 | 31.4 | 26.0 | 20.0 | 25.0 | 10.5 | 0 |
| Survey No. | ||||||
|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6+ | |
| ||||||
| No. of patients surveyed | 163 | 83 | 31 | 11 | 3 | 5 |
| Total barriers (all patients) | 533 | 235 | 84 | 22 | 7 | 8 |
| No. of barriers per patient, mean (SD) | 3.27(2.35) | 2.83 (2.11) | 2.71 (2.49) | 2.00 (1.73) | 2.33 (2.51) | 1.60 (2.30) |
| Median no. of barriers per patient | 3.0 | 3.0 | 2.0 | 1.0 | 2.0 | 0 |
| Median hospital day of survey administration | 2.0 | 3.0 | 5.0 | 6.0 | 8.0 | 13.0 |
| Initial admission survey, no. (%) | 163 (100.0) | 0 | 0 | 0 | 0 | 0 |
| Follow‐up survey, no. (%) | 0 | 38 (45.8) | 16 (51.6) | 4 (36.4) | 0 | 1 (20.0) |
| Survey 48 hours before discharge, no. (%) | 59 (36.2) | 45 (54.2) | 15 (48.4) | 7 (63.6) | 3 (100.0) | 4 (80.0) |
In total, over 889 individual barriers to discharge readiness were reported across all surveys. The total and mean numbers of barriers were highest on the admission intake survey, and numbers continued to decrease until the fourth survey. On average, the total number of barriers to discharge patients reported decreased by 0.15 (95% confidence interval: 0.01‐0.30) per day (P = 0.047).
Change in Barriers to Discharge
Sixty‐eight patients (42%) completed an admission intake survey as well as final survey 48 hours before discharge (Table 4). We observed a significant reduction in mean number of barriers reported between admission and discharge surveys (3.19 vs 2.53, P = 0.01). Sixty‐one patients (90%) left the hospital with 1 or more persistent barrier to a safe discharge. However, the 3 most common barriers to discharge readiness on the admission and final survey remained the same: unresolved pain, lack of understanding of plan for recovery, and daily living activities (eg, cooking, cleaning, and shopping). The number of patients with unresolved pain appeared to increase slightly, though this rise was not statistically significant. In contrast, there were significant reductions in patients reporting they were unaware of problems to watch out for postdischarge (28% vs 16%; P = 0.04) or did not understand their recovery plan (52% vs 40%; P = 0.03).
| Barrier to Discharge | Survey | |
|---|---|---|
| Admission, No. (%) | Final Survey, No. (%) | |
| ||
| Catheter is present? | 6 (7.2) | 6 (7.2) |
| Not out of bed, sitting in a chair, or walking? | 17 (20.5) | 13 (15.7) |
| Pain or discomfort? | 50 (60.2) | 52 (62.7) |
| Unable to get to the bathroom for toilet or to shower? | 15 (18.1) | 12 (14.5) |
| Unable to self‐care without help from others? | 27 (32.5) | 23 (27.7) |
| Unable to get your own medications? | 11 (13.3) | 14 (16.9) |
| Know what problems to watch for?* | 23 (27.7) | 13 (15.7) |
| Know where to call if you had problems? | 10 (12.0) | 8 (9.6) |
| Inability for personal care such as bathing, toileting, and eating? | 8 (9.6) | 11 (13.3) |
| Lack of support for emotional needs? | 16 (19.3) | 9 (10.8) |
| Unable to cook, clean, or do shopping? | 33 (39.8) | 25 (30.1) |
| Do not understand the overall plan for your recovery?* | 43 (51.8) | 33 (39.8) |
DISCUSSION
Assessing discharge readiness highlights an opportunity to engage patients directly in their discharge planning process. However, our prospective study of 163 hospitalized adults revealed that unresolved discharge barriers were common; 90% of patients were discharged with at least 1 issue that might inhibit an effective transition home. The majority of these patients were also discharged home without any support services. In addition, many of the major barriers patients reportedpain, lack of understanding around plans, and ability to provide self‐carewere consistent from admission to discharge, suggesting a missed opportunity to address problems present early in a patient's stay.
Some of the issues our patients described, such as pain; lack of understanding of a recovery plan; and functional, social, and environmental vulnerabilities that impede recovery, have been described in studies using data collected in the postacute time period.[13, 14, 15] Focus on postacute barriers is likely to be of limited clinical utility to assist in any real‐time discharge planning, particularly planning that assesses individual patients' needs and tailors programs and education appropriately. Having said this, consistency between our results and data collected from postdischarge patients again supports broad areas of improvement for health systems.
Persistent gaps in care at discharge may be a result of limited standardization of discharge processes and a lack of engagement in obtaining patient‐reported concerns. Lack of a framework for preparing individual patients for discharge has been recognized as a significant obstacle to effective discharge planning. For example, Hesselink et al.'s qualitative study with almost 200 patients and providers across multiple institutions described how lack of a standard approach to providing discharge planning resulted in gaps in information provision.[16] Similarly, Horwitz et al. described wide variation in discharge practices at a US academic medical center, suggesting lack of a standard approach to identifying patient needs.[14]
Although many transitions of care programs have supported implementation of specific care interventions at a hospital or health system level, there have been surprisingly few studies describing efforts to standardize the assessment of discharge barriers and prospectively engage individual patients.[17] One emblematic study used stakeholder interviews and process mapping to develop a readiness report within their electronic medical record (EMR).[17] Aggregate data from the EMR including orders and discharge plans were coded, extracted, and summarized into a report. The overall goal of the report was to identify progress toward completion of discharge tasks; however, a limitation was that it did not explicitly include patient self‐assessments. Another study by Grimmer et al. describes the development of a patient‐centered discharge checklist that incorporated patients and care concerns.[18] The themes incorporated into this checklist cover many transitional issues; however, outside of the checklist's development, few publications or Web resources describe it in actual use.
Our approach may represent an advance in approaches to engaging patients in discharge planning and preparing patients for leaving the hospital. Although our data do not support efficacy of our daily surveys in terms of improving discharge planning, this initial evaluation provides the framework upon which providers can develop discharge plans that are both standardized in terms of using a structured multidomain communication tool to elicit barriers, as well as patient‐centered and patient‐directed, by using the information collected in the survey tool to initiate tailored discharge planning earlier in the hospital stay. However, our program points out an important limitation of an entirely patient‐initiated program, which is difficulty obtaining truly daily assessments. During this study, we had a single research assistant visit patients as frequently as possible during hospitalization, but even daily visits did not yield complete information on all patients. Although this limitation may in part be due to the fact that our study was a focused pilot of an approach we hope to expand, it also represents the complexity of patient experience in the hospital, where patients are often out of their room for tests, are unable to complete a survey because of problematic symptoms, or simply are unwilling or unable to participate in regular surveys.
Our study has a number of limitations. First, the number of patients in our study overall, and the number who completed at least 2 surveys, was relatively small, limiting the generalizability of the study and our ability to determine the true prevalence of unresolved barriers at discharge. In addition, our selection criteria and response rates have limited our sample in that our final group may not be representative of all patients admitted to our medicine service. The broad exclusion of patients who had physical or psychosocial barriers, and those who were acutely unwell and symptomatic, has the potential to introduce selection bias given the excluded populations are those most at risk of readmission. We also acknowledge that some of the issues that patients' are reporting may be chronic ones. However, given the fact that patients feel these issues, even if chronic, are unaddressed or that they want to talk with their doctor about them, is still a very large potential gap in care and patient engagement.
However, despite these limitations, which seem most likely to produce a cohort that is more likely to be able to participate in our survey, and in turn more likely to participate in their care more broadly, we still observed disappointing resolution of discharge barriers. In addition, our adapted survey instrument, though based on well‐supported conceptual frameworks,[19] has not been extensively tested outside of our hospital setting. Finally, as a single‐center study, our results cannot be generalized to other settings.
Assessing discharge readiness highlights an opportunity to obtain patient self‐reported barriers to discharge. This can facilitate discharge planning that targets individual patient needs. This information also emphasizes potentially fruitful opportunities for improved communication and education activities, potentially if these data are fed back to providers in real time, potentially as part of team‐based dashboards or the context of interdisciplinary team models.
Acknowledgements
The authors thank all of the patients who participated in this project, and Yimdriuska Magan Gigi for her assistance with chart abstractions. The authors also acknowledge and thank John Boscardin for his statistical and analytic support.
Disclosures: James D. Harrison, and Drs. Ryan S. Greysen and Andrew D. Auerbach contributed to the concept, design, analysis, interpretation of data, drafting of the manuscript, critical revisions to the manuscript, and final approval of manuscript. Ronald Jacolbia and Alice Nguyen contributed to the acquisition of data, drafting and final approval of manuscript and project, and administrative and technical support. Dr. Auerbach was supported by National Heart, Lung, and Blood Institute grant K24 K24HL098372. Dr. Greysen is supported by the National Institutes of Health (NIH), National Institute of Aging (NIA) through the Claude D. Pepper Older Americans Independence Center (P30AG021342 NIH/NIA and K23AG045338‐01). The authors have no financial or other conflicts of interest to declare.
Thirty‐six million adults were discharged from US hospitals in 2012, with approximately 45% from medicine service lines.[1, 2] Discharge planning, a key aspect of care for hospitalized patients,[3] should involve the development of a plan to enable the patient to be discharged at the appropriate time and with provision of sufficient postdischarge support and services.[4]
Central to the discharge planning process is an assessment of a patient's readiness for discharge. Readiness is often a provider‐driven process, based on specific clinical and health system benchmarks.[5] However, providers' perception of readiness for discharge does not always correlate with patients' self‐assessments or objective measures of understanding.[6] For example, nurses overestimate patients' readiness for discharge compared to patients' own self‐report.[7] As a result, the need to include the patient perspective is increasingly recognized as an important contributing factor in the discharge planning process.[8, 9]
Current approaches to assessing discharge readiness are typically single assessments. However, these assessments do not take into account the complexity of discharge planning or patients' understanding, or their ability to carry out postacute care tasks.[8] In addition, few models have included assessments of physical stability and functional ability along with measures such as ability to manage self‐care activities at home, coping and social support, or access to health system and community resources.[10, 11]
To address these gaps in the existing literature, we carried out a prospective observational study of daily, patient‐reported, assessments of discharge readiness to better understand patients' perspectives on issues that could impede the transition to home. Using these data, we then sought to determine the prevalence of patient‐reported discharge barriers and the frequency with which they were resolved prior to the day of discharge. We also explored whether problems identified at discharge were associated with 30‐day readmission.
METHODS
Study Design, Setting, and Participants
We carried out a prospective observational study at the University of California San Francisco (UCSF) Medical Center, a 600‐bed tertiary care academic hospital in San Francisco, California. The UCSF Committee on Human Research approved this study. We recruited patients between November 2013 and April 2014. Patients were eligible to participate if they were admitted to the General Medicine Service; over 18 years old; English speaking; cognitively able to provide informed consent; and not under contact, droplet, airborne, or radiation isolation. Patients were eligible to participate regardless of where they were admitted from or expected to be discharged (eg, home, skilled nursing facility). Patients were excluded if they were acutely unwell or symptomatic resulting in them being unable to complete the surveys. Caregivers were not able to participate in the study on behalf of patients. We screened daily admission charts for eligibility and approached consecutive patients to consent them into the study on their first or second day of hospitalization. An enrollment tracker was used to documented reasons for patients' exclusion or refusal.
Survey Development
We adapted an existing and validated Readiness for Hospital Discharge Survey (RHDS) previously used in obstetric, surgical, and medicine patients for our study.[10, 11, 12] This initial list was culled from 23 to 12 items, based on input from patients and physicians. This feedback step also prompted a change in the response scale from a 0 to 10 scale to a simpler yes, no, or I would like to talk with someone about this scale intended to encourage discussion between patients and providers. After this revision step, we further pretested the survey among physicians and a small set of general medical patients to assess comprehension. Thus, our final question set included 12 items in 4 domains; personal status (ie, pain, mobility), knowledge (ie, medications, problems to watch for, recovery plan), coping ability (ie, emotional support, who to call with problems), and expected support (ie, related to activities and instrumental activities of daily living).
Data Collection
We collected data from interviews of patients as well as chart abstraction. Trained research assistants approached patients to complete our revised RHDS at admission, which was either on their first or second day of hospitalization. We collected data via an intake admission survey, which asked patients about their readiness for discharge, followed by a daily readiness for discharge survey until the day of discharge. A research assistant read the survey items to patients and recorded responses on a paper version of the survey. We abstracted demographic, clinical, and 30‐day readmission information from each participant's electronic medical record.
Analytic Approach
A barrier to discharge readiness was confirmed when a patient responded no' to an item (except for presence of catheter and pain or discomfort where yes was used) and/or they stated they wanted to talk to someone about the issue. We then used descriptive statistics to summarize patients' responses by survey administration number. Multilevel mixed effect regression was used to investigate any patterns in barriers to discharge over the course of hospitalization. We described the frequency of identified barriers to discharge on the intake admission and final (48 hours of discharge) surveys. McNemar's tests compared the proportion of patients reporting each barrier, and paired t tests the mean number of barriers at these 2 survey time points. We also assessed whether persistent barriers to discharge readiness on the final survey were associated with readmission to our hospital within 30‐days using t tests, 2, or Fisher exact test. Analysis was conducted in SPSS 22.0 (IBM Corp., Armonk, NY) and Stata (StataCorp, College Station, TX).
RESULTS
Patients
There were 2045 patients admitted to the general medicine service during the study period. Medical record screening resulted in 1350 exclusions. Of the remaining 695 patients, 113 refused and 419 were further found to be unable to participate. After all exclusions were applied and following direct screening, 163 patients agreed to participate in our study (Table 1). Mean length of stay among our cohort was 5.42 days (standard deviation [SD], 11.49) and the majority of patients were admitted from and discharged to home (Table 1).
| |
| Mean age, y (SD) | 56.4 (17) |
| Female gender, no. (%) | 86 (53) |
| Race, no. (%) | |
| Asian | 13 (8) |
| African American | 27 (16) |
| White | 96 (59) |
| Other | 24 (25) |
| Declined to say | 3 (1) |
| Married, no. (%) | 78 (48) |
| Insurance, no. (%) | |
| Medicare | 59 (36) |
| Medicaid | 22 (14) |
| Private | 73 (45) |
| Self‐pay | 2 (1) |
| Other | 7 (4) |
| Patient admitted from, no. (%) | |
| Home | 118 (72) |
| Outpatient clinic | 17 (10) |
| Procedural area | 6 (4) |
| Another facility | 12 (7) |
| Other | 9 (6) |
| Patient discharged to, no. (%) | |
| Home without services | 107 (66) |
| Home with services | 40 (25) |
| Home hospice | 2 (1) |
| Skilled nursing facility | 8 (5) |
| Patient deceased | 3 (2) |
| Other | 3 (2) |
Barriers to Discharge Readiness
Patients completed on average 1.82 surveys (SD 1.10; range, 18), and in total 296 surveys were administered. Only 5% of patients were captured on their admission day, whereas 77% of patients were surveyed on their second hospital day (Table 2). Between the first and second survey administration, 51% of patients were lost to follow‐up, and then by the third survey administration a further 37% were lost to follow‐up (Table 3). Patients were unable to be reinterviewed most often because they had been (1) discharged, (2) were unavailable or having a procedure at time of recruitment, or (3) became too sick and symptomatic.
| Hospital Day | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
| No. of eligible patients hospitalized | 163 | 161 | 138 | 102 | 70 | 50 | 35 | 24 | 19 | 17 |
| No. of patients surveyed | 8 | 124 | 70 | 30 | 22 | 13 | 7 | 6 | 2 | 0 |
| % of eligible patients surveyed | 4.9 | 77.0 | 50.7 | 29.4 | 31.4 | 26.0 | 20.0 | 25.0 | 10.5 | 0 |
| Survey No. | ||||||
|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6+ | |
| ||||||
| No. of patients surveyed | 163 | 83 | 31 | 11 | 3 | 5 |
| Total barriers (all patients) | 533 | 235 | 84 | 22 | 7 | 8 |
| No. of barriers per patient, mean (SD) | 3.27(2.35) | 2.83 (2.11) | 2.71 (2.49) | 2.00 (1.73) | 2.33 (2.51) | 1.60 (2.30) |
| Median no. of barriers per patient | 3.0 | 3.0 | 2.0 | 1.0 | 2.0 | 0 |
| Median hospital day of survey administration | 2.0 | 3.0 | 5.0 | 6.0 | 8.0 | 13.0 |
| Initial admission survey, no. (%) | 163 (100.0) | 0 | 0 | 0 | 0 | 0 |
| Follow‐up survey, no. (%) | 0 | 38 (45.8) | 16 (51.6) | 4 (36.4) | 0 | 1 (20.0) |
| Survey 48 hours before discharge, no. (%) | 59 (36.2) | 45 (54.2) | 15 (48.4) | 7 (63.6) | 3 (100.0) | 4 (80.0) |
In total, over 889 individual barriers to discharge readiness were reported across all surveys. The total and mean numbers of barriers were highest on the admission intake survey, and numbers continued to decrease until the fourth survey. On average, the total number of barriers to discharge patients reported decreased by 0.15 (95% confidence interval: 0.01‐0.30) per day (P = 0.047).
Change in Barriers to Discharge
Sixty‐eight patients (42%) completed an admission intake survey as well as final survey 48 hours before discharge (Table 4). We observed a significant reduction in mean number of barriers reported between admission and discharge surveys (3.19 vs 2.53, P = 0.01). Sixty‐one patients (90%) left the hospital with 1 or more persistent barrier to a safe discharge. However, the 3 most common barriers to discharge readiness on the admission and final survey remained the same: unresolved pain, lack of understanding of plan for recovery, and daily living activities (eg, cooking, cleaning, and shopping). The number of patients with unresolved pain appeared to increase slightly, though this rise was not statistically significant. In contrast, there were significant reductions in patients reporting they were unaware of problems to watch out for postdischarge (28% vs 16%; P = 0.04) or did not understand their recovery plan (52% vs 40%; P = 0.03).
| Barrier to Discharge | Survey | |
|---|---|---|
| Admission, No. (%) | Final Survey, No. (%) | |
| ||
| Catheter is present? | 6 (7.2) | 6 (7.2) |
| Not out of bed, sitting in a chair, or walking? | 17 (20.5) | 13 (15.7) |
| Pain or discomfort? | 50 (60.2) | 52 (62.7) |
| Unable to get to the bathroom for toilet or to shower? | 15 (18.1) | 12 (14.5) |
| Unable to self‐care without help from others? | 27 (32.5) | 23 (27.7) |
| Unable to get your own medications? | 11 (13.3) | 14 (16.9) |
| Know what problems to watch for?* | 23 (27.7) | 13 (15.7) |
| Know where to call if you had problems? | 10 (12.0) | 8 (9.6) |
| Inability for personal care such as bathing, toileting, and eating? | 8 (9.6) | 11 (13.3) |
| Lack of support for emotional needs? | 16 (19.3) | 9 (10.8) |
| Unable to cook, clean, or do shopping? | 33 (39.8) | 25 (30.1) |
| Do not understand the overall plan for your recovery?* | 43 (51.8) | 33 (39.8) |
DISCUSSION
Assessing discharge readiness highlights an opportunity to engage patients directly in their discharge planning process. However, our prospective study of 163 hospitalized adults revealed that unresolved discharge barriers were common; 90% of patients were discharged with at least 1 issue that might inhibit an effective transition home. The majority of these patients were also discharged home without any support services. In addition, many of the major barriers patients reportedpain, lack of understanding around plans, and ability to provide self‐carewere consistent from admission to discharge, suggesting a missed opportunity to address problems present early in a patient's stay.
Some of the issues our patients described, such as pain; lack of understanding of a recovery plan; and functional, social, and environmental vulnerabilities that impede recovery, have been described in studies using data collected in the postacute time period.[13, 14, 15] Focus on postacute barriers is likely to be of limited clinical utility to assist in any real‐time discharge planning, particularly planning that assesses individual patients' needs and tailors programs and education appropriately. Having said this, consistency between our results and data collected from postdischarge patients again supports broad areas of improvement for health systems.
Persistent gaps in care at discharge may be a result of limited standardization of discharge processes and a lack of engagement in obtaining patient‐reported concerns. Lack of a framework for preparing individual patients for discharge has been recognized as a significant obstacle to effective discharge planning. For example, Hesselink et al.'s qualitative study with almost 200 patients and providers across multiple institutions described how lack of a standard approach to providing discharge planning resulted in gaps in information provision.[16] Similarly, Horwitz et al. described wide variation in discharge practices at a US academic medical center, suggesting lack of a standard approach to identifying patient needs.[14]
Although many transitions of care programs have supported implementation of specific care interventions at a hospital or health system level, there have been surprisingly few studies describing efforts to standardize the assessment of discharge barriers and prospectively engage individual patients.[17] One emblematic study used stakeholder interviews and process mapping to develop a readiness report within their electronic medical record (EMR).[17] Aggregate data from the EMR including orders and discharge plans were coded, extracted, and summarized into a report. The overall goal of the report was to identify progress toward completion of discharge tasks; however, a limitation was that it did not explicitly include patient self‐assessments. Another study by Grimmer et al. describes the development of a patient‐centered discharge checklist that incorporated patients and care concerns.[18] The themes incorporated into this checklist cover many transitional issues; however, outside of the checklist's development, few publications or Web resources describe it in actual use.
Our approach may represent an advance in approaches to engaging patients in discharge planning and preparing patients for leaving the hospital. Although our data do not support efficacy of our daily surveys in terms of improving discharge planning, this initial evaluation provides the framework upon which providers can develop discharge plans that are both standardized in terms of using a structured multidomain communication tool to elicit barriers, as well as patient‐centered and patient‐directed, by using the information collected in the survey tool to initiate tailored discharge planning earlier in the hospital stay. However, our program points out an important limitation of an entirely patient‐initiated program, which is difficulty obtaining truly daily assessments. During this study, we had a single research assistant visit patients as frequently as possible during hospitalization, but even daily visits did not yield complete information on all patients. Although this limitation may in part be due to the fact that our study was a focused pilot of an approach we hope to expand, it also represents the complexity of patient experience in the hospital, where patients are often out of their room for tests, are unable to complete a survey because of problematic symptoms, or simply are unwilling or unable to participate in regular surveys.
Our study has a number of limitations. First, the number of patients in our study overall, and the number who completed at least 2 surveys, was relatively small, limiting the generalizability of the study and our ability to determine the true prevalence of unresolved barriers at discharge. In addition, our selection criteria and response rates have limited our sample in that our final group may not be representative of all patients admitted to our medicine service. The broad exclusion of patients who had physical or psychosocial barriers, and those who were acutely unwell and symptomatic, has the potential to introduce selection bias given the excluded populations are those most at risk of readmission. We also acknowledge that some of the issues that patients' are reporting may be chronic ones. However, given the fact that patients feel these issues, even if chronic, are unaddressed or that they want to talk with their doctor about them, is still a very large potential gap in care and patient engagement.
However, despite these limitations, which seem most likely to produce a cohort that is more likely to be able to participate in our survey, and in turn more likely to participate in their care more broadly, we still observed disappointing resolution of discharge barriers. In addition, our adapted survey instrument, though based on well‐supported conceptual frameworks,[19] has not been extensively tested outside of our hospital setting. Finally, as a single‐center study, our results cannot be generalized to other settings.
Assessing discharge readiness highlights an opportunity to obtain patient self‐reported barriers to discharge. This can facilitate discharge planning that targets individual patient needs. This information also emphasizes potentially fruitful opportunities for improved communication and education activities, potentially if these data are fed back to providers in real time, potentially as part of team‐based dashboards or the context of interdisciplinary team models.
Acknowledgements
The authors thank all of the patients who participated in this project, and Yimdriuska Magan Gigi for her assistance with chart abstractions. The authors also acknowledge and thank John Boscardin for his statistical and analytic support.
Disclosures: James D. Harrison, and Drs. Ryan S. Greysen and Andrew D. Auerbach contributed to the concept, design, analysis, interpretation of data, drafting of the manuscript, critical revisions to the manuscript, and final approval of manuscript. Ronald Jacolbia and Alice Nguyen contributed to the acquisition of data, drafting and final approval of manuscript and project, and administrative and technical support. Dr. Auerbach was supported by National Heart, Lung, and Blood Institute grant K24 K24HL098372. Dr. Greysen is supported by the National Institutes of Health (NIH), National Institute of Aging (NIA) through the Claude D. Pepper Older Americans Independence Center (P30AG021342 NIH/NIA and K23AG045338‐01). The authors have no financial or other conflicts of interest to declare.
- , , . Trends and projections in inpatient hospital costs and utilization 2003–2013. HCUP statistical brief #175. July 2014. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
- , . Overview of hospital stays in the United States 2012. HCUP statistical brief #180. October 2014. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
- Joint Commision. The Joint Commission Comprehensive Accreditation Manual for Hospitals. Oak Brook, IL: The Joint Commission; 2015.
- , , . Hospital discharge and readmission. In: Post TW, ed. UpToDate website: Available at: http://www.uptodate.com/contents/hospital‐discharge‐and‐readmission. Accessed August 14, 2015.
- , . A patient centered model of care for hospital discharge. Clin Nurse Res. 2004;13:117–136.
- , , , , , . Which reasons do doctors, nurses and patients have for hospital discharge? A mixed methods study. PLoS One. 2014;9:e91333.
- , , . Nurse and patient perceptions of discharge readiness in relation to postdischarge utilization. Med Care. 2010;48:482–486.
- , . Older people's perception of their readiness for discharge and postdischarge use of community support and services. Int J Older People Nurs. 2013;8:104–115.
- , , , . The care transitions intervention: Results of a randomized controlled trial. Arch Intern Med. 2006;166:1822–1828.
- , . Psychometric properties of the Readiness for Hospital Discharge Scale. J Nurs Meas. 2006;14:163–180.
- , , , et al. Perceived readiness for hospital discharge in adult medical‐surgical patients. Clin Nurse Spec. 2007;21:31–42.
- , , , . Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital. Health Serv Res. 2014;49:304–317.
- , , , et al. “Missing Pieces”—functional, social and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. J Am Geriatr Soc. 2014;62:1556–1561.
- , , , et al. Quality of discharge practices and patient understanding at an academic medical center. JAMA Intern Med. 2013;173:1715–1722.
- , , . Brief scale measuring patient prepardeness for hospital discharge to home: Psychometric properties. J Hosp Med. 2008;3:446–454.
- , , , et al. Improving patient discharge and reducing hospital readmission by using intervention mapping. BMC Health Serv Res. 2014;14:389.
- , , , , , . Development of a discharge readiness report within the electronic health record: a discharge planning tool. J Hosp Med. 2014;9:533–539.
- , , , . Incorporating Patient and Carer Concerns in Discharge Plans: The Development of a Practical Patient‐Centred Checklist. The Internet Journal of Allied Health Sciences and Practice. 2006;4: Article 5.
- , , , . Identifying keys to success in reducing readmissions using the ideal transitions in care framework. BMC Health Serv Res. 2014;14:423.
- , , . Trends and projections in inpatient hospital costs and utilization 2003–2013. HCUP statistical brief #175. July 2014. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
- , . Overview of hospital stays in the United States 2012. HCUP statistical brief #180. October 2014. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
- Joint Commision. The Joint Commission Comprehensive Accreditation Manual for Hospitals. Oak Brook, IL: The Joint Commission; 2015.
- , , . Hospital discharge and readmission. In: Post TW, ed. UpToDate website: Available at: http://www.uptodate.com/contents/hospital‐discharge‐and‐readmission. Accessed August 14, 2015.
- , . A patient centered model of care for hospital discharge. Clin Nurse Res. 2004;13:117–136.
- , , , , , . Which reasons do doctors, nurses and patients have for hospital discharge? A mixed methods study. PLoS One. 2014;9:e91333.
- , , . Nurse and patient perceptions of discharge readiness in relation to postdischarge utilization. Med Care. 2010;48:482–486.
- , . Older people's perception of their readiness for discharge and postdischarge use of community support and services. Int J Older People Nurs. 2013;8:104–115.
- , , , . The care transitions intervention: Results of a randomized controlled trial. Arch Intern Med. 2006;166:1822–1828.
- , . Psychometric properties of the Readiness for Hospital Discharge Scale. J Nurs Meas. 2006;14:163–180.
- , , , et al. Perceived readiness for hospital discharge in adult medical‐surgical patients. Clin Nurse Spec. 2007;21:31–42.
- , , , . Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital. Health Serv Res. 2014;49:304–317.
- , , , et al. “Missing Pieces”—functional, social and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. J Am Geriatr Soc. 2014;62:1556–1561.
- , , , et al. Quality of discharge practices and patient understanding at an academic medical center. JAMA Intern Med. 2013;173:1715–1722.
- , , . Brief scale measuring patient prepardeness for hospital discharge to home: Psychometric properties. J Hosp Med. 2008;3:446–454.
- , , , et al. Improving patient discharge and reducing hospital readmission by using intervention mapping. BMC Health Serv Res. 2014;14:389.
- , , , , , . Development of a discharge readiness report within the electronic health record: a discharge planning tool. J Hosp Med. 2014;9:533–539.
- , , , . Incorporating Patient and Carer Concerns in Discharge Plans: The Development of a Practical Patient‐Centred Checklist. The Internet Journal of Allied Health Sciences and Practice. 2006;4: Article 5.
- , , , . Identifying keys to success in reducing readmissions using the ideal transitions in care framework. BMC Health Serv Res. 2014;14:423.
Guideline change advocated on using acetaminophen for OA
AMSTERDAM – Further evidence that acetaminophen has limited benefits in patients with osteoarthritis was presented at the World Congress on Osteoarthritis, with authors of a systematic review calling for reconsideration of guidelines recommending the common analgesic as a first-line option.
“[Acetaminophen] provides minimal short-term benefits for people with hip or knee OA,” said presenting author and rheumatologist Dr. David J. Hunter of the University of Sydney. The treatment effects for both pain relief and for improving physical function were smallest in people with knee OA, he said. “In general, the small effect sizes are unlikely to be clinically relevant,” Dr. Hunter observed.
“These are mean differences across large populations in the clinical trials, and there may be certain individuals with knee or hip osteoarthritis that this may not necessarily apply to,” he conceded during a discussion following his presentation, “but I think from the perspective of the recommendations that come from guidelines, we have got to think about what would be do-able in the general population.”
The findings come shortly after the publication of a large meta-analysis of 74 trials evaluating pain-relieving medications that highlighted the ineffectiveness of acetaminophen for OA pain, particularly when compared against diclofenac and other nonsteroidal anti-inflammatory drugs (Lancet. 2016 Mar 17. doi: 10.1016/S0140-6736(16)30002-2).
Dr. Hunter and coworkers searched clinical trial and medical databases from inception to September 2015 for records relating to acetaminophen use in patients with hip or knee OA. Only placebo-controlled, randomized trials were included, and nine records were found that reported 10 trials involving 3,541 patients. Part of the analysis was published in the BMJ last year (BMJ. 2015;350:h1225. doi: 10.1136/bmj.h1225). The last prior systematic review on the topic was published in 2004 (Ann Rheum Dis. 2004;Aug;63[8]:901–7).
Pain scores were converted to a common 0-100 scale with 0 signifying no pain or disability and 100 the worst possible pain or disability and then expressed as a mean difference between the acetaminophen and placebo groups. Physical function scores were pooled to give a standardized mean difference.
There was high-quality evidence that acetaminophen given at a dose of 3-4 g per day had a significant effect on pain and physical function during a short period of more than 2 weeks to less than 3 months and a more immediate time frame of 2 weeks or less, but it was unlikely to be clinically significant, with a mean difference of just –3.14 for pain and a standardized mean difference of –0.12 to –0.15 for physical function. Differences would need to be at least 9 points for pain and greater than 0.2 for physical function to be clinically significant, Dr. Hunter explained.
Four of the trials considered knee OA only. The mean and standardized mean differences between the acetaminophen and placebo groups in those trials was just –1.09 for pain and –0.06 for physical function.
Similar numbers of patients reported being adherent to their assigned treatment group, with less rescue analgesic use in the acetaminophen-treated patients. Although no differences in adverse events, serious adverse events, or withdrawals because of adverse events were seen, there was a higher risk of liver function test (LFT) abnormalities in the acetaminophen-treated patients. The relative risk for abnormal LFTs was 3.79, but the clinical significance of this is uncertain according to the review’s authors.
“Current guidelines consistently recommend [acetaminophen] as the first line of analgesic medication for this condition,” Dr. Hunter said at the meeting, sponsored by the Osteoarthritis Research Society International. “But these results call for reconsideration of these recommendations.”
The results highlight the importance of using other, nonpharmacologic means to manage pain and physical function, the authors conclude, such as lifestyle changes, weight control, and regular physical exercise.
Dr. Hunter had no disclosures relevant to his comments.
AMSTERDAM – Further evidence that acetaminophen has limited benefits in patients with osteoarthritis was presented at the World Congress on Osteoarthritis, with authors of a systematic review calling for reconsideration of guidelines recommending the common analgesic as a first-line option.
“[Acetaminophen] provides minimal short-term benefits for people with hip or knee OA,” said presenting author and rheumatologist Dr. David J. Hunter of the University of Sydney. The treatment effects for both pain relief and for improving physical function were smallest in people with knee OA, he said. “In general, the small effect sizes are unlikely to be clinically relevant,” Dr. Hunter observed.
“These are mean differences across large populations in the clinical trials, and there may be certain individuals with knee or hip osteoarthritis that this may not necessarily apply to,” he conceded during a discussion following his presentation, “but I think from the perspective of the recommendations that come from guidelines, we have got to think about what would be do-able in the general population.”
The findings come shortly after the publication of a large meta-analysis of 74 trials evaluating pain-relieving medications that highlighted the ineffectiveness of acetaminophen for OA pain, particularly when compared against diclofenac and other nonsteroidal anti-inflammatory drugs (Lancet. 2016 Mar 17. doi: 10.1016/S0140-6736(16)30002-2).
Dr. Hunter and coworkers searched clinical trial and medical databases from inception to September 2015 for records relating to acetaminophen use in patients with hip or knee OA. Only placebo-controlled, randomized trials were included, and nine records were found that reported 10 trials involving 3,541 patients. Part of the analysis was published in the BMJ last year (BMJ. 2015;350:h1225. doi: 10.1136/bmj.h1225). The last prior systematic review on the topic was published in 2004 (Ann Rheum Dis. 2004;Aug;63[8]:901–7).
Pain scores were converted to a common 0-100 scale with 0 signifying no pain or disability and 100 the worst possible pain or disability and then expressed as a mean difference between the acetaminophen and placebo groups. Physical function scores were pooled to give a standardized mean difference.
There was high-quality evidence that acetaminophen given at a dose of 3-4 g per day had a significant effect on pain and physical function during a short period of more than 2 weeks to less than 3 months and a more immediate time frame of 2 weeks or less, but it was unlikely to be clinically significant, with a mean difference of just –3.14 for pain and a standardized mean difference of –0.12 to –0.15 for physical function. Differences would need to be at least 9 points for pain and greater than 0.2 for physical function to be clinically significant, Dr. Hunter explained.
Four of the trials considered knee OA only. The mean and standardized mean differences between the acetaminophen and placebo groups in those trials was just –1.09 for pain and –0.06 for physical function.
Similar numbers of patients reported being adherent to their assigned treatment group, with less rescue analgesic use in the acetaminophen-treated patients. Although no differences in adverse events, serious adverse events, or withdrawals because of adverse events were seen, there was a higher risk of liver function test (LFT) abnormalities in the acetaminophen-treated patients. The relative risk for abnormal LFTs was 3.79, but the clinical significance of this is uncertain according to the review’s authors.
“Current guidelines consistently recommend [acetaminophen] as the first line of analgesic medication for this condition,” Dr. Hunter said at the meeting, sponsored by the Osteoarthritis Research Society International. “But these results call for reconsideration of these recommendations.”
The results highlight the importance of using other, nonpharmacologic means to manage pain and physical function, the authors conclude, such as lifestyle changes, weight control, and regular physical exercise.
Dr. Hunter had no disclosures relevant to his comments.
AMSTERDAM – Further evidence that acetaminophen has limited benefits in patients with osteoarthritis was presented at the World Congress on Osteoarthritis, with authors of a systematic review calling for reconsideration of guidelines recommending the common analgesic as a first-line option.
“[Acetaminophen] provides minimal short-term benefits for people with hip or knee OA,” said presenting author and rheumatologist Dr. David J. Hunter of the University of Sydney. The treatment effects for both pain relief and for improving physical function were smallest in people with knee OA, he said. “In general, the small effect sizes are unlikely to be clinically relevant,” Dr. Hunter observed.
“These are mean differences across large populations in the clinical trials, and there may be certain individuals with knee or hip osteoarthritis that this may not necessarily apply to,” he conceded during a discussion following his presentation, “but I think from the perspective of the recommendations that come from guidelines, we have got to think about what would be do-able in the general population.”
The findings come shortly after the publication of a large meta-analysis of 74 trials evaluating pain-relieving medications that highlighted the ineffectiveness of acetaminophen for OA pain, particularly when compared against diclofenac and other nonsteroidal anti-inflammatory drugs (Lancet. 2016 Mar 17. doi: 10.1016/S0140-6736(16)30002-2).
Dr. Hunter and coworkers searched clinical trial and medical databases from inception to September 2015 for records relating to acetaminophen use in patients with hip or knee OA. Only placebo-controlled, randomized trials were included, and nine records were found that reported 10 trials involving 3,541 patients. Part of the analysis was published in the BMJ last year (BMJ. 2015;350:h1225. doi: 10.1136/bmj.h1225). The last prior systematic review on the topic was published in 2004 (Ann Rheum Dis. 2004;Aug;63[8]:901–7).
Pain scores were converted to a common 0-100 scale with 0 signifying no pain or disability and 100 the worst possible pain or disability and then expressed as a mean difference between the acetaminophen and placebo groups. Physical function scores were pooled to give a standardized mean difference.
There was high-quality evidence that acetaminophen given at a dose of 3-4 g per day had a significant effect on pain and physical function during a short period of more than 2 weeks to less than 3 months and a more immediate time frame of 2 weeks or less, but it was unlikely to be clinically significant, with a mean difference of just –3.14 for pain and a standardized mean difference of –0.12 to –0.15 for physical function. Differences would need to be at least 9 points for pain and greater than 0.2 for physical function to be clinically significant, Dr. Hunter explained.
Four of the trials considered knee OA only. The mean and standardized mean differences between the acetaminophen and placebo groups in those trials was just –1.09 for pain and –0.06 for physical function.
Similar numbers of patients reported being adherent to their assigned treatment group, with less rescue analgesic use in the acetaminophen-treated patients. Although no differences in adverse events, serious adverse events, or withdrawals because of adverse events were seen, there was a higher risk of liver function test (LFT) abnormalities in the acetaminophen-treated patients. The relative risk for abnormal LFTs was 3.79, but the clinical significance of this is uncertain according to the review’s authors.
“Current guidelines consistently recommend [acetaminophen] as the first line of analgesic medication for this condition,” Dr. Hunter said at the meeting, sponsored by the Osteoarthritis Research Society International. “But these results call for reconsideration of these recommendations.”
The results highlight the importance of using other, nonpharmacologic means to manage pain and physical function, the authors conclude, such as lifestyle changes, weight control, and regular physical exercise.
Dr. Hunter had no disclosures relevant to his comments.
AT OARSI 2016
Key clinical point: Acetaminophen has minimal effects on pain and physical function in patients with hip and knee osteoarthritis.
Major finding: Doses of 3-4 g of acetaminophen resulted in a mean difference of just –3.14 for pain and a standardized mean difference of –0.12 to –0.15 for physical function versus placebo.
Data source: Cochrane systematic review of 10 trials involving 3,541 patients with hip or knee OA.
Disclosures: Dr. Hunter had no disclosures relevant to his comments.
Coding Changes for 2016
New Codes for 2016
In 2016, noninvasive imaging in dermatology finally received recognition at the Current Procedural Terminology (CPT) level with the publication of 6 new Category I codes for reflectance confocal microscopy.1 These new codes are classified under the “Special Dermatological Procedures” section of CPT where codes do not have technical and professional payment splits, unlike pathology codes (Table). Currently, the new codes for reflectance confocal microscopy can only be implemented when using the VivaScope 1500 (Caliber I.D.) reflectance confocal imaging system and not with any other devices. At present, these codes are priced by each insurer and should be payable, as they are Category I codes that meet all criteria for widely used procedures that are well supported by strong evidence.
Additionally, MelaFind (MELA Sciences) has received 2 Category III CPT codes in 2016: 0400T, multispectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high-risk melanocytic atypia [1–5 lesions]; 0401T, multispectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high-risk melanocytic atypia [≥6 lesions]).
The CPT Professional Edition notes that Category III codes are a set of temporary codes for emerging technology, services, and procedures that allow data collection for these services and procedures.1 Inclusion implies nothing about safety, efficacy, frequency of use, or payment. These codes are used to differentiate emerging technology from the widely accepted Category I codes and use of alphanumeric characters instead of 5-digit codes. If reading this paragraph makes you giddy all over, pay a visit to the American Medical Association website to learn more about the process by which CPT codes come to life.2
Policy and Coding Changes
Last year saw much sturm and drang with the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).3 The MACRA repealed the Sustainable Growth Rate formula and established annual positive or flat-fee updates for 10 years. A 2-tracked fee update was instituted afterward. It also established the Merit-Based Incentive Payment System, which consolidates existing Medicare fee-for-service physician incentive programs, establishes a pathway for physicians to participate in alternative payment models including the patient-centered medical home, and makes a bunch of other changes to existing Medicare physician payment statutes. It is too early to say if and how it will work and if it will change dermatology. It could fail miserably or it could be a brave new world; stay tuned.3
On the coding front, MACRA prohibits across-the-board elimination of global periods that the Centers for Medicare & Medicaid Services (CMS) had previously announced.4 Instead, the CMS must develop and implement a process to gather data on services furnished during global periods based on a representative sample of physician data. The CMS can delay up to 5% of payments if it does not get the data it asks for and must work through the rulemaking process, which will impact medicine in 2019. Among our codes with nonzero global periods, the premalignant destruction codes 17000 and 17004, each of which contains the value of a 99212 established patient visit, are at the very apex of the hit list. It is not clear if the CMS will retrospectively pull medical records to evaluate the occurrence of the global visit or will prospectively have us use 99024, the code for a “[p]ostoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.”1 This code is not used unless your practice needs a “filler” code for nonreportable visits but that may change. Is this another unfunded mandate? Yes.
Clarifications also have been made for reporting superficial radiation therapy.1 Treatment delivery using energies below 1 MV are to be reported with CPT code 77401 and cannot be combined with radiation treatment delivery codes (77402, 77407, 77412), clinical treatment planning codes (77261–77263), treatment device development codes (77332–77334), isodose planning codes (77306, 77307, 77316–77318), radiation treatment management codes (77427, 77431, 77432, 77435, 77469, 77470, 77499), continuing medical physics consultation code (77336), and special physics consultation code (77370). Evaluation and management services may still be reported separately, when appropriate, in cases in which only superficial radiation therapy services (ie, 77401) are provided.1
Electronic brachytherapy for skin cancer has a new Category III tracking code (0394T [high-dose-rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed]) that is priced by the insurer. Noridian Healthcare Solutions pulled the plug on what many perceived as astronomical payments, but changes may be afoot, as its URL for their new policy was down at the time of publication, and there is still great variability in how payment is being made for these codes. For those interested in learning about perception, a visit to http://forums.studentdoctor.net/threads/electronic-brachy.1132531/ is in order, as the economic drivers to the utilization of this therapy are discussed in detail from the perspective of students and young physicians.
Although there are new telehealth codes for inpatient services and end-stage renal disease management, there are still none that are relevant to dermatology.
Place of service codes have been updated. Place of service code 19 refers to “off campus outpatient hospital” settings while place of service code 22 has been revised to “on campus outpatient hospital.” If your practice is a facility, consult the Medicare Claims Processing Manual (20.4.2) on the site of service payment differential for further enlightenment.5 Do note that CMS is increasingly interested in physicians who use wrong place of service codes.
Incident to billing rules are somewhat clearer. The physician or other practitioner who bills must be the supervising physician or practitioner. Services cannot be provided by individuals who have been excluded from Medicare, Medicaid, or other federal programs, nor can they be provided by an individual who has had Medicare enrollment revoked. State laws that are more restrictive take precedence.
Of course, the Relative Value Scale Update Committee (RUC) process moves on as always and you likely will receive 1 or more surveys in the near future. If you get one of these surveys, do not delete it. The surveys are the currency of the RUC, and if you give your RUC team bad or no data, the specialty will suffer cuts in valuation of what we do. If you have questions about the survey, contact the American Academy of Dermatology staff as listed in the survey. If you want to learn more about RUC, visit the American Medical Association website.6 To see the current relative value units for what dermatologists do and the typical time for these procedures, visit the CMS website, which provides resources that supply tremendous amounts of data on code valuation including documents detailing relative value units for every CPT code.7 You also can access current time values for preservice work, intraservice work, and postservice work times for all CPT codes in the entire CPT Professional Edition. They are based on typical times and are the major determinants of what you get paid. Happy reading.
1. Current Procedural Terminology 2016, Professional Edition. Chicago, IL: American Medical Association; 2015.
2. CPT–Current Procedural Terminology. American Medical Association website. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-editorial-panel.page. Accessed March 23, 2016.
3. The Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs). Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed March 23, 2016.
4. Text of the Medicare Access and CHIP Reauthorization Act of 2015. GovTrack website. https://www.govtrack.us/congress/bills/114/hr2/text. Accessed March 23, 2016.
5. Physicians/Nonphysician Practitioners. Medicare Claims Processing Manual. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed March 23, 2016.
6. American Medical Association. The RVS update committee. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/the-rvs-update-committee.page?. Accessed March 23, 2016.
7. Details for title: CMS-1631-FC. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Physician FeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1631-FC.html. Published November 16, 2015. Accessed March 23, 2016.
New Codes for 2016
In 2016, noninvasive imaging in dermatology finally received recognition at the Current Procedural Terminology (CPT) level with the publication of 6 new Category I codes for reflectance confocal microscopy.1 These new codes are classified under the “Special Dermatological Procedures” section of CPT where codes do not have technical and professional payment splits, unlike pathology codes (Table). Currently, the new codes for reflectance confocal microscopy can only be implemented when using the VivaScope 1500 (Caliber I.D.) reflectance confocal imaging system and not with any other devices. At present, these codes are priced by each insurer and should be payable, as they are Category I codes that meet all criteria for widely used procedures that are well supported by strong evidence.
Additionally, MelaFind (MELA Sciences) has received 2 Category III CPT codes in 2016: 0400T, multispectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high-risk melanocytic atypia [1–5 lesions]; 0401T, multispectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high-risk melanocytic atypia [≥6 lesions]).
The CPT Professional Edition notes that Category III codes are a set of temporary codes for emerging technology, services, and procedures that allow data collection for these services and procedures.1 Inclusion implies nothing about safety, efficacy, frequency of use, or payment. These codes are used to differentiate emerging technology from the widely accepted Category I codes and use of alphanumeric characters instead of 5-digit codes. If reading this paragraph makes you giddy all over, pay a visit to the American Medical Association website to learn more about the process by which CPT codes come to life.2
Policy and Coding Changes
Last year saw much sturm and drang with the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).3 The MACRA repealed the Sustainable Growth Rate formula and established annual positive or flat-fee updates for 10 years. A 2-tracked fee update was instituted afterward. It also established the Merit-Based Incentive Payment System, which consolidates existing Medicare fee-for-service physician incentive programs, establishes a pathway for physicians to participate in alternative payment models including the patient-centered medical home, and makes a bunch of other changes to existing Medicare physician payment statutes. It is too early to say if and how it will work and if it will change dermatology. It could fail miserably or it could be a brave new world; stay tuned.3
On the coding front, MACRA prohibits across-the-board elimination of global periods that the Centers for Medicare & Medicaid Services (CMS) had previously announced.4 Instead, the CMS must develop and implement a process to gather data on services furnished during global periods based on a representative sample of physician data. The CMS can delay up to 5% of payments if it does not get the data it asks for and must work through the rulemaking process, which will impact medicine in 2019. Among our codes with nonzero global periods, the premalignant destruction codes 17000 and 17004, each of which contains the value of a 99212 established patient visit, are at the very apex of the hit list. It is not clear if the CMS will retrospectively pull medical records to evaluate the occurrence of the global visit or will prospectively have us use 99024, the code for a “[p]ostoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.”1 This code is not used unless your practice needs a “filler” code for nonreportable visits but that may change. Is this another unfunded mandate? Yes.
Clarifications also have been made for reporting superficial radiation therapy.1 Treatment delivery using energies below 1 MV are to be reported with CPT code 77401 and cannot be combined with radiation treatment delivery codes (77402, 77407, 77412), clinical treatment planning codes (77261–77263), treatment device development codes (77332–77334), isodose planning codes (77306, 77307, 77316–77318), radiation treatment management codes (77427, 77431, 77432, 77435, 77469, 77470, 77499), continuing medical physics consultation code (77336), and special physics consultation code (77370). Evaluation and management services may still be reported separately, when appropriate, in cases in which only superficial radiation therapy services (ie, 77401) are provided.1
Electronic brachytherapy for skin cancer has a new Category III tracking code (0394T [high-dose-rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed]) that is priced by the insurer. Noridian Healthcare Solutions pulled the plug on what many perceived as astronomical payments, but changes may be afoot, as its URL for their new policy was down at the time of publication, and there is still great variability in how payment is being made for these codes. For those interested in learning about perception, a visit to http://forums.studentdoctor.net/threads/electronic-brachy.1132531/ is in order, as the economic drivers to the utilization of this therapy are discussed in detail from the perspective of students and young physicians.
Although there are new telehealth codes for inpatient services and end-stage renal disease management, there are still none that are relevant to dermatology.
Place of service codes have been updated. Place of service code 19 refers to “off campus outpatient hospital” settings while place of service code 22 has been revised to “on campus outpatient hospital.” If your practice is a facility, consult the Medicare Claims Processing Manual (20.4.2) on the site of service payment differential for further enlightenment.5 Do note that CMS is increasingly interested in physicians who use wrong place of service codes.
Incident to billing rules are somewhat clearer. The physician or other practitioner who bills must be the supervising physician or practitioner. Services cannot be provided by individuals who have been excluded from Medicare, Medicaid, or other federal programs, nor can they be provided by an individual who has had Medicare enrollment revoked. State laws that are more restrictive take precedence.
Of course, the Relative Value Scale Update Committee (RUC) process moves on as always and you likely will receive 1 or more surveys in the near future. If you get one of these surveys, do not delete it. The surveys are the currency of the RUC, and if you give your RUC team bad or no data, the specialty will suffer cuts in valuation of what we do. If you have questions about the survey, contact the American Academy of Dermatology staff as listed in the survey. If you want to learn more about RUC, visit the American Medical Association website.6 To see the current relative value units for what dermatologists do and the typical time for these procedures, visit the CMS website, which provides resources that supply tremendous amounts of data on code valuation including documents detailing relative value units for every CPT code.7 You also can access current time values for preservice work, intraservice work, and postservice work times for all CPT codes in the entire CPT Professional Edition. They are based on typical times and are the major determinants of what you get paid. Happy reading.
New Codes for 2016
In 2016, noninvasive imaging in dermatology finally received recognition at the Current Procedural Terminology (CPT) level with the publication of 6 new Category I codes for reflectance confocal microscopy.1 These new codes are classified under the “Special Dermatological Procedures” section of CPT where codes do not have technical and professional payment splits, unlike pathology codes (Table). Currently, the new codes for reflectance confocal microscopy can only be implemented when using the VivaScope 1500 (Caliber I.D.) reflectance confocal imaging system and not with any other devices. At present, these codes are priced by each insurer and should be payable, as they are Category I codes that meet all criteria for widely used procedures that are well supported by strong evidence.
Additionally, MelaFind (MELA Sciences) has received 2 Category III CPT codes in 2016: 0400T, multispectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high-risk melanocytic atypia [1–5 lesions]; 0401T, multispectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high-risk melanocytic atypia [≥6 lesions]).
The CPT Professional Edition notes that Category III codes are a set of temporary codes for emerging technology, services, and procedures that allow data collection for these services and procedures.1 Inclusion implies nothing about safety, efficacy, frequency of use, or payment. These codes are used to differentiate emerging technology from the widely accepted Category I codes and use of alphanumeric characters instead of 5-digit codes. If reading this paragraph makes you giddy all over, pay a visit to the American Medical Association website to learn more about the process by which CPT codes come to life.2
Policy and Coding Changes
Last year saw much sturm and drang with the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).3 The MACRA repealed the Sustainable Growth Rate formula and established annual positive or flat-fee updates for 10 years. A 2-tracked fee update was instituted afterward. It also established the Merit-Based Incentive Payment System, which consolidates existing Medicare fee-for-service physician incentive programs, establishes a pathway for physicians to participate in alternative payment models including the patient-centered medical home, and makes a bunch of other changes to existing Medicare physician payment statutes. It is too early to say if and how it will work and if it will change dermatology. It could fail miserably or it could be a brave new world; stay tuned.3
On the coding front, MACRA prohibits across-the-board elimination of global periods that the Centers for Medicare & Medicaid Services (CMS) had previously announced.4 Instead, the CMS must develop and implement a process to gather data on services furnished during global periods based on a representative sample of physician data. The CMS can delay up to 5% of payments if it does not get the data it asks for and must work through the rulemaking process, which will impact medicine in 2019. Among our codes with nonzero global periods, the premalignant destruction codes 17000 and 17004, each of which contains the value of a 99212 established patient visit, are at the very apex of the hit list. It is not clear if the CMS will retrospectively pull medical records to evaluate the occurrence of the global visit or will prospectively have us use 99024, the code for a “[p]ostoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.”1 This code is not used unless your practice needs a “filler” code for nonreportable visits but that may change. Is this another unfunded mandate? Yes.
Clarifications also have been made for reporting superficial radiation therapy.1 Treatment delivery using energies below 1 MV are to be reported with CPT code 77401 and cannot be combined with radiation treatment delivery codes (77402, 77407, 77412), clinical treatment planning codes (77261–77263), treatment device development codes (77332–77334), isodose planning codes (77306, 77307, 77316–77318), radiation treatment management codes (77427, 77431, 77432, 77435, 77469, 77470, 77499), continuing medical physics consultation code (77336), and special physics consultation code (77370). Evaluation and management services may still be reported separately, when appropriate, in cases in which only superficial radiation therapy services (ie, 77401) are provided.1
Electronic brachytherapy for skin cancer has a new Category III tracking code (0394T [high-dose-rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed]) that is priced by the insurer. Noridian Healthcare Solutions pulled the plug on what many perceived as astronomical payments, but changes may be afoot, as its URL for their new policy was down at the time of publication, and there is still great variability in how payment is being made for these codes. For those interested in learning about perception, a visit to http://forums.studentdoctor.net/threads/electronic-brachy.1132531/ is in order, as the economic drivers to the utilization of this therapy are discussed in detail from the perspective of students and young physicians.
Although there are new telehealth codes for inpatient services and end-stage renal disease management, there are still none that are relevant to dermatology.
Place of service codes have been updated. Place of service code 19 refers to “off campus outpatient hospital” settings while place of service code 22 has been revised to “on campus outpatient hospital.” If your practice is a facility, consult the Medicare Claims Processing Manual (20.4.2) on the site of service payment differential for further enlightenment.5 Do note that CMS is increasingly interested in physicians who use wrong place of service codes.
Incident to billing rules are somewhat clearer. The physician or other practitioner who bills must be the supervising physician or practitioner. Services cannot be provided by individuals who have been excluded from Medicare, Medicaid, or other federal programs, nor can they be provided by an individual who has had Medicare enrollment revoked. State laws that are more restrictive take precedence.
Of course, the Relative Value Scale Update Committee (RUC) process moves on as always and you likely will receive 1 or more surveys in the near future. If you get one of these surveys, do not delete it. The surveys are the currency of the RUC, and if you give your RUC team bad or no data, the specialty will suffer cuts in valuation of what we do. If you have questions about the survey, contact the American Academy of Dermatology staff as listed in the survey. If you want to learn more about RUC, visit the American Medical Association website.6 To see the current relative value units for what dermatologists do and the typical time for these procedures, visit the CMS website, which provides resources that supply tremendous amounts of data on code valuation including documents detailing relative value units for every CPT code.7 You also can access current time values for preservice work, intraservice work, and postservice work times for all CPT codes in the entire CPT Professional Edition. They are based on typical times and are the major determinants of what you get paid. Happy reading.
1. Current Procedural Terminology 2016, Professional Edition. Chicago, IL: American Medical Association; 2015.
2. CPT–Current Procedural Terminology. American Medical Association website. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-editorial-panel.page. Accessed March 23, 2016.
3. The Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs). Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed March 23, 2016.
4. Text of the Medicare Access and CHIP Reauthorization Act of 2015. GovTrack website. https://www.govtrack.us/congress/bills/114/hr2/text. Accessed March 23, 2016.
5. Physicians/Nonphysician Practitioners. Medicare Claims Processing Manual. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed March 23, 2016.
6. American Medical Association. The RVS update committee. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/the-rvs-update-committee.page?. Accessed March 23, 2016.
7. Details for title: CMS-1631-FC. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Physician FeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1631-FC.html. Published November 16, 2015. Accessed March 23, 2016.
1. Current Procedural Terminology 2016, Professional Edition. Chicago, IL: American Medical Association; 2015.
2. CPT–Current Procedural Terminology. American Medical Association website. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-editorial-panel.page. Accessed March 23, 2016.
3. The Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs). Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed March 23, 2016.
4. Text of the Medicare Access and CHIP Reauthorization Act of 2015. GovTrack website. https://www.govtrack.us/congress/bills/114/hr2/text. Accessed March 23, 2016.
5. Physicians/Nonphysician Practitioners. Medicare Claims Processing Manual. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed March 23, 2016.
6. American Medical Association. The RVS update committee. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/the-rvs-update-committee.page?. Accessed March 23, 2016.
7. Details for title: CMS-1631-FC. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Physician FeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1631-FC.html. Published November 16, 2015. Accessed March 23, 2016.
Practice Points
- Many dermatology codes are in the “Special Dermatological Procedures” section of the Current Procedural Terminology (CPT) manual.
- Physicians should purchase a new CPT manual every year, as accurate coding is critical for accurate reimbursement.
IDSA, SHEA release inpatient antibiotic stewardship guidelines
The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have jointly released evidence-based guidelines for implementing an inpatient antibiotic stewardship program.
The guidelines, published April 13 online in Clinical Infectious Diseases, address the optimal use of antibiotics in inpatient populations, and were prepared by a multidisciplinary expert panel of the IDSA and the SHEA, which included representation from the specialties of internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases.
Antibiotic stewardship has been defined by IDSA, SHEA, and the Pediatric Infectious Diseases Society as “coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration.” The new guidelines discuss a broad range of possible interventions, but the authors emphasize the need “for each site to assess its clinical needs and available resources and individualize its [antibiotic stewardship program] with that assessment in mind.”
The process used in the development of the guidelines included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, according to Dr. Tamar F. Barlam of the section of infectious diseases at Boston University, and her colleagues.
“The benefits of antibiotic stewardship include improved patient outcomes, reduced adverse events including Clostridium difficile infection, improvement in rates of antibiotic susceptibilities to targeted antibiotics, and optimization of resource utilization across the continuum of care,” Dr. Barlam and her coauthors wrote.
A complete list of any potential conflicts of interest for the multiple coauthors is provided with the full stewardship guidelines, which can be reviewed in Clinical Infectious Diseases (doi: 10.1093/cid/ciw118).
On Twitter @richpizzi
The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have jointly released evidence-based guidelines for implementing an inpatient antibiotic stewardship program.
The guidelines, published April 13 online in Clinical Infectious Diseases, address the optimal use of antibiotics in inpatient populations, and were prepared by a multidisciplinary expert panel of the IDSA and the SHEA, which included representation from the specialties of internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases.
Antibiotic stewardship has been defined by IDSA, SHEA, and the Pediatric Infectious Diseases Society as “coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration.” The new guidelines discuss a broad range of possible interventions, but the authors emphasize the need “for each site to assess its clinical needs and available resources and individualize its [antibiotic stewardship program] with that assessment in mind.”
The process used in the development of the guidelines included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, according to Dr. Tamar F. Barlam of the section of infectious diseases at Boston University, and her colleagues.
“The benefits of antibiotic stewardship include improved patient outcomes, reduced adverse events including Clostridium difficile infection, improvement in rates of antibiotic susceptibilities to targeted antibiotics, and optimization of resource utilization across the continuum of care,” Dr. Barlam and her coauthors wrote.
A complete list of any potential conflicts of interest for the multiple coauthors is provided with the full stewardship guidelines, which can be reviewed in Clinical Infectious Diseases (doi: 10.1093/cid/ciw118).
On Twitter @richpizzi
The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have jointly released evidence-based guidelines for implementing an inpatient antibiotic stewardship program.
The guidelines, published April 13 online in Clinical Infectious Diseases, address the optimal use of antibiotics in inpatient populations, and were prepared by a multidisciplinary expert panel of the IDSA and the SHEA, which included representation from the specialties of internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases.
Antibiotic stewardship has been defined by IDSA, SHEA, and the Pediatric Infectious Diseases Society as “coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration.” The new guidelines discuss a broad range of possible interventions, but the authors emphasize the need “for each site to assess its clinical needs and available resources and individualize its [antibiotic stewardship program] with that assessment in mind.”
The process used in the development of the guidelines included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, according to Dr. Tamar F. Barlam of the section of infectious diseases at Boston University, and her colleagues.
“The benefits of antibiotic stewardship include improved patient outcomes, reduced adverse events including Clostridium difficile infection, improvement in rates of antibiotic susceptibilities to targeted antibiotics, and optimization of resource utilization across the continuum of care,” Dr. Barlam and her coauthors wrote.
A complete list of any potential conflicts of interest for the multiple coauthors is provided with the full stewardship guidelines, which can be reviewed in Clinical Infectious Diseases (doi: 10.1093/cid/ciw118).
On Twitter @richpizzi
FROM CLINICAL INFECTIOUS DISEASES
