Mother and daughter

Credit: Vera Kratochvil

BOSTON—Having dependent children may motivate advanced cancer patients to pursue more aggressive treatment, a pilot study indicates.

Parental status was an important factor in treatment decision-making for most of the 42 patients studied.

A majority of patients said being a parent motivated them to pursue life-extending treatments, although some patients mentioned the importance of staying close to their families to receive treatment and retaining the ability to function as a parent.

This research was released in a presscast in advance of ASCO’s 2014 Quality Care Symposium, which is scheduled to take place October 17-18 at the Boston Marriott Copley Place. The research is set to be presented as abstract 65.*

Researchers interviewed 42 patients with metastatic cancer who have children younger than 18 years of age. The patients had an average age of 44.

When asked how having children influenced their treatment decisions, 64% of patients said being a parent motivated them to pursue life-extending treatments, largely out of a desire to have more time with their children. However, 24% of patients said being a parent did not influence their treatment decisions.

Twenty-four percent of respondents identified preserving parental functioning as a treatment priority. They didn’t want side effects interfering with their or their children’s daily lives.

And 12% of patients mentioned the importance of receiving treatment close to their families, rather than traveling for a second opinion or pursuing treatment that might require long hospital stays.

Fifty-two percent of patients indicated an interest in using hospice services. Others were specifically interested in institutional rather than home hospice care, due to a desire to protect their children from the dying experience.

Fifty-nine percent of patients reported an interest in receiving palliative care concurrent with their cancer treatment, although several patients seemed to conflate palliative care with end-of-life care.

“Numerous psychosocial factors influence patients’ decisions about cancer treatment,” said lead study author Devon Check, a PhD student at the University of North Carolina at Chapel Hill.

“It’s important for patients with dependent children to discuss their treatment priorities with their oncologist, who may not know, for example, how important it is for a patient with children to preserve their functioning at home.”

“We hope that our study can help oncologists engage patients with children in shared decision-making and promote alignment of the treatment plan with the patients’ priorities, including family responsibilities.”

Although this study included patients with a range of physical functioning and a variety of cancer types, the findings may not generalize to other patient groups.

The researchers are planning a larger study to explore the associations between parental status, parenting concerns, and decision-making about treatment for advanced cancer.

*Some of the data presented differ from data in the abstract.

Mother and daughter

Credit: Vera Kratochvil

BOSTON—Having dependent children may motivate advanced cancer patients to pursue more aggressive treatment, a pilot study indicates.

Parental status was an important factor in treatment decision-making for most of the 42 patients studied.

A majority of patients said being a parent motivated them to pursue life-extending treatments, although some patients mentioned the importance of staying close to their families to receive treatment and retaining the ability to function as a parent.

This research was released in a presscast in advance of ASCO’s 2014 Quality Care Symposium, which is scheduled to take place October 17-18 at the Boston Marriott Copley Place. The research is set to be presented as abstract 65.*

Researchers interviewed 42 patients with metastatic cancer who have children younger than 18 years of age. The patients had an average age of 44.

When asked how having children influenced their treatment decisions, 64% of patients said being a parent motivated them to pursue life-extending treatments, largely out of a desire to have more time with their children. However, 24% of patients said being a parent did not influence their treatment decisions.

Twenty-four percent of respondents identified preserving parental functioning as a treatment priority. They didn’t want side effects interfering with their or their children’s daily lives.

And 12% of patients mentioned the importance of receiving treatment close to their families, rather than traveling for a second opinion or pursuing treatment that might require long hospital stays.

Fifty-two percent of patients indicated an interest in using hospice services. Others were specifically interested in institutional rather than home hospice care, due to a desire to protect their children from the dying experience.

Fifty-nine percent of patients reported an interest in receiving palliative care concurrent with their cancer treatment, although several patients seemed to conflate palliative care with end-of-life care.

“Numerous psychosocial factors influence patients’ decisions about cancer treatment,” said lead study author Devon Check, a PhD student at the University of North Carolina at Chapel Hill.

“It’s important for patients with dependent children to discuss their treatment priorities with their oncologist, who may not know, for example, how important it is for a patient with children to preserve their functioning at home.”

“We hope that our study can help oncologists engage patients with children in shared decision-making and promote alignment of the treatment plan with the patients’ priorities, including family responsibilities.”

Although this study included patients with a range of physical functioning and a variety of cancer types, the findings may not generalize to other patient groups.

The researchers are planning a larger study to explore the associations between parental status, parenting concerns, and decision-making about treatment for advanced cancer.

*Some of the data presented differ from data in the abstract.

Mother and daughter

Credit: Vera Kratochvil

BOSTON—Having dependent children may motivate advanced cancer patients to pursue more aggressive treatment, a pilot study indicates.

Parental status was an important factor in treatment decision-making for most of the 42 patients studied.

A majority of patients said being a parent motivated them to pursue life-extending treatments, although some patients mentioned the importance of staying close to their families to receive treatment and retaining the ability to function as a parent.

This research was released in a presscast in advance of ASCO’s 2014 Quality Care Symposium, which is scheduled to take place October 17-18 at the Boston Marriott Copley Place. The research is set to be presented as abstract 65.*

Researchers interviewed 42 patients with metastatic cancer who have children younger than 18 years of age. The patients had an average age of 44.

When asked how having children influenced their treatment decisions, 64% of patients said being a parent motivated them to pursue life-extending treatments, largely out of a desire to have more time with their children. However, 24% of patients said being a parent did not influence their treatment decisions.

Twenty-four percent of respondents identified preserving parental functioning as a treatment priority. They didn’t want side effects interfering with their or their children’s daily lives.

And 12% of patients mentioned the importance of receiving treatment close to their families, rather than traveling for a second opinion or pursuing treatment that might require long hospital stays.

Fifty-two percent of patients indicated an interest in using hospice services. Others were specifically interested in institutional rather than home hospice care, due to a desire to protect their children from the dying experience.

Fifty-nine percent of patients reported an interest in receiving palliative care concurrent with their cancer treatment, although several patients seemed to conflate palliative care with end-of-life care.

“Numerous psychosocial factors influence patients’ decisions about cancer treatment,” said lead study author Devon Check, a PhD student at the University of North Carolina at Chapel Hill.

“It’s important for patients with dependent children to discuss their treatment priorities with their oncologist, who may not know, for example, how important it is for a patient with children to preserve their functioning at home.”

“We hope that our study can help oncologists engage patients with children in shared decision-making and promote alignment of the treatment plan with the patients’ priorities, including family responsibilities.”

Although this study included patients with a range of physical functioning and a variety of cancer types, the findings may not generalize to other patient groups.

The researchers are planning a larger study to explore the associations between parental status, parenting concerns, and decision-making about treatment for advanced cancer.

*Some of the data presented differ from data in the abstract.

Although some vascular surgeons are convinced that endovascular aneurysm repair (EVAR) is superior to open repair for the treatment of ruptured abdominal aortic aneurysms (rAAAs), the issue remains controversial. The naysayers for the superiority of EVAR in this setting claim that all data showing superior outcomes for EVAR are flawed by patient selection, and they demand level 1 evidence from randomized comparisons of EVAR and open repair.

Three such randomized controlled trials (RCTs) have recently been published or have had their results presented: the AJAX or Amsterdam (Dutch) trial,¹ the ECAR or French trial,² and the IMPROVE or U.K. trial.³ All three trials concluded that 30-day mortality outcomes after EVAR are no better than those after open repair. However, in these three trials, this conclusion is rendered unjustified or misleading because of serious flaws or misinterpretation of the trial data. Let us examine the specifics.

The AJAX and ECAR trials randomized small numbers (116 and 107, respectively) of patients and had the serious flaw of excluding hypotensive or unstable rAAA patients. Such high-risk patients are precisely the ones who are most likely to have better outcomes with EVAR than with open repair. Therefore, exclusion of these high-risk patients precludes these trials from demonstrating the advantage that EVAR might have in the overall population of patients with rAAAs. In addition, both these trials may have used, in a suboptimal fashion, three adjuncts generally believed to improve EVAR outcomes.

Better usage of fluid restriction (hypotensive hemostasis), supra-aortic balloon control and open abdomen treatment of abdominal compartment syndrome might have further improved the EVAR outcomes in both trials.

In contrast to these two smaller RCTs, the larger U.K. IMPROVE trial was conducted in 30 high-volume centers. Although 652 possible rAAA patients were excluded for various reasons, the trialists did randomize 613 patients with a diagnosis of rAAA to either an endovascular strategy (316 patients) or open repair (297 patients).

Patients were randomized before CT scans were performed. The 30-day mortality in the endovascular strategy group was 35%; in the open repair group, it was 37%. Obviously, there was no significant difference, and a primary conclusion of the main IMPROVE trial article was “A strategy of endovascular repair was not associated with significant reduction in 30-day mortality.” This was paraphrased in various news report headlines as, “No Difference Between Endovascular and Open Repair.”

However, the detailed data from the IMPROVE trial must be examined closely to see why these conclusions are misleading. Of the patients randomized to the endovascular strategy group, only 154 (about half) actually underwent EVAR; 112 had an open repair and 17 had no treatment. The 30-day mortality in this group was 27% for those treated by EVAR and 38% for those treated by open repair. Of the patients randomized to the open repair group, 36 actually had EVAR, 220 had open repair, and 19 had no treatment.

The 30-day mortality in this open repair group was 22% for those undergoing EVAR and 37% for those undergoing open repair. Overall in the two randomized groups, taken together, the 30-day mortality for rAAA patients actually treated by EVAR was 25% and for those actually treated by Open Repair, it was 38%.

Clearly the conclusion of the IMPROVE trial should have been, in patients with an rAAA, if they can be treated by EVAR, their 30-day survival will be superior. If one adds to this the fact that patients undergoing EVAR are less likely to receive no treatment, the conclusion is inescapable: EVAR is superior to open repair for the treatment of patients with rAAAs.

Thus, those treating rAAA patients must learn how to do EVAR in this setting, including acquiring expertise in all the adjuncts and strategies that can improve EVAR outcomes in such patients. We do not need further RCTs to confuse the issue any more.

References

1. Ann. Surg. 2013;258:248-56.

2. www.veithondemand.com/2013.

3. BMJ 2014;348:f7661.

Dr. Veith is professor of surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist. 

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or publisher.

Although some vascular surgeons are convinced that endovascular aneurysm repair (EVAR) is superior to open repair for the treatment of ruptured abdominal aortic aneurysms (rAAAs), the issue remains controversial. The naysayers for the superiority of EVAR in this setting claim that all data showing superior outcomes for EVAR are flawed by patient selection, and they demand level 1 evidence from randomized comparisons of EVAR and open repair.

Three such randomized controlled trials (RCTs) have recently been published or have had their results presented: the AJAX or Amsterdam (Dutch) trial,¹ the ECAR or French trial,² and the IMPROVE or U.K. trial.³ All three trials concluded that 30-day mortality outcomes after EVAR are no better than those after open repair. However, in these three trials, this conclusion is rendered unjustified or misleading because of serious flaws or misinterpretation of the trial data. Let us examine the specifics.

The AJAX and ECAR trials randomized small numbers (116 and 107, respectively) of patients and had the serious flaw of excluding hypotensive or unstable rAAA patients. Such high-risk patients are precisely the ones who are most likely to have better outcomes with EVAR than with open repair. Therefore, exclusion of these high-risk patients precludes these trials from demonstrating the advantage that EVAR might have in the overall population of patients with rAAAs. In addition, both these trials may have used, in a suboptimal fashion, three adjuncts generally believed to improve EVAR outcomes.

Better usage of fluid restriction (hypotensive hemostasis), supra-aortic balloon control and open abdomen treatment of abdominal compartment syndrome might have further improved the EVAR outcomes in both trials.

In contrast to these two smaller RCTs, the larger U.K. IMPROVE trial was conducted in 30 high-volume centers. Although 652 possible rAAA patients were excluded for various reasons, the trialists did randomize 613 patients with a diagnosis of rAAA to either an endovascular strategy (316 patients) or open repair (297 patients).

Patients were randomized before CT scans were performed. The 30-day mortality in the endovascular strategy group was 35%; in the open repair group, it was 37%. Obviously, there was no significant difference, and a primary conclusion of the main IMPROVE trial article was “A strategy of endovascular repair was not associated with significant reduction in 30-day mortality.” This was paraphrased in various news report headlines as, “No Difference Between Endovascular and Open Repair.”

However, the detailed data from the IMPROVE trial must be examined closely to see why these conclusions are misleading. Of the patients randomized to the endovascular strategy group, only 154 (about half) actually underwent EVAR; 112 had an open repair and 17 had no treatment. The 30-day mortality in this group was 27% for those treated by EVAR and 38% for those treated by open repair. Of the patients randomized to the open repair group, 36 actually had EVAR, 220 had open repair, and 19 had no treatment.

The 30-day mortality in this open repair group was 22% for those undergoing EVAR and 37% for those undergoing open repair. Overall in the two randomized groups, taken together, the 30-day mortality for rAAA patients actually treated by EVAR was 25% and for those actually treated by Open Repair, it was 38%.

Clearly the conclusion of the IMPROVE trial should have been, in patients with an rAAA, if they can be treated by EVAR, their 30-day survival will be superior. If one adds to this the fact that patients undergoing EVAR are less likely to receive no treatment, the conclusion is inescapable: EVAR is superior to open repair for the treatment of patients with rAAAs.

Thus, those treating rAAA patients must learn how to do EVAR in this setting, including acquiring expertise in all the adjuncts and strategies that can improve EVAR outcomes in such patients. We do not need further RCTs to confuse the issue any more.

References

1. Ann. Surg. 2013;258:248-56.

2. www.veithondemand.com/2013.

3. BMJ 2014;348:f7661.

Dr. Veith is professor of surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist. 

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or publisher.

Although some vascular surgeons are convinced that endovascular aneurysm repair (EVAR) is superior to open repair for the treatment of ruptured abdominal aortic aneurysms (rAAAs), the issue remains controversial. The naysayers for the superiority of EVAR in this setting claim that all data showing superior outcomes for EVAR are flawed by patient selection, and they demand level 1 evidence from randomized comparisons of EVAR and open repair.

Three such randomized controlled trials (RCTs) have recently been published or have had their results presented: the AJAX or Amsterdam (Dutch) trial,¹ the ECAR or French trial,² and the IMPROVE or U.K. trial.³ All three trials concluded that 30-day mortality outcomes after EVAR are no better than those after open repair. However, in these three trials, this conclusion is rendered unjustified or misleading because of serious flaws or misinterpretation of the trial data. Let us examine the specifics.

The AJAX and ECAR trials randomized small numbers (116 and 107, respectively) of patients and had the serious flaw of excluding hypotensive or unstable rAAA patients. Such high-risk patients are precisely the ones who are most likely to have better outcomes with EVAR than with open repair. Therefore, exclusion of these high-risk patients precludes these trials from demonstrating the advantage that EVAR might have in the overall population of patients with rAAAs. In addition, both these trials may have used, in a suboptimal fashion, three adjuncts generally believed to improve EVAR outcomes.

Better usage of fluid restriction (hypotensive hemostasis), supra-aortic balloon control and open abdomen treatment of abdominal compartment syndrome might have further improved the EVAR outcomes in both trials.

In contrast to these two smaller RCTs, the larger U.K. IMPROVE trial was conducted in 30 high-volume centers. Although 652 possible rAAA patients were excluded for various reasons, the trialists did randomize 613 patients with a diagnosis of rAAA to either an endovascular strategy (316 patients) or open repair (297 patients).

Patients were randomized before CT scans were performed. The 30-day mortality in the endovascular strategy group was 35%; in the open repair group, it was 37%. Obviously, there was no significant difference, and a primary conclusion of the main IMPROVE trial article was “A strategy of endovascular repair was not associated with significant reduction in 30-day mortality.” This was paraphrased in various news report headlines as, “No Difference Between Endovascular and Open Repair.”

However, the detailed data from the IMPROVE trial must be examined closely to see why these conclusions are misleading. Of the patients randomized to the endovascular strategy group, only 154 (about half) actually underwent EVAR; 112 had an open repair and 17 had no treatment. The 30-day mortality in this group was 27% for those treated by EVAR and 38% for those treated by open repair. Of the patients randomized to the open repair group, 36 actually had EVAR, 220 had open repair, and 19 had no treatment.

The 30-day mortality in this open repair group was 22% for those undergoing EVAR and 37% for those undergoing open repair. Overall in the two randomized groups, taken together, the 30-day mortality for rAAA patients actually treated by EVAR was 25% and for those actually treated by Open Repair, it was 38%.

Clearly the conclusion of the IMPROVE trial should have been, in patients with an rAAA, if they can be treated by EVAR, their 30-day survival will be superior. If one adds to this the fact that patients undergoing EVAR are less likely to receive no treatment, the conclusion is inescapable: EVAR is superior to open repair for the treatment of patients with rAAAs.

Thus, those treating rAAA patients must learn how to do EVAR in this setting, including acquiring expertise in all the adjuncts and strategies that can improve EVAR outcomes in such patients. We do not need further RCTs to confuse the issue any more.

References

1. Ann. Surg. 2013;258:248-56.

2. www.veithondemand.com/2013.

3. BMJ 2014;348:f7661.

Dr. Veith is professor of surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist. 

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or publisher.

With the increasing use of ultrasound in the first trimester, asymptomatic adnexal masses are being diagnosed earlier in pregnancy, leaving providers with an often difficult clinical scenario. The reported incidence of adnexal masses ranges from 1 in 81 to 1 in 8,000 pregnancies, and 0.93%-6% of these are malignant (Gynecol. Oncol. 2006;101:315-21; Am. J. Obstet. Gynecol. 1999;181:19-24). In light of this, the importance of recognizing adnexal masses and knowledge of their management are crucial for any practicing obstetrician gynecologist.

Differential diagnosis

In pregnancy, the majority of adnexal masses are benign simple cysts less than 5 cm (BJOG 2003;110:578-83). As such, the majority of masses (probable corpus luteum cysts) detected in the first trimester (70% in one study) will resolve by the early part of the second trimester (Clin. Obstet. Gynecol. 2006;49:492-505). Adnexal masses are commonly physiologic or functional cysts. Benign masses with complex features can include corpus luteum, mature teratomas, hydrosalpinx, theca lutein cysts, or endometriomas. Complex adnexal masses greater than 5 cm are most likely mature teratomas (Am. J. Obstet. Gynecol. 2001;184:1504-12). Degenerating or pedunculated fibroids can mimic an adnexal mass and may cause pain, clouding the diagnosis.

Of the rare malignant lesions that occur in pregnancy, approximately half are epithelial tumors and one-third are germ cell tumors. Of the epithelial neoplasms, up to 50% may be low-malignant-potential tumors.

Diagnostic evaluation

Imaging: Transvaginal ultrasound is regarded as the modality of choice when evaluating adnexal pathology. Abdominal ultrasound may be especially helpful when the ovaries are outside of the pelvis, especially later in gestation. MRI without contrast may aid in distinguishing leiomyoma and ovarian pathology, which is vital when planning surgery. However, MRI with gadolinium is not recommended as its safety in pregnancy has not been established.

Tumor markers: None of the available tumor markers may be reliably used to diagnose ovarian cancer in pregnancy. CA-125 is elevated in epithelial ovarian cancer, but it is also elevated in pregnancy. However, significant elevations (greater than 1,000 U/mL) are more likely to be associated with cancer.

Markers for germ cell tumors include alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and human chorionic gonadotropin (hCG). Maternal serum levels of AFP (MSAFP) normally rise in pregnancy, although extreme values (less than 500 ng/mL) are associated with neural tube defects while levels greater than 1,000 ng/mL may be associated with an ovarian germ cell tumor (especially when greater than 10,000 ng/mL). LDH is elevated in women with ovarian dysgerminomas and is reliable in pregnancy outside of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). Of course, hCG is elevated in pregnancy, negating its value as a germ cell tumor marker. Inhibin B may be elevated in association with granulosa cell tumors; however, it is also elevated in early gestation.

Management

Because most corpus luteum will resolve, it is recommended to electively resect adnexal masses in the second trimester when they meet the following criteria: lesions are greater than 10 cm in diameter; they are complex lesions (Fertil. Steril. 2009;91:1895-902; Obstet. Gynecol. 1999;93:585-9).

Benign-appearing but persistent simple cysts in the second trimester may be managed conservatively, as approximately 70% will resolve. Thus, routine removal of persistent cysts is not recommended (BJOG 2003;110:578-83). Risk factors for persistent lesions include size greater than 5 cm and complex morphology (Obstet. Gynecol. 1999;93:585-9).Providers may consider serial ultrasounds of ovarian cysts to detect an increase in size or change in character that may warrant further investigation.

Surgery is considered in asymptomatic women meeting the above criteria, to diagnose malignancy or reduce the risk of torsion or rupture. Torsion has been found to be more likely in the late first and early second trimester, with only 6% occurring after 20 weeks. Corpus luteum cysts may on occasion persist into the second trimester and can account for up to 17% of all cystic adnexal masses (Am. J. Obstet. Gynecol. 1999;181:19-24). It is important to remember that if a corpus luteum is surgically resected in the first trimester, progesterone needs to be replaced to avoid pregnancy loss. Of those complex lesions diagnosed in the first trimester that persist into the second trimester, up to 10% may be malignant.

Providers who feel comfortable with laparoscopic techniques can proceed with minimally invasive surgery, with optimal timing in the early second trimester (J. Minim. Invasive Gynecol. 2011;18:720-5). Care should be taken to consider fundal height when choosing trocar placement. If there is a high suspicion for malignancy, providers may want to proceed via laparotomy, which should be via a vertical midline incision. Tocolytic therapy given prophylactically at the time of surgery has no proven benefit and should not be routinely administered.

Washings should be obtained and providers should perform a thorough inspection of the abdomen, contralateral ovary, omentum, and peritoneal surfaces. Any suspicious lesions should be biopsied. A simple cystectomy is reasonable with benign lesions; however, a unilateral salpingo-oophorectomy should be performed with frozen confirmation if there are any concerning findings for malignancy. If a malignancy is confirmed, a gynecologic oncologist should be consulted, and surgical staging should be considered.

Dr. Sullivan is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology at the university. Dr. Sullivan, Dr. Gehrig, and Dr. Clarke-Pearson said they had no relevant financial disclosures.

With the increasing use of ultrasound in the first trimester, asymptomatic adnexal masses are being diagnosed earlier in pregnancy, leaving providers with an often difficult clinical scenario. The reported incidence of adnexal masses ranges from 1 in 81 to 1 in 8,000 pregnancies, and 0.93%-6% of these are malignant (Gynecol. Oncol. 2006;101:315-21; Am. J. Obstet. Gynecol. 1999;181:19-24). In light of this, the importance of recognizing adnexal masses and knowledge of their management are crucial for any practicing obstetrician gynecologist.

Differential diagnosis

In pregnancy, the majority of adnexal masses are benign simple cysts less than 5 cm (BJOG 2003;110:578-83). As such, the majority of masses (probable corpus luteum cysts) detected in the first trimester (70% in one study) will resolve by the early part of the second trimester (Clin. Obstet. Gynecol. 2006;49:492-505). Adnexal masses are commonly physiologic or functional cysts. Benign masses with complex features can include corpus luteum, mature teratomas, hydrosalpinx, theca lutein cysts, or endometriomas. Complex adnexal masses greater than 5 cm are most likely mature teratomas (Am. J. Obstet. Gynecol. 2001;184:1504-12). Degenerating or pedunculated fibroids can mimic an adnexal mass and may cause pain, clouding the diagnosis.

Of the rare malignant lesions that occur in pregnancy, approximately half are epithelial tumors and one-third are germ cell tumors. Of the epithelial neoplasms, up to 50% may be low-malignant-potential tumors.

Diagnostic evaluation

Imaging: Transvaginal ultrasound is regarded as the modality of choice when evaluating adnexal pathology. Abdominal ultrasound may be especially helpful when the ovaries are outside of the pelvis, especially later in gestation. MRI without contrast may aid in distinguishing leiomyoma and ovarian pathology, which is vital when planning surgery. However, MRI with gadolinium is not recommended as its safety in pregnancy has not been established.

Tumor markers: None of the available tumor markers may be reliably used to diagnose ovarian cancer in pregnancy. CA-125 is elevated in epithelial ovarian cancer, but it is also elevated in pregnancy. However, significant elevations (greater than 1,000 U/mL) are more likely to be associated with cancer.

Markers for germ cell tumors include alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and human chorionic gonadotropin (hCG). Maternal serum levels of AFP (MSAFP) normally rise in pregnancy, although extreme values (less than 500 ng/mL) are associated with neural tube defects while levels greater than 1,000 ng/mL may be associated with an ovarian germ cell tumor (especially when greater than 10,000 ng/mL). LDH is elevated in women with ovarian dysgerminomas and is reliable in pregnancy outside of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). Of course, hCG is elevated in pregnancy, negating its value as a germ cell tumor marker. Inhibin B may be elevated in association with granulosa cell tumors; however, it is also elevated in early gestation.

Management

Because most corpus luteum will resolve, it is recommended to electively resect adnexal masses in the second trimester when they meet the following criteria: lesions are greater than 10 cm in diameter; they are complex lesions (Fertil. Steril. 2009;91:1895-902; Obstet. Gynecol. 1999;93:585-9).

Benign-appearing but persistent simple cysts in the second trimester may be managed conservatively, as approximately 70% will resolve. Thus, routine removal of persistent cysts is not recommended (BJOG 2003;110:578-83). Risk factors for persistent lesions include size greater than 5 cm and complex morphology (Obstet. Gynecol. 1999;93:585-9).Providers may consider serial ultrasounds of ovarian cysts to detect an increase in size or change in character that may warrant further investigation.

Surgery is considered in asymptomatic women meeting the above criteria, to diagnose malignancy or reduce the risk of torsion or rupture. Torsion has been found to be more likely in the late first and early second trimester, with only 6% occurring after 20 weeks. Corpus luteum cysts may on occasion persist into the second trimester and can account for up to 17% of all cystic adnexal masses (Am. J. Obstet. Gynecol. 1999;181:19-24). It is important to remember that if a corpus luteum is surgically resected in the first trimester, progesterone needs to be replaced to avoid pregnancy loss. Of those complex lesions diagnosed in the first trimester that persist into the second trimester, up to 10% may be malignant.

Providers who feel comfortable with laparoscopic techniques can proceed with minimally invasive surgery, with optimal timing in the early second trimester (J. Minim. Invasive Gynecol. 2011;18:720-5). Care should be taken to consider fundal height when choosing trocar placement. If there is a high suspicion for malignancy, providers may want to proceed via laparotomy, which should be via a vertical midline incision. Tocolytic therapy given prophylactically at the time of surgery has no proven benefit and should not be routinely administered.

Washings should be obtained and providers should perform a thorough inspection of the abdomen, contralateral ovary, omentum, and peritoneal surfaces. Any suspicious lesions should be biopsied. A simple cystectomy is reasonable with benign lesions; however, a unilateral salpingo-oophorectomy should be performed with frozen confirmation if there are any concerning findings for malignancy. If a malignancy is confirmed, a gynecologic oncologist should be consulted, and surgical staging should be considered.

Dr. Sullivan is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology at the university. Dr. Sullivan, Dr. Gehrig, and Dr. Clarke-Pearson said they had no relevant financial disclosures.

With the increasing use of ultrasound in the first trimester, asymptomatic adnexal masses are being diagnosed earlier in pregnancy, leaving providers with an often difficult clinical scenario. The reported incidence of adnexal masses ranges from 1 in 81 to 1 in 8,000 pregnancies, and 0.93%-6% of these are malignant (Gynecol. Oncol. 2006;101:315-21; Am. J. Obstet. Gynecol. 1999;181:19-24). In light of this, the importance of recognizing adnexal masses and knowledge of their management are crucial for any practicing obstetrician gynecologist.

Differential diagnosis

In pregnancy, the majority of adnexal masses are benign simple cysts less than 5 cm (BJOG 2003;110:578-83). As such, the majority of masses (probable corpus luteum cysts) detected in the first trimester (70% in one study) will resolve by the early part of the second trimester (Clin. Obstet. Gynecol. 2006;49:492-505). Adnexal masses are commonly physiologic or functional cysts. Benign masses with complex features can include corpus luteum, mature teratomas, hydrosalpinx, theca lutein cysts, or endometriomas. Complex adnexal masses greater than 5 cm are most likely mature teratomas (Am. J. Obstet. Gynecol. 2001;184:1504-12). Degenerating or pedunculated fibroids can mimic an adnexal mass and may cause pain, clouding the diagnosis.

Of the rare malignant lesions that occur in pregnancy, approximately half are epithelial tumors and one-third are germ cell tumors. Of the epithelial neoplasms, up to 50% may be low-malignant-potential tumors.

Diagnostic evaluation

Imaging: Transvaginal ultrasound is regarded as the modality of choice when evaluating adnexal pathology. Abdominal ultrasound may be especially helpful when the ovaries are outside of the pelvis, especially later in gestation. MRI without contrast may aid in distinguishing leiomyoma and ovarian pathology, which is vital when planning surgery. However, MRI with gadolinium is not recommended as its safety in pregnancy has not been established.

Tumor markers: None of the available tumor markers may be reliably used to diagnose ovarian cancer in pregnancy. CA-125 is elevated in epithelial ovarian cancer, but it is also elevated in pregnancy. However, significant elevations (greater than 1,000 U/mL) are more likely to be associated with cancer.

Markers for germ cell tumors include alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and human chorionic gonadotropin (hCG). Maternal serum levels of AFP (MSAFP) normally rise in pregnancy, although extreme values (less than 500 ng/mL) are associated with neural tube defects while levels greater than 1,000 ng/mL may be associated with an ovarian germ cell tumor (especially when greater than 10,000 ng/mL). LDH is elevated in women with ovarian dysgerminomas and is reliable in pregnancy outside of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). Of course, hCG is elevated in pregnancy, negating its value as a germ cell tumor marker. Inhibin B may be elevated in association with granulosa cell tumors; however, it is also elevated in early gestation.

Management

Because most corpus luteum will resolve, it is recommended to electively resect adnexal masses in the second trimester when they meet the following criteria: lesions are greater than 10 cm in diameter; they are complex lesions (Fertil. Steril. 2009;91:1895-902; Obstet. Gynecol. 1999;93:585-9).

Benign-appearing but persistent simple cysts in the second trimester may be managed conservatively, as approximately 70% will resolve. Thus, routine removal of persistent cysts is not recommended (BJOG 2003;110:578-83). Risk factors for persistent lesions include size greater than 5 cm and complex morphology (Obstet. Gynecol. 1999;93:585-9).Providers may consider serial ultrasounds of ovarian cysts to detect an increase in size or change in character that may warrant further investigation.

Surgery is considered in asymptomatic women meeting the above criteria, to diagnose malignancy or reduce the risk of torsion or rupture. Torsion has been found to be more likely in the late first and early second trimester, with only 6% occurring after 20 weeks. Corpus luteum cysts may on occasion persist into the second trimester and can account for up to 17% of all cystic adnexal masses (Am. J. Obstet. Gynecol. 1999;181:19-24). It is important to remember that if a corpus luteum is surgically resected in the first trimester, progesterone needs to be replaced to avoid pregnancy loss. Of those complex lesions diagnosed in the first trimester that persist into the second trimester, up to 10% may be malignant.

Providers who feel comfortable with laparoscopic techniques can proceed with minimally invasive surgery, with optimal timing in the early second trimester (J. Minim. Invasive Gynecol. 2011;18:720-5). Care should be taken to consider fundal height when choosing trocar placement. If there is a high suspicion for malignancy, providers may want to proceed via laparotomy, which should be via a vertical midline incision. Tocolytic therapy given prophylactically at the time of surgery has no proven benefit and should not be routinely administered.

Washings should be obtained and providers should perform a thorough inspection of the abdomen, contralateral ovary, omentum, and peritoneal surfaces. Any suspicious lesions should be biopsied. A simple cystectomy is reasonable with benign lesions; however, a unilateral salpingo-oophorectomy should be performed with frozen confirmation if there are any concerning findings for malignancy. If a malignancy is confirmed, a gynecologic oncologist should be consulted, and surgical staging should be considered.

Dr. Sullivan is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology at the university. Dr. Sullivan, Dr. Gehrig, and Dr. Clarke-Pearson said they had no relevant financial disclosures.

The Institute for Healthcare Improvement (IHI) released its Triple Aim Initiative in 2008, challenging the healthcare industry to undergo extensive systematic change, with the following goals:¹

• Reduce the per capita cost of healthcare;
• Improve the patient experience of care, including quality and satisfaction; and
• Improve the health of populations.

The first two aims are difficult enough, but the third involves engaging and empowering patients and their families to take ownership of their own health and wellness. This is much more than just understanding what your diagnoses are and which medications to take; it is about getting and staying well. Keeping patients and their families well is a goal that has eluded the healthcare industry since before Hippocrates and is an extremely challenging one for hospitalists, whose time with patients is usually limited to an acute care hospital stay.

Naturally, when one industry cannot figure out how to do something well, another industry will develop a breakthrough innovation. Enter Apple Inc., which has officially moved into the health and wellness business. Apple Health is a new app that will share multiple inputs of patient information in a cloud platform called “HealthKit.” HealthKit will allow a user to view a personalized dashboard of health and fitness metrics, which conglomerates information from a myriad of different health and wellness apps, helping them “communicate” with one another.²

The breadth and choice of health and wellness apps available to users is astounding. In a five-minute browse through the app store on my iPhone, I found the following free options to help patients track and understand their health and wellness:

• MyPlate Calorie Tracker, Calorie Counter, and Fooducate help educate and monitor caloric intake.
• iTriage, WebMD, and Mango Health Medication Manager, which can answer questions about symptoms you may be experiencing, will save a list of medications, conditions, procedures, physicians, appointments, and more, and can help you manage your medications.
• Nexercise, MapMyRun, MapMyRide, MapMyFitness, Pacer, and Health Mate track physical activity.
• Fitness Buddy and Daily Workout allow users to view daily workout options and target muscle groups for appropriate exercises.
• ShopWell allows you to scan food labels and evaluate ingredients, calories, gluten, and so on in most store-bought food products.

What Apple proposes to do with its new HealthKit is coordinate the input of these types of apps to synthesize a patient’s health and wellness onto a single platform, which can be shared with caretakers and healthcare providers as needed. The company, as only Apple can, actually declared that its app might be “the beginning of a health revolution.”

A New Day

What HealthKit offers is truly unique from a data security standpoint, which will appeal to Orwellian paranoids. Traditionally, when customers use services such as Google or Yahoo, these services use your personal identity—gathered in pieces of data such as your location and your browsing histories—and then use that data to collect, store, or sell such information on their terms. But Apple promises to help manage health and wellness data on the users’ terms. The purpose is to enable easy but secure sharing of complex health information, which can be updated by users or by other devices. Apple has coordinated with other developers to import information to HealthKit from multiple platforms and devices (such as Nike+, Withings Scale, and Fitbit Flex), acting as a central repository of personalized information.

With this technology, it’s easy to envision hospitals, clinics, pharmacies, laboratories, and even insurers integrating bilaterally with any patient information housed on HealthKit, at the discretion of the user. Mayo Clinic, Cleveland Clinic, Kaiser Permanente, Stanford, UCLA, and Mount Sinai Hospital are all rumored to be working with Apple to figure out how to exchange relevant patient information to enhance the continuity of a patient’s care. In addition to these potential collaborators, electronic health record providers Epic Systems and Allscripts are rumored to be working with Apple in some sort of partnership.^3,4

Not only will HealthKit be a secure repository of information, but it will constantly monitor all the metrics and can be programmed to send alerts to key stakeholders, such as family members or healthcare providers, when any of the metrics veer outside predetermined boundaries.⁴

This “new revolution” in healthcare and wellness should prove extremely helpful to hospitalists, who are often caught in the crosshairs of disjointed patient care delivery systems, and patients who need someone (or something) to track their health and wellness. Imagine a late afternoon admission of a patient who knows exactly what medications she is taking, who can outline several months’ history of caloric intake, physical activity, and basic vital signs, who has an accurate and updated inventory of laboratory exams from other medical centers, and who has a list of all recent physicians and appointments. Although this may seem too good to be true, such an admission may not be too far in the future.

What would be even better is if a patient’s health and wellness tracking keeps him out of the hospital altogether. After all, an Apple a day keeps the doctors away.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Institute for Healthcare Improvement. IHI Triple Aim Initiative. Available at: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed August 31, 2014.
2. Apple Inc. Healthkit information page. Available at: https://developer.apple.com/healthkit/. Accessed August 31, 2014.
3. The Advisory Board Company. Daily Briefing: Apple in talks with top hospitals to become ‘hub of health data.’ Available at: http://www.advisory.com/daily-briefing/2014/08/12/apple-in-talks-with-top-hospitals-to-become-hub-of-health-data. Accessed August 31, 2014.
4. Sullivan M. VentureBeat News. Apple announces HealthKit platform and new health app. Available at: http://venturebeat.com/2014/06/02/apple-announces-heath-kit-platform-and-health-app/. Accessed August 31, 2014.

The Institute for Healthcare Improvement (IHI) released its Triple Aim Initiative in 2008, challenging the healthcare industry to undergo extensive systematic change, with the following goals:¹

• Reduce the per capita cost of healthcare;
• Improve the patient experience of care, including quality and satisfaction; and
• Improve the health of populations.

The first two aims are difficult enough, but the third involves engaging and empowering patients and their families to take ownership of their own health and wellness. This is much more than just understanding what your diagnoses are and which medications to take; it is about getting and staying well. Keeping patients and their families well is a goal that has eluded the healthcare industry since before Hippocrates and is an extremely challenging one for hospitalists, whose time with patients is usually limited to an acute care hospital stay.

Naturally, when one industry cannot figure out how to do something well, another industry will develop a breakthrough innovation. Enter Apple Inc., which has officially moved into the health and wellness business. Apple Health is a new app that will share multiple inputs of patient information in a cloud platform called “HealthKit.” HealthKit will allow a user to view a personalized dashboard of health and fitness metrics, which conglomerates information from a myriad of different health and wellness apps, helping them “communicate” with one another.²

The breadth and choice of health and wellness apps available to users is astounding. In a five-minute browse through the app store on my iPhone, I found the following free options to help patients track and understand their health and wellness:

• MyPlate Calorie Tracker, Calorie Counter, and Fooducate help educate and monitor caloric intake.
• iTriage, WebMD, and Mango Health Medication Manager, which can answer questions about symptoms you may be experiencing, will save a list of medications, conditions, procedures, physicians, appointments, and more, and can help you manage your medications.
• Nexercise, MapMyRun, MapMyRide, MapMyFitness, Pacer, and Health Mate track physical activity.
• Fitness Buddy and Daily Workout allow users to view daily workout options and target muscle groups for appropriate exercises.
• ShopWell allows you to scan food labels and evaluate ingredients, calories, gluten, and so on in most store-bought food products.

What Apple proposes to do with its new HealthKit is coordinate the input of these types of apps to synthesize a patient’s health and wellness onto a single platform, which can be shared with caretakers and healthcare providers as needed. The company, as only Apple can, actually declared that its app might be “the beginning of a health revolution.”

A New Day

What HealthKit offers is truly unique from a data security standpoint, which will appeal to Orwellian paranoids. Traditionally, when customers use services such as Google or Yahoo, these services use your personal identity—gathered in pieces of data such as your location and your browsing histories—and then use that data to collect, store, or sell such information on their terms. But Apple promises to help manage health and wellness data on the users’ terms. The purpose is to enable easy but secure sharing of complex health information, which can be updated by users or by other devices. Apple has coordinated with other developers to import information to HealthKit from multiple platforms and devices (such as Nike+, Withings Scale, and Fitbit Flex), acting as a central repository of personalized information.

With this technology, it’s easy to envision hospitals, clinics, pharmacies, laboratories, and even insurers integrating bilaterally with any patient information housed on HealthKit, at the discretion of the user. Mayo Clinic, Cleveland Clinic, Kaiser Permanente, Stanford, UCLA, and Mount Sinai Hospital are all rumored to be working with Apple to figure out how to exchange relevant patient information to enhance the continuity of a patient’s care. In addition to these potential collaborators, electronic health record providers Epic Systems and Allscripts are rumored to be working with Apple in some sort of partnership.^3,4

Not only will HealthKit be a secure repository of information, but it will constantly monitor all the metrics and can be programmed to send alerts to key stakeholders, such as family members or healthcare providers, when any of the metrics veer outside predetermined boundaries.⁴

This “new revolution” in healthcare and wellness should prove extremely helpful to hospitalists, who are often caught in the crosshairs of disjointed patient care delivery systems, and patients who need someone (or something) to track their health and wellness. Imagine a late afternoon admission of a patient who knows exactly what medications she is taking, who can outline several months’ history of caloric intake, physical activity, and basic vital signs, who has an accurate and updated inventory of laboratory exams from other medical centers, and who has a list of all recent physicians and appointments. Although this may seem too good to be true, such an admission may not be too far in the future.

What would be even better is if a patient’s health and wellness tracking keeps him out of the hospital altogether. After all, an Apple a day keeps the doctors away.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Institute for Healthcare Improvement. IHI Triple Aim Initiative. Available at: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed August 31, 2014.
2. Apple Inc. Healthkit information page. Available at: https://developer.apple.com/healthkit/. Accessed August 31, 2014.
3. The Advisory Board Company. Daily Briefing: Apple in talks with top hospitals to become ‘hub of health data.’ Available at: http://www.advisory.com/daily-briefing/2014/08/12/apple-in-talks-with-top-hospitals-to-become-hub-of-health-data. Accessed August 31, 2014.
4. Sullivan M. VentureBeat News. Apple announces HealthKit platform and new health app. Available at: http://venturebeat.com/2014/06/02/apple-announces-heath-kit-platform-and-health-app/. Accessed August 31, 2014.

The Institute for Healthcare Improvement (IHI) released its Triple Aim Initiative in 2008, challenging the healthcare industry to undergo extensive systematic change, with the following goals:¹

• Reduce the per capita cost of healthcare;
• Improve the patient experience of care, including quality and satisfaction; and
• Improve the health of populations.

The first two aims are difficult enough, but the third involves engaging and empowering patients and their families to take ownership of their own health and wellness. This is much more than just understanding what your diagnoses are and which medications to take; it is about getting and staying well. Keeping patients and their families well is a goal that has eluded the healthcare industry since before Hippocrates and is an extremely challenging one for hospitalists, whose time with patients is usually limited to an acute care hospital stay.

Naturally, when one industry cannot figure out how to do something well, another industry will develop a breakthrough innovation. Enter Apple Inc., which has officially moved into the health and wellness business. Apple Health is a new app that will share multiple inputs of patient information in a cloud platform called “HealthKit.” HealthKit will allow a user to view a personalized dashboard of health and fitness metrics, which conglomerates information from a myriad of different health and wellness apps, helping them “communicate” with one another.²

The breadth and choice of health and wellness apps available to users is astounding. In a five-minute browse through the app store on my iPhone, I found the following free options to help patients track and understand their health and wellness:

• MyPlate Calorie Tracker, Calorie Counter, and Fooducate help educate and monitor caloric intake.
• iTriage, WebMD, and Mango Health Medication Manager, which can answer questions about symptoms you may be experiencing, will save a list of medications, conditions, procedures, physicians, appointments, and more, and can help you manage your medications.
• Nexercise, MapMyRun, MapMyRide, MapMyFitness, Pacer, and Health Mate track physical activity.
• Fitness Buddy and Daily Workout allow users to view daily workout options and target muscle groups for appropriate exercises.
• ShopWell allows you to scan food labels and evaluate ingredients, calories, gluten, and so on in most store-bought food products.

What Apple proposes to do with its new HealthKit is coordinate the input of these types of apps to synthesize a patient’s health and wellness onto a single platform, which can be shared with caretakers and healthcare providers as needed. The company, as only Apple can, actually declared that its app might be “the beginning of a health revolution.”

A New Day

What HealthKit offers is truly unique from a data security standpoint, which will appeal to Orwellian paranoids. Traditionally, when customers use services such as Google or Yahoo, these services use your personal identity—gathered in pieces of data such as your location and your browsing histories—and then use that data to collect, store, or sell such information on their terms. But Apple promises to help manage health and wellness data on the users’ terms. The purpose is to enable easy but secure sharing of complex health information, which can be updated by users or by other devices. Apple has coordinated with other developers to import information to HealthKit from multiple platforms and devices (such as Nike+, Withings Scale, and Fitbit Flex), acting as a central repository of personalized information.

With this technology, it’s easy to envision hospitals, clinics, pharmacies, laboratories, and even insurers integrating bilaterally with any patient information housed on HealthKit, at the discretion of the user. Mayo Clinic, Cleveland Clinic, Kaiser Permanente, Stanford, UCLA, and Mount Sinai Hospital are all rumored to be working with Apple to figure out how to exchange relevant patient information to enhance the continuity of a patient’s care. In addition to these potential collaborators, electronic health record providers Epic Systems and Allscripts are rumored to be working with Apple in some sort of partnership.^3,4

Not only will HealthKit be a secure repository of information, but it will constantly monitor all the metrics and can be programmed to send alerts to key stakeholders, such as family members or healthcare providers, when any of the metrics veer outside predetermined boundaries.⁴

This “new revolution” in healthcare and wellness should prove extremely helpful to hospitalists, who are often caught in the crosshairs of disjointed patient care delivery systems, and patients who need someone (or something) to track their health and wellness. Imagine a late afternoon admission of a patient who knows exactly what medications she is taking, who can outline several months’ history of caloric intake, physical activity, and basic vital signs, who has an accurate and updated inventory of laboratory exams from other medical centers, and who has a list of all recent physicians and appointments. Although this may seem too good to be true, such an admission may not be too far in the future.

What would be even better is if a patient’s health and wellness tracking keeps him out of the hospital altogether. After all, an Apple a day keeps the doctors away.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Institute for Healthcare Improvement. IHI Triple Aim Initiative. Available at: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed August 31, 2014.
2. Apple Inc. Healthkit information page. Available at: https://developer.apple.com/healthkit/. Accessed August 31, 2014.
3. The Advisory Board Company. Daily Briefing: Apple in talks with top hospitals to become ‘hub of health data.’ Available at: http://www.advisory.com/daily-briefing/2014/08/12/apple-in-talks-with-top-hospitals-to-become-hub-of-health-data. Accessed August 31, 2014.
4. Sullivan M. VentureBeat News. Apple announces HealthKit platform and new health app. Available at: http://venturebeat.com/2014/06/02/apple-announces-heath-kit-platform-and-health-app/. Accessed August 31, 2014.

“People don’t always remember what you say or even what you do, but they always remember how you made them feel.”—Maya Angelou

When SHM surveyed its members last year about why they had attended the annual meeting, the single most common response was to “be part of the hospital medicine movement.”

In the first three of my presidential columns, I talked about what that meant for the first 15 years of our specialty. HM’s rise occurred in the mid 1990s, during a time of despair in medicine, when pressures from rising costs and the new managed care industry upended the usual way of doing things, and then, around the turn of the century, amid a growing awareness that the care we had been delivering was wildly variable in quality—and often unsafe. Our field, created by members of the Baby Boomer generation, ultimately proved highly attractive to Generation X’ers, and our growth was accelerated by this new supply of young doctors. Fueled by the influx of dollars and attention brought on by the patient safety and quality movement, HM became the fastest growing medical specialty in history.

So, now we know what being part of the hospitalist movement meant before, but what does it mean today? Are the issues and drivers the same? I left my last column in 2006, with the partnership between the Institute for Healthcare Improvement (IHI), SHM, and six other key organizations to create the 5 Million Lives Campaign. It was an important year in several other ways, as what it meant to be a hospitalist began to change.

Enter the Millenials

In 2006 a new generation, the Millenials, born between 1985 and 2000, began entering medical schools across the country. This group, raised on a diet of positive reinforcement and cooperation, is characterized by confidence and a desire to work in teams. Born after the introduction of the Macintosh computer, Millenials are not just tech savvy; they have grown up in the world of social media and are digital media savvy. Even more than Gen X, Millenials strive for work-life balance. It almost seems this was a generation born and raised to be hospitalists!

Not only is their life philosophy different than the Boomers and X’ers before them, but their medical training has been unlike any before. From the moment they entered medical school, they were taught about patient quality and safety. To them, doctors aren’t the isolated pillars of strength and sole possessors of sacred knowledge that they used to be. They intuitively get that medicine is a team sport. In fact, most of the attendings on their ward rotations have been hospitalists.

Rise of Experience

In the early days of medicine, we as physicians understood that patients might not have the best experience, but that was just part of the deal, right? It’s just not supposed to be fun to be hospitalized—and sometimes you had to go through hell to get better. Those were the days of pure, unadulterated paternalism. We did things to patients to make them get better.

In the late 1970s, Irwin Press, PhD, began to study and lecture on patient satisfaction. In 1985, he joined forces with statistician Rod Ganey, PhD, to found Press Ganey Inc.¹ Patient experience as a concept began to enter the conversation of hospital administration, especially around the one-dimensional idea that better experience could contribute to the better financial health of an organization.

During the rise of the patient safety and quality movement in the late 1990s and early 2000s, our zeal to improve care led us to begin doing many things for patients. But a collateral idea began to rise in importance, too—the idea that a patient’s experience was critical to improving quality, not just a tool to attract more patients.

The entire national quality infrastructure I described in my last column (CMS, JCAHO, AHRQ, NQF) began to work on adding experience to the suite of measurements being developed. In 2006, CMS introduced the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. This was a set of questions designed to be used at all hospitals nationwide, a significant development, because there was now a national standard for patient experience that could be compared over time and across hospitals anywhere in the country.²

In 2007, all hospitals subject to the Inpatient Prospective Payment System—pretty much all hospitals except critical access hospitals—were required to submit their HCAHPS survey data or face up to a 2% penalty. In 2008, this experience data was released publicly for the first time.²

And, of course, the Patient Protection and Affordable Care Act of 2010 (ACA) included HCAHPS results in calculating Hospital Value-Based Purchasing payments.³

The Institute of Medicine, in laying out a vision for better healthcare in 2012, called for more involvement of patients and families.

We are even seeing organizations creating leadership positions solely focused on patient experience. The Cleveland Clinic created the first physician leadership position dedicated to patient experience in the country, appointing Bridget Duffy, MD, a hospitalist, as its first chief experience officer in 2010. In 2012, Sound Physicians became the first hospitalist company to create such a position, to which it appointed Mark Rudolph, MD. Who would have imagined this 10 years ago?

Life for hospitalists has changed dramatically from the early 1990s to the Millenials now entering our workforce. The forces guiding our work and stimulating our growth have evolved, but the overarching theme of the last twenty years has been improvement. When the medical world took a cold hard look at the care being delivered, we suddenly saw a world of opportunities for improvement.

I talked before about how the rise of the patient safety and quality movement coincided perfectly with the emergence of hospitalists. Here I told you about how patient experience emerged in prominence as we, collectively, in becoming aware of our quality deficits, gained newfound empathy for what patients were going through. This focus on patient experience again plays into our strength and the opportunity we have as a specialty.

In the December issue of The Hospitalist, the final column in this five-part series will examine how to put it all together as we move toward the future of the field. But first I’ll introduce one last factor, a problem that helped launch our field and is now the greatest threat to our success.

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

References

1. Press Ganey Associates, Inc. A spark ignited nearly three decades ago. Available at: http://www.pressganey.com/aboutUs/ourHistory.aspx. Accessed August 31, 2014.
2. Centers for Medicare and Medicaid Services. HCAHPS Fact Sheet. Available at: www.hcahpsonline.org. Accessed August 31, 2014.
3. American Hospital Association. Inpatient PPS. Available at: http://www.aha.org/advocacy-issues/medicare/ipps/index.shtml. Accessed August 31, 2014.

“People don’t always remember what you say or even what you do, but they always remember how you made them feel.”—Maya Angelou

When SHM surveyed its members last year about why they had attended the annual meeting, the single most common response was to “be part of the hospital medicine movement.”

In the first three of my presidential columns, I talked about what that meant for the first 15 years of our specialty. HM’s rise occurred in the mid 1990s, during a time of despair in medicine, when pressures from rising costs and the new managed care industry upended the usual way of doing things, and then, around the turn of the century, amid a growing awareness that the care we had been delivering was wildly variable in quality—and often unsafe. Our field, created by members of the Baby Boomer generation, ultimately proved highly attractive to Generation X’ers, and our growth was accelerated by this new supply of young doctors. Fueled by the influx of dollars and attention brought on by the patient safety and quality movement, HM became the fastest growing medical specialty in history.

So, now we know what being part of the hospitalist movement meant before, but what does it mean today? Are the issues and drivers the same? I left my last column in 2006, with the partnership between the Institute for Healthcare Improvement (IHI), SHM, and six other key organizations to create the 5 Million Lives Campaign. It was an important year in several other ways, as what it meant to be a hospitalist began to change.

Enter the Millenials

In 2006 a new generation, the Millenials, born between 1985 and 2000, began entering medical schools across the country. This group, raised on a diet of positive reinforcement and cooperation, is characterized by confidence and a desire to work in teams. Born after the introduction of the Macintosh computer, Millenials are not just tech savvy; they have grown up in the world of social media and are digital media savvy. Even more than Gen X, Millenials strive for work-life balance. It almost seems this was a generation born and raised to be hospitalists!

Not only is their life philosophy different than the Boomers and X’ers before them, but their medical training has been unlike any before. From the moment they entered medical school, they were taught about patient quality and safety. To them, doctors aren’t the isolated pillars of strength and sole possessors of sacred knowledge that they used to be. They intuitively get that medicine is a team sport. In fact, most of the attendings on their ward rotations have been hospitalists.

Rise of Experience

In the early days of medicine, we as physicians understood that patients might not have the best experience, but that was just part of the deal, right? It’s just not supposed to be fun to be hospitalized—and sometimes you had to go through hell to get better. Those were the days of pure, unadulterated paternalism. We did things to patients to make them get better.

In the late 1970s, Irwin Press, PhD, began to study and lecture on patient satisfaction. In 1985, he joined forces with statistician Rod Ganey, PhD, to found Press Ganey Inc.¹ Patient experience as a concept began to enter the conversation of hospital administration, especially around the one-dimensional idea that better experience could contribute to the better financial health of an organization.

During the rise of the patient safety and quality movement in the late 1990s and early 2000s, our zeal to improve care led us to begin doing many things for patients. But a collateral idea began to rise in importance, too—the idea that a patient’s experience was critical to improving quality, not just a tool to attract more patients.

The entire national quality infrastructure I described in my last column (CMS, JCAHO, AHRQ, NQF) began to work on adding experience to the suite of measurements being developed. In 2006, CMS introduced the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. This was a set of questions designed to be used at all hospitals nationwide, a significant development, because there was now a national standard for patient experience that could be compared over time and across hospitals anywhere in the country.²

In 2007, all hospitals subject to the Inpatient Prospective Payment System—pretty much all hospitals except critical access hospitals—were required to submit their HCAHPS survey data or face up to a 2% penalty. In 2008, this experience data was released publicly for the first time.²

And, of course, the Patient Protection and Affordable Care Act of 2010 (ACA) included HCAHPS results in calculating Hospital Value-Based Purchasing payments.³

The Institute of Medicine, in laying out a vision for better healthcare in 2012, called for more involvement of patients and families.

We are even seeing organizations creating leadership positions solely focused on patient experience. The Cleveland Clinic created the first physician leadership position dedicated to patient experience in the country, appointing Bridget Duffy, MD, a hospitalist, as its first chief experience officer in 2010. In 2012, Sound Physicians became the first hospitalist company to create such a position, to which it appointed Mark Rudolph, MD. Who would have imagined this 10 years ago?

Life for hospitalists has changed dramatically from the early 1990s to the Millenials now entering our workforce. The forces guiding our work and stimulating our growth have evolved, but the overarching theme of the last twenty years has been improvement. When the medical world took a cold hard look at the care being delivered, we suddenly saw a world of opportunities for improvement.

I talked before about how the rise of the patient safety and quality movement coincided perfectly with the emergence of hospitalists. Here I told you about how patient experience emerged in prominence as we, collectively, in becoming aware of our quality deficits, gained newfound empathy for what patients were going through. This focus on patient experience again plays into our strength and the opportunity we have as a specialty.

In the December issue of The Hospitalist, the final column in this five-part series will examine how to put it all together as we move toward the future of the field. But first I’ll introduce one last factor, a problem that helped launch our field and is now the greatest threat to our success.

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

References

1. Press Ganey Associates, Inc. A spark ignited nearly three decades ago. Available at: http://www.pressganey.com/aboutUs/ourHistory.aspx. Accessed August 31, 2014.
2. Centers for Medicare and Medicaid Services. HCAHPS Fact Sheet. Available at: www.hcahpsonline.org. Accessed August 31, 2014.
3. American Hospital Association. Inpatient PPS. Available at: http://www.aha.org/advocacy-issues/medicare/ipps/index.shtml. Accessed August 31, 2014.

“People don’t always remember what you say or even what you do, but they always remember how you made them feel.”—Maya Angelou

When SHM surveyed its members last year about why they had attended the annual meeting, the single most common response was to “be part of the hospital medicine movement.”

In the first three of my presidential columns, I talked about what that meant for the first 15 years of our specialty. HM’s rise occurred in the mid 1990s, during a time of despair in medicine, when pressures from rising costs and the new managed care industry upended the usual way of doing things, and then, around the turn of the century, amid a growing awareness that the care we had been delivering was wildly variable in quality—and often unsafe. Our field, created by members of the Baby Boomer generation, ultimately proved highly attractive to Generation X’ers, and our growth was accelerated by this new supply of young doctors. Fueled by the influx of dollars and attention brought on by the patient safety and quality movement, HM became the fastest growing medical specialty in history.

So, now we know what being part of the hospitalist movement meant before, but what does it mean today? Are the issues and drivers the same? I left my last column in 2006, with the partnership between the Institute for Healthcare Improvement (IHI), SHM, and six other key organizations to create the 5 Million Lives Campaign. It was an important year in several other ways, as what it meant to be a hospitalist began to change.

Enter the Millenials

In 2006 a new generation, the Millenials, born between 1985 and 2000, began entering medical schools across the country. This group, raised on a diet of positive reinforcement and cooperation, is characterized by confidence and a desire to work in teams. Born after the introduction of the Macintosh computer, Millenials are not just tech savvy; they have grown up in the world of social media and are digital media savvy. Even more than Gen X, Millenials strive for work-life balance. It almost seems this was a generation born and raised to be hospitalists!

Not only is their life philosophy different than the Boomers and X’ers before them, but their medical training has been unlike any before. From the moment they entered medical school, they were taught about patient quality and safety. To them, doctors aren’t the isolated pillars of strength and sole possessors of sacred knowledge that they used to be. They intuitively get that medicine is a team sport. In fact, most of the attendings on their ward rotations have been hospitalists.

Rise of Experience

In the early days of medicine, we as physicians understood that patients might not have the best experience, but that was just part of the deal, right? It’s just not supposed to be fun to be hospitalized—and sometimes you had to go through hell to get better. Those were the days of pure, unadulterated paternalism. We did things to patients to make them get better.

In the late 1970s, Irwin Press, PhD, began to study and lecture on patient satisfaction. In 1985, he joined forces with statistician Rod Ganey, PhD, to found Press Ganey Inc.¹ Patient experience as a concept began to enter the conversation of hospital administration, especially around the one-dimensional idea that better experience could contribute to the better financial health of an organization.

During the rise of the patient safety and quality movement in the late 1990s and early 2000s, our zeal to improve care led us to begin doing many things for patients. But a collateral idea began to rise in importance, too—the idea that a patient’s experience was critical to improving quality, not just a tool to attract more patients.

The entire national quality infrastructure I described in my last column (CMS, JCAHO, AHRQ, NQF) began to work on adding experience to the suite of measurements being developed. In 2006, CMS introduced the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. This was a set of questions designed to be used at all hospitals nationwide, a significant development, because there was now a national standard for patient experience that could be compared over time and across hospitals anywhere in the country.²

In 2007, all hospitals subject to the Inpatient Prospective Payment System—pretty much all hospitals except critical access hospitals—were required to submit their HCAHPS survey data or face up to a 2% penalty. In 2008, this experience data was released publicly for the first time.²

And, of course, the Patient Protection and Affordable Care Act of 2010 (ACA) included HCAHPS results in calculating Hospital Value-Based Purchasing payments.³

The Institute of Medicine, in laying out a vision for better healthcare in 2012, called for more involvement of patients and families.

We are even seeing organizations creating leadership positions solely focused on patient experience. The Cleveland Clinic created the first physician leadership position dedicated to patient experience in the country, appointing Bridget Duffy, MD, a hospitalist, as its first chief experience officer in 2010. In 2012, Sound Physicians became the first hospitalist company to create such a position, to which it appointed Mark Rudolph, MD. Who would have imagined this 10 years ago?

Life for hospitalists has changed dramatically from the early 1990s to the Millenials now entering our workforce. The forces guiding our work and stimulating our growth have evolved, but the overarching theme of the last twenty years has been improvement. When the medical world took a cold hard look at the care being delivered, we suddenly saw a world of opportunities for improvement.

I talked before about how the rise of the patient safety and quality movement coincided perfectly with the emergence of hospitalists. Here I told you about how patient experience emerged in prominence as we, collectively, in becoming aware of our quality deficits, gained newfound empathy for what patients were going through. This focus on patient experience again plays into our strength and the opportunity we have as a specialty.

In the December issue of The Hospitalist, the final column in this five-part series will examine how to put it all together as we move toward the future of the field. But first I’ll introduce one last factor, a problem that helped launch our field and is now the greatest threat to our success.

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

References

1. Press Ganey Associates, Inc. A spark ignited nearly three decades ago. Available at: http://www.pressganey.com/aboutUs/ourHistory.aspx. Accessed August 31, 2014.
2. Centers for Medicare and Medicaid Services. HCAHPS Fact Sheet. Available at: www.hcahpsonline.org. Accessed August 31, 2014.
3. American Hospital Association. Inpatient PPS. Available at: http://www.aha.org/advocacy-issues/medicare/ipps/index.shtml. Accessed August 31, 2014.

One of the toughest jobs of group management is teasing out the trends that will define HM in the future. In the past few years, hospitalist leaders have tried to forecast whether the growth in compensation would slow or even recede. Instead, median compensation nationwide climbed 17.7% between 2010 and 2014, telling

Dr. Landis that a specialty barely 20 years old still has room to grow.

“There’s a lot at stake here,” he says. “Our patients’ lives are at stake. A lot of our country’s resources are going into healthcare, and the hospital is a very expensive place to receive care, so we want to be delivering the best value.

“We’ve got to do a better job, The information [in the report] is there to help hospital medicine groups and hospitalists.”

IPC’s Taylor adds that trying to understand trends begins with noticing shifts before they become industry standards. He’s tracking two of those right now.

“We’re now seeing hospital stipends starting to be examined by the hospitals,” he says, noting that healthcare executives are asking if this is “a rational amount of money to be paying to support a program?

“We’re [also] starting to see a reversal in the trend of hospitals employing their own hospitalists, which gained quite a bit of steam about five years ago, but it seemed to start running out of steam. Now, from what we are seeing in the marketplace, it appears to be tipping back the other way, particularly with hospitals that have done the math, and they’re beginning to outsource.”

Whether those early warning signs become full-blown trends or not, Taylor says the best management approach is to measure as much information as possible moving forward. Having the SOHM’s baseline every other year is another piece of that information pie.

“It’s interesting data, but I think it’s going to be more interesting to me to see how that data looks three to four years from now, [to understand] if the trends we see or we believe we see beginning, continue,” he adds. “It will be interesting to see the impact of those two forces on the data.”—RQ

One of the toughest jobs of group management is teasing out the trends that will define HM in the future. In the past few years, hospitalist leaders have tried to forecast whether the growth in compensation would slow or even recede. Instead, median compensation nationwide climbed 17.7% between 2010 and 2014, telling

Dr. Landis that a specialty barely 20 years old still has room to grow.

“There’s a lot at stake here,” he says. “Our patients’ lives are at stake. A lot of our country’s resources are going into healthcare, and the hospital is a very expensive place to receive care, so we want to be delivering the best value.

“We’ve got to do a better job, The information [in the report] is there to help hospital medicine groups and hospitalists.”

IPC’s Taylor adds that trying to understand trends begins with noticing shifts before they become industry standards. He’s tracking two of those right now.

“We’re now seeing hospital stipends starting to be examined by the hospitals,” he says, noting that healthcare executives are asking if this is “a rational amount of money to be paying to support a program?

“We’re [also] starting to see a reversal in the trend of hospitals employing their own hospitalists, which gained quite a bit of steam about five years ago, but it seemed to start running out of steam. Now, from what we are seeing in the marketplace, it appears to be tipping back the other way, particularly with hospitals that have done the math, and they’re beginning to outsource.”

Whether those early warning signs become full-blown trends or not, Taylor says the best management approach is to measure as much information as possible moving forward. Having the SOHM’s baseline every other year is another piece of that information pie.

“It’s interesting data, but I think it’s going to be more interesting to me to see how that data looks three to four years from now, [to understand] if the trends we see or we believe we see beginning, continue,” he adds. “It will be interesting to see the impact of those two forces on the data.”—RQ

One of the toughest jobs of group management is teasing out the trends that will define HM in the future. In the past few years, hospitalist leaders have tried to forecast whether the growth in compensation would slow or even recede. Instead, median compensation nationwide climbed 17.7% between 2010 and 2014, telling

Dr. Landis that a specialty barely 20 years old still has room to grow.

“There’s a lot at stake here,” he says. “Our patients’ lives are at stake. A lot of our country’s resources are going into healthcare, and the hospital is a very expensive place to receive care, so we want to be delivering the best value.

“We’ve got to do a better job, The information [in the report] is there to help hospital medicine groups and hospitalists.”

IPC’s Taylor adds that trying to understand trends begins with noticing shifts before they become industry standards. He’s tracking two of those right now.

“We’re now seeing hospital stipends starting to be examined by the hospitals,” he says, noting that healthcare executives are asking if this is “a rational amount of money to be paying to support a program?

“We’re [also] starting to see a reversal in the trend of hospitals employing their own hospitalists, which gained quite a bit of steam about five years ago, but it seemed to start running out of steam. Now, from what we are seeing in the marketplace, it appears to be tipping back the other way, particularly with hospitals that have done the math, and they’re beginning to outsource.”

Whether those early warning signs become full-blown trends or not, Taylor says the best management approach is to measure as much information as possible moving forward. Having the SOHM’s baseline every other year is another piece of that information pie.

“It’s interesting data, but I think it’s going to be more interesting to me to see how that data looks three to four years from now, [to understand] if the trends we see or we believe we see beginning, continue,” he adds. “It will be interesting to see the impact of those two forces on the data.”—RQ

EDITOR’S NOTE: First in a series of reviews of the “Hospital Medicine: Current Concepts” series by members of Team Hospitalist.

According to the Advisory Board projections of inpatient service line volume through 2017, most service lines will experience a decrease. Those that are projected to increase include neurosurgery, vascular surgery, orthopedic surgery, and general surgery. It seems clear that the need for hospital medicine to engage in the care of the surgical patient is sure to grow.

That makes the publication of this book so prescient. As one in a series titled Hospital Medicine: Current Concepts, edited by Scott Flanders, MD, MHM, and Sanjay Saint, MD, MPH, this is a valuable contribution to hospitalist leaders, policymakers, and anyone routinely caring for the peri-operative patient.

Part one focuses on systems of care. The authors articulate the essential elements of developing a consultation service, a clinic, and a co-management program. Eric Siegal, MD, FHM, authors the second chapter, clearly delineating the important differences between a co-management program and a consultation program. He provides the reader with pearls as well as potential pitfalls.

The first eight chapters of this book will have a long shelf life; they deliver sound advice on quality and practice management in the peri-operative arena. Identifying elements of a successful program, engaging key stakeholders, and managing medications are all skills a hospitalist needs and will not change anytime soon. Anyone planning to build a consultation or co-management service will be well served by the guidance in part one.

The next three parts explore the assessment and management of various risks, post-operative care, and post-operative conditions. Although written by a veritable who’s who of hospital medicine and peri-operative medicine giants, some parts of these sections fall prey to the rapidly changing world of clinical care. For example, Chapter 9 provides a great review of the history of developing cardiac risk assessment tools for the patient undergoing noncardiac surgery. The chapter also reviews strategies to mitigate risk; however, it falls short by failing to discuss the Gupta risk score, which was developed over 200,000 cases, compared with about 4,000 for the revised cardiac risk index. That omission is likely a result of publication timing. Although the chapter does not call out the recent implications of scientific misconduct related to the Dutch peri-operative beta blocker trials, the authors’ conclusions on the use of beta blockers remains appropriate and could have been more timely if it had included a recent meta-analysis omitting the Dutch data.

Similarly, Chapter 10 provides an excellent review of the etiology and burden of peri-operative pulmonary complications. Relatively recent literature that updates previous guidelines, indicating the benefits of respiratory muscle training, is included; however, the recently completed IMPROVE trial was likely published too late for inclusion in this chapter. Thus the benefits of a low tidal volume/lung protective strategy in those at intermediate to high risk could be missed. Still, the clinical foundation provided by the chapters in parts two through four fill the void most of us experienced in training—namely, not learning how to care for the peri-operative patient.

Special sections on the bariatric and neurosurgical patient will be welcomed by those of us never trained in the care of such conditions.

Key Takeaways

As hospitalists become increasingly important in the care of surgical patients, this book will provide an excellent foundation for critical peri-operative concepts and tools.

The authors include specific recommendations that will help in the management of almost every surgical patient encountered. For example, the anticoagulation and glycemic control strategies are well written, as well as easy to understand and apply.

If you are a hospitalist group leader, this is a must read that will help define quality, scope of practice, and practice management issues we all struggle with.

Dr. Fitterman is vice chair of hospital medicine in the department of medicine North Shore-LIJ Health System and assistant professor of medicine at Hofstra North Shore-LIJ School of Medicine.

EDITOR’S NOTE: First in a series of reviews of the “Hospital Medicine: Current Concepts” series by members of Team Hospitalist.

According to the Advisory Board projections of inpatient service line volume through 2017, most service lines will experience a decrease. Those that are projected to increase include neurosurgery, vascular surgery, orthopedic surgery, and general surgery. It seems clear that the need for hospital medicine to engage in the care of the surgical patient is sure to grow.

That makes the publication of this book so prescient. As one in a series titled Hospital Medicine: Current Concepts, edited by Scott Flanders, MD, MHM, and Sanjay Saint, MD, MPH, this is a valuable contribution to hospitalist leaders, policymakers, and anyone routinely caring for the peri-operative patient.

Part one focuses on systems of care. The authors articulate the essential elements of developing a consultation service, a clinic, and a co-management program. Eric Siegal, MD, FHM, authors the second chapter, clearly delineating the important differences between a co-management program and a consultation program. He provides the reader with pearls as well as potential pitfalls.

The first eight chapters of this book will have a long shelf life; they deliver sound advice on quality and practice management in the peri-operative arena. Identifying elements of a successful program, engaging key stakeholders, and managing medications are all skills a hospitalist needs and will not change anytime soon. Anyone planning to build a consultation or co-management service will be well served by the guidance in part one.

The next three parts explore the assessment and management of various risks, post-operative care, and post-operative conditions. Although written by a veritable who’s who of hospital medicine and peri-operative medicine giants, some parts of these sections fall prey to the rapidly changing world of clinical care. For example, Chapter 9 provides a great review of the history of developing cardiac risk assessment tools for the patient undergoing noncardiac surgery. The chapter also reviews strategies to mitigate risk; however, it falls short by failing to discuss the Gupta risk score, which was developed over 200,000 cases, compared with about 4,000 for the revised cardiac risk index. That omission is likely a result of publication timing. Although the chapter does not call out the recent implications of scientific misconduct related to the Dutch peri-operative beta blocker trials, the authors’ conclusions on the use of beta blockers remains appropriate and could have been more timely if it had included a recent meta-analysis omitting the Dutch data.

Similarly, Chapter 10 provides an excellent review of the etiology and burden of peri-operative pulmonary complications. Relatively recent literature that updates previous guidelines, indicating the benefits of respiratory muscle training, is included; however, the recently completed IMPROVE trial was likely published too late for inclusion in this chapter. Thus the benefits of a low tidal volume/lung protective strategy in those at intermediate to high risk could be missed. Still, the clinical foundation provided by the chapters in parts two through four fill the void most of us experienced in training—namely, not learning how to care for the peri-operative patient.

Special sections on the bariatric and neurosurgical patient will be welcomed by those of us never trained in the care of such conditions.

Key Takeaways

As hospitalists become increasingly important in the care of surgical patients, this book will provide an excellent foundation for critical peri-operative concepts and tools.

The authors include specific recommendations that will help in the management of almost every surgical patient encountered. For example, the anticoagulation and glycemic control strategies are well written, as well as easy to understand and apply.

If you are a hospitalist group leader, this is a must read that will help define quality, scope of practice, and practice management issues we all struggle with.

Dr. Fitterman is vice chair of hospital medicine in the department of medicine North Shore-LIJ Health System and assistant professor of medicine at Hofstra North Shore-LIJ School of Medicine.

EDITOR’S NOTE: First in a series of reviews of the “Hospital Medicine: Current Concepts” series by members of Team Hospitalist.

According to the Advisory Board projections of inpatient service line volume through 2017, most service lines will experience a decrease. Those that are projected to increase include neurosurgery, vascular surgery, orthopedic surgery, and general surgery. It seems clear that the need for hospital medicine to engage in the care of the surgical patient is sure to grow.

That makes the publication of this book so prescient. As one in a series titled Hospital Medicine: Current Concepts, edited by Scott Flanders, MD, MHM, and Sanjay Saint, MD, MPH, this is a valuable contribution to hospitalist leaders, policymakers, and anyone routinely caring for the peri-operative patient.

Part one focuses on systems of care. The authors articulate the essential elements of developing a consultation service, a clinic, and a co-management program. Eric Siegal, MD, FHM, authors the second chapter, clearly delineating the important differences between a co-management program and a consultation program. He provides the reader with pearls as well as potential pitfalls.

The first eight chapters of this book will have a long shelf life; they deliver sound advice on quality and practice management in the peri-operative arena. Identifying elements of a successful program, engaging key stakeholders, and managing medications are all skills a hospitalist needs and will not change anytime soon. Anyone planning to build a consultation or co-management service will be well served by the guidance in part one.

The next three parts explore the assessment and management of various risks, post-operative care, and post-operative conditions. Although written by a veritable who’s who of hospital medicine and peri-operative medicine giants, some parts of these sections fall prey to the rapidly changing world of clinical care. For example, Chapter 9 provides a great review of the history of developing cardiac risk assessment tools for the patient undergoing noncardiac surgery. The chapter also reviews strategies to mitigate risk; however, it falls short by failing to discuss the Gupta risk score, which was developed over 200,000 cases, compared with about 4,000 for the revised cardiac risk index. That omission is likely a result of publication timing. Although the chapter does not call out the recent implications of scientific misconduct related to the Dutch peri-operative beta blocker trials, the authors’ conclusions on the use of beta blockers remains appropriate and could have been more timely if it had included a recent meta-analysis omitting the Dutch data.

Similarly, Chapter 10 provides an excellent review of the etiology and burden of peri-operative pulmonary complications. Relatively recent literature that updates previous guidelines, indicating the benefits of respiratory muscle training, is included; however, the recently completed IMPROVE trial was likely published too late for inclusion in this chapter. Thus the benefits of a low tidal volume/lung protective strategy in those at intermediate to high risk could be missed. Still, the clinical foundation provided by the chapters in parts two through four fill the void most of us experienced in training—namely, not learning how to care for the peri-operative patient.

Special sections on the bariatric and neurosurgical patient will be welcomed by those of us never trained in the care of such conditions.

Key Takeaways

As hospitalists become increasingly important in the care of surgical patients, this book will provide an excellent foundation for critical peri-operative concepts and tools.

The authors include specific recommendations that will help in the management of almost every surgical patient encountered. For example, the anticoagulation and glycemic control strategies are well written, as well as easy to understand and apply.

If you are a hospitalist group leader, this is a must read that will help define quality, scope of practice, and practice management issues we all struggle with.

Dr. Fitterman is vice chair of hospital medicine in the department of medicine North Shore-LIJ Health System and assistant professor of medicine at Hofstra North Shore-LIJ School of Medicine.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.