First, there were hospitalists. Then there was hospitalist-specific maintenance of certification.

Now, SHM is introducing hospital medicine’s first preparation tool for the exam.

For the hundreds of hospitalists considering taking the American Board of Internal Medicine’s Focused Practice in Hospital Medicine Maintenance of Certification exam in the near future, SHM’s SPARK exam prep tool is the perfect way to brush up on the skills and knowledge needed to pass.

SHM SPARK gives hospitalists the peace of mind that comes from knowing they are ready for the topics unique to hospitalists in the exam, including:

• Palliative care, medical ethics, and decision making;
  
• Peri-operative care and consultative comanagement; and
• Quality, safety, and clinical reasoning.

Best of all, SPARK is available exclusively online, making it easy to access from the hospital, the home, the coffee shop, or on the go.

SHM SPARK is a unique online self-assessment tool featuring 175 vignette-style, single-best-answer, multiple-choice questions, complete with answers, discussion, reasoning, references, and quizzing capabilities.

In addition to educating hospitalists with nearly 200 questions online, SHM SPARK empowers users to:

• Create customized practice quizzes in topic areas that meet your specific knowledge gaps/study needs;
• Progress at your own pace using the self-study reference feature; and
• Claim MOC Part II medical knowledge points through ABIM and download a CME certificate for earned AMA Physician’s Recognition Award (PRA) Category 1 Credit™.

The tool includes:

• Robust teaching points for each vignette;
• The option to save key questions for later review; and
• Question-level comparisons to the average response.

Access to SHM Spark is $199 for SHM members and $349 for nonmembers. Groups of 10 or more hospitalists receive a 10% discount.

First, there were hospitalists. Then there was hospitalist-specific maintenance of certification.

Now, SHM is introducing hospital medicine’s first preparation tool for the exam.

For the hundreds of hospitalists considering taking the American Board of Internal Medicine’s Focused Practice in Hospital Medicine Maintenance of Certification exam in the near future, SHM’s SPARK exam prep tool is the perfect way to brush up on the skills and knowledge needed to pass.

SHM SPARK gives hospitalists the peace of mind that comes from knowing they are ready for the topics unique to hospitalists in the exam, including:

• Palliative care, medical ethics, and decision making;
  
• Peri-operative care and consultative comanagement; and
• Quality, safety, and clinical reasoning.

Best of all, SPARK is available exclusively online, making it easy to access from the hospital, the home, the coffee shop, or on the go.

SHM SPARK is a unique online self-assessment tool featuring 175 vignette-style, single-best-answer, multiple-choice questions, complete with answers, discussion, reasoning, references, and quizzing capabilities.

In addition to educating hospitalists with nearly 200 questions online, SHM SPARK empowers users to:

• Create customized practice quizzes in topic areas that meet your specific knowledge gaps/study needs;
• Progress at your own pace using the self-study reference feature; and
• Claim MOC Part II medical knowledge points through ABIM and download a CME certificate for earned AMA Physician’s Recognition Award (PRA) Category 1 Credit™.

The tool includes:

• Robust teaching points for each vignette;
• The option to save key questions for later review; and
• Question-level comparisons to the average response.

Access to SHM Spark is $199 for SHM members and $349 for nonmembers. Groups of 10 or more hospitalists receive a 10% discount.

First, there were hospitalists. Then there was hospitalist-specific maintenance of certification.

Now, SHM is introducing hospital medicine’s first preparation tool for the exam.

For the hundreds of hospitalists considering taking the American Board of Internal Medicine’s Focused Practice in Hospital Medicine Maintenance of Certification exam in the near future, SHM’s SPARK exam prep tool is the perfect way to brush up on the skills and knowledge needed to pass.

SHM SPARK gives hospitalists the peace of mind that comes from knowing they are ready for the topics unique to hospitalists in the exam, including:

• Palliative care, medical ethics, and decision making;
  
• Peri-operative care and consultative comanagement; and
• Quality, safety, and clinical reasoning.

Best of all, SPARK is available exclusively online, making it easy to access from the hospital, the home, the coffee shop, or on the go.

SHM SPARK is a unique online self-assessment tool featuring 175 vignette-style, single-best-answer, multiple-choice questions, complete with answers, discussion, reasoning, references, and quizzing capabilities.

In addition to educating hospitalists with nearly 200 questions online, SHM SPARK empowers users to:

• Create customized practice quizzes in topic areas that meet your specific knowledge gaps/study needs;
• Progress at your own pace using the self-study reference feature; and
• Claim MOC Part II medical knowledge points through ABIM and download a CME certificate for earned AMA Physician’s Recognition Award (PRA) Category 1 Credit™.

The tool includes:

• Robust teaching points for each vignette;
• The option to save key questions for later review; and
• Question-level comparisons to the average response.

Access to SHM Spark is $199 for SHM members and $349 for nonmembers. Groups of 10 or more hospitalists receive a 10% discount.

In 2015, three medical students received the first SHM Student Hospitalist Scholar Grant to complete scholarly work related to patient safety in the hospital. Earlier this summer, they began presenting their work on SHM’s blog, The Hospital Leader.

The following are excerpts of those posts.

Why We Should Care about Alarm Fatigue

By Mimi Zander

When I arrived back at the Children’s Hospital of Philadelphia (CHOP) after my first year of medical school, I knew what was awaiting me: thousands of alarms from physiologic monitors, most of them inconsequential, lined up neatly in spreadsheets, splattered all over research databases, lighting up on video screens, chirping down hallways and up elevators. Of course, they were incessantly firing at the bedside, but when patient care is video recorded for Dr. Bonafide’s research study on alarm fatigue, those patient care hours turn into data points that live on hard drives and servers waiting to be classified, annotated, and cataloged by a team of research assistants, including me.

I began working at the CHOP while attending the University of Pennsylvania’s post-baccalaureate premed program. What started as a temporary summer research position turned into an almost three-year endeavor. The pilot that I helped design uses video cameras in hospitalized patient rooms to record patient care. We download the video, edit it so we can review multiple viewing angles at one time, download a spreadsheet of all of the alarms that fired during the study period, and then, with a little patience and some subtraction, we can line up every alarm that fired with the video clip. That’s the easy part.

This small pilot has transformed into a much larger study with a much larger volume of alarms. Since I started medical school last July, the research team has steadily collected video data all year. With support from SHM’s student scholar grant program, I have been able to return to CHOP for the summer. And now the video review begins.

The First Two Years—Pathways and Patient Outcomes

By Frank Zadravecz, MPH

The first two years of our medical curriculum are an introduction to the human body’s normal and pathophysiology and an attempt to untangle the complex pathways involved in the interactions between self and nonself. We hope to make connections between our physical exam findings and the physiologic pathways we have at our educational foundation. We begin to realize that there is a fine line to walk when treating a patient: Altering the inputs of a single system can drastically affect the outputs of another.

If we place patient outcomes in the context of the dance that occurs in clinical care for patients on the wards, similar to the downstream effects of disrupting biological pathways in illness, there is a multifactorial system underlying hospitalized patient outcomes.

Prior to medical school, I worked for several years as a population health epidemiologist in the Democratic Republic of Congo and then as a research data analyst at the University of Chicago. During my work in both of these settings, I quickly learned the relevance of contextual clues in complex systems-based problem solving. Over the course of my first year of medical school, I realized that nowhere is this creative use of information more important than in the inpatient setting, where we attempt to distill out the most important available information when assessing a patient.

But there are caveats to our interpretations of data points: Are we recognizing the most relevant physiologic associations when making clinical decisions? Are patient data really telling us what we think they are? What systemic factors are at play when patients experience an adverse outcome?

 

In my exploration of the importance of contextualizing inpatient data, I have been incredibly fortunate to work with Dana Edelson, MD, MS, and Matthew Churpek, MD, PhD, MPH, two mentors at the University of Chicago who are equally passionate about asking these same questions surrounding clinical care. Using ward patient data, we have investigated the importance of physician judgment in clinical deterioration and documented the need for greater sensitivity in recognition of sepsis and organ dysfunction in ward patients. But what can be done to reorient clinicians who are overwhelmed by and desensitized to data streams and bedside alarms?

Improving Patient Care as a Trainee

By Monica Shah

Patient safety has always been a priority for me, but it is only recently that I became aware of the many issues that threaten quality of care for patients. As a medical student, I vividly remember shadowing at the hospital and being shocked at what I saw. I walked through patient rooms and noticed loud beeps, the constant chatter of hospital staff, and the automatic entrance into patients’ rooms without even a knock. I wondered whether all of the disruptions and commotion impacted patient recovery in the hospital and after discharge. After pondering this, I decided that I wanted to take action and see what I, as a medical student, could do to improve daily inpatient conditions.

In order to begin addressing my vision, I knew I needed to find the right mentor in the right location. As a medical student, I feel like my life is on pause at times. During the school year, when exams come in constant waves and my days are spent with my head in notes and books, I am pausing my time with friends and family, using my energy to pursue my dream of helping others improve their health. While I am blessed to have such an opportunity, I knew that during my time off between my first and second year of medical school, I wanted to be in Chicago, near my close friends. And, from there, it seemed as if everything fell into place perfectly. I found on the University of Chicago Medical School website that Dr. Vineet Arora is a prominent Society of Hospital Medicine member who was looking for medical students to conduct research on sleep/functional recovery during hospital stay and post-discharge. The minute I spoke to Dr. Arora, I knew that she would be a great mentor. Not only are her credentials and accomplishments unbelievable, but I could tell she is really passionate about the work she is doing. Her excitement for the project is contagious, and I started getting really excited to start!

In 2015, three medical students received the first SHM Student Hospitalist Scholar Grant to complete scholarly work related to patient safety in the hospital. Earlier this summer, they began presenting their work on SHM’s blog, The Hospital Leader.

The following are excerpts of those posts.

Why We Should Care about Alarm Fatigue

By Mimi Zander

When I arrived back at the Children’s Hospital of Philadelphia (CHOP) after my first year of medical school, I knew what was awaiting me: thousands of alarms from physiologic monitors, most of them inconsequential, lined up neatly in spreadsheets, splattered all over research databases, lighting up on video screens, chirping down hallways and up elevators. Of course, they were incessantly firing at the bedside, but when patient care is video recorded for Dr. Bonafide’s research study on alarm fatigue, those patient care hours turn into data points that live on hard drives and servers waiting to be classified, annotated, and cataloged by a team of research assistants, including me.

I began working at the CHOP while attending the University of Pennsylvania’s post-baccalaureate premed program. What started as a temporary summer research position turned into an almost three-year endeavor. The pilot that I helped design uses video cameras in hospitalized patient rooms to record patient care. We download the video, edit it so we can review multiple viewing angles at one time, download a spreadsheet of all of the alarms that fired during the study period, and then, with a little patience and some subtraction, we can line up every alarm that fired with the video clip. That’s the easy part.

This small pilot has transformed into a much larger study with a much larger volume of alarms. Since I started medical school last July, the research team has steadily collected video data all year. With support from SHM’s student scholar grant program, I have been able to return to CHOP for the summer. And now the video review begins.

The First Two Years—Pathways and Patient Outcomes

By Frank Zadravecz, MPH

The first two years of our medical curriculum are an introduction to the human body’s normal and pathophysiology and an attempt to untangle the complex pathways involved in the interactions between self and nonself. We hope to make connections between our physical exam findings and the physiologic pathways we have at our educational foundation. We begin to realize that there is a fine line to walk when treating a patient: Altering the inputs of a single system can drastically affect the outputs of another.

If we place patient outcomes in the context of the dance that occurs in clinical care for patients on the wards, similar to the downstream effects of disrupting biological pathways in illness, there is a multifactorial system underlying hospitalized patient outcomes.

Prior to medical school, I worked for several years as a population health epidemiologist in the Democratic Republic of Congo and then as a research data analyst at the University of Chicago. During my work in both of these settings, I quickly learned the relevance of contextual clues in complex systems-based problem solving. Over the course of my first year of medical school, I realized that nowhere is this creative use of information more important than in the inpatient setting, where we attempt to distill out the most important available information when assessing a patient.

But there are caveats to our interpretations of data points: Are we recognizing the most relevant physiologic associations when making clinical decisions? Are patient data really telling us what we think they are? What systemic factors are at play when patients experience an adverse outcome?

 

In my exploration of the importance of contextualizing inpatient data, I have been incredibly fortunate to work with Dana Edelson, MD, MS, and Matthew Churpek, MD, PhD, MPH, two mentors at the University of Chicago who are equally passionate about asking these same questions surrounding clinical care. Using ward patient data, we have investigated the importance of physician judgment in clinical deterioration and documented the need for greater sensitivity in recognition of sepsis and organ dysfunction in ward patients. But what can be done to reorient clinicians who are overwhelmed by and desensitized to data streams and bedside alarms?

Improving Patient Care as a Trainee

By Monica Shah

Patient safety has always been a priority for me, but it is only recently that I became aware of the many issues that threaten quality of care for patients. As a medical student, I vividly remember shadowing at the hospital and being shocked at what I saw. I walked through patient rooms and noticed loud beeps, the constant chatter of hospital staff, and the automatic entrance into patients’ rooms without even a knock. I wondered whether all of the disruptions and commotion impacted patient recovery in the hospital and after discharge. After pondering this, I decided that I wanted to take action and see what I, as a medical student, could do to improve daily inpatient conditions.

In order to begin addressing my vision, I knew I needed to find the right mentor in the right location. As a medical student, I feel like my life is on pause at times. During the school year, when exams come in constant waves and my days are spent with my head in notes and books, I am pausing my time with friends and family, using my energy to pursue my dream of helping others improve their health. While I am blessed to have such an opportunity, I knew that during my time off between my first and second year of medical school, I wanted to be in Chicago, near my close friends. And, from there, it seemed as if everything fell into place perfectly. I found on the University of Chicago Medical School website that Dr. Vineet Arora is a prominent Society of Hospital Medicine member who was looking for medical students to conduct research on sleep/functional recovery during hospital stay and post-discharge. The minute I spoke to Dr. Arora, I knew that she would be a great mentor. Not only are her credentials and accomplishments unbelievable, but I could tell she is really passionate about the work she is doing. Her excitement for the project is contagious, and I started getting really excited to start!

In 2015, three medical students received the first SHM Student Hospitalist Scholar Grant to complete scholarly work related to patient safety in the hospital. Earlier this summer, they began presenting their work on SHM’s blog, The Hospital Leader.

The following are excerpts of those posts.

Why We Should Care about Alarm Fatigue

By Mimi Zander

When I arrived back at the Children’s Hospital of Philadelphia (CHOP) after my first year of medical school, I knew what was awaiting me: thousands of alarms from physiologic monitors, most of them inconsequential, lined up neatly in spreadsheets, splattered all over research databases, lighting up on video screens, chirping down hallways and up elevators. Of course, they were incessantly firing at the bedside, but when patient care is video recorded for Dr. Bonafide’s research study on alarm fatigue, those patient care hours turn into data points that live on hard drives and servers waiting to be classified, annotated, and cataloged by a team of research assistants, including me.

I began working at the CHOP while attending the University of Pennsylvania’s post-baccalaureate premed program. What started as a temporary summer research position turned into an almost three-year endeavor. The pilot that I helped design uses video cameras in hospitalized patient rooms to record patient care. We download the video, edit it so we can review multiple viewing angles at one time, download a spreadsheet of all of the alarms that fired during the study period, and then, with a little patience and some subtraction, we can line up every alarm that fired with the video clip. That’s the easy part.

This small pilot has transformed into a much larger study with a much larger volume of alarms. Since I started medical school last July, the research team has steadily collected video data all year. With support from SHM’s student scholar grant program, I have been able to return to CHOP for the summer. And now the video review begins.

The First Two Years—Pathways and Patient Outcomes

By Frank Zadravecz, MPH

The first two years of our medical curriculum are an introduction to the human body’s normal and pathophysiology and an attempt to untangle the complex pathways involved in the interactions between self and nonself. We hope to make connections between our physical exam findings and the physiologic pathways we have at our educational foundation. We begin to realize that there is a fine line to walk when treating a patient: Altering the inputs of a single system can drastically affect the outputs of another.

If we place patient outcomes in the context of the dance that occurs in clinical care for patients on the wards, similar to the downstream effects of disrupting biological pathways in illness, there is a multifactorial system underlying hospitalized patient outcomes.

Prior to medical school, I worked for several years as a population health epidemiologist in the Democratic Republic of Congo and then as a research data analyst at the University of Chicago. During my work in both of these settings, I quickly learned the relevance of contextual clues in complex systems-based problem solving. Over the course of my first year of medical school, I realized that nowhere is this creative use of information more important than in the inpatient setting, where we attempt to distill out the most important available information when assessing a patient.

But there are caveats to our interpretations of data points: Are we recognizing the most relevant physiologic associations when making clinical decisions? Are patient data really telling us what we think they are? What systemic factors are at play when patients experience an adverse outcome?

 

In my exploration of the importance of contextualizing inpatient data, I have been incredibly fortunate to work with Dana Edelson, MD, MS, and Matthew Churpek, MD, PhD, MPH, two mentors at the University of Chicago who are equally passionate about asking these same questions surrounding clinical care. Using ward patient data, we have investigated the importance of physician judgment in clinical deterioration and documented the need for greater sensitivity in recognition of sepsis and organ dysfunction in ward patients. But what can be done to reorient clinicians who are overwhelmed by and desensitized to data streams and bedside alarms?

Improving Patient Care as a Trainee

By Monica Shah

Patient safety has always been a priority for me, but it is only recently that I became aware of the many issues that threaten quality of care for patients. As a medical student, I vividly remember shadowing at the hospital and being shocked at what I saw. I walked through patient rooms and noticed loud beeps, the constant chatter of hospital staff, and the automatic entrance into patients’ rooms without even a knock. I wondered whether all of the disruptions and commotion impacted patient recovery in the hospital and after discharge. After pondering this, I decided that I wanted to take action and see what I, as a medical student, could do to improve daily inpatient conditions.

In order to begin addressing my vision, I knew I needed to find the right mentor in the right location. As a medical student, I feel like my life is on pause at times. During the school year, when exams come in constant waves and my days are spent with my head in notes and books, I am pausing my time with friends and family, using my energy to pursue my dream of helping others improve their health. While I am blessed to have such an opportunity, I knew that during my time off between my first and second year of medical school, I wanted to be in Chicago, near my close friends. And, from there, it seemed as if everything fell into place perfectly. I found on the University of Chicago Medical School website that Dr. Vineet Arora is a prominent Society of Hospital Medicine member who was looking for medical students to conduct research on sleep/functional recovery during hospital stay and post-discharge. The minute I spoke to Dr. Arora, I knew that she would be a great mentor. Not only are her credentials and accomplishments unbelievable, but I could tell she is really passionate about the work she is doing. Her excitement for the project is contagious, and I started getting really excited to start!

Among pregnant women receiving inpatient neurologic consultation, more than one-third have secondary headache, according to a study of 140 pregnant women presenting with acute headache. Researchers found:

• The women had a mean age of 29 years and 56.4% presented in the third trimester.

• Diagnoses were 65.0% primary and 35% secondary disorders.

• Most common primary headache disorder was migraine (91.2%) and secondary headache disorders were hypertensive disorders (51.0%).

• Groups were similar in demographics, gestational ages, and most headache features.

• In univariate analysis, secondary headaches were associated with: lack of headache history, seizures, elevated blood pressure, fever, and an abnormal neurological exam.

• In multivariate logistic regression, elevated blood pressure and a lack of headache history had an increased association with secondary headache, while psychiatric comorbidity and phonophobia had a reduced association with secondary headache.

Citation: Robbins MS, Farmakidis C, Dayal AK, Lipton RB. Acute headache diagnosis in pregnant women: A hospital-based study. [Published online ahead of print August 19, 2015]. Neurology. doi:  http:/​/​dx.​doi.​org/​10.​1212/​WNL.​0000000000001954.

Among pregnant women receiving inpatient neurologic consultation, more than one-third have secondary headache, according to a study of 140 pregnant women presenting with acute headache. Researchers found:

• The women had a mean age of 29 years and 56.4% presented in the third trimester.

• Diagnoses were 65.0% primary and 35% secondary disorders.

• Most common primary headache disorder was migraine (91.2%) and secondary headache disorders were hypertensive disorders (51.0%).

• Groups were similar in demographics, gestational ages, and most headache features.

• In univariate analysis, secondary headaches were associated with: lack of headache history, seizures, elevated blood pressure, fever, and an abnormal neurological exam.

• In multivariate logistic regression, elevated blood pressure and a lack of headache history had an increased association with secondary headache, while psychiatric comorbidity and phonophobia had a reduced association with secondary headache.

Citation: Robbins MS, Farmakidis C, Dayal AK, Lipton RB. Acute headache diagnosis in pregnant women: A hospital-based study. [Published online ahead of print August 19, 2015]. Neurology. doi:  http:/​/​dx.​doi.​org/​10.​1212/​WNL.​0000000000001954.

Among pregnant women receiving inpatient neurologic consultation, more than one-third have secondary headache, according to a study of 140 pregnant women presenting with acute headache. Researchers found:

• The women had a mean age of 29 years and 56.4% presented in the third trimester.

• Diagnoses were 65.0% primary and 35% secondary disorders.

• Most common primary headache disorder was migraine (91.2%) and secondary headache disorders were hypertensive disorders (51.0%).

• Groups were similar in demographics, gestational ages, and most headache features.

• In univariate analysis, secondary headaches were associated with: lack of headache history, seizures, elevated blood pressure, fever, and an abnormal neurological exam.

• In multivariate logistic regression, elevated blood pressure and a lack of headache history had an increased association with secondary headache, while psychiatric comorbidity and phonophobia had a reduced association with secondary headache.

Citation: Robbins MS, Farmakidis C, Dayal AK, Lipton RB. Acute headache diagnosis in pregnant women: A hospital-based study. [Published online ahead of print August 19, 2015]. Neurology. doi:  http:/​/​dx.​doi.​org/​10.​1212/​WNL.​0000000000001954.

Editor’s note: In July, SHM board member Howard Epstein supported the new CMS proposal to pay for advance care planning, calling it a “procedure” for hospitalists. Below are excerpts from his blog post. For the full post, click here.

Last week, the Centers for Medicare and Medicaid Services (CMS), the nation’s largest payer of healthcare services and the 800-pound gorilla in setting medical necessity and coverage policies, announced a proposal to begin paying for goals of care and advance care planning (ACP) discussions between medical providers and patients. Sound familiar? It should. This is the same, seemingly no-brainer proposal that in 2009 was stricken from the eventually approved Patient Protection and Affordable Care Act (PPACA, aka the ACA, aka “Obamacare”) in response to the intentional and patently false accusations of government-run “death panels,” in the hopes of salvaging some measure of bipartisan support. As we all know, the bill eventually passed the following year without a single Republican voting in favor in either the House or Senate, and without funding for ACP sessions!

The need for ACP and access to primary and specialty palliative care is so great and accepted in the healthcare community. In their Choosing Wisely recommendations, numerous medical specialty societies, including ACEP [American College of Emergency Physicians], AAHPM [American Academy of Hospice and Palliative Medicine], AGS [American Geriatrics Society], and AMDA [The Society for Post-Acute and Long-Term Care Medicine], have included early and reliable access to palliative care and avoidance of non-value added care, such as placement of feeding tubes in patients with advanced dementia, calling out the gap between quality, evidence-based, patient and family-centered care, and “usual care” (e.g. medical and disease-focused care) that patients receive too often near the end of life.

So where is the disconnect between what people want and what actually happens to them at end of life?

The answer is clear: We’re not having “The Conversation.”

And, though our primary care and even specialty care colleagues are involved regularly in the care of these patients, they may be inclined to postpone or avoid ACP with patients and families in the outpatient setting due to lack of comfort [or] skill or even recognizing that the person they’ve been trying valiantly to cure or at least prolong the inevitable [for] is on that downslope of life we all eventually experience—it’s called dying.

Our current reimbursement system throws another barrier in front of providers. Like many other “nonprocedural” activities, ACP is not only undervalued; there is currently a lack of value assigned to this important cognitive, empathic, and communication-based “procedure.” And I refer to it as a procedure because, like a surgical or invasive vascular procedure, when it goes badly, the consequences and sequelae can be just as damaging, and even irreparable.

Thus, intentionally or not, the can is kicked further down the proverbial road until the patient reaches the hospital in a state of crisis—sometimes in extremis—and the hospitalist is left to make sense of all the clinical, emotional, psychological, spiritual, and frequently familial history (baggage?) leading up to that hospital admission. We are expected to develop instant rapport and trust while simultaneously attempting to develop (in collaboration with our specialty care providers and, preferably, the patient’s primary care provider) a plan of care that takes into account the personal values and treatment preferences for that individual within the clinical realities of the patient’s illness and disease trajectory as they lie before us.

Sound familiar?

For the full blog post, including Dr. Epstein’s recommendations for what hospitalists can do to support the CMS proposal, visit Hospital Leader.

Editor’s note: In July, SHM board member Howard Epstein supported the new CMS proposal to pay for advance care planning, calling it a “procedure” for hospitalists. Below are excerpts from his blog post. For the full post, click here.

Last week, the Centers for Medicare and Medicaid Services (CMS), the nation’s largest payer of healthcare services and the 800-pound gorilla in setting medical necessity and coverage policies, announced a proposal to begin paying for goals of care and advance care planning (ACP) discussions between medical providers and patients. Sound familiar? It should. This is the same, seemingly no-brainer proposal that in 2009 was stricken from the eventually approved Patient Protection and Affordable Care Act (PPACA, aka the ACA, aka “Obamacare”) in response to the intentional and patently false accusations of government-run “death panels,” in the hopes of salvaging some measure of bipartisan support. As we all know, the bill eventually passed the following year without a single Republican voting in favor in either the House or Senate, and without funding for ACP sessions!

The need for ACP and access to primary and specialty palliative care is so great and accepted in the healthcare community. In their Choosing Wisely recommendations, numerous medical specialty societies, including ACEP [American College of Emergency Physicians], AAHPM [American Academy of Hospice and Palliative Medicine], AGS [American Geriatrics Society], and AMDA [The Society for Post-Acute and Long-Term Care Medicine], have included early and reliable access to palliative care and avoidance of non-value added care, such as placement of feeding tubes in patients with advanced dementia, calling out the gap between quality, evidence-based, patient and family-centered care, and “usual care” (e.g. medical and disease-focused care) that patients receive too often near the end of life.

So where is the disconnect between what people want and what actually happens to them at end of life?

The answer is clear: We’re not having “The Conversation.”

And, though our primary care and even specialty care colleagues are involved regularly in the care of these patients, they may be inclined to postpone or avoid ACP with patients and families in the outpatient setting due to lack of comfort [or] skill or even recognizing that the person they’ve been trying valiantly to cure or at least prolong the inevitable [for] is on that downslope of life we all eventually experience—it’s called dying.

Our current reimbursement system throws another barrier in front of providers. Like many other “nonprocedural” activities, ACP is not only undervalued; there is currently a lack of value assigned to this important cognitive, empathic, and communication-based “procedure.” And I refer to it as a procedure because, like a surgical or invasive vascular procedure, when it goes badly, the consequences and sequelae can be just as damaging, and even irreparable.

Thus, intentionally or not, the can is kicked further down the proverbial road until the patient reaches the hospital in a state of crisis—sometimes in extremis—and the hospitalist is left to make sense of all the clinical, emotional, psychological, spiritual, and frequently familial history (baggage?) leading up to that hospital admission. We are expected to develop instant rapport and trust while simultaneously attempting to develop (in collaboration with our specialty care providers and, preferably, the patient’s primary care provider) a plan of care that takes into account the personal values and treatment preferences for that individual within the clinical realities of the patient’s illness and disease trajectory as they lie before us.

Sound familiar?

For the full blog post, including Dr. Epstein’s recommendations for what hospitalists can do to support the CMS proposal, visit Hospital Leader.

Editor’s note: In July, SHM board member Howard Epstein supported the new CMS proposal to pay for advance care planning, calling it a “procedure” for hospitalists. Below are excerpts from his blog post. For the full post, click here.

Last week, the Centers for Medicare and Medicaid Services (CMS), the nation’s largest payer of healthcare services and the 800-pound gorilla in setting medical necessity and coverage policies, announced a proposal to begin paying for goals of care and advance care planning (ACP) discussions between medical providers and patients. Sound familiar? It should. This is the same, seemingly no-brainer proposal that in 2009 was stricken from the eventually approved Patient Protection and Affordable Care Act (PPACA, aka the ACA, aka “Obamacare”) in response to the intentional and patently false accusations of government-run “death panels,” in the hopes of salvaging some measure of bipartisan support. As we all know, the bill eventually passed the following year without a single Republican voting in favor in either the House or Senate, and without funding for ACP sessions!

The need for ACP and access to primary and specialty palliative care is so great and accepted in the healthcare community. In their Choosing Wisely recommendations, numerous medical specialty societies, including ACEP [American College of Emergency Physicians], AAHPM [American Academy of Hospice and Palliative Medicine], AGS [American Geriatrics Society], and AMDA [The Society for Post-Acute and Long-Term Care Medicine], have included early and reliable access to palliative care and avoidance of non-value added care, such as placement of feeding tubes in patients with advanced dementia, calling out the gap between quality, evidence-based, patient and family-centered care, and “usual care” (e.g. medical and disease-focused care) that patients receive too often near the end of life.

So where is the disconnect between what people want and what actually happens to them at end of life?

The answer is clear: We’re not having “The Conversation.”

And, though our primary care and even specialty care colleagues are involved regularly in the care of these patients, they may be inclined to postpone or avoid ACP with patients and families in the outpatient setting due to lack of comfort [or] skill or even recognizing that the person they’ve been trying valiantly to cure or at least prolong the inevitable [for] is on that downslope of life we all eventually experience—it’s called dying.

Our current reimbursement system throws another barrier in front of providers. Like many other “nonprocedural” activities, ACP is not only undervalued; there is currently a lack of value assigned to this important cognitive, empathic, and communication-based “procedure.” And I refer to it as a procedure because, like a surgical or invasive vascular procedure, when it goes badly, the consequences and sequelae can be just as damaging, and even irreparable.

Thus, intentionally or not, the can is kicked further down the proverbial road until the patient reaches the hospital in a state of crisis—sometimes in extremis—and the hospitalist is left to make sense of all the clinical, emotional, psychological, spiritual, and frequently familial history (baggage?) leading up to that hospital admission. We are expected to develop instant rapport and trust while simultaneously attempting to develop (in collaboration with our specialty care providers and, preferably, the patient’s primary care provider) a plan of care that takes into account the personal values and treatment preferences for that individual within the clinical realities of the patient’s illness and disease trajectory as they lie before us.

Sound familiar?

For the full blog post, including Dr. Epstein’s recommendations for what hospitalists can do to support the CMS proposal, visit Hospital Leader.

ATLANTA – Expanded influenza vaccination coverage among children between 2002 and 2012 appears to have provided direct benefit with respect to influenza-related hospitalizations among vaccinated children, according to an analysis of vaccination and hospitalization data.

Additionally, the coverage among children appears to have provided indirect benefits in adults, Cecile Viboud, Ph.D. of the National Institutes of Health, Bethesda, Md., reported at the International Conference on Emerging Infectious Diseases.

Between 2006-2007 and 2010-2011, the U.S. Advisory Committee on Immunization Practices (ACIP) broadened vaccination recommendations to include not only children aged 6-23 months, but also those aged 24-59 months, then those aged 5-18 years, and eventually all those over age 6 months. Consequently, the vaccine coverage rate increased from less than 5% in 2002 to about 52% in 2012 (and to about 70% in those under age 5 years). Modeling of weekly influenza-related hospitalization outcomes (pneumonia and influenza outcomes and respiratory and circulatory outcomes) provided solid evidence of a direct and significant protective effect of vaccination both in children under age 5 years and in those aged 5-19 years. This finding was consistent across disease outcomes, and remained significant in those under age 5 after adjusting for state, but the association was weaker with stratification by season, Dr. Viboud noted.

Further, hospitalization rates among working-age adults and seniors aged 65-74 years declined with increasing pediatric vaccine coverage, suggesting an indirect protective effect in that population, she said, noting that the vaccination rate among older adults remained stable across the study period.

No evidence was seen for an indirect protective effect among adults over age 74 years, she said.

Dr. Viboud and her colleagues used age-specific annual vaccination rates derived from the National Immunization Survey and the Behavioral Risk Factor Surveillance System. Age-specific rates of influenza-associated hospitalizations were estimated for each season during 1989-2012 by modeling weekly pneumonia and influenza outcomes plus respiratory and circulatory outcomes from the State Inpatient Databases of the Agency for Healthcare Research & Quality.

“In a nutshell, we see strong statistical evidence for the direct protective effects of the influenza vaccination program in children on the basis of analyses of population-level hospitalization data, which supports the expansion of the ACIP flu vaccine recommendations in the past decade,” Dr. Viboud said in an interview. “We also find weak evidence of herd immunity effects, whereby hospitalization rates are reduced in adults. That the evidence is weak is perhaps not surprising given that vaccine uptake in children remains moderate (60% in most highly vaccinated states) and vaccine effectiveness is modest at 40%-60% depending on the season. Independent information from mathematical transmission models confirms that herd immunity benefits are expected to be low given these levels of vaccine coverage.”

The indirect effects may become clearer with increasing vaccine uptake, she added.

Dr. Viboud reported having no disclosures.

[email protected]

ATLANTA – Expanded influenza vaccination coverage among children between 2002 and 2012 appears to have provided direct benefit with respect to influenza-related hospitalizations among vaccinated children, according to an analysis of vaccination and hospitalization data.

Additionally, the coverage among children appears to have provided indirect benefits in adults, Cecile Viboud, Ph.D. of the National Institutes of Health, Bethesda, Md., reported at the International Conference on Emerging Infectious Diseases.

Between 2006-2007 and 2010-2011, the U.S. Advisory Committee on Immunization Practices (ACIP) broadened vaccination recommendations to include not only children aged 6-23 months, but also those aged 24-59 months, then those aged 5-18 years, and eventually all those over age 6 months. Consequently, the vaccine coverage rate increased from less than 5% in 2002 to about 52% in 2012 (and to about 70% in those under age 5 years). Modeling of weekly influenza-related hospitalization outcomes (pneumonia and influenza outcomes and respiratory and circulatory outcomes) provided solid evidence of a direct and significant protective effect of vaccination both in children under age 5 years and in those aged 5-19 years. This finding was consistent across disease outcomes, and remained significant in those under age 5 after adjusting for state, but the association was weaker with stratification by season, Dr. Viboud noted.

Further, hospitalization rates among working-age adults and seniors aged 65-74 years declined with increasing pediatric vaccine coverage, suggesting an indirect protective effect in that population, she said, noting that the vaccination rate among older adults remained stable across the study period.

No evidence was seen for an indirect protective effect among adults over age 74 years, she said.

Dr. Viboud and her colleagues used age-specific annual vaccination rates derived from the National Immunization Survey and the Behavioral Risk Factor Surveillance System. Age-specific rates of influenza-associated hospitalizations were estimated for each season during 1989-2012 by modeling weekly pneumonia and influenza outcomes plus respiratory and circulatory outcomes from the State Inpatient Databases of the Agency for Healthcare Research & Quality.

“In a nutshell, we see strong statistical evidence for the direct protective effects of the influenza vaccination program in children on the basis of analyses of population-level hospitalization data, which supports the expansion of the ACIP flu vaccine recommendations in the past decade,” Dr. Viboud said in an interview. “We also find weak evidence of herd immunity effects, whereby hospitalization rates are reduced in adults. That the evidence is weak is perhaps not surprising given that vaccine uptake in children remains moderate (60% in most highly vaccinated states) and vaccine effectiveness is modest at 40%-60% depending on the season. Independent information from mathematical transmission models confirms that herd immunity benefits are expected to be low given these levels of vaccine coverage.”

The indirect effects may become clearer with increasing vaccine uptake, she added.

Dr. Viboud reported having no disclosures.

[email protected]

ATLANTA – Expanded influenza vaccination coverage among children between 2002 and 2012 appears to have provided direct benefit with respect to influenza-related hospitalizations among vaccinated children, according to an analysis of vaccination and hospitalization data.

Additionally, the coverage among children appears to have provided indirect benefits in adults, Cecile Viboud, Ph.D. of the National Institutes of Health, Bethesda, Md., reported at the International Conference on Emerging Infectious Diseases.

Between 2006-2007 and 2010-2011, the U.S. Advisory Committee on Immunization Practices (ACIP) broadened vaccination recommendations to include not only children aged 6-23 months, but also those aged 24-59 months, then those aged 5-18 years, and eventually all those over age 6 months. Consequently, the vaccine coverage rate increased from less than 5% in 2002 to about 52% in 2012 (and to about 70% in those under age 5 years). Modeling of weekly influenza-related hospitalization outcomes (pneumonia and influenza outcomes and respiratory and circulatory outcomes) provided solid evidence of a direct and significant protective effect of vaccination both in children under age 5 years and in those aged 5-19 years. This finding was consistent across disease outcomes, and remained significant in those under age 5 after adjusting for state, but the association was weaker with stratification by season, Dr. Viboud noted.

Further, hospitalization rates among working-age adults and seniors aged 65-74 years declined with increasing pediatric vaccine coverage, suggesting an indirect protective effect in that population, she said, noting that the vaccination rate among older adults remained stable across the study period.

No evidence was seen for an indirect protective effect among adults over age 74 years, she said.

Dr. Viboud and her colleagues used age-specific annual vaccination rates derived from the National Immunization Survey and the Behavioral Risk Factor Surveillance System. Age-specific rates of influenza-associated hospitalizations were estimated for each season during 1989-2012 by modeling weekly pneumonia and influenza outcomes plus respiratory and circulatory outcomes from the State Inpatient Databases of the Agency for Healthcare Research & Quality.

“In a nutshell, we see strong statistical evidence for the direct protective effects of the influenza vaccination program in children on the basis of analyses of population-level hospitalization data, which supports the expansion of the ACIP flu vaccine recommendations in the past decade,” Dr. Viboud said in an interview. “We also find weak evidence of herd immunity effects, whereby hospitalization rates are reduced in adults. That the evidence is weak is perhaps not surprising given that vaccine uptake in children remains moderate (60% in most highly vaccinated states) and vaccine effectiveness is modest at 40%-60% depending on the season. Independent information from mathematical transmission models confirms that herd immunity benefits are expected to be low given these levels of vaccine coverage.”

The indirect effects may become clearer with increasing vaccine uptake, she added.

Dr. Viboud reported having no disclosures.

[email protected]

Ready to get the best information on improving care in your hospital, directly from the nation’s top experts? Check out this month’s QI webinars from SHM.

Glycemic Control Webinar

Subcutaneous Insulin Order Sets in the Inpatient Setting: Design and Implementation

Presenter: Kristi Kulasa, MD

Date: September 17

Time: 4 p.m. EDT

---

General QI Webinars

Quality Improvement for Hospital Medicine Groups: Self-Assessment and Self-Improvement Using the SHM Key Characteristics

Presenter: Steve Deitelzweig, MD, SFHM

Date: September 16

Time: 2 p.m. EDT

---

Other online resources at www.hospitalmedicine.org:

• New FREE clinical topics and guide: chronic obstructive pulmonary disease.
• Coming soon: antibiotic stewardship.
• And now, all of SHM’s popular SHMConsults modules are available on the Learning Portal.

---

With new quality improvement resources available online every month, Hospital Medicine is THE source for hospitalists ready to improve their hospitals.

Ready to get the best information on improving care in your hospital, directly from the nation’s top experts? Check out this month’s QI webinars from SHM.

Glycemic Control Webinar

Subcutaneous Insulin Order Sets in the Inpatient Setting: Design and Implementation

Presenter: Kristi Kulasa, MD

Date: September 17

Time: 4 p.m. EDT

---

General QI Webinars

Quality Improvement for Hospital Medicine Groups: Self-Assessment and Self-Improvement Using the SHM Key Characteristics

Presenter: Steve Deitelzweig, MD, SFHM

Date: September 16

Time: 2 p.m. EDT

---

Other online resources at www.hospitalmedicine.org:

• New FREE clinical topics and guide: chronic obstructive pulmonary disease.
• Coming soon: antibiotic stewardship.
• And now, all of SHM’s popular SHMConsults modules are available on the Learning Portal.

---

With new quality improvement resources available online every month, Hospital Medicine is THE source for hospitalists ready to improve their hospitals.

Ready to get the best information on improving care in your hospital, directly from the nation’s top experts? Check out this month’s QI webinars from SHM.

Glycemic Control Webinar

Subcutaneous Insulin Order Sets in the Inpatient Setting: Design and Implementation

Presenter: Kristi Kulasa, MD

Date: September 17

Time: 4 p.m. EDT

---

General QI Webinars

Quality Improvement for Hospital Medicine Groups: Self-Assessment and Self-Improvement Using the SHM Key Characteristics

Presenter: Steve Deitelzweig, MD, SFHM

Date: September 16

Time: 2 p.m. EDT

---

Other online resources at www.hospitalmedicine.org:

• New FREE clinical topics and guide: chronic obstructive pulmonary disease.
• Coming soon: antibiotic stewardship.
• And now, all of SHM’s popular SHMConsults modules are available on the Learning Portal.

---

With new quality improvement resources available online every month, Hospital Medicine is THE source for hospitalists ready to improve their hospitals.

SHM’s practice analysis committee has geared up over the last month or two in preparation for January’s biannual State of Hospital Medicine survey. We’ve been reviewing topics included in the survey with an eye toward making sure the content stays relevant to what hospitalists and hospital leaders want to know. And we’ve been parsing the language and construction of each question with the goal of making it as clear as possible.

Once the committee finalizes the survey questions, it will be time for our intrepid SHM staffer Patrick Vulgamore, MPH, to build and test the survey instrument. At the same time, the committee will complete supporting materials like FAQs, the survey guide, and the communication plan.

But not all the work is on our side. There are a number of things that you can do now to begin preparing for your survey participation.

First, Commit to Participating

The survey is only as good as the number and quality of responses that we receive. We need everyone to participate, whether your hospital medicine group works in an academic or community setting, whether you serve adult or pediatric patients or both, and whether you are employed by a hospital/system, a management company, or a private group.

Go ask the leaders of your group whether they plan to participate, and lobby heavily to be part of the process. In addition to helping define the current state of hospital medicine, your group will also receive a free copy of the survey report.

Make a Plan

Your next step is to identify who will be responsible for pulling together the required information and completing the survey instrument. You’ll also want to be thinking now about where the various pieces of information you’ll need will come from. The survey includes topics such as scope of clinical practice, schedule, skill mix and work allocation, compensation methodology and benefits, CPT code distribution, and amount of financial support received. Then make sure you set aside time in the January-March period to complete the survey, and check to see that any necessary approvals have been obtained.

Look for Survey Communications in January 2016

The practice analysis committee tries hard to cover every possible communication avenue, but invariably people will say, “We didn’t know it was time for the survey.” So this is your heads up to be on the lookout for your survey invitation—in the regular mail, in both targeted and general emails, in The Hospitalist and other SHM publications, and on the SHM website.

Participate in the MGMA Survey, Too

The SoHM survey doesn’t include questions about individual provider productivity and compensation, but those are some of the most often looked for data points. Instead, SHM partners with the Medical Group Management Association (MGMA) to encourage hospital medicine groups to participate in the MGMA compensation and production survey—which will be conducted concurrently with SHM’s survey for both academic and non-academic groups. SHM then licenses this information for inclusion in the SoHM report.

Full participation in the SHM survey process means not just completing SHM’s SoHM survey but also completing the applicable MGMA survey. This is the only way we can obtain robust information about trends in hospitalist compensation and productivity to share with you.

So don’t wait until January. Start working now to ensure your group is well positioned to contribute to what we learn about the state of hospital medicine!

 

---

Leslie Flores is a member of SHM’s Practice Analysis Committee and a partner in Nelson Flores Hospital Medicine Consultants.

SHM’s practice analysis committee has geared up over the last month or two in preparation for January’s biannual State of Hospital Medicine survey. We’ve been reviewing topics included in the survey with an eye toward making sure the content stays relevant to what hospitalists and hospital leaders want to know. And we’ve been parsing the language and construction of each question with the goal of making it as clear as possible.

Once the committee finalizes the survey questions, it will be time for our intrepid SHM staffer Patrick Vulgamore, MPH, to build and test the survey instrument. At the same time, the committee will complete supporting materials like FAQs, the survey guide, and the communication plan.

But not all the work is on our side. There are a number of things that you can do now to begin preparing for your survey participation.

First, Commit to Participating

The survey is only as good as the number and quality of responses that we receive. We need everyone to participate, whether your hospital medicine group works in an academic or community setting, whether you serve adult or pediatric patients or both, and whether you are employed by a hospital/system, a management company, or a private group.

Go ask the leaders of your group whether they plan to participate, and lobby heavily to be part of the process. In addition to helping define the current state of hospital medicine, your group will also receive a free copy of the survey report.

Make a Plan

Your next step is to identify who will be responsible for pulling together the required information and completing the survey instrument. You’ll also want to be thinking now about where the various pieces of information you’ll need will come from. The survey includes topics such as scope of clinical practice, schedule, skill mix and work allocation, compensation methodology and benefits, CPT code distribution, and amount of financial support received. Then make sure you set aside time in the January-March period to complete the survey, and check to see that any necessary approvals have been obtained.

Look for Survey Communications in January 2016

The practice analysis committee tries hard to cover every possible communication avenue, but invariably people will say, “We didn’t know it was time for the survey.” So this is your heads up to be on the lookout for your survey invitation—in the regular mail, in both targeted and general emails, in The Hospitalist and other SHM publications, and on the SHM website.

Participate in the MGMA Survey, Too

The SoHM survey doesn’t include questions about individual provider productivity and compensation, but those are some of the most often looked for data points. Instead, SHM partners with the Medical Group Management Association (MGMA) to encourage hospital medicine groups to participate in the MGMA compensation and production survey—which will be conducted concurrently with SHM’s survey for both academic and non-academic groups. SHM then licenses this information for inclusion in the SoHM report.

Full participation in the SHM survey process means not just completing SHM’s SoHM survey but also completing the applicable MGMA survey. This is the only way we can obtain robust information about trends in hospitalist compensation and productivity to share with you.

So don’t wait until January. Start working now to ensure your group is well positioned to contribute to what we learn about the state of hospital medicine!

 

---

Leslie Flores is a member of SHM’s Practice Analysis Committee and a partner in Nelson Flores Hospital Medicine Consultants.

SHM’s practice analysis committee has geared up over the last month or two in preparation for January’s biannual State of Hospital Medicine survey. We’ve been reviewing topics included in the survey with an eye toward making sure the content stays relevant to what hospitalists and hospital leaders want to know. And we’ve been parsing the language and construction of each question with the goal of making it as clear as possible.

Once the committee finalizes the survey questions, it will be time for our intrepid SHM staffer Patrick Vulgamore, MPH, to build and test the survey instrument. At the same time, the committee will complete supporting materials like FAQs, the survey guide, and the communication plan.

But not all the work is on our side. There are a number of things that you can do now to begin preparing for your survey participation.

First, Commit to Participating

The survey is only as good as the number and quality of responses that we receive. We need everyone to participate, whether your hospital medicine group works in an academic or community setting, whether you serve adult or pediatric patients or both, and whether you are employed by a hospital/system, a management company, or a private group.

Go ask the leaders of your group whether they plan to participate, and lobby heavily to be part of the process. In addition to helping define the current state of hospital medicine, your group will also receive a free copy of the survey report.

Make a Plan

Your next step is to identify who will be responsible for pulling together the required information and completing the survey instrument. You’ll also want to be thinking now about where the various pieces of information you’ll need will come from. The survey includes topics such as scope of clinical practice, schedule, skill mix and work allocation, compensation methodology and benefits, CPT code distribution, and amount of financial support received. Then make sure you set aside time in the January-March period to complete the survey, and check to see that any necessary approvals have been obtained.

Look for Survey Communications in January 2016

The practice analysis committee tries hard to cover every possible communication avenue, but invariably people will say, “We didn’t know it was time for the survey.” So this is your heads up to be on the lookout for your survey invitation—in the regular mail, in both targeted and general emails, in The Hospitalist and other SHM publications, and on the SHM website.

Participate in the MGMA Survey, Too

The SoHM survey doesn’t include questions about individual provider productivity and compensation, but those are some of the most often looked for data points. Instead, SHM partners with the Medical Group Management Association (MGMA) to encourage hospital medicine groups to participate in the MGMA compensation and production survey—which will be conducted concurrently with SHM’s survey for both academic and non-academic groups. SHM then licenses this information for inclusion in the SoHM report.

Full participation in the SHM survey process means not just completing SHM’s SoHM survey but also completing the applicable MGMA survey. This is the only way we can obtain robust information about trends in hospitalist compensation and productivity to share with you.

So don’t wait until January. Start working now to ensure your group is well positioned to contribute to what we learn about the state of hospital medicine!

 

---

Leslie Flores is a member of SHM’s Practice Analysis Committee and a partner in Nelson Flores Hospital Medicine Consultants.

Clinical question: Can a diagnostic strategy that utilizes a clinical prediction rule combined with an immunoassay appropriately guide management for patients with suspected heparin-induced thrombocytopenia (HIT)?

Background: The appropriate and timely diagnosis of HIT can decrease the risks of thromboembolic and major bleeding events. Unfortunately, the reference standard tests for diagnosing HIT (e.g. serotonin release assay) are time-intensive. Immunoassays such as PF4/H-PaGIA provide a faster diagnostic approach but have been limited by poor specificity.

Study design: Single-group prospective cohort trial.

Setting: Four hospitals in Ontario, Canada between 2008 and 2013.

Synopsis: In 526 patients with suspected HIT, the results of a diagnostic strategy that combined the 4Ts score system and a PF4/H-PaGIA assay were compared to a HIT reference standard. For the identification of patients with HIT, the use of (1) an intermediate 4Ts score and negative PF4/H-PaGIA or (2) a low 4Ts score regardless of PF4/H-PaGIA result incorrectly excluded patients with HIT in 1.1% of cases (95% confidence interval 0.2-2.1%). For patients with low and intermediate 4Ts scores, however, a negative PF4/H-PaGIA result did not result in any incorrect exclusion.

Bottom line: In patients with low or intermediate 4Ts scores, a negative PF4/H-PaGIA assay may be used to exclude HIT, but further research into how to approach patients with a low 4Ts score and a positive PF4/H-PaGIA assay is needed.

Citation: Linkins LA, Bates SM, Lee AY, Heddle NM, Wang G, Warkentin TE. Combination of 4Ts score and PF4/H-PaGIA for diagnosis and management of heparin-induced thrombocytopenia: prospective cohort study. Blood. 2015;126(5):597-603.

Clinical question: Can a diagnostic strategy that utilizes a clinical prediction rule combined with an immunoassay appropriately guide management for patients with suspected heparin-induced thrombocytopenia (HIT)?

Background: The appropriate and timely diagnosis of HIT can decrease the risks of thromboembolic and major bleeding events. Unfortunately, the reference standard tests for diagnosing HIT (e.g. serotonin release assay) are time-intensive. Immunoassays such as PF4/H-PaGIA provide a faster diagnostic approach but have been limited by poor specificity.

Study design: Single-group prospective cohort trial.

Setting: Four hospitals in Ontario, Canada between 2008 and 2013.

Synopsis: In 526 patients with suspected HIT, the results of a diagnostic strategy that combined the 4Ts score system and a PF4/H-PaGIA assay were compared to a HIT reference standard. For the identification of patients with HIT, the use of (1) an intermediate 4Ts score and negative PF4/H-PaGIA or (2) a low 4Ts score regardless of PF4/H-PaGIA result incorrectly excluded patients with HIT in 1.1% of cases (95% confidence interval 0.2-2.1%). For patients with low and intermediate 4Ts scores, however, a negative PF4/H-PaGIA result did not result in any incorrect exclusion.

Bottom line: In patients with low or intermediate 4Ts scores, a negative PF4/H-PaGIA assay may be used to exclude HIT, but further research into how to approach patients with a low 4Ts score and a positive PF4/H-PaGIA assay is needed.

Citation: Linkins LA, Bates SM, Lee AY, Heddle NM, Wang G, Warkentin TE. Combination of 4Ts score and PF4/H-PaGIA for diagnosis and management of heparin-induced thrombocytopenia: prospective cohort study. Blood. 2015;126(5):597-603.

Clinical question: Can a diagnostic strategy that utilizes a clinical prediction rule combined with an immunoassay appropriately guide management for patients with suspected heparin-induced thrombocytopenia (HIT)?

Background: The appropriate and timely diagnosis of HIT can decrease the risks of thromboembolic and major bleeding events. Unfortunately, the reference standard tests for diagnosing HIT (e.g. serotonin release assay) are time-intensive. Immunoassays such as PF4/H-PaGIA provide a faster diagnostic approach but have been limited by poor specificity.

Study design: Single-group prospective cohort trial.

Setting: Four hospitals in Ontario, Canada between 2008 and 2013.

Synopsis: In 526 patients with suspected HIT, the results of a diagnostic strategy that combined the 4Ts score system and a PF4/H-PaGIA assay were compared to a HIT reference standard. For the identification of patients with HIT, the use of (1) an intermediate 4Ts score and negative PF4/H-PaGIA or (2) a low 4Ts score regardless of PF4/H-PaGIA result incorrectly excluded patients with HIT in 1.1% of cases (95% confidence interval 0.2-2.1%). For patients with low and intermediate 4Ts scores, however, a negative PF4/H-PaGIA result did not result in any incorrect exclusion.

Bottom line: In patients with low or intermediate 4Ts scores, a negative PF4/H-PaGIA assay may be used to exclude HIT, but further research into how to approach patients with a low 4Ts score and a positive PF4/H-PaGIA assay is needed.

Citation: Linkins LA, Bates SM, Lee AY, Heddle NM, Wang G, Warkentin TE. Combination of 4Ts score and PF4/H-PaGIA for diagnosis and management of heparin-induced thrombocytopenia: prospective cohort study. Blood. 2015;126(5):597-603.

Researchers say they have created a model that can show how nearly any drug behaves in P-glycoprotein (P-gp), a protein associated with chemotherapy failure.

The team developed this computer-generated model to overcome the problem of relying on static images for the structure of P-gp.

When the researchers introduced drugs into the model, the drugs responded the way they do in real life and behaved according to predictions.

John G. Wise, PhD, of Southern Methodist University in Dallas, Texas, and his colleagues described the model in Biochemistry.

“The value of this fundamental research is that it generates dynamic mechanisms that let us understand something in biochemistry, in biology,” Dr Wise said. “And by understanding P-gp in such detail, we can now think of ways to better and more specifically inhibit it.”

Dr Wise and his colleagues noted that P-gp protects cells by pumping out toxins, but that can include chemotherapy drugs. So inhibiting P-gp’s pumping action might circumvent chemotherapy failure.

With than in mind, the team tested tariquidar, a P-gp inhibitor in clinical trials, in their model.

It hasn’t been clear exactly where tariquidar binds in P-gp. But the model showed the drug prefers to bind high in the protein. Tariquidar also behaved as expected. It wasn’t effectively pumped from the cell.

“Now we have more details on how tariquidar inhibits P-gp, where it inhibits, and what it’s actually binding to,” Dr Wise said.

He and his colleagues also used their model to uncover additional details about the behavior of other drugs in P-gp.

“For a long time, it’s been thought that there are at least a couple of distinct binding sites for drugs,” Dr Wise said.

“Sure enough, with our models, we found that [the chemotherapeutic agent] daunorubicin, at least, prefers to bind on one side of the P-gp model, while verapamil—a commonly prescribed blood pressure medicine—prefers the other side.”

Not only did the researchers show computationally that there are 2 different starting points for drugs, they also showed that there are 2 different pathways to get the drugs through.

“The 2 different drugs start at different sites, and they’re funneled to the outside by being pushed by the protein,” Dr Wise said. “But the actual parts of the protein that are pushing the drugs out are different.”

Drug discovery

Being able to watch molecular machinery up close, while it is doing its job the way it does in real life, may spark new drug discoveries to fight cancer, Dr Wise said.

“Having an accurate model that actually moves—that shows the dynamics of the thing—is incredibly helpful in developing therapies against a molecular target to inhibit it,” Dr Wise said. “The only other ways to do it are blind, and the chances of success using blind methods are very low.”

“Scientists have tried for 30 years to find inhibitors of this pump and have done it without knowing the structure and with only little knowledge about the mechanism, screening more or less blindly for compounds that inhibit the thing.”

“They found drugs that worked in the test tube and that worked in cultured cells but that didn’t work in the patient. With our model, because we can see the pump moving, we can probably predict better what’s going to make an inhibitor actually work well.”

Dr Wise and his colleagues used the P-gp model to virtually screen millions of publicly available compounds. They discovered 3 new drug leads that could ultimately inhibit P-gp and offer better odds of survival to prostate cancer patients.

 

The researchers reported these findings in Pharmacology Research & Perspectives.

Creating the model

To build the P-gp model, Dr Wise and his colleagues used static structures from the US Protein Data Bank repository. They used structures showing various stages of transport to simulate 4 points of reference.

From there, the team fed a supercomputer parameters and characteristics of the protein, as well as how it should behave physically, including when kinetic energy was added to bring the protein and its surrounding membrane and water up to body temperature.

The animated model resulted from calculating differences between 2 structures and using targeted molecular dynamics programs to slightly nudge the model to the next step.

“You do that several million times and make several trillion calculations, and you arrive at the next structure,” Dr Wise said. “In this way, we can nudge P-gp through a full catalytic transport cycle.”

Finally, using a docking program, the researchers individually introduced daunorubicin and other drugs into the protein and watched the drugs move through P-gp’s catalytic cycle.

“What happened was: the drugs moved,” Dr Wise said. “And they moved the way they should move, clinically, biochemically, physiologically, to pump the compounds out of the cell.”

Challenging the model

The researchers ran a critical control to further test if the model worked.

“We thought maybe anything you put in the protein, relevant or not, would get pumped through,” Dr Wise said. “So we put in something that is not a transport substrate of P-gp, something that, biochemically, would never be transported by P-gp.”

“We put it in, starting where daunorubicin is effectively pumped out, and, very quickly, the compound left the protein. But it left the opposite way, back into the cell. This experiment gave us more confidence that what we are seeing in these models is reflecting what happens in the cell.”

Dr Wise admitted that, until he saw it for himself, he had doubts the virtual P-gp model would behave like real-life P-gp.

“It’s a crude approximation of a complex, sophisticated human protein, but it’s so much better than the static images available now,” Dr Wise said.

“I’ve got to emphasize for all the disbelievers, for the ‘culture of doubters’ out there, that this model works. It moves the drugs through the membrane. That speaks for itself. What P-gp does in the cell, cancerous or normal, it does in our simulations.”

Researchers say they have created a model that can show how nearly any drug behaves in P-glycoprotein (P-gp), a protein associated with chemotherapy failure.

The team developed this computer-generated model to overcome the problem of relying on static images for the structure of P-gp.

When the researchers introduced drugs into the model, the drugs responded the way they do in real life and behaved according to predictions.

John G. Wise, PhD, of Southern Methodist University in Dallas, Texas, and his colleagues described the model in Biochemistry.

“The value of this fundamental research is that it generates dynamic mechanisms that let us understand something in biochemistry, in biology,” Dr Wise said. “And by understanding P-gp in such detail, we can now think of ways to better and more specifically inhibit it.”

Dr Wise and his colleagues noted that P-gp protects cells by pumping out toxins, but that can include chemotherapy drugs. So inhibiting P-gp’s pumping action might circumvent chemotherapy failure.

With than in mind, the team tested tariquidar, a P-gp inhibitor in clinical trials, in their model.

It hasn’t been clear exactly where tariquidar binds in P-gp. But the model showed the drug prefers to bind high in the protein. Tariquidar also behaved as expected. It wasn’t effectively pumped from the cell.

“Now we have more details on how tariquidar inhibits P-gp, where it inhibits, and what it’s actually binding to,” Dr Wise said.

He and his colleagues also used their model to uncover additional details about the behavior of other drugs in P-gp.

“For a long time, it’s been thought that there are at least a couple of distinct binding sites for drugs,” Dr Wise said.

“Sure enough, with our models, we found that [the chemotherapeutic agent] daunorubicin, at least, prefers to bind on one side of the P-gp model, while verapamil—a commonly prescribed blood pressure medicine—prefers the other side.”

Not only did the researchers show computationally that there are 2 different starting points for drugs, they also showed that there are 2 different pathways to get the drugs through.

“The 2 different drugs start at different sites, and they’re funneled to the outside by being pushed by the protein,” Dr Wise said. “But the actual parts of the protein that are pushing the drugs out are different.”

Drug discovery

Being able to watch molecular machinery up close, while it is doing its job the way it does in real life, may spark new drug discoveries to fight cancer, Dr Wise said.

“Having an accurate model that actually moves—that shows the dynamics of the thing—is incredibly helpful in developing therapies against a molecular target to inhibit it,” Dr Wise said. “The only other ways to do it are blind, and the chances of success using blind methods are very low.”

“Scientists have tried for 30 years to find inhibitors of this pump and have done it without knowing the structure and with only little knowledge about the mechanism, screening more or less blindly for compounds that inhibit the thing.”

“They found drugs that worked in the test tube and that worked in cultured cells but that didn’t work in the patient. With our model, because we can see the pump moving, we can probably predict better what’s going to make an inhibitor actually work well.”

Dr Wise and his colleagues used the P-gp model to virtually screen millions of publicly available compounds. They discovered 3 new drug leads that could ultimately inhibit P-gp and offer better odds of survival to prostate cancer patients.

 

The researchers reported these findings in Pharmacology Research & Perspectives.

Creating the model

To build the P-gp model, Dr Wise and his colleagues used static structures from the US Protein Data Bank repository. They used structures showing various stages of transport to simulate 4 points of reference.

From there, the team fed a supercomputer parameters and characteristics of the protein, as well as how it should behave physically, including when kinetic energy was added to bring the protein and its surrounding membrane and water up to body temperature.

The animated model resulted from calculating differences between 2 structures and using targeted molecular dynamics programs to slightly nudge the model to the next step.

“You do that several million times and make several trillion calculations, and you arrive at the next structure,” Dr Wise said. “In this way, we can nudge P-gp through a full catalytic transport cycle.”

Finally, using a docking program, the researchers individually introduced daunorubicin and other drugs into the protein and watched the drugs move through P-gp’s catalytic cycle.

“What happened was: the drugs moved,” Dr Wise said. “And they moved the way they should move, clinically, biochemically, physiologically, to pump the compounds out of the cell.”

Challenging the model

The researchers ran a critical control to further test if the model worked.

“We thought maybe anything you put in the protein, relevant or not, would get pumped through,” Dr Wise said. “So we put in something that is not a transport substrate of P-gp, something that, biochemically, would never be transported by P-gp.”

“We put it in, starting where daunorubicin is effectively pumped out, and, very quickly, the compound left the protein. But it left the opposite way, back into the cell. This experiment gave us more confidence that what we are seeing in these models is reflecting what happens in the cell.”

Dr Wise admitted that, until he saw it for himself, he had doubts the virtual P-gp model would behave like real-life P-gp.

“It’s a crude approximation of a complex, sophisticated human protein, but it’s so much better than the static images available now,” Dr Wise said.

“I’ve got to emphasize for all the disbelievers, for the ‘culture of doubters’ out there, that this model works. It moves the drugs through the membrane. That speaks for itself. What P-gp does in the cell, cancerous or normal, it does in our simulations.”

Researchers say they have created a model that can show how nearly any drug behaves in P-glycoprotein (P-gp), a protein associated with chemotherapy failure.

The team developed this computer-generated model to overcome the problem of relying on static images for the structure of P-gp.

When the researchers introduced drugs into the model, the drugs responded the way they do in real life and behaved according to predictions.

John G. Wise, PhD, of Southern Methodist University in Dallas, Texas, and his colleagues described the model in Biochemistry.

“The value of this fundamental research is that it generates dynamic mechanisms that let us understand something in biochemistry, in biology,” Dr Wise said. “And by understanding P-gp in such detail, we can now think of ways to better and more specifically inhibit it.”

Dr Wise and his colleagues noted that P-gp protects cells by pumping out toxins, but that can include chemotherapy drugs. So inhibiting P-gp’s pumping action might circumvent chemotherapy failure.

With than in mind, the team tested tariquidar, a P-gp inhibitor in clinical trials, in their model.

It hasn’t been clear exactly where tariquidar binds in P-gp. But the model showed the drug prefers to bind high in the protein. Tariquidar also behaved as expected. It wasn’t effectively pumped from the cell.

“Now we have more details on how tariquidar inhibits P-gp, where it inhibits, and what it’s actually binding to,” Dr Wise said.

He and his colleagues also used their model to uncover additional details about the behavior of other drugs in P-gp.

“For a long time, it’s been thought that there are at least a couple of distinct binding sites for drugs,” Dr Wise said.

“Sure enough, with our models, we found that [the chemotherapeutic agent] daunorubicin, at least, prefers to bind on one side of the P-gp model, while verapamil—a commonly prescribed blood pressure medicine—prefers the other side.”

Not only did the researchers show computationally that there are 2 different starting points for drugs, they also showed that there are 2 different pathways to get the drugs through.

“The 2 different drugs start at different sites, and they’re funneled to the outside by being pushed by the protein,” Dr Wise said. “But the actual parts of the protein that are pushing the drugs out are different.”

Drug discovery

Being able to watch molecular machinery up close, while it is doing its job the way it does in real life, may spark new drug discoveries to fight cancer, Dr Wise said.

“Having an accurate model that actually moves—that shows the dynamics of the thing—is incredibly helpful in developing therapies against a molecular target to inhibit it,” Dr Wise said. “The only other ways to do it are blind, and the chances of success using blind methods are very low.”

“Scientists have tried for 30 years to find inhibitors of this pump and have done it without knowing the structure and with only little knowledge about the mechanism, screening more or less blindly for compounds that inhibit the thing.”

“They found drugs that worked in the test tube and that worked in cultured cells but that didn’t work in the patient. With our model, because we can see the pump moving, we can probably predict better what’s going to make an inhibitor actually work well.”

Dr Wise and his colleagues used the P-gp model to virtually screen millions of publicly available compounds. They discovered 3 new drug leads that could ultimately inhibit P-gp and offer better odds of survival to prostate cancer patients.

 

The researchers reported these findings in Pharmacology Research & Perspectives.

Creating the model

To build the P-gp model, Dr Wise and his colleagues used static structures from the US Protein Data Bank repository. They used structures showing various stages of transport to simulate 4 points of reference.

From there, the team fed a supercomputer parameters and characteristics of the protein, as well as how it should behave physically, including when kinetic energy was added to bring the protein and its surrounding membrane and water up to body temperature.

The animated model resulted from calculating differences between 2 structures and using targeted molecular dynamics programs to slightly nudge the model to the next step.

“You do that several million times and make several trillion calculations, and you arrive at the next structure,” Dr Wise said. “In this way, we can nudge P-gp through a full catalytic transport cycle.”

Finally, using a docking program, the researchers individually introduced daunorubicin and other drugs into the protein and watched the drugs move through P-gp’s catalytic cycle.

“What happened was: the drugs moved,” Dr Wise said. “And they moved the way they should move, clinically, biochemically, physiologically, to pump the compounds out of the cell.”

Challenging the model

The researchers ran a critical control to further test if the model worked.

“We thought maybe anything you put in the protein, relevant or not, would get pumped through,” Dr Wise said. “So we put in something that is not a transport substrate of P-gp, something that, biochemically, would never be transported by P-gp.”

“We put it in, starting where daunorubicin is effectively pumped out, and, very quickly, the compound left the protein. But it left the opposite way, back into the cell. This experiment gave us more confidence that what we are seeing in these models is reflecting what happens in the cell.”

Dr Wise admitted that, until he saw it for himself, he had doubts the virtual P-gp model would behave like real-life P-gp.

“It’s a crude approximation of a complex, sophisticated human protein, but it’s so much better than the static images available now,” Dr Wise said.

“I’ve got to emphasize for all the disbelievers, for the ‘culture of doubters’ out there, that this model works. It moves the drugs through the membrane. That speaks for itself. What P-gp does in the cell, cancerous or normal, it does in our simulations.”

Results of a single-center study seem to support the use of tranexamic acid (TXA) in all eligible patients undergoing hip or knee replacement.

By giving TXA to every eligible patient undergoing hip or knee arthroplasty, a Canadian hospital significantly reduced its use of red blood cell transfusions during these surgeries without increasing the incidence of adverse events or the patients’ length of hospital stay.

The results were published in the Canadian Journal of Anesthesia.

TXA is known to prevent excessive blood loss during surgeries and has proven effective in orthopedic, trauma, and cardiac patients.

However, a few years ago, less than half of eligible patients at St. Michael’s Hospital in Toronto, Ontario, were receiving TXA because of a province-wide shortage. The drug was given only to patients at high risk of requiring a blood transfusion.

The TXA shortage ended in early 2013 and, in October 2013, St. Michael’s implemented a protocol to facilitate universal administration of TXA in patients undergoing total hip or knee arthroplasty.

“We wanted to optimize TXA’s use in patients undergoing hip or knee replacements because these procedures often result in high blood loss and frequently require transfusions,” said study author Greg Hare, MD, PhD, an anesthesiologist at St. Michael’s.

“The drug costs about $10 per patient, while the average cost of transfusing one unit of blood is $1200.”

So every eligible patient undergoing hip or knee replacement received TXA at 20 mg/kg⁻¹. The drug was not used in patients considered at risk of thromboembolic events, stroke, or any other cardiovascular issues.

A total of 402 patients received the drug from October 21, 2013, to April 30, 2014. The researchers compared this group of patients to a group of 422 hip/knee replacement patients treated before the universal administration protocol was implemented (when TXA was given to high-risk patients only).

As expected, there was a significant increase in TXA use post-protocol, from 45.8% to 95.3% (P<0.001). And the rate of red blood cell transfusions decreased from 8.8% to 5.2% (P=0.043).

There was no significant difference in mean preoperative hemoglobin (Hb) levels between the pre- and post-protocol groups—133 g/L^-1 and 135 g/L^-1, respectively (P=0.073).

But there was a significant increase in Hb in the post-protocol group on days 1 and 3 after surgery. On day 1, the mean Hb was 108 g/L^-1 in the pre-protocol group and 112 g/L^-1 in the post-protocol group (P<0.001). On day 3, the mean Hb was 97 g/L^-1 and 101 g/L^-1, respectively (P<0.001).

There was no significant difference between the groups with regard to length of hospital stay. The mean length of stay was 3.93 days pre-protocol and 3.87 days post-protocol (P=0.652).

The adverse events assessed were death, myocardial infarction (MI), stroke, seizure, pulmonary embolism (PE), deep vein thrombosis (DVT), and acute kidney injury (AKI).

There were 13 such events in the pre-protocol group, including 1 MI, 3 PEs, and 9 AKIs. And there were 19 such events in the post-protocol group, including 1 MI, 1 DVT, 1 PE, and 16 AKIs (P=0.368 for all events and P=0.223 for AKIs).

Because TXA decreased the use of transfusions without increasing the rate of adverse events, Dr Hare and his colleagues consider their universal administration protocol a success.

“Making TXA mandatory for eligible patients has made care more efficient, ensuring the best possible care for our patients,” Dr Hare said.

“Other hospitals and surgical centers should consider making TXA mandatory for similar surgeries because it can improve quality of care, decrease the need for blood transfusions, and even save money.”

Results of a single-center study seem to support the use of tranexamic acid (TXA) in all eligible patients undergoing hip or knee replacement.

By giving TXA to every eligible patient undergoing hip or knee arthroplasty, a Canadian hospital significantly reduced its use of red blood cell transfusions during these surgeries without increasing the incidence of adverse events or the patients’ length of hospital stay.

The results were published in the Canadian Journal of Anesthesia.

TXA is known to prevent excessive blood loss during surgeries and has proven effective in orthopedic, trauma, and cardiac patients.

However, a few years ago, less than half of eligible patients at St. Michael’s Hospital in Toronto, Ontario, were receiving TXA because of a province-wide shortage. The drug was given only to patients at high risk of requiring a blood transfusion.

The TXA shortage ended in early 2013 and, in October 2013, St. Michael’s implemented a protocol to facilitate universal administration of TXA in patients undergoing total hip or knee arthroplasty.

“We wanted to optimize TXA’s use in patients undergoing hip or knee replacements because these procedures often result in high blood loss and frequently require transfusions,” said study author Greg Hare, MD, PhD, an anesthesiologist at St. Michael’s.

“The drug costs about $10 per patient, while the average cost of transfusing one unit of blood is $1200.”

So every eligible patient undergoing hip or knee replacement received TXA at 20 mg/kg⁻¹. The drug was not used in patients considered at risk of thromboembolic events, stroke, or any other cardiovascular issues.

A total of 402 patients received the drug from October 21, 2013, to April 30, 2014. The researchers compared this group of patients to a group of 422 hip/knee replacement patients treated before the universal administration protocol was implemented (when TXA was given to high-risk patients only).

As expected, there was a significant increase in TXA use post-protocol, from 45.8% to 95.3% (P<0.001). And the rate of red blood cell transfusions decreased from 8.8% to 5.2% (P=0.043).

There was no significant difference in mean preoperative hemoglobin (Hb) levels between the pre- and post-protocol groups—133 g/L^-1 and 135 g/L^-1, respectively (P=0.073).

But there was a significant increase in Hb in the post-protocol group on days 1 and 3 after surgery. On day 1, the mean Hb was 108 g/L^-1 in the pre-protocol group and 112 g/L^-1 in the post-protocol group (P<0.001). On day 3, the mean Hb was 97 g/L^-1 and 101 g/L^-1, respectively (P<0.001).

There was no significant difference between the groups with regard to length of hospital stay. The mean length of stay was 3.93 days pre-protocol and 3.87 days post-protocol (P=0.652).

The adverse events assessed were death, myocardial infarction (MI), stroke, seizure, pulmonary embolism (PE), deep vein thrombosis (DVT), and acute kidney injury (AKI).

There were 13 such events in the pre-protocol group, including 1 MI, 3 PEs, and 9 AKIs. And there were 19 such events in the post-protocol group, including 1 MI, 1 DVT, 1 PE, and 16 AKIs (P=0.368 for all events and P=0.223 for AKIs).

Because TXA decreased the use of transfusions without increasing the rate of adverse events, Dr Hare and his colleagues consider their universal administration protocol a success.

“Making TXA mandatory for eligible patients has made care more efficient, ensuring the best possible care for our patients,” Dr Hare said.

“Other hospitals and surgical centers should consider making TXA mandatory for similar surgeries because it can improve quality of care, decrease the need for blood transfusions, and even save money.”

Results of a single-center study seem to support the use of tranexamic acid (TXA) in all eligible patients undergoing hip or knee replacement.

By giving TXA to every eligible patient undergoing hip or knee arthroplasty, a Canadian hospital significantly reduced its use of red blood cell transfusions during these surgeries without increasing the incidence of adverse events or the patients’ length of hospital stay.

The results were published in the Canadian Journal of Anesthesia.

TXA is known to prevent excessive blood loss during surgeries and has proven effective in orthopedic, trauma, and cardiac patients.

However, a few years ago, less than half of eligible patients at St. Michael’s Hospital in Toronto, Ontario, were receiving TXA because of a province-wide shortage. The drug was given only to patients at high risk of requiring a blood transfusion.

The TXA shortage ended in early 2013 and, in October 2013, St. Michael’s implemented a protocol to facilitate universal administration of TXA in patients undergoing total hip or knee arthroplasty.

“We wanted to optimize TXA’s use in patients undergoing hip or knee replacements because these procedures often result in high blood loss and frequently require transfusions,” said study author Greg Hare, MD, PhD, an anesthesiologist at St. Michael’s.

“The drug costs about $10 per patient, while the average cost of transfusing one unit of blood is $1200.”

So every eligible patient undergoing hip or knee replacement received TXA at 20 mg/kg⁻¹. The drug was not used in patients considered at risk of thromboembolic events, stroke, or any other cardiovascular issues.

A total of 402 patients received the drug from October 21, 2013, to April 30, 2014. The researchers compared this group of patients to a group of 422 hip/knee replacement patients treated before the universal administration protocol was implemented (when TXA was given to high-risk patients only).

As expected, there was a significant increase in TXA use post-protocol, from 45.8% to 95.3% (P<0.001). And the rate of red blood cell transfusions decreased from 8.8% to 5.2% (P=0.043).

There was no significant difference in mean preoperative hemoglobin (Hb) levels between the pre- and post-protocol groups—133 g/L^-1 and 135 g/L^-1, respectively (P=0.073).

But there was a significant increase in Hb in the post-protocol group on days 1 and 3 after surgery. On day 1, the mean Hb was 108 g/L^-1 in the pre-protocol group and 112 g/L^-1 in the post-protocol group (P<0.001). On day 3, the mean Hb was 97 g/L^-1 and 101 g/L^-1, respectively (P<0.001).

There was no significant difference between the groups with regard to length of hospital stay. The mean length of stay was 3.93 days pre-protocol and 3.87 days post-protocol (P=0.652).

The adverse events assessed were death, myocardial infarction (MI), stroke, seizure, pulmonary embolism (PE), deep vein thrombosis (DVT), and acute kidney injury (AKI).

There were 13 such events in the pre-protocol group, including 1 MI, 3 PEs, and 9 AKIs. And there were 19 such events in the post-protocol group, including 1 MI, 1 DVT, 1 PE, and 16 AKIs (P=0.368 for all events and P=0.223 for AKIs).

Because TXA decreased the use of transfusions without increasing the rate of adverse events, Dr Hare and his colleagues consider their universal administration protocol a success.

“Making TXA mandatory for eligible patients has made care more efficient, ensuring the best possible care for our patients,” Dr Hare said.

“Other hospitals and surgical centers should consider making TXA mandatory for similar surgeries because it can improve quality of care, decrease the need for blood transfusions, and even save money.”