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Regional CMO Robert Zipper, MD, MMM, SFHM, is Proud to Be Known as a Leader
Any hospitalist working for the largest HM group (HMG) in the country has one heck of a top-down perspective. And if you’re Robert Zipper, MD, MMM, SFHM, a regional chief medical officer (CMO) overseeing 25 hospitalist programs in the Pacific Northwest and Northern California for Sound Physicians, you love it.
“In my role, I really like working with younger leaders and those that are the future of the specialty,” he says, “but mostly I like knowing that I am supporting people that are doing incredible work, day in and day out.
“And I am never, ever bored.”
And, while never unengaged in his day-to-day job, Dr. Zipper has also been an active member of SHM. A former member of the Hospital Quality and Patient Safety (HQPS) Committee, Dr. Zipper currently chairs the Leadership Committee. The latest line on his resume is his role as one of seven new members of Team Hospitalist, the volunteer editorial advisory board of SHM’s official newsmagazine.
–Dr. Zipper
Question: Why did you choose a career in medicine?
Answer: Both of my parents were psychotherapists, and I knew that I wanted to do something in healthcare…but not that!
Q: How/when did you decide to become a hospitalist?
A: I always liked inpatient medicine. I did 50/50 inpatient and outpatient for my first three years out of training, and the hospitalist part of that crumbled. That led to the opportunity to do pure hospital medicine in the same community in 2002, and I took it!
Q: Tell me a little more about medical school, residency, etc. Was there a single moment you knew “I can do this?”
A: I chose a single large institution because I wanted to know the people I worked with, as healthcare is all about relationships. In medical school, I didn’t spend more than two months at any given hospital doing rotations, and that didn’t seem like the best way to learn. It wasn’t like the real world. I never had self doubt that I would finish what I had started, partly because I had to work so hard to get into medical school in the first place.
Q: What do you like most about working as a hospitalist?
A: I enjoy the high acuity, but miss the longer-term relationships of outpatient care.
Q: What do you dislike most?
A: My role as regional CMO for a large management company never ends. I’m never “done with my shift,” so to speak. I love my job but would love more family time, too.
Q: What’s the best advice you ever received?
A: I was applying for medical school in the late 1990s, and I worked as a tech in an emergency department in Michigan. Many physicians at that time were jaded, feeling that the golden era of being a doctor had come and gone. The best advice I ever received was to ignore their negativity and to make my own future. This came from an emergency medicine resident named Paul Blackburn, who later went on to be the ED residency director at University of Arizona.
Q: Did you have a mentor during training or early career?
A: Not really, though I thought about oncology, and one of my oncology attendings played a special role for me. I ultimately chose not to do that specialty because I couldn’t deal with the high mortality—I took the grim reality that so many patients face home with me.
Q: What’s the biggest change you’ve seen in HM in your career?
A: Where to start? HM used to be a “thing,” requiring a lot of explanation. Now we have a peer-reviewed journal, and some of the best internists and family physicians in the U.S. choose hospital medicine as a career. Patients are more accepting.
Q: What’s the biggest change you would like to see in HM?
A: This may sound odd, but I would like compensation to stabilize. It will happen, but the continuous upward climb, while benefitting physicians on one hand, also serves to destabilize programs and create difficult financial situations for hospitals, particularly smaller hospitals that are at risk of closing nowadays.
Q: As a leader, why is it important for you to continue seeing patients?
A: I think that being able to see things from a variety of perspectives is very important.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Time management on a hospitalist’s first day is a challenge, as it always takes more time to really understand a patient and their course. Patients generally don’t like being asked the same questions repetitively.
Q: What aspect of patient care is most rewarding?
A: The human connection and feeling that you’ve played an important part in a patient’s and their family’s lives.
Q: What is your biggest professional challenge?
A: The very rapid pace of change when working with several hospitals and systems that each have their own set of strengths and challenges.
Q: What is your biggest professional reward?
A: Feeling like a part of something really meaningful. I am proud of being a leader in my organization, and I have never felt that way in any other job.
Q: What did it mean to you to be elected a Senior Fellow in Hospital Medicine?
A: I was elected SFHM in the first cohort, and I was not sure what to make of it. It has become something that is more meaningful over time as it is more widely recognized.
Q: What’s next professionally?
A: Transitional care. We are working hard to improve care in the post-acute period. The variability there is incredible, and where there is variability, there is waste. Making it work as a business, though, is another matter.
Q: If you weren’t a doctor, what would you be doing right now?
A: Probably either in information technology in some fashion—I built my first PC back when the 386 processor was king—or in music. I’ve played drums for a long time and still do whenever I get the chance.
Q: When you aren’t working, what is important to you?
A: Given that I travel quite a bit, I like to spend time with my family. We live in Bend, Ore., which offers great outdoor activities like mountain biking and skiing. We like to stay active as a family.
Q: What’s the best book you’ve read recently?
A: Being Mortal by Atul Gawande.
Any hospitalist working for the largest HM group (HMG) in the country has one heck of a top-down perspective. And if you’re Robert Zipper, MD, MMM, SFHM, a regional chief medical officer (CMO) overseeing 25 hospitalist programs in the Pacific Northwest and Northern California for Sound Physicians, you love it.
“In my role, I really like working with younger leaders and those that are the future of the specialty,” he says, “but mostly I like knowing that I am supporting people that are doing incredible work, day in and day out.
“And I am never, ever bored.”
And, while never unengaged in his day-to-day job, Dr. Zipper has also been an active member of SHM. A former member of the Hospital Quality and Patient Safety (HQPS) Committee, Dr. Zipper currently chairs the Leadership Committee. The latest line on his resume is his role as one of seven new members of Team Hospitalist, the volunteer editorial advisory board of SHM’s official newsmagazine.
–Dr. Zipper
Question: Why did you choose a career in medicine?
Answer: Both of my parents were psychotherapists, and I knew that I wanted to do something in healthcare…but not that!
Q: How/when did you decide to become a hospitalist?
A: I always liked inpatient medicine. I did 50/50 inpatient and outpatient for my first three years out of training, and the hospitalist part of that crumbled. That led to the opportunity to do pure hospital medicine in the same community in 2002, and I took it!
Q: Tell me a little more about medical school, residency, etc. Was there a single moment you knew “I can do this?”
A: I chose a single large institution because I wanted to know the people I worked with, as healthcare is all about relationships. In medical school, I didn’t spend more than two months at any given hospital doing rotations, and that didn’t seem like the best way to learn. It wasn’t like the real world. I never had self doubt that I would finish what I had started, partly because I had to work so hard to get into medical school in the first place.
Q: What do you like most about working as a hospitalist?
A: I enjoy the high acuity, but miss the longer-term relationships of outpatient care.
Q: What do you dislike most?
A: My role as regional CMO for a large management company never ends. I’m never “done with my shift,” so to speak. I love my job but would love more family time, too.
Q: What’s the best advice you ever received?
A: I was applying for medical school in the late 1990s, and I worked as a tech in an emergency department in Michigan. Many physicians at that time were jaded, feeling that the golden era of being a doctor had come and gone. The best advice I ever received was to ignore their negativity and to make my own future. This came from an emergency medicine resident named Paul Blackburn, who later went on to be the ED residency director at University of Arizona.
Q: Did you have a mentor during training or early career?
A: Not really, though I thought about oncology, and one of my oncology attendings played a special role for me. I ultimately chose not to do that specialty because I couldn’t deal with the high mortality—I took the grim reality that so many patients face home with me.
Q: What’s the biggest change you’ve seen in HM in your career?
A: Where to start? HM used to be a “thing,” requiring a lot of explanation. Now we have a peer-reviewed journal, and some of the best internists and family physicians in the U.S. choose hospital medicine as a career. Patients are more accepting.
Q: What’s the biggest change you would like to see in HM?
A: This may sound odd, but I would like compensation to stabilize. It will happen, but the continuous upward climb, while benefitting physicians on one hand, also serves to destabilize programs and create difficult financial situations for hospitals, particularly smaller hospitals that are at risk of closing nowadays.
Q: As a leader, why is it important for you to continue seeing patients?
A: I think that being able to see things from a variety of perspectives is very important.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Time management on a hospitalist’s first day is a challenge, as it always takes more time to really understand a patient and their course. Patients generally don’t like being asked the same questions repetitively.
Q: What aspect of patient care is most rewarding?
A: The human connection and feeling that you’ve played an important part in a patient’s and their family’s lives.
Q: What is your biggest professional challenge?
A: The very rapid pace of change when working with several hospitals and systems that each have their own set of strengths and challenges.
Q: What is your biggest professional reward?
A: Feeling like a part of something really meaningful. I am proud of being a leader in my organization, and I have never felt that way in any other job.
Q: What did it mean to you to be elected a Senior Fellow in Hospital Medicine?
A: I was elected SFHM in the first cohort, and I was not sure what to make of it. It has become something that is more meaningful over time as it is more widely recognized.
Q: What’s next professionally?
A: Transitional care. We are working hard to improve care in the post-acute period. The variability there is incredible, and where there is variability, there is waste. Making it work as a business, though, is another matter.
Q: If you weren’t a doctor, what would you be doing right now?
A: Probably either in information technology in some fashion—I built my first PC back when the 386 processor was king—or in music. I’ve played drums for a long time and still do whenever I get the chance.
Q: When you aren’t working, what is important to you?
A: Given that I travel quite a bit, I like to spend time with my family. We live in Bend, Ore., which offers great outdoor activities like mountain biking and skiing. We like to stay active as a family.
Q: What’s the best book you’ve read recently?
A: Being Mortal by Atul Gawande.
Any hospitalist working for the largest HM group (HMG) in the country has one heck of a top-down perspective. And if you’re Robert Zipper, MD, MMM, SFHM, a regional chief medical officer (CMO) overseeing 25 hospitalist programs in the Pacific Northwest and Northern California for Sound Physicians, you love it.
“In my role, I really like working with younger leaders and those that are the future of the specialty,” he says, “but mostly I like knowing that I am supporting people that are doing incredible work, day in and day out.
“And I am never, ever bored.”
And, while never unengaged in his day-to-day job, Dr. Zipper has also been an active member of SHM. A former member of the Hospital Quality and Patient Safety (HQPS) Committee, Dr. Zipper currently chairs the Leadership Committee. The latest line on his resume is his role as one of seven new members of Team Hospitalist, the volunteer editorial advisory board of SHM’s official newsmagazine.
–Dr. Zipper
Question: Why did you choose a career in medicine?
Answer: Both of my parents were psychotherapists, and I knew that I wanted to do something in healthcare…but not that!
Q: How/when did you decide to become a hospitalist?
A: I always liked inpatient medicine. I did 50/50 inpatient and outpatient for my first three years out of training, and the hospitalist part of that crumbled. That led to the opportunity to do pure hospital medicine in the same community in 2002, and I took it!
Q: Tell me a little more about medical school, residency, etc. Was there a single moment you knew “I can do this?”
A: I chose a single large institution because I wanted to know the people I worked with, as healthcare is all about relationships. In medical school, I didn’t spend more than two months at any given hospital doing rotations, and that didn’t seem like the best way to learn. It wasn’t like the real world. I never had self doubt that I would finish what I had started, partly because I had to work so hard to get into medical school in the first place.
Q: What do you like most about working as a hospitalist?
A: I enjoy the high acuity, but miss the longer-term relationships of outpatient care.
Q: What do you dislike most?
A: My role as regional CMO for a large management company never ends. I’m never “done with my shift,” so to speak. I love my job but would love more family time, too.
Q: What’s the best advice you ever received?
A: I was applying for medical school in the late 1990s, and I worked as a tech in an emergency department in Michigan. Many physicians at that time were jaded, feeling that the golden era of being a doctor had come and gone. The best advice I ever received was to ignore their negativity and to make my own future. This came from an emergency medicine resident named Paul Blackburn, who later went on to be the ED residency director at University of Arizona.
Q: Did you have a mentor during training or early career?
A: Not really, though I thought about oncology, and one of my oncology attendings played a special role for me. I ultimately chose not to do that specialty because I couldn’t deal with the high mortality—I took the grim reality that so many patients face home with me.
Q: What’s the biggest change you’ve seen in HM in your career?
A: Where to start? HM used to be a “thing,” requiring a lot of explanation. Now we have a peer-reviewed journal, and some of the best internists and family physicians in the U.S. choose hospital medicine as a career. Patients are more accepting.
Q: What’s the biggest change you would like to see in HM?
A: This may sound odd, but I would like compensation to stabilize. It will happen, but the continuous upward climb, while benefitting physicians on one hand, also serves to destabilize programs and create difficult financial situations for hospitals, particularly smaller hospitals that are at risk of closing nowadays.
Q: As a leader, why is it important for you to continue seeing patients?
A: I think that being able to see things from a variety of perspectives is very important.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Time management on a hospitalist’s first day is a challenge, as it always takes more time to really understand a patient and their course. Patients generally don’t like being asked the same questions repetitively.
Q: What aspect of patient care is most rewarding?
A: The human connection and feeling that you’ve played an important part in a patient’s and their family’s lives.
Q: What is your biggest professional challenge?
A: The very rapid pace of change when working with several hospitals and systems that each have their own set of strengths and challenges.
Q: What is your biggest professional reward?
A: Feeling like a part of something really meaningful. I am proud of being a leader in my organization, and I have never felt that way in any other job.
Q: What did it mean to you to be elected a Senior Fellow in Hospital Medicine?
A: I was elected SFHM in the first cohort, and I was not sure what to make of it. It has become something that is more meaningful over time as it is more widely recognized.
Q: What’s next professionally?
A: Transitional care. We are working hard to improve care in the post-acute period. The variability there is incredible, and where there is variability, there is waste. Making it work as a business, though, is another matter.
Q: If you weren’t a doctor, what would you be doing right now?
A: Probably either in information technology in some fashion—I built my first PC back when the 386 processor was king—or in music. I’ve played drums for a long time and still do whenever I get the chance.
Q: When you aren’t working, what is important to you?
A: Given that I travel quite a bit, I like to spend time with my family. We live in Bend, Ore., which offers great outdoor activities like mountain biking and skiing. We like to stay active as a family.
Q: What’s the best book you’ve read recently?
A: Being Mortal by Atul Gawande.
PPI Usage with SBP Prophylaxis Predicts Recurrent Infections in Cirrhosis
Clinical question: What are the risk factors for development of a recurrent infection in cirrhotic patients hospitalized with an initial infection?
Background: Infections are a major cause of morbidity and mortality in patients with cirrhosis. Prior retrospective data suggest that proton pump inhibitors (PPIs) increase the risk of infections in cirrhotic patients, while beta blockers do not. This study sought to prospectively evaluate risk factors for recurrent infections in hospitalized patients with cirrhosis.
Study design: Prospective, multicenter study.
Setting: Twelve North American hospitalists enrolled in the North American Consortium for the Study of End-Stage Liver Disease.
Synopsis: Researchers enrolled 188 hospitalized cirrhotic patients who had or developed an infection during their hospitalization. Patients were followed for six months to determine risk of development of subsequent infection and to identify independent risk factors associated with recurrent infections.
Forty-five percent of patients developed a subsequent infection, 74% of which occurred in a different location than the primary infection. This risk was independent of liver disease severity.
Age (OR 1.06; CI 1.02-1.11), PPI use (OR 2.72; CI 1.30-5.71), and spontaneous bacterial peritonitis (SBP) prophylaxis (OR 3.66; CI 1.60-8.37) were found to be independent predictors of recurrent infections. Beta blocker use did not differ between those who developed an infection and those who did not. An initial infection of SBP (compared to other infection sites) was protective (OR 0.37; CI 0.15-0.91) against subsequent infection.
Notably, study size was small, and 18% of patients were lost to follow-up. Further studies are needed to determine effective strategies to prevent recurrent infections in cirrhotics.
Bottom line: Cirrhotic patients hospitalized with an infection are at high risk of recurrent infections, and the long-term use of SBP prophylaxis and PPIs independently increase this risk.
Citation: O’Leary JG, Reddy KR, Wong F, et al. Long-term use of antibiotics and proton pump inhibitors predict development of infections in patients with cirrhosis. Clinical Gastro Hepatol. 2015;13(4):753-759.
Clinical question: What are the risk factors for development of a recurrent infection in cirrhotic patients hospitalized with an initial infection?
Background: Infections are a major cause of morbidity and mortality in patients with cirrhosis. Prior retrospective data suggest that proton pump inhibitors (PPIs) increase the risk of infections in cirrhotic patients, while beta blockers do not. This study sought to prospectively evaluate risk factors for recurrent infections in hospitalized patients with cirrhosis.
Study design: Prospective, multicenter study.
Setting: Twelve North American hospitalists enrolled in the North American Consortium for the Study of End-Stage Liver Disease.
Synopsis: Researchers enrolled 188 hospitalized cirrhotic patients who had or developed an infection during their hospitalization. Patients were followed for six months to determine risk of development of subsequent infection and to identify independent risk factors associated with recurrent infections.
Forty-five percent of patients developed a subsequent infection, 74% of which occurred in a different location than the primary infection. This risk was independent of liver disease severity.
Age (OR 1.06; CI 1.02-1.11), PPI use (OR 2.72; CI 1.30-5.71), and spontaneous bacterial peritonitis (SBP) prophylaxis (OR 3.66; CI 1.60-8.37) were found to be independent predictors of recurrent infections. Beta blocker use did not differ between those who developed an infection and those who did not. An initial infection of SBP (compared to other infection sites) was protective (OR 0.37; CI 0.15-0.91) against subsequent infection.
Notably, study size was small, and 18% of patients were lost to follow-up. Further studies are needed to determine effective strategies to prevent recurrent infections in cirrhotics.
Bottom line: Cirrhotic patients hospitalized with an infection are at high risk of recurrent infections, and the long-term use of SBP prophylaxis and PPIs independently increase this risk.
Citation: O’Leary JG, Reddy KR, Wong F, et al. Long-term use of antibiotics and proton pump inhibitors predict development of infections in patients with cirrhosis. Clinical Gastro Hepatol. 2015;13(4):753-759.
Clinical question: What are the risk factors for development of a recurrent infection in cirrhotic patients hospitalized with an initial infection?
Background: Infections are a major cause of morbidity and mortality in patients with cirrhosis. Prior retrospective data suggest that proton pump inhibitors (PPIs) increase the risk of infections in cirrhotic patients, while beta blockers do not. This study sought to prospectively evaluate risk factors for recurrent infections in hospitalized patients with cirrhosis.
Study design: Prospective, multicenter study.
Setting: Twelve North American hospitalists enrolled in the North American Consortium for the Study of End-Stage Liver Disease.
Synopsis: Researchers enrolled 188 hospitalized cirrhotic patients who had or developed an infection during their hospitalization. Patients were followed for six months to determine risk of development of subsequent infection and to identify independent risk factors associated with recurrent infections.
Forty-five percent of patients developed a subsequent infection, 74% of which occurred in a different location than the primary infection. This risk was independent of liver disease severity.
Age (OR 1.06; CI 1.02-1.11), PPI use (OR 2.72; CI 1.30-5.71), and spontaneous bacterial peritonitis (SBP) prophylaxis (OR 3.66; CI 1.60-8.37) were found to be independent predictors of recurrent infections. Beta blocker use did not differ between those who developed an infection and those who did not. An initial infection of SBP (compared to other infection sites) was protective (OR 0.37; CI 0.15-0.91) against subsequent infection.
Notably, study size was small, and 18% of patients were lost to follow-up. Further studies are needed to determine effective strategies to prevent recurrent infections in cirrhotics.
Bottom line: Cirrhotic patients hospitalized with an infection are at high risk of recurrent infections, and the long-term use of SBP prophylaxis and PPIs independently increase this risk.
Citation: O’Leary JG, Reddy KR, Wong F, et al. Long-term use of antibiotics and proton pump inhibitors predict development of infections in patients with cirrhosis. Clinical Gastro Hepatol. 2015;13(4):753-759.
Nontoxigenic C. diff Spores May Decrease Rates of Recurrent CDI
Clinical question: Is treatment with nontoxigenic C. diff strain M-3 (NTCD-M3) safe and effective in preventing recurrent Clostridium difficile infection (CDI)?
Background: C. diff is the most commonly identified healthcare pathogen, and CDI has a 25%-30% recurrence rate. Not all C. diff strains produce toxins, and gastrointestinal (GI) tract colonization with NTCD has been shown to prevent CDI when the patient is subsequently exposed to a toxigenic strain.
Study design: Multicenter, phase 2, randomized, double-blind, placebo-controlled, dose-ranging trial.
Setting: Forty-four centers in the U.S., Canada, and Europe.
Synopsis: Patients who had clinically recovered from CDI were randomized to placebo or NTCD-M3 at a dose of 104 spores/day for seven days, 107 spores/day for seven days, or 107 spores per day for 14 days. Patients were excluded who had multiple recurrences or other significant GI illnesses, were treated with antimicrobials other than metronidazole or PO [by mouth] vancomycin, had planned antibiotics, were unable to take PO, or had immunosuppression. Patients were monitored for side effects, rates of colonization, and incidence of CDI recurrence within six weeks.
Both overall and serious treatment-emergent adverse events were similar in patients receiving NTCD-M3 and those receiving placebo, but no statistical analysis was performed. Headache was more common in treatment groups.
CDI recurrence occurred in 31% of placebo patients and 11% of patients who received NTCD-M3 (OR 0.28). Fecal colonization was achieved in 69% of NTCD-M3 patients; this subset of patients had a 2% recurrence. Patients who received NTDC but did not achieve GI colonization had rates of recurrent CDI similar to placebo.
Bottom line: Use of NTCD-M3 spores appears safe and well tolerated and led to decreased recurrent CDI, primarily in patients who achieved fecal colonization.
Citation: Gerding DN, Meyer T, Lee C, et al. Administration of spores of nontoxigenic Clostridium difficile strain M3 for prevention of recurrent C. difficile infection: a randomized clinical trial. JAMA. 2015;313(17):1719-1727.
Clinical question: Is treatment with nontoxigenic C. diff strain M-3 (NTCD-M3) safe and effective in preventing recurrent Clostridium difficile infection (CDI)?
Background: C. diff is the most commonly identified healthcare pathogen, and CDI has a 25%-30% recurrence rate. Not all C. diff strains produce toxins, and gastrointestinal (GI) tract colonization with NTCD has been shown to prevent CDI when the patient is subsequently exposed to a toxigenic strain.
Study design: Multicenter, phase 2, randomized, double-blind, placebo-controlled, dose-ranging trial.
Setting: Forty-four centers in the U.S., Canada, and Europe.
Synopsis: Patients who had clinically recovered from CDI were randomized to placebo or NTCD-M3 at a dose of 104 spores/day for seven days, 107 spores/day for seven days, or 107 spores per day for 14 days. Patients were excluded who had multiple recurrences or other significant GI illnesses, were treated with antimicrobials other than metronidazole or PO [by mouth] vancomycin, had planned antibiotics, were unable to take PO, or had immunosuppression. Patients were monitored for side effects, rates of colonization, and incidence of CDI recurrence within six weeks.
Both overall and serious treatment-emergent adverse events were similar in patients receiving NTCD-M3 and those receiving placebo, but no statistical analysis was performed. Headache was more common in treatment groups.
CDI recurrence occurred in 31% of placebo patients and 11% of patients who received NTCD-M3 (OR 0.28). Fecal colonization was achieved in 69% of NTCD-M3 patients; this subset of patients had a 2% recurrence. Patients who received NTDC but did not achieve GI colonization had rates of recurrent CDI similar to placebo.
Bottom line: Use of NTCD-M3 spores appears safe and well tolerated and led to decreased recurrent CDI, primarily in patients who achieved fecal colonization.
Citation: Gerding DN, Meyer T, Lee C, et al. Administration of spores of nontoxigenic Clostridium difficile strain M3 for prevention of recurrent C. difficile infection: a randomized clinical trial. JAMA. 2015;313(17):1719-1727.
Clinical question: Is treatment with nontoxigenic C. diff strain M-3 (NTCD-M3) safe and effective in preventing recurrent Clostridium difficile infection (CDI)?
Background: C. diff is the most commonly identified healthcare pathogen, and CDI has a 25%-30% recurrence rate. Not all C. diff strains produce toxins, and gastrointestinal (GI) tract colonization with NTCD has been shown to prevent CDI when the patient is subsequently exposed to a toxigenic strain.
Study design: Multicenter, phase 2, randomized, double-blind, placebo-controlled, dose-ranging trial.
Setting: Forty-four centers in the U.S., Canada, and Europe.
Synopsis: Patients who had clinically recovered from CDI were randomized to placebo or NTCD-M3 at a dose of 104 spores/day for seven days, 107 spores/day for seven days, or 107 spores per day for 14 days. Patients were excluded who had multiple recurrences or other significant GI illnesses, were treated with antimicrobials other than metronidazole or PO [by mouth] vancomycin, had planned antibiotics, were unable to take PO, or had immunosuppression. Patients were monitored for side effects, rates of colonization, and incidence of CDI recurrence within six weeks.
Both overall and serious treatment-emergent adverse events were similar in patients receiving NTCD-M3 and those receiving placebo, but no statistical analysis was performed. Headache was more common in treatment groups.
CDI recurrence occurred in 31% of placebo patients and 11% of patients who received NTCD-M3 (OR 0.28). Fecal colonization was achieved in 69% of NTCD-M3 patients; this subset of patients had a 2% recurrence. Patients who received NTDC but did not achieve GI colonization had rates of recurrent CDI similar to placebo.
Bottom line: Use of NTCD-M3 spores appears safe and well tolerated and led to decreased recurrent CDI, primarily in patients who achieved fecal colonization.
Citation: Gerding DN, Meyer T, Lee C, et al. Administration of spores of nontoxigenic Clostridium difficile strain M3 for prevention of recurrent C. difficile infection: a randomized clinical trial. JAMA. 2015;313(17):1719-1727.
Retrievable IVC Plus Anticoagulation Does Not Reduce Risk of Recurrent Pulmonary Embolism
Clinical question: Does a retrievable inferior vena cava (IVC) filter in addition to anticoagulation in patients with an acute pulmonary embolism (PE) decrease the risk of recurrent PE?
Background: Inferior vena cava placement has increased dramatically over the last three decades. Although IVC filter placement benefits patients with a contraindication to anticoagulation, the benefit of a temporary IVC filter in addition to anticoagulation to prevent PE in patients at high risk of recurrence is unknown.
Study design: Randomized, open-label.
Setting: Seventeen French hospitals.
Synopsis: Nearly 400 patients with an acute PE associated with lower extremity thrombosis and at least one additional risk factor for severity were randomized to anticoagulation in combination with a retrievable IVC filter versus anticoagulation alone. Risk factors included age, active cancer, chronic cardiac or respiratory disease, recent ischemic stroke with leg paralysis, bilateral deep vein thrombosis, or right ventricular failure or myocardial injury. Both groups received anticoagulation for six months.
Overall, there was no difference in fatal or symptomatic nonfatal PE in each group at three and six months.
The open-label design is subject to interpretative bias. A blinded outcome assessment committee and a central randomization process were implemented in order to minimize bias. In addition, the study could have been underpowered given the limited number of patients and low PE recurrence rate.
Bottom line: In patients with an acute PE at high risk of recurrent PE, retrievable IVC filter in addition to standard anticoagulation therapy does not decrease the risk of recurrence.
Citation: Mismetti, P, Laporte, S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism. JAMA. 2015;313(16):1627-1635.
Clinical question: Does a retrievable inferior vena cava (IVC) filter in addition to anticoagulation in patients with an acute pulmonary embolism (PE) decrease the risk of recurrent PE?
Background: Inferior vena cava placement has increased dramatically over the last three decades. Although IVC filter placement benefits patients with a contraindication to anticoagulation, the benefit of a temporary IVC filter in addition to anticoagulation to prevent PE in patients at high risk of recurrence is unknown.
Study design: Randomized, open-label.
Setting: Seventeen French hospitals.
Synopsis: Nearly 400 patients with an acute PE associated with lower extremity thrombosis and at least one additional risk factor for severity were randomized to anticoagulation in combination with a retrievable IVC filter versus anticoagulation alone. Risk factors included age, active cancer, chronic cardiac or respiratory disease, recent ischemic stroke with leg paralysis, bilateral deep vein thrombosis, or right ventricular failure or myocardial injury. Both groups received anticoagulation for six months.
Overall, there was no difference in fatal or symptomatic nonfatal PE in each group at three and six months.
The open-label design is subject to interpretative bias. A blinded outcome assessment committee and a central randomization process were implemented in order to minimize bias. In addition, the study could have been underpowered given the limited number of patients and low PE recurrence rate.
Bottom line: In patients with an acute PE at high risk of recurrent PE, retrievable IVC filter in addition to standard anticoagulation therapy does not decrease the risk of recurrence.
Citation: Mismetti, P, Laporte, S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism. JAMA. 2015;313(16):1627-1635.
Clinical question: Does a retrievable inferior vena cava (IVC) filter in addition to anticoagulation in patients with an acute pulmonary embolism (PE) decrease the risk of recurrent PE?
Background: Inferior vena cava placement has increased dramatically over the last three decades. Although IVC filter placement benefits patients with a contraindication to anticoagulation, the benefit of a temporary IVC filter in addition to anticoagulation to prevent PE in patients at high risk of recurrence is unknown.
Study design: Randomized, open-label.
Setting: Seventeen French hospitals.
Synopsis: Nearly 400 patients with an acute PE associated with lower extremity thrombosis and at least one additional risk factor for severity were randomized to anticoagulation in combination with a retrievable IVC filter versus anticoagulation alone. Risk factors included age, active cancer, chronic cardiac or respiratory disease, recent ischemic stroke with leg paralysis, bilateral deep vein thrombosis, or right ventricular failure or myocardial injury. Both groups received anticoagulation for six months.
Overall, there was no difference in fatal or symptomatic nonfatal PE in each group at three and six months.
The open-label design is subject to interpretative bias. A blinded outcome assessment committee and a central randomization process were implemented in order to minimize bias. In addition, the study could have been underpowered given the limited number of patients and low PE recurrence rate.
Bottom line: In patients with an acute PE at high risk of recurrent PE, retrievable IVC filter in addition to standard anticoagulation therapy does not decrease the risk of recurrence.
Citation: Mismetti, P, Laporte, S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism. JAMA. 2015;313(16):1627-1635.
Joint Commission Leaders Call on Physicians to Embrace Quality Improvement
In a May 12 JAMA “Viewpoint” article, Mark Chassin, MD, FACP, MPP, MPH, The Joint Commission’s president and CEO, and David Baker, MD, FACP, MPH, The Joint Commission’s vice president for healthcare quality evaluation, called on American physicians to acquire the necessary skills to take on new responsibilities to become leaders for QI and patient safety in an increasingly complex healthcare environment.1
The Joint Commission, they said, has embraced the tools, methods, and science of QI used in other industries, including Lean Six Sigma and change management, for all of its internal improvement functions and for its Center for Transforming Healthcare. They urge physicians to do the same or risk jeopardizing medicine’s long-standing self-governance status because of societal concerns about patient safety.
Drs. Chassin and Baker note that medicine has too often tolerated problematic behaviors and is viewed by some stakeholders as failing to address poor quality of care and safety, lack of access, and high costs of care.
“Physicians could make a much stronger case for continued self-government if they took a more visible and vigorous leadership role in efforts that led to major improvement in the quality and safety of patient care,” they said.
Reference
- Chassin MR, Baker DW. Aiming higher to enhance professionalism: beyond accreditation and certification. JAMA. 2015;313(18):1795-1796.
In a May 12 JAMA “Viewpoint” article, Mark Chassin, MD, FACP, MPP, MPH, The Joint Commission’s president and CEO, and David Baker, MD, FACP, MPH, The Joint Commission’s vice president for healthcare quality evaluation, called on American physicians to acquire the necessary skills to take on new responsibilities to become leaders for QI and patient safety in an increasingly complex healthcare environment.1
The Joint Commission, they said, has embraced the tools, methods, and science of QI used in other industries, including Lean Six Sigma and change management, for all of its internal improvement functions and for its Center for Transforming Healthcare. They urge physicians to do the same or risk jeopardizing medicine’s long-standing self-governance status because of societal concerns about patient safety.
Drs. Chassin and Baker note that medicine has too often tolerated problematic behaviors and is viewed by some stakeholders as failing to address poor quality of care and safety, lack of access, and high costs of care.
“Physicians could make a much stronger case for continued self-government if they took a more visible and vigorous leadership role in efforts that led to major improvement in the quality and safety of patient care,” they said.
Reference
- Chassin MR, Baker DW. Aiming higher to enhance professionalism: beyond accreditation and certification. JAMA. 2015;313(18):1795-1796.
In a May 12 JAMA “Viewpoint” article, Mark Chassin, MD, FACP, MPP, MPH, The Joint Commission’s president and CEO, and David Baker, MD, FACP, MPH, The Joint Commission’s vice president for healthcare quality evaluation, called on American physicians to acquire the necessary skills to take on new responsibilities to become leaders for QI and patient safety in an increasingly complex healthcare environment.1
The Joint Commission, they said, has embraced the tools, methods, and science of QI used in other industries, including Lean Six Sigma and change management, for all of its internal improvement functions and for its Center for Transforming Healthcare. They urge physicians to do the same or risk jeopardizing medicine’s long-standing self-governance status because of societal concerns about patient safety.
Drs. Chassin and Baker note that medicine has too often tolerated problematic behaviors and is viewed by some stakeholders as failing to address poor quality of care and safety, lack of access, and high costs of care.
“Physicians could make a much stronger case for continued self-government if they took a more visible and vigorous leadership role in efforts that led to major improvement in the quality and safety of patient care,” they said.
Reference
- Chassin MR, Baker DW. Aiming higher to enhance professionalism: beyond accreditation and certification. JAMA. 2015;313(18):1795-1796.
Hospitalists Choose Quality Metrics Most Important to Them
Fantasy sports, hospital medicine, and quality metrics. Those were the unique elements of an RIV poster presented by Noppon Setji, MD, medical director of the Duke University Medical Center’s hospital medicine program in Durham, N.C., at HM15.
Dr. Setji, who participates in a fantasy football league for physicians, says he aimed to apply the approaches of fantasy sports leagues to hospitalist quality metrics.1 Dr. Setji wanted to find a way to recognize high-performing hospitalists in his group on a regular basis, beyond the group metrics that had been reported to faculty members—and to create greater accountability and evaluate physicians’ performance over time.
A team developed a survey instrument compiling common clinical process and outcome measures for hospitalists, and faculty members were asked to rate how important the various metrics were to them individually as indicators of physician performance. Their responses were combined into a weighted, composite hospital medicine provider performance score, which reflects the relative value practicing hospitalists assign to available performance measures. Results are easily tabulated on an Excel spreadsheet, Dr. Setji says.
Every three months—or football quarter—the top overall performer is awarded two bottles of wine and possession of the traveling trophy.
“We’re always looking for ways to measure our performance,” Dr. Setji says, “and we all want to know how we’re doing relative to our peers.”
Reference
- Setji NP, Bae JG, Griffith BC, Daley C. Fantasy physician leagues? Introducing the physician equivalent of the Qbr (Quarterly Metric-Based Rating) [abstract]. J Hosp Med. 2015;10(suppl 2).
Fantasy sports, hospital medicine, and quality metrics. Those were the unique elements of an RIV poster presented by Noppon Setji, MD, medical director of the Duke University Medical Center’s hospital medicine program in Durham, N.C., at HM15.
Dr. Setji, who participates in a fantasy football league for physicians, says he aimed to apply the approaches of fantasy sports leagues to hospitalist quality metrics.1 Dr. Setji wanted to find a way to recognize high-performing hospitalists in his group on a regular basis, beyond the group metrics that had been reported to faculty members—and to create greater accountability and evaluate physicians’ performance over time.
A team developed a survey instrument compiling common clinical process and outcome measures for hospitalists, and faculty members were asked to rate how important the various metrics were to them individually as indicators of physician performance. Their responses were combined into a weighted, composite hospital medicine provider performance score, which reflects the relative value practicing hospitalists assign to available performance measures. Results are easily tabulated on an Excel spreadsheet, Dr. Setji says.
Every three months—or football quarter—the top overall performer is awarded two bottles of wine and possession of the traveling trophy.
“We’re always looking for ways to measure our performance,” Dr. Setji says, “and we all want to know how we’re doing relative to our peers.”
Reference
- Setji NP, Bae JG, Griffith BC, Daley C. Fantasy physician leagues? Introducing the physician equivalent of the Qbr (Quarterly Metric-Based Rating) [abstract]. J Hosp Med. 2015;10(suppl 2).
Fantasy sports, hospital medicine, and quality metrics. Those were the unique elements of an RIV poster presented by Noppon Setji, MD, medical director of the Duke University Medical Center’s hospital medicine program in Durham, N.C., at HM15.
Dr. Setji, who participates in a fantasy football league for physicians, says he aimed to apply the approaches of fantasy sports leagues to hospitalist quality metrics.1 Dr. Setji wanted to find a way to recognize high-performing hospitalists in his group on a regular basis, beyond the group metrics that had been reported to faculty members—and to create greater accountability and evaluate physicians’ performance over time.
A team developed a survey instrument compiling common clinical process and outcome measures for hospitalists, and faculty members were asked to rate how important the various metrics were to them individually as indicators of physician performance. Their responses were combined into a weighted, composite hospital medicine provider performance score, which reflects the relative value practicing hospitalists assign to available performance measures. Results are easily tabulated on an Excel spreadsheet, Dr. Setji says.
Every three months—or football quarter—the top overall performer is awarded two bottles of wine and possession of the traveling trophy.
“We’re always looking for ways to measure our performance,” Dr. Setji says, “and we all want to know how we’re doing relative to our peers.”
Reference
- Setji NP, Bae JG, Griffith BC, Daley C. Fantasy physician leagues? Introducing the physician equivalent of the Qbr (Quarterly Metric-Based Rating) [abstract]. J Hosp Med. 2015;10(suppl 2).
Rivaroxaban Less Expensive for Low-Risk VTE
NEW YORK (Reuters Health) - For patients with low-risk venous thromboembolism (VTE) who can safely be discharged from the emergency department, rivaroxaban is a less costly treatment than heparin and warfarin, according to results of a case-control study.
"The biggest surprise to me was that using the Hestia criteria in the emergency department produced a low-enough risk population that we had zero incidence of either recurrent clots or bleeding," Dr. Jeffrey A. Kline, from Indiana University School of Medicine in Indianapolis, told Reuters Health by email. "The second surprise was the strength of gratitude by the patients that they did not have to have injections and take warfarin."
Dr. Kline's team developed a protocol for home treatment of low-risk patients with VTE using a target-specific anticoagulant like rivaroxaban. They compared the costs of medical care accrued by 50 patients treated with rivaroxaban and 47 matched controls who received bridging low-molecular-weight heparin (LMWH) for five to seven days and were then transitioned to warfarin.
All 50 rivaroxaban patients were discharged home from the emergency department on the day of diagnosis, whereas only 18 control patients were treated at home, according to the June 25 Academic Emergency Medicine online report.
Over the six months of follow-up, median total charges were $4787 with rivaroxaban, compared with $11,128 with LMWH-warfarin.
When the analysis was confined to patients who were never hospitalized, rivaroxaban was still less costly (median, $5932 vs $9016), although the difference was not statistically significant.
In-patient pharmacy median charges were significantly less with rivaroxaban than with LMWH-warfarin (median, $215 vs $742), but a survey of hospital outpatient pharmacies found the median cash cost of rivaroxaban to be significantly higher than that of LMWH-warfarin ($1856 vs $724 for six months).
"In low-risk patients, target-specific anticoagulants require minimal maintenance, and patients can be managed with no coagulation testing at all, and almost no other laboratory monitoring unless other factors suggest anemia or a reason to suspect change in renal function," Dr. Kline said.
Dr. Nathan T. Connell, from Brigham and Women's Hospital in Boston, told Reuters Health by email, "Recently, there has been a lot of discussion about cost differences between various anticoagulation strategies. This paper helps put the cost in perspective and that treatment with rivaroxaban may be more cost-effective in the long term."
"This difference went away when hospitalized patients were removed from the analysis, suggesting that the cost of hospitalization was the major driver for cost difference between the two strategies," Dr. Connell said. "For well-selected low-risk patients, however, rivaroxaban is an attractive choice because it often allows direct discharge from the Emergency Department. Also, we know from other studies that the risk of certain types of serious bleeding, such as intracerebral hemorrhage, is lower with rivaroxaban as compared to warfarin."
Dr. Connell noted, "This is a retrospective study, which can have issues with selection bias. The authors took several steps to minimize this bias, such as matching on a comorbidity score, in an attempt to make sure the two comparison groups were as balanced as possible."
NEW YORK (Reuters Health) - For patients with low-risk venous thromboembolism (VTE) who can safely be discharged from the emergency department, rivaroxaban is a less costly treatment than heparin and warfarin, according to results of a case-control study.
"The biggest surprise to me was that using the Hestia criteria in the emergency department produced a low-enough risk population that we had zero incidence of either recurrent clots or bleeding," Dr. Jeffrey A. Kline, from Indiana University School of Medicine in Indianapolis, told Reuters Health by email. "The second surprise was the strength of gratitude by the patients that they did not have to have injections and take warfarin."
Dr. Kline's team developed a protocol for home treatment of low-risk patients with VTE using a target-specific anticoagulant like rivaroxaban. They compared the costs of medical care accrued by 50 patients treated with rivaroxaban and 47 matched controls who received bridging low-molecular-weight heparin (LMWH) for five to seven days and were then transitioned to warfarin.
All 50 rivaroxaban patients were discharged home from the emergency department on the day of diagnosis, whereas only 18 control patients were treated at home, according to the June 25 Academic Emergency Medicine online report.
Over the six months of follow-up, median total charges were $4787 with rivaroxaban, compared with $11,128 with LMWH-warfarin.
When the analysis was confined to patients who were never hospitalized, rivaroxaban was still less costly (median, $5932 vs $9016), although the difference was not statistically significant.
In-patient pharmacy median charges were significantly less with rivaroxaban than with LMWH-warfarin (median, $215 vs $742), but a survey of hospital outpatient pharmacies found the median cash cost of rivaroxaban to be significantly higher than that of LMWH-warfarin ($1856 vs $724 for six months).
"In low-risk patients, target-specific anticoagulants require minimal maintenance, and patients can be managed with no coagulation testing at all, and almost no other laboratory monitoring unless other factors suggest anemia or a reason to suspect change in renal function," Dr. Kline said.
Dr. Nathan T. Connell, from Brigham and Women's Hospital in Boston, told Reuters Health by email, "Recently, there has been a lot of discussion about cost differences between various anticoagulation strategies. This paper helps put the cost in perspective and that treatment with rivaroxaban may be more cost-effective in the long term."
"This difference went away when hospitalized patients were removed from the analysis, suggesting that the cost of hospitalization was the major driver for cost difference between the two strategies," Dr. Connell said. "For well-selected low-risk patients, however, rivaroxaban is an attractive choice because it often allows direct discharge from the Emergency Department. Also, we know from other studies that the risk of certain types of serious bleeding, such as intracerebral hemorrhage, is lower with rivaroxaban as compared to warfarin."
Dr. Connell noted, "This is a retrospective study, which can have issues with selection bias. The authors took several steps to minimize this bias, such as matching on a comorbidity score, in an attempt to make sure the two comparison groups were as balanced as possible."
NEW YORK (Reuters Health) - For patients with low-risk venous thromboembolism (VTE) who can safely be discharged from the emergency department, rivaroxaban is a less costly treatment than heparin and warfarin, according to results of a case-control study.
"The biggest surprise to me was that using the Hestia criteria in the emergency department produced a low-enough risk population that we had zero incidence of either recurrent clots or bleeding," Dr. Jeffrey A. Kline, from Indiana University School of Medicine in Indianapolis, told Reuters Health by email. "The second surprise was the strength of gratitude by the patients that they did not have to have injections and take warfarin."
Dr. Kline's team developed a protocol for home treatment of low-risk patients with VTE using a target-specific anticoagulant like rivaroxaban. They compared the costs of medical care accrued by 50 patients treated with rivaroxaban and 47 matched controls who received bridging low-molecular-weight heparin (LMWH) for five to seven days and were then transitioned to warfarin.
All 50 rivaroxaban patients were discharged home from the emergency department on the day of diagnosis, whereas only 18 control patients were treated at home, according to the June 25 Academic Emergency Medicine online report.
Over the six months of follow-up, median total charges were $4787 with rivaroxaban, compared with $11,128 with LMWH-warfarin.
When the analysis was confined to patients who were never hospitalized, rivaroxaban was still less costly (median, $5932 vs $9016), although the difference was not statistically significant.
In-patient pharmacy median charges were significantly less with rivaroxaban than with LMWH-warfarin (median, $215 vs $742), but a survey of hospital outpatient pharmacies found the median cash cost of rivaroxaban to be significantly higher than that of LMWH-warfarin ($1856 vs $724 for six months).
"In low-risk patients, target-specific anticoagulants require minimal maintenance, and patients can be managed with no coagulation testing at all, and almost no other laboratory monitoring unless other factors suggest anemia or a reason to suspect change in renal function," Dr. Kline said.
Dr. Nathan T. Connell, from Brigham and Women's Hospital in Boston, told Reuters Health by email, "Recently, there has been a lot of discussion about cost differences between various anticoagulation strategies. This paper helps put the cost in perspective and that treatment with rivaroxaban may be more cost-effective in the long term."
"This difference went away when hospitalized patients were removed from the analysis, suggesting that the cost of hospitalization was the major driver for cost difference between the two strategies," Dr. Connell said. "For well-selected low-risk patients, however, rivaroxaban is an attractive choice because it often allows direct discharge from the Emergency Department. Also, we know from other studies that the risk of certain types of serious bleeding, such as intracerebral hemorrhage, is lower with rivaroxaban as compared to warfarin."
Dr. Connell noted, "This is a retrospective study, which can have issues with selection bias. The authors took several steps to minimize this bias, such as matching on a comorbidity score, in an attempt to make sure the two comparison groups were as balanced as possible."
PHM15: Incorporating Active Learning Strategies into Your Teaching
Presenters: Alison Holmes, MD, MPH; Michele Long, MD; Carrie Rossbach, MD; Jennifer Rosenthal, MD
Being a hospitalist naturally lends itself to participating in education. Whether teaching on the wards at the bedside, giving didactic lectures in the classroom, or divulging informal clinical pearls throughout the day, the hospitalists’ role is entrenched in teaching. And while hospitalists make every attempt to stay current on the latest medical and clinical information, much of their teaching toolbox remains outdated.
Active learning is not a new concept, but is becoming more and more of a hot topic in the educational field. In the 1900s, medical education had become so cumbersome that the educators began bringing the students into the laboratory setting to more actively engage them. By the 1950s, constructivism brought the idea that learners obtain knowledge best by using real experiences with real subject matter and using interaction. In the 1970s, Malcolm Knowles revolutionized education for the adult by bringing forth the idea of andragogy.
However, despite these advances, it wasn’t until the 1990s that active learning began being applied to the medical community. Despite numerous studies validating the adult learning principles in both the medical school and residency settings, there were numerous barriers that prevented active learning from being integrated into the curricula.
Formal medical lectures tend to be geared to large audiences making active learning unwieldy. Residents are often under time constraints and are fatigued, making them passive learners by default. Faculty members commonly find transforming large volumes of information into an active process a daunting task.
The presenters provided four different active learning applications that could be used in virtually any setting with any source material.
- Case Based Discussions allow the transformation of a passive power point into an interactive session with leading questions and giving information in a “morning report” style.
- Quizzes promote pre-reading and then immediate feedback of their knowledge gaps, often providing increased learner satisfaction by showing improvement in retaking the quiz at the end of the session.
- Case Applications are exercises where groups apply content of reading to a challenging and sophisticated case, forcing them to move beyond their current knowledge and to test the boundaries of their logical applications.
- Role Playing can allow a dramatic, live presentation of a case and re-enact in live time a clinical scenario.
The session then broke into individual small groups and developed a lecture based on one of the four modalities. Every group successfully produced an interesting, active learning lecture in just 15 minutes. This demonstrated that with minimal effort and time, such applications can be used to prepare an active learning session that would encompass as little as ten minutes or as much as an hour. By thoughtfully considering these techniques and applying them to old, worn out lectures, the material can be easily brought to life, enhancing the educational experience.
Travis W. Crook, MD, FAAP
Assistant Professor, Pediatrics
Assistant Pediatric Clerkship Director
Division of Hospitalist Medicine
Department of Pediatrics
Vanderbilt University School of Medicine
Monroe Carell Jr Children's Hospital at Vanderbilt
Presenters: Alison Holmes, MD, MPH; Michele Long, MD; Carrie Rossbach, MD; Jennifer Rosenthal, MD
Being a hospitalist naturally lends itself to participating in education. Whether teaching on the wards at the bedside, giving didactic lectures in the classroom, or divulging informal clinical pearls throughout the day, the hospitalists’ role is entrenched in teaching. And while hospitalists make every attempt to stay current on the latest medical and clinical information, much of their teaching toolbox remains outdated.
Active learning is not a new concept, but is becoming more and more of a hot topic in the educational field. In the 1900s, medical education had become so cumbersome that the educators began bringing the students into the laboratory setting to more actively engage them. By the 1950s, constructivism brought the idea that learners obtain knowledge best by using real experiences with real subject matter and using interaction. In the 1970s, Malcolm Knowles revolutionized education for the adult by bringing forth the idea of andragogy.
However, despite these advances, it wasn’t until the 1990s that active learning began being applied to the medical community. Despite numerous studies validating the adult learning principles in both the medical school and residency settings, there were numerous barriers that prevented active learning from being integrated into the curricula.
Formal medical lectures tend to be geared to large audiences making active learning unwieldy. Residents are often under time constraints and are fatigued, making them passive learners by default. Faculty members commonly find transforming large volumes of information into an active process a daunting task.
The presenters provided four different active learning applications that could be used in virtually any setting with any source material.
- Case Based Discussions allow the transformation of a passive power point into an interactive session with leading questions and giving information in a “morning report” style.
- Quizzes promote pre-reading and then immediate feedback of their knowledge gaps, often providing increased learner satisfaction by showing improvement in retaking the quiz at the end of the session.
- Case Applications are exercises where groups apply content of reading to a challenging and sophisticated case, forcing them to move beyond their current knowledge and to test the boundaries of their logical applications.
- Role Playing can allow a dramatic, live presentation of a case and re-enact in live time a clinical scenario.
The session then broke into individual small groups and developed a lecture based on one of the four modalities. Every group successfully produced an interesting, active learning lecture in just 15 minutes. This demonstrated that with minimal effort and time, such applications can be used to prepare an active learning session that would encompass as little as ten minutes or as much as an hour. By thoughtfully considering these techniques and applying them to old, worn out lectures, the material can be easily brought to life, enhancing the educational experience.
Travis W. Crook, MD, FAAP
Assistant Professor, Pediatrics
Assistant Pediatric Clerkship Director
Division of Hospitalist Medicine
Department of Pediatrics
Vanderbilt University School of Medicine
Monroe Carell Jr Children's Hospital at Vanderbilt
Presenters: Alison Holmes, MD, MPH; Michele Long, MD; Carrie Rossbach, MD; Jennifer Rosenthal, MD
Being a hospitalist naturally lends itself to participating in education. Whether teaching on the wards at the bedside, giving didactic lectures in the classroom, or divulging informal clinical pearls throughout the day, the hospitalists’ role is entrenched in teaching. And while hospitalists make every attempt to stay current on the latest medical and clinical information, much of their teaching toolbox remains outdated.
Active learning is not a new concept, but is becoming more and more of a hot topic in the educational field. In the 1900s, medical education had become so cumbersome that the educators began bringing the students into the laboratory setting to more actively engage them. By the 1950s, constructivism brought the idea that learners obtain knowledge best by using real experiences with real subject matter and using interaction. In the 1970s, Malcolm Knowles revolutionized education for the adult by bringing forth the idea of andragogy.
However, despite these advances, it wasn’t until the 1990s that active learning began being applied to the medical community. Despite numerous studies validating the adult learning principles in both the medical school and residency settings, there were numerous barriers that prevented active learning from being integrated into the curricula.
Formal medical lectures tend to be geared to large audiences making active learning unwieldy. Residents are often under time constraints and are fatigued, making them passive learners by default. Faculty members commonly find transforming large volumes of information into an active process a daunting task.
The presenters provided four different active learning applications that could be used in virtually any setting with any source material.
- Case Based Discussions allow the transformation of a passive power point into an interactive session with leading questions and giving information in a “morning report” style.
- Quizzes promote pre-reading and then immediate feedback of their knowledge gaps, often providing increased learner satisfaction by showing improvement in retaking the quiz at the end of the session.
- Case Applications are exercises where groups apply content of reading to a challenging and sophisticated case, forcing them to move beyond their current knowledge and to test the boundaries of their logical applications.
- Role Playing can allow a dramatic, live presentation of a case and re-enact in live time a clinical scenario.
The session then broke into individual small groups and developed a lecture based on one of the four modalities. Every group successfully produced an interesting, active learning lecture in just 15 minutes. This demonstrated that with minimal effort and time, such applications can be used to prepare an active learning session that would encompass as little as ten minutes or as much as an hour. By thoughtfully considering these techniques and applying them to old, worn out lectures, the material can be easily brought to life, enhancing the educational experience.
Travis W. Crook, MD, FAAP
Assistant Professor, Pediatrics
Assistant Pediatric Clerkship Director
Division of Hospitalist Medicine
Department of Pediatrics
Vanderbilt University School of Medicine
Monroe Carell Jr Children's Hospital at Vanderbilt
PHM15: Evidence-Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event
Summary:
Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.
The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.
Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.
Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:
- Multiple events,
- Prematurity,
- Fever/hypothermia,
- Toxic appearance,
- Altered mental status, or
- Clinical signs of pertussis.
From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.
Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.
Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH
Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.
Summary:
Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.
The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.
Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.
Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:
- Multiple events,
- Prematurity,
- Fever/hypothermia,
- Toxic appearance,
- Altered mental status, or
- Clinical signs of pertussis.
From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.
Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.
Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH
Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.
Summary:
Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.
The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.
Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.
Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:
- Multiple events,
- Prematurity,
- Fever/hypothermia,
- Toxic appearance,
- Altered mental status, or
- Clinical signs of pertussis.
From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.
Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.
Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH
Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.
Study suggests hemophilia therapies are too costly
Hemophilia therapies account for the largest portion of pharmacy expenditures among publicly insured children with serious chronic illnesses in California, according to a study published in JAMA.
Hemophilia therapies accounted for 41% of expenditures for these children, even though hemophilia patients made up only 0.4% of the group studied.
Researchers said this finding suggests a need to improve pricing for hemophilia therapies and other high-cost medications. However, they noted that pricing varies from state to state.
Sonja M. Swenson, of Stanford University in California, and her colleagues conducted this research, analyzing paid claims for children (ages 0-21 years) using the California Children’s Services (CCS) paid claims data set (2010-2012).
CCS provides insurance coverage, care coordination, and a regionalized system of pediatric specialty care facilities for approximately 180,000 publicly insured children with serious chronic illnesses.
The data set includes age, sex, race/ethnicity, county of residence, enrollment dates, primary and secondary eligible diagnoses, claim diagnoses, and procedures for every enrollee. This study included children enrolled through fee-for-service care for at least 6 continuous months.
The researchers examined the records of 34,330 children. Outpatient pharmacy expenditures totaled $475,718,130 (20% of total healthcare expenditures).
Per-child pharmacy expenditures ranged from $0.16 to $56,849,034. The average and median per-child expenditures were $13,857 and $791, respectively.
Expenditures for all products analyzed were as follows:
| Product Class | Expenditures | % of Total
Expenditures |
No. of Children | Expenditures/
Child |
|---|---|---|---|---|
| Blood formation, coagulation, and thrombosis agents | $199,498,843 | 41.9% | 3499 | $57,016 |
| Central nervous system agents | $43,633,418 | 9.2% | 23,351 | $1869 |
| Electrolytic, caloric, and water balance | $39,617,776 | 8.3% | 10,959 | $3615 |
| Anti-infective agents | $35,827,958 | 7.5% | 26,165 | $1369 |
| Respiratory agents | $29,614,645 | 6.2% | 16,706 | $1173 |
| Hormones and synthetic substitutes | $24,722,256 | 5.2% | 8542 | $2894 |
| Enzymes | $13,294,509 | 2.8% | 27 | $492,389 |
| Gastrointestinal drugs | $12,500,330 | 2.6% | 11,817 | $1058 |
| Heavy metal antagonists | $6,983,828 | 1.5% | 108 | $64,665 |
| Cardiovascular drugs | $6,173,792 | 1.3% | 4031 | $1532 |
Hemophilia expenditures
As seen in the above table, the product class of blood formation, coagulation, and thrombosis agents accounted for the greatest share of outpatient pharmacy expenditures (42%).
Antihemophilic factors represented 98% of this class’s expenditures, or 41% of total pharmacy expenditures. Children with an antihemophilic factor paid claim were 0.4% of the entire cohort (n=145). And the average per-child expenditure for antihemophilic factor was $1,343,262.
Among children with antihemophilic factor claims who were enrolled for all 3 years studied, the average and median per-child annualized expenditures were $634,054 and $152,280, respectively.
The researchers said these results suggest a need for better pricing for hemophilia therapies, but it’s important to note that expenditures vary from state to state.
For instance, CCS’s mean per-child antihemophilic factor annual expenditure ($634,054) significantly surpassed that of North Carolina’s Medicaid program ($233,968 in fiscal year 2012) and Medicaid programs in 10 other states ($148,215 in 2008). 
Hemophilia therapies account for the largest portion of pharmacy expenditures among publicly insured children with serious chronic illnesses in California, according to a study published in JAMA.
Hemophilia therapies accounted for 41% of expenditures for these children, even though hemophilia patients made up only 0.4% of the group studied.
Researchers said this finding suggests a need to improve pricing for hemophilia therapies and other high-cost medications. However, they noted that pricing varies from state to state.
Sonja M. Swenson, of Stanford University in California, and her colleagues conducted this research, analyzing paid claims for children (ages 0-21 years) using the California Children’s Services (CCS) paid claims data set (2010-2012).
CCS provides insurance coverage, care coordination, and a regionalized system of pediatric specialty care facilities for approximately 180,000 publicly insured children with serious chronic illnesses.
The data set includes age, sex, race/ethnicity, county of residence, enrollment dates, primary and secondary eligible diagnoses, claim diagnoses, and procedures for every enrollee. This study included children enrolled through fee-for-service care for at least 6 continuous months.
The researchers examined the records of 34,330 children. Outpatient pharmacy expenditures totaled $475,718,130 (20% of total healthcare expenditures).
Per-child pharmacy expenditures ranged from $0.16 to $56,849,034. The average and median per-child expenditures were $13,857 and $791, respectively.
Expenditures for all products analyzed were as follows:
| Product Class | Expenditures | % of Total
Expenditures |
No. of Children | Expenditures/
Child |
|---|---|---|---|---|
| Blood formation, coagulation, and thrombosis agents | $199,498,843 | 41.9% | 3499 | $57,016 |
| Central nervous system agents | $43,633,418 | 9.2% | 23,351 | $1869 |
| Electrolytic, caloric, and water balance | $39,617,776 | 8.3% | 10,959 | $3615 |
| Anti-infective agents | $35,827,958 | 7.5% | 26,165 | $1369 |
| Respiratory agents | $29,614,645 | 6.2% | 16,706 | $1173 |
| Hormones and synthetic substitutes | $24,722,256 | 5.2% | 8542 | $2894 |
| Enzymes | $13,294,509 | 2.8% | 27 | $492,389 |
| Gastrointestinal drugs | $12,500,330 | 2.6% | 11,817 | $1058 |
| Heavy metal antagonists | $6,983,828 | 1.5% | 108 | $64,665 |
| Cardiovascular drugs | $6,173,792 | 1.3% | 4031 | $1532 |
Hemophilia expenditures
As seen in the above table, the product class of blood formation, coagulation, and thrombosis agents accounted for the greatest share of outpatient pharmacy expenditures (42%).
Antihemophilic factors represented 98% of this class’s expenditures, or 41% of total pharmacy expenditures. Children with an antihemophilic factor paid claim were 0.4% of the entire cohort (n=145). And the average per-child expenditure for antihemophilic factor was $1,343,262.
Among children with antihemophilic factor claims who were enrolled for all 3 years studied, the average and median per-child annualized expenditures were $634,054 and $152,280, respectively.
The researchers said these results suggest a need for better pricing for hemophilia therapies, but it’s important to note that expenditures vary from state to state.
For instance, CCS’s mean per-child antihemophilic factor annual expenditure ($634,054) significantly surpassed that of North Carolina’s Medicaid program ($233,968 in fiscal year 2012) and Medicaid programs in 10 other states ($148,215 in 2008).
Hemophilia therapies account for the largest portion of pharmacy expenditures among publicly insured children with serious chronic illnesses in California, according to a study published in JAMA.
Hemophilia therapies accounted for 41% of expenditures for these children, even though hemophilia patients made up only 0.4% of the group studied.
Researchers said this finding suggests a need to improve pricing for hemophilia therapies and other high-cost medications. However, they noted that pricing varies from state to state.
Sonja M. Swenson, of Stanford University in California, and her colleagues conducted this research, analyzing paid claims for children (ages 0-21 years) using the California Children’s Services (CCS) paid claims data set (2010-2012).
CCS provides insurance coverage, care coordination, and a regionalized system of pediatric specialty care facilities for approximately 180,000 publicly insured children with serious chronic illnesses.
The data set includes age, sex, race/ethnicity, county of residence, enrollment dates, primary and secondary eligible diagnoses, claim diagnoses, and procedures for every enrollee. This study included children enrolled through fee-for-service care for at least 6 continuous months.
The researchers examined the records of 34,330 children. Outpatient pharmacy expenditures totaled $475,718,130 (20% of total healthcare expenditures).
Per-child pharmacy expenditures ranged from $0.16 to $56,849,034. The average and median per-child expenditures were $13,857 and $791, respectively.
Expenditures for all products analyzed were as follows:
| Product Class | Expenditures | % of Total
Expenditures |
No. of Children | Expenditures/
Child |
|---|---|---|---|---|
| Blood formation, coagulation, and thrombosis agents | $199,498,843 | 41.9% | 3499 | $57,016 |
| Central nervous system agents | $43,633,418 | 9.2% | 23,351 | $1869 |
| Electrolytic, caloric, and water balance | $39,617,776 | 8.3% | 10,959 | $3615 |
| Anti-infective agents | $35,827,958 | 7.5% | 26,165 | $1369 |
| Respiratory agents | $29,614,645 | 6.2% | 16,706 | $1173 |
| Hormones and synthetic substitutes | $24,722,256 | 5.2% | 8542 | $2894 |
| Enzymes | $13,294,509 | 2.8% | 27 | $492,389 |
| Gastrointestinal drugs | $12,500,330 | 2.6% | 11,817 | $1058 |
| Heavy metal antagonists | $6,983,828 | 1.5% | 108 | $64,665 |
| Cardiovascular drugs | $6,173,792 | 1.3% | 4031 | $1532 |
Hemophilia expenditures
As seen in the above table, the product class of blood formation, coagulation, and thrombosis agents accounted for the greatest share of outpatient pharmacy expenditures (42%).
Antihemophilic factors represented 98% of this class’s expenditures, or 41% of total pharmacy expenditures. Children with an antihemophilic factor paid claim were 0.4% of the entire cohort (n=145). And the average per-child expenditure for antihemophilic factor was $1,343,262.
Among children with antihemophilic factor claims who were enrolled for all 3 years studied, the average and median per-child annualized expenditures were $634,054 and $152,280, respectively.
The researchers said these results suggest a need for better pricing for hemophilia therapies, but it’s important to note that expenditures vary from state to state.
For instance, CCS’s mean per-child antihemophilic factor annual expenditure ($634,054) significantly surpassed that of North Carolina’s Medicaid program ($233,968 in fiscal year 2012) and Medicaid programs in 10 other states ($148,215 in 2008).