Survivors of childhood acute lymphoblastic leukemia (ALL) who underwent CNS-directed chemotherapy show significant attention problems that impair their functioning 2 years later, according to a report published online Feb. 8 in the Journal of Clinical Oncology.

The attention problems were isolated from intelligence and academic performance, but they still “significantly and negatively impact real-world functioning,” said Lisa M. Jacola, Ph.D. of the department of psychology and her associates at St. Jude Children’s Research Hospital, Memphis (J Clin Oncol. 2016 Feb 8. [doi: 10.1200/JCO.2015.64.3205]).

Intrathecal chemotherapy has largely replaced cranial radiation therapy to protect the CNS in childhood ALL, but most research concerning neurocognitive outcomes after this treatment has been retrospective and has involved small sample sizes. So investigators performed a prospective study using data from an ongoing trial involving a representative cohort of more than 400 patients aged 1-18 years who were treated at a single center during a 7-year period.

These patients were classified as low- or high-risk based on comprehensive biologic and clinical factors, such as blast cell immunophenotype and genotype, presenting clinical features, and early treatment response. They then received intrathecal methotrexate, cytarabine, and hydrocortisone in doses appropriate to their risk status, as well as standardized leucovorin followed by mercaptopurine and vincristine plus dexamethasone.

The researchers focused on the 211 patients who underwent comprehensive neurocognitive assessment 2 years after diagnosis and treatment. “The overall group did not significantly differ from normative expectations on measures of global intelligence (estimated IQ), academic skills (reading, math, or spelling), and learning and memory.” However, half of them were rated as below average on several measures of attention. In addition, caregivers reported a significantly greater than expected frequency of hyperactivity, impulsivity, and learning problems in the children.

This adverse effect was strongest among children who were younger than age 5 at diagnosis and among those at high risk who received more aggressive treatment.

“Our findings ... emphasize the importance of routine neurocognitive monitoring of all survivors treated with contemporary therapy.” But early detection will only be helpful if effective interventions are developed to remediate these attention and behavior problems. Research has shown that pharmacologic therapies “have reduced acceptability among survivors of childhood cancer,” so nonpharmacologic approaches would be especially useful, the researchers added.

Survivors of childhood acute lymphoblastic leukemia (ALL) who underwent CNS-directed chemotherapy show significant attention problems that impair their functioning 2 years later, according to a report published online Feb. 8 in the Journal of Clinical Oncology.

The attention problems were isolated from intelligence and academic performance, but they still “significantly and negatively impact real-world functioning,” said Lisa M. Jacola, Ph.D. of the department of psychology and her associates at St. Jude Children’s Research Hospital, Memphis (J Clin Oncol. 2016 Feb 8. [doi: 10.1200/JCO.2015.64.3205]).

Intrathecal chemotherapy has largely replaced cranial radiation therapy to protect the CNS in childhood ALL, but most research concerning neurocognitive outcomes after this treatment has been retrospective and has involved small sample sizes. So investigators performed a prospective study using data from an ongoing trial involving a representative cohort of more than 400 patients aged 1-18 years who were treated at a single center during a 7-year period.

These patients were classified as low- or high-risk based on comprehensive biologic and clinical factors, such as blast cell immunophenotype and genotype, presenting clinical features, and early treatment response. They then received intrathecal methotrexate, cytarabine, and hydrocortisone in doses appropriate to their risk status, as well as standardized leucovorin followed by mercaptopurine and vincristine plus dexamethasone.

The researchers focused on the 211 patients who underwent comprehensive neurocognitive assessment 2 years after diagnosis and treatment. “The overall group did not significantly differ from normative expectations on measures of global intelligence (estimated IQ), academic skills (reading, math, or spelling), and learning and memory.” However, half of them were rated as below average on several measures of attention. In addition, caregivers reported a significantly greater than expected frequency of hyperactivity, impulsivity, and learning problems in the children.

This adverse effect was strongest among children who were younger than age 5 at diagnosis and among those at high risk who received more aggressive treatment.

“Our findings ... emphasize the importance of routine neurocognitive monitoring of all survivors treated with contemporary therapy.” But early detection will only be helpful if effective interventions are developed to remediate these attention and behavior problems. Research has shown that pharmacologic therapies “have reduced acceptability among survivors of childhood cancer,” so nonpharmacologic approaches would be especially useful, the researchers added.

Survivors of childhood acute lymphoblastic leukemia (ALL) who underwent CNS-directed chemotherapy show significant attention problems that impair their functioning 2 years later, according to a report published online Feb. 8 in the Journal of Clinical Oncology.

The attention problems were isolated from intelligence and academic performance, but they still “significantly and negatively impact real-world functioning,” said Lisa M. Jacola, Ph.D. of the department of psychology and her associates at St. Jude Children’s Research Hospital, Memphis (J Clin Oncol. 2016 Feb 8. [doi: 10.1200/JCO.2015.64.3205]).

Intrathecal chemotherapy has largely replaced cranial radiation therapy to protect the CNS in childhood ALL, but most research concerning neurocognitive outcomes after this treatment has been retrospective and has involved small sample sizes. So investigators performed a prospective study using data from an ongoing trial involving a representative cohort of more than 400 patients aged 1-18 years who were treated at a single center during a 7-year period.

These patients were classified as low- or high-risk based on comprehensive biologic and clinical factors, such as blast cell immunophenotype and genotype, presenting clinical features, and early treatment response. They then received intrathecal methotrexate, cytarabine, and hydrocortisone in doses appropriate to their risk status, as well as standardized leucovorin followed by mercaptopurine and vincristine plus dexamethasone.

The researchers focused on the 211 patients who underwent comprehensive neurocognitive assessment 2 years after diagnosis and treatment. “The overall group did not significantly differ from normative expectations on measures of global intelligence (estimated IQ), academic skills (reading, math, or spelling), and learning and memory.” However, half of them were rated as below average on several measures of attention. In addition, caregivers reported a significantly greater than expected frequency of hyperactivity, impulsivity, and learning problems in the children.

This adverse effect was strongest among children who were younger than age 5 at diagnosis and among those at high risk who received more aggressive treatment.

“Our findings ... emphasize the importance of routine neurocognitive monitoring of all survivors treated with contemporary therapy.” But early detection will only be helpful if effective interventions are developed to remediate these attention and behavior problems. Research has shown that pharmacologic therapies “have reduced acceptability among survivors of childhood cancer,” so nonpharmacologic approaches would be especially useful, the researchers added.

AATS Week 2016 Registration & Housing Open!

AATS Week 2016 includes Two Terrific Events

Aortic Symposium
May 12–13, 2016
New York, NY

96th Annual Meeting
May 14-18, 2016
Baltimore, MD

Register for AATS Week 2016 today & receive a $100 discount off the AATS Aortic Symposium registration fee

Registration & Housing Now Open: Register online or via phone or mail/fax.

Online
Phone: Customer Service Desk: (US) 800- 424-5249; (International) 847-996-5829
Mail/fax: Get the registration form online. By mail: AATS/Experient, 5202 Presidents Court, Frederick, MD 21705 with check and credit card information. By fax: 301-694-5124.

Take Advantage of These AATS Annual Meeting Opportunities

Annual Meeting Registration Packages

Health Care Professional Package: Includes registration for the Saturday Courses, Sunday Symposium and the 96th Annual Meeting (Monday-Wednesday). Register before March 25, 2016 for only $400, after which the fee goes up to $500 — a savings of $300.

Resident/Fellow and Medical Student Package: Includes registration for the Saturday Courses, Sunday Symposium and the 96th Annual Meeting (Monday-Wednesday). Register before March 25, 2016 and attend for no charge. After that date, the fee is $300 — a savings of $300.

Saturday Courses and Sunday Symposium Registration: Register for a Saturday course and/or a Sunday symposium and have access to all other courses/symposia taking place that same day. Note: Registration for the Saturday courses and/or Sunday symposium is separate from the Annual Meeting fee.

Learn More 

AATS Aortic Symposium
May 12–13, 2016
New York, NY

Course Directors
Joseph S. Coselli
Steven L. Lansman

The 2016 AATS Aortic Symposium is a two-day symposium focused on the pathophysiology, diagnosis and treatment of aortic aneurysms and dissections. The conference is designed for cardiovascular and thoracic surgeons, residents, perfusionists, ICU and OR nurses and others involved in aortic disease patient care. Faculty members include world leaders in the field who will share their experiences treating difficult aortic disease cases.

View Preliminary Program, Speakers, Presentations & Full Abstracts 

AATS 96th Annual Meeting
May 14-18, 2016
Baltimore, MD

President & Annual Meeting ChaiR
Joseph S. Coselli

Annual Meeting Co-Chairs
Charles D. Fraser
David R. Jones

View Preliminary Program, Speakers, Presentations and Full Abstracts

The 96th Annual Meeting is a five-day program of state-of-the-art presentations by renowned experts. Attendees will enhance their knowledge and skills in a wide-range of subjects including general and specialized cardiac surgery, emerging technologies, congenital heart disease, critical care and aortic/endovascular surgery.

Don’t miss this year’s exciting program including:

Saturday Skills Courses featuring Combined Luncheon Speaker: Denton A. Cooley, followed by Hands-On Sessions

Sunday Postgraduate Symposia with Legends Luncheons featuring Joel D. Cooper and John L. Ochsner

New: Survival Guide for the Cardiothoracic Surgical Team course following by a Hands-On Session (Available to Residents, Fellows and Health Care Professionals Only)

Presidential Address: Competition: Perspiration to Inspiration “Aut viam inveniam aut faciam”, Joseph S. Coselli, Baylor College of Medicine

Basic Science Lecture: Stopping Incurable Cancers through Eliminating their Anti-Oxidative Defenses, James D. Watson, a Nobel Prize-winning biophysicist and researcher who is credited with co-discovering the double-helix structure of DNA.

Honored Guest Lecture: Brian Kelly, Notre Dame Head Football Coach and a veteran of 23 seasons as a collegiate head coach. Brian Kelly brings a championship tradition to his fifth year as the 29th head football coach at the University of Notre Dame.

Emerging Technologies & Techniques Fora: Adult Cardiac and General Thoracic

VAD/ECMO Session

Masters of Surgery: Video Sessions

AATS Learning Center: Featuring cutting-edge case videos of novel procedures and surgical techniques.

AATS Week 2016 Registration & Housing Open!

AATS Week 2016 includes Two Terrific Events

Aortic Symposium
May 12–13, 2016
New York, NY

96th Annual Meeting
May 14-18, 2016
Baltimore, MD

Register for AATS Week 2016 today & receive a $100 discount off the AATS Aortic Symposium registration fee

Registration & Housing Now Open: Register online or via phone or mail/fax.

Online
Phone: Customer Service Desk: (US) 800- 424-5249; (International) 847-996-5829
Mail/fax: Get the registration form online. By mail: AATS/Experient, 5202 Presidents Court, Frederick, MD 21705 with check and credit card information. By fax: 301-694-5124.

Take Advantage of These AATS Annual Meeting Opportunities

Annual Meeting Registration Packages

Health Care Professional Package: Includes registration for the Saturday Courses, Sunday Symposium and the 96th Annual Meeting (Monday-Wednesday). Register before March 25, 2016 for only $400, after which the fee goes up to $500 — a savings of $300.

Resident/Fellow and Medical Student Package: Includes registration for the Saturday Courses, Sunday Symposium and the 96th Annual Meeting (Monday-Wednesday). Register before March 25, 2016 and attend for no charge. After that date, the fee is $300 — a savings of $300.

Saturday Courses and Sunday Symposium Registration: Register for a Saturday course and/or a Sunday symposium and have access to all other courses/symposia taking place that same day. Note: Registration for the Saturday courses and/or Sunday symposium is separate from the Annual Meeting fee.

Learn More 

AATS Aortic Symposium
May 12–13, 2016
New York, NY

Course Directors
Joseph S. Coselli
Steven L. Lansman

The 2016 AATS Aortic Symposium is a two-day symposium focused on the pathophysiology, diagnosis and treatment of aortic aneurysms and dissections. The conference is designed for cardiovascular and thoracic surgeons, residents, perfusionists, ICU and OR nurses and others involved in aortic disease patient care. Faculty members include world leaders in the field who will share their experiences treating difficult aortic disease cases.

View Preliminary Program, Speakers, Presentations & Full Abstracts 

AATS 96th Annual Meeting
May 14-18, 2016
Baltimore, MD

President & Annual Meeting ChaiR
Joseph S. Coselli

Annual Meeting Co-Chairs
Charles D. Fraser
David R. Jones

View Preliminary Program, Speakers, Presentations and Full Abstracts

The 96th Annual Meeting is a five-day program of state-of-the-art presentations by renowned experts. Attendees will enhance their knowledge and skills in a wide-range of subjects including general and specialized cardiac surgery, emerging technologies, congenital heart disease, critical care and aortic/endovascular surgery.

Don’t miss this year’s exciting program including:

Saturday Skills Courses featuring Combined Luncheon Speaker: Denton A. Cooley, followed by Hands-On Sessions

Sunday Postgraduate Symposia with Legends Luncheons featuring Joel D. Cooper and John L. Ochsner

New: Survival Guide for the Cardiothoracic Surgical Team course following by a Hands-On Session (Available to Residents, Fellows and Health Care Professionals Only)

Presidential Address: Competition: Perspiration to Inspiration “Aut viam inveniam aut faciam”, Joseph S. Coselli, Baylor College of Medicine

Basic Science Lecture: Stopping Incurable Cancers through Eliminating their Anti-Oxidative Defenses, James D. Watson, a Nobel Prize-winning biophysicist and researcher who is credited with co-discovering the double-helix structure of DNA.

Honored Guest Lecture: Brian Kelly, Notre Dame Head Football Coach and a veteran of 23 seasons as a collegiate head coach. Brian Kelly brings a championship tradition to his fifth year as the 29th head football coach at the University of Notre Dame.

Emerging Technologies & Techniques Fora: Adult Cardiac and General Thoracic

VAD/ECMO Session

Masters of Surgery: Video Sessions

AATS Learning Center: Featuring cutting-edge case videos of novel procedures and surgical techniques.

AATS Week 2016 Registration & Housing Open!

AATS Week 2016 includes Two Terrific Events

Aortic Symposium
May 12–13, 2016
New York, NY

96th Annual Meeting
May 14-18, 2016
Baltimore, MD

Register for AATS Week 2016 today & receive a $100 discount off the AATS Aortic Symposium registration fee

Registration & Housing Now Open: Register online or via phone or mail/fax.

Online
Phone: Customer Service Desk: (US) 800- 424-5249; (International) 847-996-5829
Mail/fax: Get the registration form online. By mail: AATS/Experient, 5202 Presidents Court, Frederick, MD 21705 with check and credit card information. By fax: 301-694-5124.

Take Advantage of These AATS Annual Meeting Opportunities

Annual Meeting Registration Packages

Health Care Professional Package: Includes registration for the Saturday Courses, Sunday Symposium and the 96th Annual Meeting (Monday-Wednesday). Register before March 25, 2016 for only $400, after which the fee goes up to $500 — a savings of $300.

Resident/Fellow and Medical Student Package: Includes registration for the Saturday Courses, Sunday Symposium and the 96th Annual Meeting (Monday-Wednesday). Register before March 25, 2016 and attend for no charge. After that date, the fee is $300 — a savings of $300.

Saturday Courses and Sunday Symposium Registration: Register for a Saturday course and/or a Sunday symposium and have access to all other courses/symposia taking place that same day. Note: Registration for the Saturday courses and/or Sunday symposium is separate from the Annual Meeting fee.

Learn More 

AATS Aortic Symposium
May 12–13, 2016
New York, NY

Course Directors
Joseph S. Coselli
Steven L. Lansman

The 2016 AATS Aortic Symposium is a two-day symposium focused on the pathophysiology, diagnosis and treatment of aortic aneurysms and dissections. The conference is designed for cardiovascular and thoracic surgeons, residents, perfusionists, ICU and OR nurses and others involved in aortic disease patient care. Faculty members include world leaders in the field who will share their experiences treating difficult aortic disease cases.

View Preliminary Program, Speakers, Presentations & Full Abstracts 

AATS 96th Annual Meeting
May 14-18, 2016
Baltimore, MD

President & Annual Meeting ChaiR
Joseph S. Coselli

Annual Meeting Co-Chairs
Charles D. Fraser
David R. Jones

View Preliminary Program, Speakers, Presentations and Full Abstracts

The 96th Annual Meeting is a five-day program of state-of-the-art presentations by renowned experts. Attendees will enhance their knowledge and skills in a wide-range of subjects including general and specialized cardiac surgery, emerging technologies, congenital heart disease, critical care and aortic/endovascular surgery.

Don’t miss this year’s exciting program including:

Saturday Skills Courses featuring Combined Luncheon Speaker: Denton A. Cooley, followed by Hands-On Sessions

Sunday Postgraduate Symposia with Legends Luncheons featuring Joel D. Cooper and John L. Ochsner

New: Survival Guide for the Cardiothoracic Surgical Team course following by a Hands-On Session (Available to Residents, Fellows and Health Care Professionals Only)

Presidential Address: Competition: Perspiration to Inspiration “Aut viam inveniam aut faciam”, Joseph S. Coselli, Baylor College of Medicine

Basic Science Lecture: Stopping Incurable Cancers through Eliminating their Anti-Oxidative Defenses, James D. Watson, a Nobel Prize-winning biophysicist and researcher who is credited with co-discovering the double-helix structure of DNA.

Honored Guest Lecture: Brian Kelly, Notre Dame Head Football Coach and a veteran of 23 seasons as a collegiate head coach. Brian Kelly brings a championship tradition to his fifth year as the 29th head football coach at the University of Notre Dame.

Emerging Technologies & Techniques Fora: Adult Cardiac and General Thoracic

VAD/ECMO Session

Masters of Surgery: Video Sessions

AATS Learning Center: Featuring cutting-edge case videos of novel procedures and surgical techniques.

Listen to more of our interview with Robert Blendon, professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health and Harvard Kennedy School of Government.

Listen to more of our interview with Robert Blendon, professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health and Harvard Kennedy School of Government.

Listen to more of our interview with Robert Blendon, professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health and Harvard Kennedy School of Government.

Kendall Rogers, MD, SFHM, chair of SHM’s Health IT Committee, discusses HM16 having a separate track for health IT, to whom the track is geared, and translating tech-savviness into actually being effective in helping to develop practical health IT.

Kendall Rogers, MD, SFHM, chair of SHM’s Health IT Committee, discusses HM16 having a separate track for health IT, to whom the track is geared, and translating tech-savviness into actually being effective in helping to develop practical health IT.

Kendall Rogers, MD, SFHM, chair of SHM’s Health IT Committee, discusses HM16 having a separate track for health IT, to whom the track is geared, and translating tech-savviness into actually being effective in helping to develop practical health IT.

Course Director Melissa Mattison, MD, SFHM, assistant professor of medicine at Harvard Medical School, talks about the SHM annual meeting's new emphasis on work-life balance and on how her past experience at the annual meeting influenced how she helped shape this year's meeting.

Course Director Melissa Mattison, MD, SFHM, assistant professor of medicine at Harvard Medical School, talks about the SHM annual meeting's new emphasis on work-life balance and on how her past experience at the annual meeting influenced how she helped shape this year's meeting.

Course Director Melissa Mattison, MD, SFHM, assistant professor of medicine at Harvard Medical School, talks about the SHM annual meeting's new emphasis on work-life balance and on how her past experience at the annual meeting influenced how she helped shape this year's meeting.

As Karen Smith, MD, SFHM, chief of hospital medicine at Children’s National Health System in Washington, D.C., sees it, communication problems often arise at the first possible opportunity, when she’s trying to find out whom to call when she needs to inform a primary care physician or specialist about a hospitalized patient. Sometimes, that information isn’t readily available.

“Which specialist is on and available to talk?” she says.

Then there’s timing.

“By the time we can set up a time to actually talk to people, it’s after normal business hours,” Dr. Smith says. “People aren’t answering their office phones after five. …Your other choice is going through the answering service, but then you get a variety of people and not the person who knows this patient.”

Dr. Smith spearheaded an effort to reach out in a more reliable fashion to community physicians, with a goal of speaking to—or, more commonly, leaving messages with—at least 90% of hospitalized patients’ physicians. They reached the goal, but it was an eye-opening effort.

“The feedback I got from the hospitalists was it’s ‘just so difficult,’” Dr. Smith says. “I’m sitting on the phone waiting to get ahold of someone. Even trying to use administrative people and have them call and contact us, which is kind of complicated to do.”

Yul Ejnes, MD, MACP, a past chair of the board of regents of the American College of Physicians and an internist at Coastal Medical in R.I., says that if he were grading hospitalist communication with primary care providers on a poor-fair-good-excellent scale, he would give it a “fair.”

“It runs the spectrum from getting nothing—which is rare, I have to say—to getting at least a notification that your patient is in the hospital: ‘Here’s a contact number,’ sometimes with diagnosis,” he says. “And, much less commonly, getting a phone call. That usually occurs when there are questions.”

Dr. Ejnes says consistent communication is not as “robust as I would like it to be.”

“Some institutions do much better than others, in terms of the hospitalist always letting us know patients have come in,” he says. “With others, it doesn’t seem to be part of the institutional culture.”

There has to be a better way.

And, in fact, Dr. Smith and many other hospitalists are developing ways to better use technology to communicate more effectively with primary care, specialists, nurses, and patients. The goal is to make communication more routine, more effective, and more convenient for both parties, all the while—hopefully—improving patient care and strengthening working relationships.

Most of the approaches are not ultra-high tech. Too high tech might, in itself, be a potential barrier to communication for those who might be uncomfortable with new technology. Instead, the initiatives are mostly common sense tweaks to—or new, logical uses of—existing technology.

EHR-Embedded Communication

At Children’s National, Dr. Smith and colleagues use a standardized letter as part of a patient’s electronic health record (EHR). In addition to facts about the patient’s condition, the EHR includes information that makes it easier for physicians to communicate.

“What’s lovely with that is that [the letter] tells the provider the team that they’re on,” she said, adding that teams are divided by letter and color. “It has information on how you can reach the doctor. All of our doctors carry a phone around with them, and so it’s got that number.”

The EHR also includes a note suggesting that physicians avoid calling during rounds and gives them information on how to access the portal, so they can follow along with the patient’s care, should they choose to do so.

The amount of actual contact from primary care physicians? Scarce. Maybe one of 20 pediatricians will actually place a call to the hospitalist, but the response she has received has been positive, Dr. Smith says.

The EHR note also includes a sentence further characterizing the patient’s care, such as: Bobby C. was admitted with bronchiolitis. He’s doing fine; I anticipate he will go home tomorrow.

“Pediatricians have loved that,” she says. “They say, ‘I know exactly what my patient’s there for. I had the ability to call if I want.’”

Smarter Pages

At Vanderbilt University Medical Center in Nashville, Tenn., hospitalists noticed a frequent occurrence with pages: Many times, the hospitalist would only receive a phone number.

“With that, you don’t know which patient it’s about, who called you, how urgent it is, or what they need,” says researcher Sunil Kripalani, MD, MSc, SFHM, associate professor and chief of the section of hospital medicine at Vanderbilt.

It’s a tough spot for a busy hospitalist, who might be on the phone or at a bedside with another patient when three, four, or even five pages come through. The page might just be an FYI requiring no callback. It might be urgent. It might be the same page sent multiple times from different numbers (e.g. nursing moving to various phones). Many times, Dr. Kripalani and his hospitalists have had no way to know.

Now, Vanderbilt has established an online template for text pages, with the following basic information:

• Patient;
• Room number;
• Urgency level;
• Name of the sender;
• Callback number;
• Message; and
• Whether or not a callback is needed.

“That structure is very helpful for allowing physicians to triage which pages to call back and how quickly,” Dr. Kripalani says.

He acknowledges it isn’t “fancy bells and whistles.”

“Sometimes it’s doing the basic things well that makes the difference,” he adds.

The “structured pages” have allowed the nature of pages to be analyzed. Dr. Kripalani and colleagues have found that approximately 5% of pages were about a patient’s dietary status. If the patient was ordered not to receive anything by mouth, pages asked, when did that order expire and what diet should the patient resume?

Now, a prompt for that information is included in the hospital’s order entry system, which has cut the number of pages sent.

Vanderbilt is now looking at other, similar ways to streamline communication.

Patients and iPads

At the University of Colorado Hospital in Denver, researchers had an idea to facilitate communication and patient education: Patients are always inquiring about their discharge status and other facets of their hospitalization; what if they got their own tablet to follow along with everything in real time?1

The only real requirements for the study were that patients had to have Internet access at home and an understanding of how to work a web browser, says Jonathan Pell, MD, SFHM, assistant professor of internal medicine at the University of Colorado in Aurora and a hospitalist at University of Colorado Hospital. Patients were shown how to access their schedule for the day, their medication list and dosing schedule, and test results. Much of the information was delivered in real time, so patients who were told that if a lab result came back at a certain level they could be discharged could perhaps start preparing for that possibility earlier than they might have otherwise.

Researchers found that their patients worried less and reported less confusion. They also found that providing the tablets didn’t cause any increase in workload for doctors or nurses.

Providers and nurses expected that patients would notice medication errors, but that endpoint was not significant. Surprisingly, patients’ understanding of discharge times did not live up to expectations. But the results overall were encouraging enough that the effort will continue.

“We have these mixed results,” Dr. Pell says. “I think it’s good to get something out there in the literature and see what else people may be interested in doing. Our next step is to potentially open up notes to patients and let them see their doctor’s and nurse’s notes during their hospitalization.”

He says that, in some cases, communication with patients is the most crucial channel for hospitalists.

“For the very engaged patient [who has] a busy primary care doctor who’s hard to get in touch with,” he explains, “using the patient, informing them well, and getting them all the information they need is actually the best way to make sure that transition of care is smooth.”

Discharge, Facebook-Style

New England Inpatient Specialists (NEIS), a hospitalist group in North Andover, Mass., has an interesting approach to discharge. Instead of a nurse picking up the phone to make a follow-up appointment for a patient leaving the hospital, a secretary posts a message on “Chatter,” a secure tool similar to Facebook. The technology was developed by Salesforce.com, which offers platforms mainly designed to assist businesses with communication.

The idea behind Chatter is that the primary care office personnel can respond to a post at a time that’s convenient to them.

“All of this is so time-consuming. Why would you want somebody like an RN spending 15 to 20 minutes on the phone setting up an appointment when she could be on the floor?” says Sawad Thotathil, MD, vice president of performance and physician recruitment at NEIS. “Our program secretary will just post a discharge, and then somebody at the practice will look at it when they can and find out what associated information is needed and answer at their own convenience.”

Dr. Thotathil’s group also has been using the Imprivata Cortext secure text messaging system for more than a year, with what he deems “overall positive” results. About 60% of the practices with which NEIS staff need to communicate have signed on to the system.

“That kind of helps in management,” he says. “Sometimes, a patient is in the hospital and you can text the cardiologist, asking if the patient can be taken on for a procedure. That kind of communication, which would have taken longer or would not have happened, is happening now.

“Have we been able to directly link it to better outcomes?” he adds. “No, we haven’t looked at it that way. But what we have seen is that there’s always going to be a variation in how many people in a network actually will use it. ... There are going to be those high users, and there are going to be those providers who are going to be minimally using it.”

Videoconferencing

Pediatric hospitalists at the main hospital at Children’s National have been helping to provide care to children who are seen at five community sites. Dr. Smith says the communication at these sites, mostly from the ED, in which the pediatric hospitalists are helping make medical decisions, has been dramatically enhanced.

“The visual aspect of it changes the whole conversation,” she says. “You could tell them the exact same thing verbally and they are like, ‘OK, that’s fine,’ and there doesn’t seem to be a true understanding of what I’m trying to impart to you. Once people look at the child, all of a sudden there is a true shared mental model of, ‘OK, I understand what you’re doing. What’s going on?’”

Hospitalists also have been spearheading videoconferencing at diabetes clinics, to provide better care at community sites.

“We know what the need is. We know the gap in care,” Dr. Smith says. “We’ve been able to advocate and get those specialists brought out to the community via telemedicine, if it’s too difficult to get out on a regular basis.”

There are no hard data on the effects of the programs, but Dr. Smith says the improvement is noticeable.

“Anecdotally, we’ve seen a decrease in kids coming in with DKA (diabetic ketoacidosis) to the emergency room, so we’ve been able to change some of the trajectory. Many of those kids just didn’t have access to care. [For some], it would be a day’s trip for them to get to one of the academic centers to get follow up. They just wouldn’t go.”

EHR-Facilitated Calls

At Cincinnati Children’s, phone contact with community pediatricians at discharge is established with remarkable consistency: 98% to 99% of the time. The reason? A communication system, “Priority Link,” is connected to the EHR.

When the hospitalist signs a discharge order, the patient’s name is put in a queue. An operator sends out a page to inform the resident that the call is about to be made to the outpatient physician, making sure they’re ready for the call to be made.

“The key innovation was that we were trying to make sure that the inpatient side of it was really ready for the call, so we weren’t placing calls out to doctors and then we weren’t ready,” says Jeffrey Simmons, MD, MSc, associate director of clinical operations and quality in Cincinnati Children’s hospital medicine division.

He says there has been some pushback from pediatricians who feel the calls don’t provide any more value than the discharge summary itself. But the opportunity for questions and for a dialogue makes the calls worthwhile, Dr. Simmons notes. The system could be improved by tailoring communications to the community physicians’ preference—via fax or email, perhaps—and by having the call placed by physicians who are more knowledgeable about the details of the case.

Priority Link also is used to help community physicians with direct admissions for patients who don’t need to go to the ED. The operator coordinates a three-way call among the community physician, the hospitalist, and a nurse familiar with the bed situation.

“That three-way call is really great because we’re big and busy enough that sometimes we need that nurse manager on the phone, too, to No. 1, let us know if there really is a bed and, No. 2, coordinate with the nursing unit,” he says. TH

Tom Collins is a freelance writer in South Florida.

Reference

Pell JM, Mancuso M, Limon S, Oman K, Lin CT. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi: 10.1001/jamainternmed.2015.121.

Sometimes, Communication Outside the Hospital Is the Problem

Yul Ejnes, MD, MACP, an internist at Coastal Medicine in R.I., and a past chair of the American College of Physician’s Board of Regents, points to the ACP’s “High Value Care” toolkit as a model for how primary care-hospitalist communication should take place.

The toolkit includes a suggested “agreement” between PCPs and the hospital care team, which calls for PCPs to provide pertinent information (i.e., reconciled medications lists, medical history, and advanced directives) to hospital teams upon notification of an admission. It also calls for establishing standard communication methods and discharge notifications and encourages hospitalists to keep PCPs updated on new developments, provide appropriate information to patients at discharge, and send a “concise discharge summary” to the PCP within 48 to 72 hours of discharge.

It’s a two-way street, Dr. Ejnes says. He also acknowledges that sometimes the problems are on the community physicians’ side. Phone calls can be highly valuable in this dynamic, but it is often difficult for internists to make or take those calls.

“Sitting where I am, in my office, I am certainly interested in what’s going on with my patients,” he says. “On the other hand, the inertia I have to overcome in order to get that information, when I’m in the middle of seeing a whole bunch of patients during my day, involves getting on the phone, punching some numbers, waiting for a call back, as opposed to having the information available on my screen automatically through some information technology solution.”

He has provided his staff with a list of contacts, including hospitalists, for whom he is to be interrupted in order to take calls.

Jeffrey Simmons, MD, MSc, of Cincinnati Children’s, says that in their effort to boost the reliability of placing calls to PCPs, his hospitalists found that confusion within primary care offices is a stumbling block.

“About half the time when we get complaints about this process, when we investigate, we learn that the major problem has been within the practice,” he says. “We may have made a call to Partner X and had a good conversation … [but] between then and when the patient sees Dr. Y, there’s been very little communication between Partner X and Partner Y.”

Setting up the right system is the key—on both ends, Dr. Ejnes says.

“It’s all about workflow,” he says. “If you can integrate these communications into the regular workflow of the physician, either community-based or hospitalist, it’s more likely to happen. Having the will to do it is the first step. But I think it’s got to be facilitated as much as possible.”

— Thomas R. Collins

As Karen Smith, MD, SFHM, chief of hospital medicine at Children’s National Health System in Washington, D.C., sees it, communication problems often arise at the first possible opportunity, when she’s trying to find out whom to call when she needs to inform a primary care physician or specialist about a hospitalized patient. Sometimes, that information isn’t readily available.

“Which specialist is on and available to talk?” she says.

Then there’s timing.

“By the time we can set up a time to actually talk to people, it’s after normal business hours,” Dr. Smith says. “People aren’t answering their office phones after five. …Your other choice is going through the answering service, but then you get a variety of people and not the person who knows this patient.”

Dr. Smith spearheaded an effort to reach out in a more reliable fashion to community physicians, with a goal of speaking to—or, more commonly, leaving messages with—at least 90% of hospitalized patients’ physicians. They reached the goal, but it was an eye-opening effort.

“The feedback I got from the hospitalists was it’s ‘just so difficult,’” Dr. Smith says. “I’m sitting on the phone waiting to get ahold of someone. Even trying to use administrative people and have them call and contact us, which is kind of complicated to do.”

Yul Ejnes, MD, MACP, a past chair of the board of regents of the American College of Physicians and an internist at Coastal Medical in R.I., says that if he were grading hospitalist communication with primary care providers on a poor-fair-good-excellent scale, he would give it a “fair.”

“It runs the spectrum from getting nothing—which is rare, I have to say—to getting at least a notification that your patient is in the hospital: ‘Here’s a contact number,’ sometimes with diagnosis,” he says. “And, much less commonly, getting a phone call. That usually occurs when there are questions.”

Dr. Ejnes says consistent communication is not as “robust as I would like it to be.”

“Some institutions do much better than others, in terms of the hospitalist always letting us know patients have come in,” he says. “With others, it doesn’t seem to be part of the institutional culture.”

There has to be a better way.

And, in fact, Dr. Smith and many other hospitalists are developing ways to better use technology to communicate more effectively with primary care, specialists, nurses, and patients. The goal is to make communication more routine, more effective, and more convenient for both parties, all the while—hopefully—improving patient care and strengthening working relationships.

Most of the approaches are not ultra-high tech. Too high tech might, in itself, be a potential barrier to communication for those who might be uncomfortable with new technology. Instead, the initiatives are mostly common sense tweaks to—or new, logical uses of—existing technology.

EHR-Embedded Communication

At Children’s National, Dr. Smith and colleagues use a standardized letter as part of a patient’s electronic health record (EHR). In addition to facts about the patient’s condition, the EHR includes information that makes it easier for physicians to communicate.

“What’s lovely with that is that [the letter] tells the provider the team that they’re on,” she said, adding that teams are divided by letter and color. “It has information on how you can reach the doctor. All of our doctors carry a phone around with them, and so it’s got that number.”

The EHR also includes a note suggesting that physicians avoid calling during rounds and gives them information on how to access the portal, so they can follow along with the patient’s care, should they choose to do so.

The amount of actual contact from primary care physicians? Scarce. Maybe one of 20 pediatricians will actually place a call to the hospitalist, but the response she has received has been positive, Dr. Smith says.

The EHR note also includes a sentence further characterizing the patient’s care, such as: Bobby C. was admitted with bronchiolitis. He’s doing fine; I anticipate he will go home tomorrow.

“Pediatricians have loved that,” she says. “They say, ‘I know exactly what my patient’s there for. I had the ability to call if I want.’”

Smarter Pages

At Vanderbilt University Medical Center in Nashville, Tenn., hospitalists noticed a frequent occurrence with pages: Many times, the hospitalist would only receive a phone number.

“With that, you don’t know which patient it’s about, who called you, how urgent it is, or what they need,” says researcher Sunil Kripalani, MD, MSc, SFHM, associate professor and chief of the section of hospital medicine at Vanderbilt.

It’s a tough spot for a busy hospitalist, who might be on the phone or at a bedside with another patient when three, four, or even five pages come through. The page might just be an FYI requiring no callback. It might be urgent. It might be the same page sent multiple times from different numbers (e.g. nursing moving to various phones). Many times, Dr. Kripalani and his hospitalists have had no way to know.

Now, Vanderbilt has established an online template for text pages, with the following basic information:

• Patient;
• Room number;
• Urgency level;
• Name of the sender;
• Callback number;
• Message; and
• Whether or not a callback is needed.

“That structure is very helpful for allowing physicians to triage which pages to call back and how quickly,” Dr. Kripalani says.

He acknowledges it isn’t “fancy bells and whistles.”

“Sometimes it’s doing the basic things well that makes the difference,” he adds.

The “structured pages” have allowed the nature of pages to be analyzed. Dr. Kripalani and colleagues have found that approximately 5% of pages were about a patient’s dietary status. If the patient was ordered not to receive anything by mouth, pages asked, when did that order expire and what diet should the patient resume?

Now, a prompt for that information is included in the hospital’s order entry system, which has cut the number of pages sent.

Vanderbilt is now looking at other, similar ways to streamline communication.

Patients and iPads

At the University of Colorado Hospital in Denver, researchers had an idea to facilitate communication and patient education: Patients are always inquiring about their discharge status and other facets of their hospitalization; what if they got their own tablet to follow along with everything in real time?1

The only real requirements for the study were that patients had to have Internet access at home and an understanding of how to work a web browser, says Jonathan Pell, MD, SFHM, assistant professor of internal medicine at the University of Colorado in Aurora and a hospitalist at University of Colorado Hospital. Patients were shown how to access their schedule for the day, their medication list and dosing schedule, and test results. Much of the information was delivered in real time, so patients who were told that if a lab result came back at a certain level they could be discharged could perhaps start preparing for that possibility earlier than they might have otherwise.

Researchers found that their patients worried less and reported less confusion. They also found that providing the tablets didn’t cause any increase in workload for doctors or nurses.

Providers and nurses expected that patients would notice medication errors, but that endpoint was not significant. Surprisingly, patients’ understanding of discharge times did not live up to expectations. But the results overall were encouraging enough that the effort will continue.

“We have these mixed results,” Dr. Pell says. “I think it’s good to get something out there in the literature and see what else people may be interested in doing. Our next step is to potentially open up notes to patients and let them see their doctor’s and nurse’s notes during their hospitalization.”

He says that, in some cases, communication with patients is the most crucial channel for hospitalists.

“For the very engaged patient [who has] a busy primary care doctor who’s hard to get in touch with,” he explains, “using the patient, informing them well, and getting them all the information they need is actually the best way to make sure that transition of care is smooth.”

Discharge, Facebook-Style

New England Inpatient Specialists (NEIS), a hospitalist group in North Andover, Mass., has an interesting approach to discharge. Instead of a nurse picking up the phone to make a follow-up appointment for a patient leaving the hospital, a secretary posts a message on “Chatter,” a secure tool similar to Facebook. The technology was developed by Salesforce.com, which offers platforms mainly designed to assist businesses with communication.

The idea behind Chatter is that the primary care office personnel can respond to a post at a time that’s convenient to them.

“All of this is so time-consuming. Why would you want somebody like an RN spending 15 to 20 minutes on the phone setting up an appointment when she could be on the floor?” says Sawad Thotathil, MD, vice president of performance and physician recruitment at NEIS. “Our program secretary will just post a discharge, and then somebody at the practice will look at it when they can and find out what associated information is needed and answer at their own convenience.”

Dr. Thotathil’s group also has been using the Imprivata Cortext secure text messaging system for more than a year, with what he deems “overall positive” results. About 60% of the practices with which NEIS staff need to communicate have signed on to the system.

“That kind of helps in management,” he says. “Sometimes, a patient is in the hospital and you can text the cardiologist, asking if the patient can be taken on for a procedure. That kind of communication, which would have taken longer or would not have happened, is happening now.

“Have we been able to directly link it to better outcomes?” he adds. “No, we haven’t looked at it that way. But what we have seen is that there’s always going to be a variation in how many people in a network actually will use it. ... There are going to be those high users, and there are going to be those providers who are going to be minimally using it.”

Videoconferencing

Pediatric hospitalists at the main hospital at Children’s National have been helping to provide care to children who are seen at five community sites. Dr. Smith says the communication at these sites, mostly from the ED, in which the pediatric hospitalists are helping make medical decisions, has been dramatically enhanced.

“The visual aspect of it changes the whole conversation,” she says. “You could tell them the exact same thing verbally and they are like, ‘OK, that’s fine,’ and there doesn’t seem to be a true understanding of what I’m trying to impart to you. Once people look at the child, all of a sudden there is a true shared mental model of, ‘OK, I understand what you’re doing. What’s going on?’”

Hospitalists also have been spearheading videoconferencing at diabetes clinics, to provide better care at community sites.

“We know what the need is. We know the gap in care,” Dr. Smith says. “We’ve been able to advocate and get those specialists brought out to the community via telemedicine, if it’s too difficult to get out on a regular basis.”

There are no hard data on the effects of the programs, but Dr. Smith says the improvement is noticeable.

“Anecdotally, we’ve seen a decrease in kids coming in with DKA (diabetic ketoacidosis) to the emergency room, so we’ve been able to change some of the trajectory. Many of those kids just didn’t have access to care. [For some], it would be a day’s trip for them to get to one of the academic centers to get follow up. They just wouldn’t go.”

EHR-Facilitated Calls

At Cincinnati Children’s, phone contact with community pediatricians at discharge is established with remarkable consistency: 98% to 99% of the time. The reason? A communication system, “Priority Link,” is connected to the EHR.

When the hospitalist signs a discharge order, the patient’s name is put in a queue. An operator sends out a page to inform the resident that the call is about to be made to the outpatient physician, making sure they’re ready for the call to be made.

“The key innovation was that we were trying to make sure that the inpatient side of it was really ready for the call, so we weren’t placing calls out to doctors and then we weren’t ready,” says Jeffrey Simmons, MD, MSc, associate director of clinical operations and quality in Cincinnati Children’s hospital medicine division.

He says there has been some pushback from pediatricians who feel the calls don’t provide any more value than the discharge summary itself. But the opportunity for questions and for a dialogue makes the calls worthwhile, Dr. Simmons notes. The system could be improved by tailoring communications to the community physicians’ preference—via fax or email, perhaps—and by having the call placed by physicians who are more knowledgeable about the details of the case.

Priority Link also is used to help community physicians with direct admissions for patients who don’t need to go to the ED. The operator coordinates a three-way call among the community physician, the hospitalist, and a nurse familiar with the bed situation.

“That three-way call is really great because we’re big and busy enough that sometimes we need that nurse manager on the phone, too, to No. 1, let us know if there really is a bed and, No. 2, coordinate with the nursing unit,” he says. TH

Tom Collins is a freelance writer in South Florida.

Reference

Pell JM, Mancuso M, Limon S, Oman K, Lin CT. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi: 10.1001/jamainternmed.2015.121.

Sometimes, Communication Outside the Hospital Is the Problem

Yul Ejnes, MD, MACP, an internist at Coastal Medicine in R.I., and a past chair of the American College of Physician’s Board of Regents, points to the ACP’s “High Value Care” toolkit as a model for how primary care-hospitalist communication should take place.

The toolkit includes a suggested “agreement” between PCPs and the hospital care team, which calls for PCPs to provide pertinent information (i.e., reconciled medications lists, medical history, and advanced directives) to hospital teams upon notification of an admission. It also calls for establishing standard communication methods and discharge notifications and encourages hospitalists to keep PCPs updated on new developments, provide appropriate information to patients at discharge, and send a “concise discharge summary” to the PCP within 48 to 72 hours of discharge.

It’s a two-way street, Dr. Ejnes says. He also acknowledges that sometimes the problems are on the community physicians’ side. Phone calls can be highly valuable in this dynamic, but it is often difficult for internists to make or take those calls.

“Sitting where I am, in my office, I am certainly interested in what’s going on with my patients,” he says. “On the other hand, the inertia I have to overcome in order to get that information, when I’m in the middle of seeing a whole bunch of patients during my day, involves getting on the phone, punching some numbers, waiting for a call back, as opposed to having the information available on my screen automatically through some information technology solution.”

He has provided his staff with a list of contacts, including hospitalists, for whom he is to be interrupted in order to take calls.

Jeffrey Simmons, MD, MSc, of Cincinnati Children’s, says that in their effort to boost the reliability of placing calls to PCPs, his hospitalists found that confusion within primary care offices is a stumbling block.

“About half the time when we get complaints about this process, when we investigate, we learn that the major problem has been within the practice,” he says. “We may have made a call to Partner X and had a good conversation … [but] between then and when the patient sees Dr. Y, there’s been very little communication between Partner X and Partner Y.”

Setting up the right system is the key—on both ends, Dr. Ejnes says.

“It’s all about workflow,” he says. “If you can integrate these communications into the regular workflow of the physician, either community-based or hospitalist, it’s more likely to happen. Having the will to do it is the first step. But I think it’s got to be facilitated as much as possible.”

— Thomas R. Collins

As Karen Smith, MD, SFHM, chief of hospital medicine at Children’s National Health System in Washington, D.C., sees it, communication problems often arise at the first possible opportunity, when she’s trying to find out whom to call when she needs to inform a primary care physician or specialist about a hospitalized patient. Sometimes, that information isn’t readily available.

“Which specialist is on and available to talk?” she says.

Then there’s timing.

“By the time we can set up a time to actually talk to people, it’s after normal business hours,” Dr. Smith says. “People aren’t answering their office phones after five. …Your other choice is going through the answering service, but then you get a variety of people and not the person who knows this patient.”

Dr. Smith spearheaded an effort to reach out in a more reliable fashion to community physicians, with a goal of speaking to—or, more commonly, leaving messages with—at least 90% of hospitalized patients’ physicians. They reached the goal, but it was an eye-opening effort.

“The feedback I got from the hospitalists was it’s ‘just so difficult,’” Dr. Smith says. “I’m sitting on the phone waiting to get ahold of someone. Even trying to use administrative people and have them call and contact us, which is kind of complicated to do.”

Yul Ejnes, MD, MACP, a past chair of the board of regents of the American College of Physicians and an internist at Coastal Medical in R.I., says that if he were grading hospitalist communication with primary care providers on a poor-fair-good-excellent scale, he would give it a “fair.”

“It runs the spectrum from getting nothing—which is rare, I have to say—to getting at least a notification that your patient is in the hospital: ‘Here’s a contact number,’ sometimes with diagnosis,” he says. “And, much less commonly, getting a phone call. That usually occurs when there are questions.”

Dr. Ejnes says consistent communication is not as “robust as I would like it to be.”

“Some institutions do much better than others, in terms of the hospitalist always letting us know patients have come in,” he says. “With others, it doesn’t seem to be part of the institutional culture.”

There has to be a better way.

And, in fact, Dr. Smith and many other hospitalists are developing ways to better use technology to communicate more effectively with primary care, specialists, nurses, and patients. The goal is to make communication more routine, more effective, and more convenient for both parties, all the while—hopefully—improving patient care and strengthening working relationships.

Most of the approaches are not ultra-high tech. Too high tech might, in itself, be a potential barrier to communication for those who might be uncomfortable with new technology. Instead, the initiatives are mostly common sense tweaks to—or new, logical uses of—existing technology.

EHR-Embedded Communication

At Children’s National, Dr. Smith and colleagues use a standardized letter as part of a patient’s electronic health record (EHR). In addition to facts about the patient’s condition, the EHR includes information that makes it easier for physicians to communicate.

“What’s lovely with that is that [the letter] tells the provider the team that they’re on,” she said, adding that teams are divided by letter and color. “It has information on how you can reach the doctor. All of our doctors carry a phone around with them, and so it’s got that number.”

The EHR also includes a note suggesting that physicians avoid calling during rounds and gives them information on how to access the portal, so they can follow along with the patient’s care, should they choose to do so.

The amount of actual contact from primary care physicians? Scarce. Maybe one of 20 pediatricians will actually place a call to the hospitalist, but the response she has received has been positive, Dr. Smith says.

The EHR note also includes a sentence further characterizing the patient’s care, such as: Bobby C. was admitted with bronchiolitis. He’s doing fine; I anticipate he will go home tomorrow.

“Pediatricians have loved that,” she says. “They say, ‘I know exactly what my patient’s there for. I had the ability to call if I want.’”

Smarter Pages

At Vanderbilt University Medical Center in Nashville, Tenn., hospitalists noticed a frequent occurrence with pages: Many times, the hospitalist would only receive a phone number.

“With that, you don’t know which patient it’s about, who called you, how urgent it is, or what they need,” says researcher Sunil Kripalani, MD, MSc, SFHM, associate professor and chief of the section of hospital medicine at Vanderbilt.

It’s a tough spot for a busy hospitalist, who might be on the phone or at a bedside with another patient when three, four, or even five pages come through. The page might just be an FYI requiring no callback. It might be urgent. It might be the same page sent multiple times from different numbers (e.g. nursing moving to various phones). Many times, Dr. Kripalani and his hospitalists have had no way to know.

Now, Vanderbilt has established an online template for text pages, with the following basic information:

• Patient;
• Room number;
• Urgency level;
• Name of the sender;
• Callback number;
• Message; and
• Whether or not a callback is needed.

“That structure is very helpful for allowing physicians to triage which pages to call back and how quickly,” Dr. Kripalani says.

He acknowledges it isn’t “fancy bells and whistles.”

“Sometimes it’s doing the basic things well that makes the difference,” he adds.

The “structured pages” have allowed the nature of pages to be analyzed. Dr. Kripalani and colleagues have found that approximately 5% of pages were about a patient’s dietary status. If the patient was ordered not to receive anything by mouth, pages asked, when did that order expire and what diet should the patient resume?

Now, a prompt for that information is included in the hospital’s order entry system, which has cut the number of pages sent.

Vanderbilt is now looking at other, similar ways to streamline communication.

Patients and iPads

At the University of Colorado Hospital in Denver, researchers had an idea to facilitate communication and patient education: Patients are always inquiring about their discharge status and other facets of their hospitalization; what if they got their own tablet to follow along with everything in real time?1

The only real requirements for the study were that patients had to have Internet access at home and an understanding of how to work a web browser, says Jonathan Pell, MD, SFHM, assistant professor of internal medicine at the University of Colorado in Aurora and a hospitalist at University of Colorado Hospital. Patients were shown how to access their schedule for the day, their medication list and dosing schedule, and test results. Much of the information was delivered in real time, so patients who were told that if a lab result came back at a certain level they could be discharged could perhaps start preparing for that possibility earlier than they might have otherwise.

Researchers found that their patients worried less and reported less confusion. They also found that providing the tablets didn’t cause any increase in workload for doctors or nurses.

Providers and nurses expected that patients would notice medication errors, but that endpoint was not significant. Surprisingly, patients’ understanding of discharge times did not live up to expectations. But the results overall were encouraging enough that the effort will continue.

“We have these mixed results,” Dr. Pell says. “I think it’s good to get something out there in the literature and see what else people may be interested in doing. Our next step is to potentially open up notes to patients and let them see their doctor’s and nurse’s notes during their hospitalization.”

He says that, in some cases, communication with patients is the most crucial channel for hospitalists.

“For the very engaged patient [who has] a busy primary care doctor who’s hard to get in touch with,” he explains, “using the patient, informing them well, and getting them all the information they need is actually the best way to make sure that transition of care is smooth.”

Discharge, Facebook-Style

New England Inpatient Specialists (NEIS), a hospitalist group in North Andover, Mass., has an interesting approach to discharge. Instead of a nurse picking up the phone to make a follow-up appointment for a patient leaving the hospital, a secretary posts a message on “Chatter,” a secure tool similar to Facebook. The technology was developed by Salesforce.com, which offers platforms mainly designed to assist businesses with communication.

The idea behind Chatter is that the primary care office personnel can respond to a post at a time that’s convenient to them.

“All of this is so time-consuming. Why would you want somebody like an RN spending 15 to 20 minutes on the phone setting up an appointment when she could be on the floor?” says Sawad Thotathil, MD, vice president of performance and physician recruitment at NEIS. “Our program secretary will just post a discharge, and then somebody at the practice will look at it when they can and find out what associated information is needed and answer at their own convenience.”

Dr. Thotathil’s group also has been using the Imprivata Cortext secure text messaging system for more than a year, with what he deems “overall positive” results. About 60% of the practices with which NEIS staff need to communicate have signed on to the system.

“That kind of helps in management,” he says. “Sometimes, a patient is in the hospital and you can text the cardiologist, asking if the patient can be taken on for a procedure. That kind of communication, which would have taken longer or would not have happened, is happening now.

“Have we been able to directly link it to better outcomes?” he adds. “No, we haven’t looked at it that way. But what we have seen is that there’s always going to be a variation in how many people in a network actually will use it. ... There are going to be those high users, and there are going to be those providers who are going to be minimally using it.”

Videoconferencing

Pediatric hospitalists at the main hospital at Children’s National have been helping to provide care to children who are seen at five community sites. Dr. Smith says the communication at these sites, mostly from the ED, in which the pediatric hospitalists are helping make medical decisions, has been dramatically enhanced.

“The visual aspect of it changes the whole conversation,” she says. “You could tell them the exact same thing verbally and they are like, ‘OK, that’s fine,’ and there doesn’t seem to be a true understanding of what I’m trying to impart to you. Once people look at the child, all of a sudden there is a true shared mental model of, ‘OK, I understand what you’re doing. What’s going on?’”

Hospitalists also have been spearheading videoconferencing at diabetes clinics, to provide better care at community sites.

“We know what the need is. We know the gap in care,” Dr. Smith says. “We’ve been able to advocate and get those specialists brought out to the community via telemedicine, if it’s too difficult to get out on a regular basis.”

There are no hard data on the effects of the programs, but Dr. Smith says the improvement is noticeable.

“Anecdotally, we’ve seen a decrease in kids coming in with DKA (diabetic ketoacidosis) to the emergency room, so we’ve been able to change some of the trajectory. Many of those kids just didn’t have access to care. [For some], it would be a day’s trip for them to get to one of the academic centers to get follow up. They just wouldn’t go.”

EHR-Facilitated Calls

At Cincinnati Children’s, phone contact with community pediatricians at discharge is established with remarkable consistency: 98% to 99% of the time. The reason? A communication system, “Priority Link,” is connected to the EHR.

When the hospitalist signs a discharge order, the patient’s name is put in a queue. An operator sends out a page to inform the resident that the call is about to be made to the outpatient physician, making sure they’re ready for the call to be made.

“The key innovation was that we were trying to make sure that the inpatient side of it was really ready for the call, so we weren’t placing calls out to doctors and then we weren’t ready,” says Jeffrey Simmons, MD, MSc, associate director of clinical operations and quality in Cincinnati Children’s hospital medicine division.

He says there has been some pushback from pediatricians who feel the calls don’t provide any more value than the discharge summary itself. But the opportunity for questions and for a dialogue makes the calls worthwhile, Dr. Simmons notes. The system could be improved by tailoring communications to the community physicians’ preference—via fax or email, perhaps—and by having the call placed by physicians who are more knowledgeable about the details of the case.

Priority Link also is used to help community physicians with direct admissions for patients who don’t need to go to the ED. The operator coordinates a three-way call among the community physician, the hospitalist, and a nurse familiar with the bed situation.

“That three-way call is really great because we’re big and busy enough that sometimes we need that nurse manager on the phone, too, to No. 1, let us know if there really is a bed and, No. 2, coordinate with the nursing unit,” he says. TH

Tom Collins is a freelance writer in South Florida.

Reference

Pell JM, Mancuso M, Limon S, Oman K, Lin CT. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi: 10.1001/jamainternmed.2015.121.

Sometimes, Communication Outside the Hospital Is the Problem

Yul Ejnes, MD, MACP, an internist at Coastal Medicine in R.I., and a past chair of the American College of Physician’s Board of Regents, points to the ACP’s “High Value Care” toolkit as a model for how primary care-hospitalist communication should take place.

The toolkit includes a suggested “agreement” between PCPs and the hospital care team, which calls for PCPs to provide pertinent information (i.e., reconciled medications lists, medical history, and advanced directives) to hospital teams upon notification of an admission. It also calls for establishing standard communication methods and discharge notifications and encourages hospitalists to keep PCPs updated on new developments, provide appropriate information to patients at discharge, and send a “concise discharge summary” to the PCP within 48 to 72 hours of discharge.

It’s a two-way street, Dr. Ejnes says. He also acknowledges that sometimes the problems are on the community physicians’ side. Phone calls can be highly valuable in this dynamic, but it is often difficult for internists to make or take those calls.

“Sitting where I am, in my office, I am certainly interested in what’s going on with my patients,” he says. “On the other hand, the inertia I have to overcome in order to get that information, when I’m in the middle of seeing a whole bunch of patients during my day, involves getting on the phone, punching some numbers, waiting for a call back, as opposed to having the information available on my screen automatically through some information technology solution.”

He has provided his staff with a list of contacts, including hospitalists, for whom he is to be interrupted in order to take calls.

Jeffrey Simmons, MD, MSc, of Cincinnati Children’s, says that in their effort to boost the reliability of placing calls to PCPs, his hospitalists found that confusion within primary care offices is a stumbling block.

“About half the time when we get complaints about this process, when we investigate, we learn that the major problem has been within the practice,” he says. “We may have made a call to Partner X and had a good conversation … [but] between then and when the patient sees Dr. Y, there’s been very little communication between Partner X and Partner Y.”

Setting up the right system is the key—on both ends, Dr. Ejnes says.

“It’s all about workflow,” he says. “If you can integrate these communications into the regular workflow of the physician, either community-based or hospitalist, it’s more likely to happen. Having the will to do it is the first step. But I think it’s got to be facilitated as much as possible.”

— Thomas R. Collins

Kawasaki disease (KD) is an acute systemic vasculitis of unknown etiology that occurs in children. Because there is no specific diagnostic test or pathognomonic clinical feature, clinical diagnostic criteria have been established to guide physicians. When a patient presents with a history, examination, and laboratory findings consistent with KD without meeting the typical diagnostic standard, incomplete KD should be considered.

[WpProQuiz 4]

[WpProQuiz_toplist 4]

Kawasaki disease (KD) is an acute systemic vasculitis of unknown etiology that occurs in children. Because there is no specific diagnostic test or pathognomonic clinical feature, clinical diagnostic criteria have been established to guide physicians. When a patient presents with a history, examination, and laboratory findings consistent with KD without meeting the typical diagnostic standard, incomplete KD should be considered.

[WpProQuiz 4]

[WpProQuiz_toplist 4]

Kawasaki disease (KD) is an acute systemic vasculitis of unknown etiology that occurs in children. Because there is no specific diagnostic test or pathognomonic clinical feature, clinical diagnostic criteria have been established to guide physicians. When a patient presents with a history, examination, and laboratory findings consistent with KD without meeting the typical diagnostic standard, incomplete KD should be considered.

[WpProQuiz 4]

[WpProQuiz_toplist 4]

NEW YORK (Reuters Health) - An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction

(NSTEMI) or unstable angina, according to the After Eighty clinical trial.

"Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group dueto comorbidities," Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. "These factors may reduce the benefits and increase the risk of complications from invasive treatment."

Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.

Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a

conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.

The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.

In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet, online January 12.

During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41% vs. 61%, p=0.0001).

Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48% less likely to experience MI and 81% less likely to require urgent revascularization. They were also 40% less likely to have a stroke and 11% less likely to die, but these latter differences were not significant.

Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10%) than in the conservative strategy group (7%).

"The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina," Dr.Bendz and Dr. Tegn said. "However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference."

Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, "The After-80 study now provides the direct

evidence we needed to support this 'early invasive' approach. Given how difficult it is to recruit very elderly patients to clinical studies - and this was reflected by the fact that almost 80% of screened patients were not actually enrolled into After-80 - the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many 'very old' patients admitted to our cardiology and general medicine wards with ACS."

"In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70-80% of patients who were screened for this study were ultimately not

enrolled," he reiterated. "There would have been many reasons why so many patients were excluded, but it does emphasize that the study's findings won't apply to everyone over the age of 80 who presents with ACS."

"As always, the decision making process needs to be individually tailored," Dr. Psaltis said. "The patient's pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account."

"Moreover, we should not just consider its potential benefits in terms of whether it will reduce mortality or risk of recurrent infarcts," Dr. Psaltis added. "In certain individuals >90, an invasive approach may be taken to improve quality of life and symptom burden, help to keep patients in independent living at home, or reduce readmission rates to hospital or even

the use of anti-anginal medications that can be associated with debilitating side-effects."

Dr. Paul Erne from the University of Zurich in Switzerland, who heads the steering committee of the Acute Myocardial Infarction in Sweden (AMIS), stressed, "Conservative treatment

does not result in a poor outcome in every patient and we need to know much more about differential approach."

"However, active treatment remains a great option for part of the elderly patients," regardless of age, he told Reuters Health by email. "Please note the increasing number of patients

treated at age above 100 years which proves to be a good option if the patients want to live actively."

Dr. Rahul Potluri, founder of the ACALM (Algorithm for Comorbidities, Associations, Length of Stay and Mortality) Study Unit, Birmingham, U.K., recently reviewed the role of

angioplasty in octogenarian ACS patients.

He told Reuters Health by email, "This study is the most conclusive evidence to date, showing the benefits of an invasive approach in patients above the age of 80 with the most common types of ACS (namely NSTEMI and unstable angina). The findings are most surprising given that both the groups were very similar in terms of patient characteristics and medications taken, thus delineating the true benefit of the invasive strategy in the most controlled fashion and in a short follow-up period."

The study did not have commercial funding and the researchers declared no competing interests.

NEW YORK (Reuters Health) - An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction

(NSTEMI) or unstable angina, according to the After Eighty clinical trial.

"Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group dueto comorbidities," Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. "These factors may reduce the benefits and increase the risk of complications from invasive treatment."

Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.

Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a

conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.

The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.

In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet, online January 12.

During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41% vs. 61%, p=0.0001).

Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48% less likely to experience MI and 81% less likely to require urgent revascularization. They were also 40% less likely to have a stroke and 11% less likely to die, but these latter differences were not significant.

Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10%) than in the conservative strategy group (7%).

"The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina," Dr.Bendz and Dr. Tegn said. "However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference."

Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, "The After-80 study now provides the direct

evidence we needed to support this 'early invasive' approach. Given how difficult it is to recruit very elderly patients to clinical studies - and this was reflected by the fact that almost 80% of screened patients were not actually enrolled into After-80 - the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many 'very old' patients admitted to our cardiology and general medicine wards with ACS."

"In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70-80% of patients who were screened for this study were ultimately not

enrolled," he reiterated. "There would have been many reasons why so many patients were excluded, but it does emphasize that the study's findings won't apply to everyone over the age of 80 who presents with ACS."

"As always, the decision making process needs to be individually tailored," Dr. Psaltis said. "The patient's pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account."

"Moreover, we should not just consider its potential benefits in terms of whether it will reduce mortality or risk of recurrent infarcts," Dr. Psaltis added. "In certain individuals >90, an invasive approach may be taken to improve quality of life and symptom burden, help to keep patients in independent living at home, or reduce readmission rates to hospital or even

the use of anti-anginal medications that can be associated with debilitating side-effects."

Dr. Paul Erne from the University of Zurich in Switzerland, who heads the steering committee of the Acute Myocardial Infarction in Sweden (AMIS), stressed, "Conservative treatment

does not result in a poor outcome in every patient and we need to know much more about differential approach."

"However, active treatment remains a great option for part of the elderly patients," regardless of age, he told Reuters Health by email. "Please note the increasing number of patients

treated at age above 100 years which proves to be a good option if the patients want to live actively."

Dr. Rahul Potluri, founder of the ACALM (Algorithm for Comorbidities, Associations, Length of Stay and Mortality) Study Unit, Birmingham, U.K., recently reviewed the role of

angioplasty in octogenarian ACS patients.

He told Reuters Health by email, "This study is the most conclusive evidence to date, showing the benefits of an invasive approach in patients above the age of 80 with the most common types of ACS (namely NSTEMI and unstable angina). The findings are most surprising given that both the groups were very similar in terms of patient characteristics and medications taken, thus delineating the true benefit of the invasive strategy in the most controlled fashion and in a short follow-up period."

The study did not have commercial funding and the researchers declared no competing interests.

NEW YORK (Reuters Health) - An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction

(NSTEMI) or unstable angina, according to the After Eighty clinical trial.

"Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group dueto comorbidities," Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. "These factors may reduce the benefits and increase the risk of complications from invasive treatment."

Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.

Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a

conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.

The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.

In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet, online January 12.

During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41% vs. 61%, p=0.0001).

Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48% less likely to experience MI and 81% less likely to require urgent revascularization. They were also 40% less likely to have a stroke and 11% less likely to die, but these latter differences were not significant.

Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10%) than in the conservative strategy group (7%).

"The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina," Dr.Bendz and Dr. Tegn said. "However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference."

Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, "The After-80 study now provides the direct

evidence we needed to support this 'early invasive' approach. Given how difficult it is to recruit very elderly patients to clinical studies - and this was reflected by the fact that almost 80% of screened patients were not actually enrolled into After-80 - the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many 'very old' patients admitted to our cardiology and general medicine wards with ACS."

"In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70-80% of patients who were screened for this study were ultimately not

enrolled," he reiterated. "There would have been many reasons why so many patients were excluded, but it does emphasize that the study's findings won't apply to everyone over the age of 80 who presents with ACS."

"As always, the decision making process needs to be individually tailored," Dr. Psaltis said. "The patient's pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account."

"Moreover, we should not just consider its potential benefits in terms of whether it will reduce mortality or risk of recurrent infarcts," Dr. Psaltis added. "In certain individuals >90, an invasive approach may be taken to improve quality of life and symptom burden, help to keep patients in independent living at home, or reduce readmission rates to hospital or even

the use of anti-anginal medications that can be associated with debilitating side-effects."

Dr. Paul Erne from the University of Zurich in Switzerland, who heads the steering committee of the Acute Myocardial Infarction in Sweden (AMIS), stressed, "Conservative treatment

does not result in a poor outcome in every patient and we need to know much more about differential approach."

"However, active treatment remains a great option for part of the elderly patients," regardless of age, he told Reuters Health by email. "Please note the increasing number of patients

treated at age above 100 years which proves to be a good option if the patients want to live actively."

Dr. Rahul Potluri, founder of the ACALM (Algorithm for Comorbidities, Associations, Length of Stay and Mortality) Study Unit, Birmingham, U.K., recently reviewed the role of

angioplasty in octogenarian ACS patients.

He told Reuters Health by email, "This study is the most conclusive evidence to date, showing the benefits of an invasive approach in patients above the age of 80 with the most common types of ACS (namely NSTEMI and unstable angina). The findings are most surprising given that both the groups were very similar in terms of patient characteristics and medications taken, thus delineating the true benefit of the invasive strategy in the most controlled fashion and in a short follow-up period."

The study did not have commercial funding and the researchers declared no competing interests.

HSCT preparation

Photo by Chad McNeeley

Tandem autologous/allogeneic hematopoietic stem cell transplant (HSCT) may cure multiple myeloma (MM), according to a phase 2 study.

The study included newly diagnosed patients who received induction therapy followed by an autograft and a non-myeloablative allograft from a matched sibling donor.

The patients have been followed for a median of 8.8 years.

The probability of progression-free survival at 10 years is 41%, and the overall survival is 62%.

The rate of chronic graft-vs-host disease (GVHD) is high, but the rate of non-relapse mortality is low.

“In many hospitals, doctors have abandoned the use of allografts for multiple myeloma due to the risk of toxicity and relapse,” said study author Jean Roy, MD, of the Maisonneuve-Rosemont Hospital and University of Montreal in Quebec, Canada.

“Our results, on the other hand, have led us to offer the treatment to more patients, especially younger patients and those with poorer prognoses.”

Dr Roy and his colleagues reported these results in Bone Marrow Transplantation.

The researchers assessed 92 patients newly diagnosed with MM between 2001 and 2010. Their median age was 52 (range, 39-64), and 97% had Durie–Salmon stage II or III disease.

Patients received an induction regimen consisting of vincristine, doxorubicin, and dexamethasone (2001–2007, n=75) or a bortezomib-based regimen (2008–2010, n=17).

After induction, patients underwent autologous HSCT using melphalan 200 mg/m².

A median of 4 months later (range, 2-13), after complete clinical recovery, the patients received an allogeneic transplant from a 6/6 HLA-matched sibling donor. Fifty-seven percent of patients had achieved at least a very good partial response before the second transplant.

The allogeneic transplant was performed on an outpatient basis. The graft consisted of G-CSF-mobilized peripheral blood stem cells (target dose ≥ 4×10⁶ CD34⁺cells/kg).

The conditioning regimen consisted of fludarabine at 30 mg/m² and cyclophosphamide at 300 mg/m² for 5 days. GVHD prophylaxis was oral tacrolimus and mycophenolate mofetil.

Results

At a median follow-up of 8.8 years, 56 patients were still alive (and 36 had died).

Forty patients had no evidence of progression, including 11 patients who were still taking systemic immunosuppressive drugs for GVHD. The remaining 16 patients who were still alive had relapsed after allogeneic HSCT.

A total of 45 patients relapsed. Thirty-nine went on to receive treatment with at least 1 new drug (thalidomide, lenalidomide, bortezomib, or pomalidomide).

They received a median of 2 lines of therapy (range, 1–6), and their 5-year overall survival from first relapse was 49%. Ten of these patients were in very good partial response or greater at last follow-up.

Ten patients died from causes other than refractory MM—6 from refractory GVHD, 3 from lung adenocarcinoma (1 smoker), and 1 from invasive aspergillosis.

The cumulative incidence of extensive chronic GVHD was 79%. The cumulative incidence of grade 2-4 acute GVHD at 6 months was 9%. And 3 patients developed grade 3-4 acute GVHD.

Among the 56 patients who were still alive at last follow-up, the probability of being on any systemic immunosuppressive treatment for GVHD is 38% at 5 years and 22% at 10 years.

The probability of overall survival at 10 years is 62%, the probability of progression-free survival is 41%, and the cumulative incidence of non-relapse mortality is 10%.

HSCT preparation

Photo by Chad McNeeley

Tandem autologous/allogeneic hematopoietic stem cell transplant (HSCT) may cure multiple myeloma (MM), according to a phase 2 study.

The study included newly diagnosed patients who received induction therapy followed by an autograft and a non-myeloablative allograft from a matched sibling donor.

The patients have been followed for a median of 8.8 years.

The probability of progression-free survival at 10 years is 41%, and the overall survival is 62%.

The rate of chronic graft-vs-host disease (GVHD) is high, but the rate of non-relapse mortality is low.

“In many hospitals, doctors have abandoned the use of allografts for multiple myeloma due to the risk of toxicity and relapse,” said study author Jean Roy, MD, of the Maisonneuve-Rosemont Hospital and University of Montreal in Quebec, Canada.

“Our results, on the other hand, have led us to offer the treatment to more patients, especially younger patients and those with poorer prognoses.”

Dr Roy and his colleagues reported these results in Bone Marrow Transplantation.

The researchers assessed 92 patients newly diagnosed with MM between 2001 and 2010. Their median age was 52 (range, 39-64), and 97% had Durie–Salmon stage II or III disease.

Patients received an induction regimen consisting of vincristine, doxorubicin, and dexamethasone (2001–2007, n=75) or a bortezomib-based regimen (2008–2010, n=17).

After induction, patients underwent autologous HSCT using melphalan 200 mg/m².

A median of 4 months later (range, 2-13), after complete clinical recovery, the patients received an allogeneic transplant from a 6/6 HLA-matched sibling donor. Fifty-seven percent of patients had achieved at least a very good partial response before the second transplant.

The allogeneic transplant was performed on an outpatient basis. The graft consisted of G-CSF-mobilized peripheral blood stem cells (target dose ≥ 4×10⁶ CD34⁺cells/kg).

The conditioning regimen consisted of fludarabine at 30 mg/m² and cyclophosphamide at 300 mg/m² for 5 days. GVHD prophylaxis was oral tacrolimus and mycophenolate mofetil.

Results

At a median follow-up of 8.8 years, 56 patients were still alive (and 36 had died).

Forty patients had no evidence of progression, including 11 patients who were still taking systemic immunosuppressive drugs for GVHD. The remaining 16 patients who were still alive had relapsed after allogeneic HSCT.

A total of 45 patients relapsed. Thirty-nine went on to receive treatment with at least 1 new drug (thalidomide, lenalidomide, bortezomib, or pomalidomide).

They received a median of 2 lines of therapy (range, 1–6), and their 5-year overall survival from first relapse was 49%. Ten of these patients were in very good partial response or greater at last follow-up.

Ten patients died from causes other than refractory MM—6 from refractory GVHD, 3 from lung adenocarcinoma (1 smoker), and 1 from invasive aspergillosis.

The cumulative incidence of extensive chronic GVHD was 79%. The cumulative incidence of grade 2-4 acute GVHD at 6 months was 9%. And 3 patients developed grade 3-4 acute GVHD.

Among the 56 patients who were still alive at last follow-up, the probability of being on any systemic immunosuppressive treatment for GVHD is 38% at 5 years and 22% at 10 years.

The probability of overall survival at 10 years is 62%, the probability of progression-free survival is 41%, and the cumulative incidence of non-relapse mortality is 10%.

HSCT preparation

Photo by Chad McNeeley

Tandem autologous/allogeneic hematopoietic stem cell transplant (HSCT) may cure multiple myeloma (MM), according to a phase 2 study.

The study included newly diagnosed patients who received induction therapy followed by an autograft and a non-myeloablative allograft from a matched sibling donor.

The patients have been followed for a median of 8.8 years.

The probability of progression-free survival at 10 years is 41%, and the overall survival is 62%.

The rate of chronic graft-vs-host disease (GVHD) is high, but the rate of non-relapse mortality is low.

“In many hospitals, doctors have abandoned the use of allografts for multiple myeloma due to the risk of toxicity and relapse,” said study author Jean Roy, MD, of the Maisonneuve-Rosemont Hospital and University of Montreal in Quebec, Canada.

“Our results, on the other hand, have led us to offer the treatment to more patients, especially younger patients and those with poorer prognoses.”

Dr Roy and his colleagues reported these results in Bone Marrow Transplantation.

The researchers assessed 92 patients newly diagnosed with MM between 2001 and 2010. Their median age was 52 (range, 39-64), and 97% had Durie–Salmon stage II or III disease.

Patients received an induction regimen consisting of vincristine, doxorubicin, and dexamethasone (2001–2007, n=75) or a bortezomib-based regimen (2008–2010, n=17).

After induction, patients underwent autologous HSCT using melphalan 200 mg/m².

A median of 4 months later (range, 2-13), after complete clinical recovery, the patients received an allogeneic transplant from a 6/6 HLA-matched sibling donor. Fifty-seven percent of patients had achieved at least a very good partial response before the second transplant.

The allogeneic transplant was performed on an outpatient basis. The graft consisted of G-CSF-mobilized peripheral blood stem cells (target dose ≥ 4×10⁶ CD34⁺cells/kg).

The conditioning regimen consisted of fludarabine at 30 mg/m² and cyclophosphamide at 300 mg/m² for 5 days. GVHD prophylaxis was oral tacrolimus and mycophenolate mofetil.

Results

At a median follow-up of 8.8 years, 56 patients were still alive (and 36 had died).

Forty patients had no evidence of progression, including 11 patients who were still taking systemic immunosuppressive drugs for GVHD. The remaining 16 patients who were still alive had relapsed after allogeneic HSCT.

A total of 45 patients relapsed. Thirty-nine went on to receive treatment with at least 1 new drug (thalidomide, lenalidomide, bortezomib, or pomalidomide).

They received a median of 2 lines of therapy (range, 1–6), and their 5-year overall survival from first relapse was 49%. Ten of these patients were in very good partial response or greater at last follow-up.

Ten patients died from causes other than refractory MM—6 from refractory GVHD, 3 from lung adenocarcinoma (1 smoker), and 1 from invasive aspergillosis.

The cumulative incidence of extensive chronic GVHD was 79%. The cumulative incidence of grade 2-4 acute GVHD at 6 months was 9%. And 3 patients developed grade 3-4 acute GVHD.

Among the 56 patients who were still alive at last follow-up, the probability of being on any systemic immunosuppressive treatment for GVHD is 38% at 5 years and 22% at 10 years.

The probability of overall survival at 10 years is 62%, the probability of progression-free survival is 41%, and the cumulative incidence of non-relapse mortality is 10%.

Drug vials and a syringe

The European Medicines Agency (EMA) has recommended marketing authorization for Coagadex to treat hereditary factor X deficiency, a rare bleeding disorder.

The active substance in Coagadex is coagulation factor X, a protein derived from human plasma.

Coagadex is intended to treat and prevent bleeding episodes and control bleeding during surgical procedures in patients with hereditary factor X deficiency.

If the European Commission follows the EMA’s recommendation, Coagadex will be the first specific replacement therapy approved in the European Union (EU) to treat patients with this disorder.

Current treatment for factor X deficiency in the EU includes replacement therapies that contain a mix of coagulation factors. These are associated with dosing problems and the risk of elevating other clotting factors, which may result in complications.

Due to the lack of specific treatment options for factor X deficiency, the EMA’s Committee for Medicinal Products for Human Use (CHMP) decided to speed up the evaluation of Coagadex and recommended marketing authorization following an accelerated assessment. This is one of the agency’s tools to speed up patient access to new medicines if they address an unmet medical need.

The CHMP based its recommendation for authorization of Coagadex on the results of 2 non-randomized studies.

The first trial included 16 patients who received Coagadex for pharmacokinetic evaluation, on-demand treatment and control of bleeding episodes, and/or perioperative management of minor surgical or dental procedures.

Coagadex was used to treat 208 bleeding episodes, and 187 of these episodes (in 15 patients) were evaluated for efficacy. Ninety-eight episodes were major bleeds, 88 were minor bleeds, and 1 was not assessed.

One hundred and fifty-five bleeds (83%) were treated with a single infusion of Coagadex, 28 (15%) were treated with 2 infusions, 3 bleeds (2%) required 3 infusions, and 1 bleed (0.5%) required 4 infusions. Four bleeding episodes in 2 patients were considered treatment failures.

The mean dose of Coagadex per infusion was 25.4 IU/kg, and the mean total dose was 30.4 IU/kg. The recommended dose of 25 IU/kg to treat a bleed was maintained for 14 of the 16 patients. The other 2 patients used doses of up to 30 IU/kg and 33 IU/kg.

There were 176 adverse events in this trial, but only 6 events in 2 patients were considered possibly related to Coagadex. This included 2 reports of infusion site erythema in 1 patient, 2 reports of fatigue in 1 patient, 1 report of back pain, and 1 report of infusion site pain.

The second trial included patients who received Coagadex for perioperative management. Five patients received Coagadex for 7 surgical procedures.

For major surgeries, a median of 13 infusions (range, 2-15) and a median cumulative dose of 181 IU/kg (range, 45-210 IU/kg) were required to maintain hemostasis.

For minor surgeries, a median of 2.5 infusions (range, 1-4) and a median cumulative dose of 89 IU/kg (range, 51-127 IU/kg) were required to maintain hemostasis.

There were no adverse events related to Coagadex in this trial.

The company developing Coagadex, Bio Products Laboratory, received scientific advice on the design of the trials from the CHMP. Scientific advice is one of the agency’s main tools to facilitate and stimulate research and development within the EU.

Because factor X deficiency is rare, Coagadex was designated as an orphan medicine by the EMA’s Committee for Orphan Medicinal Products. Orphan designation gives pharmaceutical companies access to incentives that encourage the development of medicines for patients with rare diseases.

The CHMP’s recommendation to approve Coagadex for use in the EU is an intermediary step on Coagadex’s path to patient access. The CHMP’s opinion will now be sent to the European Commission for the adoption of a decision on an EU-wide marketing authorization.

Once a marketing authorization has been granted, decisions about price and reimbursement will take place at the level of each member state, taking into account the potential role/use of this medicine in the context of the national health system of that country.

Drug vials and a syringe

The European Medicines Agency (EMA) has recommended marketing authorization for Coagadex to treat hereditary factor X deficiency, a rare bleeding disorder.

The active substance in Coagadex is coagulation factor X, a protein derived from human plasma.

Coagadex is intended to treat and prevent bleeding episodes and control bleeding during surgical procedures in patients with hereditary factor X deficiency.

If the European Commission follows the EMA’s recommendation, Coagadex will be the first specific replacement therapy approved in the European Union (EU) to treat patients with this disorder.

Current treatment for factor X deficiency in the EU includes replacement therapies that contain a mix of coagulation factors. These are associated with dosing problems and the risk of elevating other clotting factors, which may result in complications.

Due to the lack of specific treatment options for factor X deficiency, the EMA’s Committee for Medicinal Products for Human Use (CHMP) decided to speed up the evaluation of Coagadex and recommended marketing authorization following an accelerated assessment. This is one of the agency’s tools to speed up patient access to new medicines if they address an unmet medical need.

The CHMP based its recommendation for authorization of Coagadex on the results of 2 non-randomized studies.

The first trial included 16 patients who received Coagadex for pharmacokinetic evaluation, on-demand treatment and control of bleeding episodes, and/or perioperative management of minor surgical or dental procedures.

Coagadex was used to treat 208 bleeding episodes, and 187 of these episodes (in 15 patients) were evaluated for efficacy. Ninety-eight episodes were major bleeds, 88 were minor bleeds, and 1 was not assessed.

One hundred and fifty-five bleeds (83%) were treated with a single infusion of Coagadex, 28 (15%) were treated with 2 infusions, 3 bleeds (2%) required 3 infusions, and 1 bleed (0.5%) required 4 infusions. Four bleeding episodes in 2 patients were considered treatment failures.

The mean dose of Coagadex per infusion was 25.4 IU/kg, and the mean total dose was 30.4 IU/kg. The recommended dose of 25 IU/kg to treat a bleed was maintained for 14 of the 16 patients. The other 2 patients used doses of up to 30 IU/kg and 33 IU/kg.

There were 176 adverse events in this trial, but only 6 events in 2 patients were considered possibly related to Coagadex. This included 2 reports of infusion site erythema in 1 patient, 2 reports of fatigue in 1 patient, 1 report of back pain, and 1 report of infusion site pain.

The second trial included patients who received Coagadex for perioperative management. Five patients received Coagadex for 7 surgical procedures.

For major surgeries, a median of 13 infusions (range, 2-15) and a median cumulative dose of 181 IU/kg (range, 45-210 IU/kg) were required to maintain hemostasis.

For minor surgeries, a median of 2.5 infusions (range, 1-4) and a median cumulative dose of 89 IU/kg (range, 51-127 IU/kg) were required to maintain hemostasis.

There were no adverse events related to Coagadex in this trial.

The company developing Coagadex, Bio Products Laboratory, received scientific advice on the design of the trials from the CHMP. Scientific advice is one of the agency’s main tools to facilitate and stimulate research and development within the EU.

Because factor X deficiency is rare, Coagadex was designated as an orphan medicine by the EMA’s Committee for Orphan Medicinal Products. Orphan designation gives pharmaceutical companies access to incentives that encourage the development of medicines for patients with rare diseases.

The CHMP’s recommendation to approve Coagadex for use in the EU is an intermediary step on Coagadex’s path to patient access. The CHMP’s opinion will now be sent to the European Commission for the adoption of a decision on an EU-wide marketing authorization.

Once a marketing authorization has been granted, decisions about price and reimbursement will take place at the level of each member state, taking into account the potential role/use of this medicine in the context of the national health system of that country.

Drug vials and a syringe

The European Medicines Agency (EMA) has recommended marketing authorization for Coagadex to treat hereditary factor X deficiency, a rare bleeding disorder.

The active substance in Coagadex is coagulation factor X, a protein derived from human plasma.

Coagadex is intended to treat and prevent bleeding episodes and control bleeding during surgical procedures in patients with hereditary factor X deficiency.

If the European Commission follows the EMA’s recommendation, Coagadex will be the first specific replacement therapy approved in the European Union (EU) to treat patients with this disorder.

Current treatment for factor X deficiency in the EU includes replacement therapies that contain a mix of coagulation factors. These are associated with dosing problems and the risk of elevating other clotting factors, which may result in complications.

Due to the lack of specific treatment options for factor X deficiency, the EMA’s Committee for Medicinal Products for Human Use (CHMP) decided to speed up the evaluation of Coagadex and recommended marketing authorization following an accelerated assessment. This is one of the agency’s tools to speed up patient access to new medicines if they address an unmet medical need.

The CHMP based its recommendation for authorization of Coagadex on the results of 2 non-randomized studies.

The first trial included 16 patients who received Coagadex for pharmacokinetic evaluation, on-demand treatment and control of bleeding episodes, and/or perioperative management of minor surgical or dental procedures.

Coagadex was used to treat 208 bleeding episodes, and 187 of these episodes (in 15 patients) were evaluated for efficacy. Ninety-eight episodes were major bleeds, 88 were minor bleeds, and 1 was not assessed.

One hundred and fifty-five bleeds (83%) were treated with a single infusion of Coagadex, 28 (15%) were treated with 2 infusions, 3 bleeds (2%) required 3 infusions, and 1 bleed (0.5%) required 4 infusions. Four bleeding episodes in 2 patients were considered treatment failures.

The mean dose of Coagadex per infusion was 25.4 IU/kg, and the mean total dose was 30.4 IU/kg. The recommended dose of 25 IU/kg to treat a bleed was maintained for 14 of the 16 patients. The other 2 patients used doses of up to 30 IU/kg and 33 IU/kg.

There were 176 adverse events in this trial, but only 6 events in 2 patients were considered possibly related to Coagadex. This included 2 reports of infusion site erythema in 1 patient, 2 reports of fatigue in 1 patient, 1 report of back pain, and 1 report of infusion site pain.

The second trial included patients who received Coagadex for perioperative management. Five patients received Coagadex for 7 surgical procedures.

For major surgeries, a median of 13 infusions (range, 2-15) and a median cumulative dose of 181 IU/kg (range, 45-210 IU/kg) were required to maintain hemostasis.

For minor surgeries, a median of 2.5 infusions (range, 1-4) and a median cumulative dose of 89 IU/kg (range, 51-127 IU/kg) were required to maintain hemostasis.

There were no adverse events related to Coagadex in this trial.

The company developing Coagadex, Bio Products Laboratory, received scientific advice on the design of the trials from the CHMP. Scientific advice is one of the agency’s main tools to facilitate and stimulate research and development within the EU.

Because factor X deficiency is rare, Coagadex was designated as an orphan medicine by the EMA’s Committee for Orphan Medicinal Products. Orphan designation gives pharmaceutical companies access to incentives that encourage the development of medicines for patients with rare diseases.

The CHMP’s recommendation to approve Coagadex for use in the EU is an intermediary step on Coagadex’s path to patient access. The CHMP’s opinion will now be sent to the European Commission for the adoption of a decision on an EU-wide marketing authorization.

Once a marketing authorization has been granted, decisions about price and reimbursement will take place at the level of each member state, taking into account the potential role/use of this medicine in the context of the national health system of that country.