In This Edition

Literature At A Glance

A guide to this month’s studies

1. Facecards improve familiarity with physician names, not satisfaction
2. Pre-operative beta-blockers may benefit some cardiac patients
3. Benefit of therapeutic hypothermia after cardiac arrest unclear
4. Patients prefer inpatient boarding to ED boarding
5. Triple rule outs for chest pain
6. Colloids vs. crystalloids for critically ill patients presenting with hypovolemic shock
7. Interdisciplinary intervention improves medication compliance, not blood pressure or LDL-C levels
8. Edoxaban is noninferior to warfarin in Afib patients
9. Beta blockers lower mortality after acute MI in COPD patients
10. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction

Facecards Improve Familiarity with Physician Names but Not Satisfaction

Clinical question: Do facecards improve patients’ familiarity with physicians and increase satisfaction, trust, and agreement with physicians?

Background: Facecards can improve patients’ knowledge of names and roles of physicians, but their impact on other outcomes is unclear. This pilot trial was designed to assess facecards’ impact on patient satisfaction, trust, or agreement with physicians.

Study design: Cluster, randomized controlled trial (RCT).

Setting: A large teaching hospital in the United States.

Synopsis: Patients (n=138) were randomized to receive either facecards with the name and picture of their hospitalists, as well as a brief description of the hospitalist’s role (n=66), or to receive traditional communication (n=72). There were no significant differences in patient age, sex, or race.

Patients who received a facecard were more likely to correctly identify their hospital physician (89.1% vs. 51.1%; P< 0.01) and were more likely to correctly identify the role of their hospital physician than those in the control group (67.4% vs. 16.3%; P<0.01).

Patients who received a facecard rated satisfaction, trust, and agreement slightly higher compared with those who had not received a card, but the results were not statistically significant (P values 0.27, 0.32, 0.37, respectively.) The authors note that larger studies may be needed to see a difference in these areas.

Bottom line: Facecards improve patients’ knowledge of the names and roles of hospital physicians but have no clear impact on satisfaction with, trust of, or agreement with physicians.

Citation: Simons Y, Caprio T, Furiasse N, Kriss, M, Williams MV, O’Leary KJ. The impact of facecards on patients’ knowledge, satisfaction, trust, and agreement with hospitalist physicians: a pilot study. J Hosp Med. 2014;9(3):137-141.

Pre-Operative Beta Blockers May Benefit Some Cardiac Patients

Clinical question: In patients with ischemic heart disease (IHD) undergoing non-cardiac surgery, do pre-operative beta blockers reduce post-operative major cardiovascular events (MACE) or mortality at 30 days?

Background: Peri-operative beta blocker use has become more restricted, as evidence about which patients derive benefit has become clearer. Opinions and practice vary regarding whether all patients with IHD, or only certain populations within this group, benefit from peri-operative beta blockers.

Study design: Retrospective, national registry-based cohort study.

Setting: Denmark, 2004-2009.

Synopsis: No benefit was found for the overall cohort of 28,263 patients. Patients with IHD and heart failure (n=7990) had lower risk of MACE (HR=0.75, 95% CI, 0.70-0.87) and mortality (HR=0.80, 95% CI, 0.70-0.92). Patients with IHD and myocardial infarction within two years (n=1664) had lower risk of MACE (HR=0.54, 95% CI, 0.37-0.78) but not mortality.

Beta blocker dose and compliance were unknown. Whether patients had symptoms or inducible ischemia was not clear.

This study supports the concept that higher-risk patients benefit more from peri-operative beta blockers, but it is not high-grade evidence.

Bottom line: Not all patients with IHD benefit from pre-operative beta blockers; those with concomitant heart failure or recent MI have a lower risk of MACE and/or mortality at 30 days with beta blockers.

Citation: Andersson C, Merie C, Jorgensen M, et al. Association of ß-blocker therapy with risks of adverse cardiovascular events and deaths in patients with ischemic heart disease undergoing non-cardiac surgery: a Danish nationwide cohort study. JAMA Intern Med. 2014;174(3):336-344.

Benefit of Therapeutic Hypothermia after Cardiac Arrest Unclear

Clinical question: Does targeted hypothermia (33°C) after cardiac arrest confer benefits compared with targeted temperature management at 36°C?

Background: Therapeutic hypothermia is a current recommendation in resuscitation guidelines after cardiac arrest. Fever develops in many patients after arrest, and it is unclear if the treatment benefit is due to hypothermia or due to the prevention of fever.

Study design: RCT.

Setting: ICUs in Europe and Australia.

Synopsis: The study authors randomized 950 patients who experienced out-of-hospital cardiac arrest to targeted temperature management at either 36°C or 33°C. The goal of this trial was to prevent fever in both groups during the first 36 hours after cardiac arrest. No statistically significant difference in outcomes between these two approaches was found. In the 33°C group, 54% died or had poor neurologic function, compared with 52% in the 36°C group (risk ratio 1.02; 95% CI 0.88 to 1.16; P=0.78).

Given the wide confidence interval, a trial with either more participants or more events might be able to determine whether a true difference in these management approaches exists.

Bottom line: Therapeutic hypothermia at 33°C after out-of-hospital cardiac arrest did not confer a benefit compared with targeted temperature management at 36°C.

Citation: Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369(23):2197-2206.

Patients Prefer Inpatient Boarding to Emergency Department Boarding

Clinical question: Do patients who experience overcrowding and long waits in the emergency department (ED) prefer boarding within ED hallways or within inpatient medical unit hallways?

Background: Boarding of admitted patients in EDs can be problematic, especially with regard to patient safety and patient satisfaction. Patient satisfaction data comparing boarding in the ED versus boarding in an inpatient unit hallway is limited.

Study design: Post-discharge, structured, telephone satisfaction survey.

Setting: Suburban, university-based teaching hospital.

Synopsis: A group of patients who experienced hallway boarding in the ED and then hallway boarding on the inpatient medical unit were identified. They were contacted by phone and asked to take a survey on their experience; 105 of 110 patients identified agreed. Patients were asked to rate their location preference with regard to various aspects of care. A five-point Likert scale consisting of the following answers was used: ED hallway much better, ED hallway better, no preference, inpatient hallway better, and inpatient hallway much better.

The inpatient hallway was the overall preferred location in 85% of respondents. Respondents preferred inpatient boarding with regard to multiple other parameters: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED.

Patient demographics in this hospital may differ from other settings and should be considered when applying the results. With Hospital Consumer Assessment of Healthcare Providers and Systems scores and ED throughput being publicly reported, further studies in this area would be valuable.

Bottom line: In a post-discharge telephone survey, patients preferred boarding in inpatient unit hallways rather than boarding in the ED.

Citation: Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013;45(6):942-946.

“Triple Rule Outs” for Chest Pain: A Tool to Evaluate the Coronaries but Not Pulmonary Embolism or Aortic Dissection

Clinical question: How does “triple rule out” (TRO) computed tomographic (CT) angiography compare to other imaging modalities in evaluating coronary and other life-threatening etiologies of chest pain, such as pulmonary embolism (PE) and aortic dissection?

Background: TRO CT angiography is a noninvasive technology that evaluates the coronary arteries, thoracic aorta, and pulmonary vasculature simultaneously. Comparison with other tests in the diagnosis of common clinical conditions is useful information for clinical practice.

Study design: Systematic review and meta-analysis.

Setting: Systematic review of 11 studies (one randomized, 10 observational).

Synopsis: Using an enrolled population of 3,539 patients, TRO CT was compared to other imaging modalities on the basis of image quality, diagnostic accuracy, radiation, and contrast volume. When TRO CT was compared to dedicated CT scans, no significant imaging difference was discovered. TRO CT detected CAD with a sensitivity of 94.3% (95% CI, 89.1% to 97.5%, I2=58.2%) and specificity of 97.4% (95% CI, 96.1% to 98.5%, I2=91.2%).

An insufficient number of patients with PE or aortic dissection were studied to generate diagnostic accuracy for these conditions. TRO CT involved greater radiation exposure and contrast exposure than non-TRO CT.

This study reports high accuracy of TRO CT in the diagnosis of coronary artery disease. Due to the low prevalence of patients with PE or aortic dissection (<1%), the data cannot be extrapolated to these conditions.

Bottom line: Although TRO CT is highly accurate for detecting coronary artery disease, there is insufficient data to recommend its use for the diagnosis of PE or aortic dissection.

Citation: Ayaram D, Bellolio MF, Murad MH, et al. Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis. Acad Emerg Med. 2013;20(9):861-871.

Colloids vs. Crystalloids for Critically Ill Patients Presenting with Hypovolemic Shock

Clinical question: In critically ill patients admitted to the ICU with hypovolemic shock, does the use of colloid for fluid resuscitation, compared with crystalloid, improve mortality?

Background: The current Surviving Sepsis Campaign guidelines recommend crystalloids as the preferred fluid for resuscitation of patients with hypovolemic shock; however, evidence supporting the choice of intravenous colloid vs. crystalloid solutions for management of hypovolemic shock is weak.

Study design: RCT.

Setting: International, multi-center study.

Synopsis: Researchers randomized 2,857 adult patients who were admitted to an ICU and required fluid resuscitation for acute hypovolemia to receive either crystalloids or colloids.

At 28 days, there were 359 deaths (25.4%) in the colloids group vs. 390 deaths (27.0%) in the crystalloids group (P=0.26). At 90 days, there were 434 deaths (30.7%) in the colloids group vs. 493 deaths (34.2%) in the crystalloids group (P=0.03).

Renal replacement therapy was used in 11.0% of the colloids group vs. 12.5% of the crystalloids group (P=0.19). There were more days alive without mechanical ventilation in the colloids group vs. the crystalloids group at seven days (P=0.01) and at 28 days (P=0.01), and there were more days alive without vasopressor therapy in the colloids group vs. the crystalloids group at seven days (P=0.04) and at 28 days (P=0.03).

Major limitations of the study included the use of open-labeled fluids during allocation, so the initial investigators were not blinded to the type of fluid. Moreover, the study compared two therapeutic strategies (colloid vs. crystalloids) rather than two types of molecules.

Bottom line: In ICU patients with hypovolemia requiring resuscitation, the use of colloids vs. crystalloids did not result in a significant difference in 28-day mortality; however, 90-day mortality was lower among patients receiving colloids.

Citation: Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality of critically ill patients presenting with hypovolemic shock: the CRISTAL randomization trial. JAMA. 2013;310(17):1809-1817.

Interdisciplinary Intervention Improves Medication Compliance, Not Blood Pressure or LDL-C Levels

Clinical question: Can intervention by pharmacists and physicians improve compliance to cardio-protective medications?

Background: Adherence to cardio-protective medications in the year after hospitalization for acute coronary syndrome is poor.

Study design: RCT.

Setting: Four Department of Veterans Affairs medical centers.

Synopsis: The intervention consisted of pharmacist-led medication reconciliation, patient education, pharmacist and PCP +/- cardiologist collaboration, and voice messaging. The outcome measured was the proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) >0.80 in the year after discharge, using pharmacy refill data for clopidogrel, beta blockers, statins, and ACEI/ARBs.

Two hundred forty-one patients (95.3%) completed the study. In the intervention group, 89.3% of patients were adherent vs. 73.9% in the usual care group (P=0.003). Mean PDC was higher in the intervention group (0.94 vs. 0.87; P<0.001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs. 70.7%; P=0.03), statins (93.2% vs. 71.3%; P<0.001), and ACEI/ARBs (93.1% vs. 81.7%; P=0.03), but not beta blockers (88.1% vs. 84.8%; P=0.59). There were no statistically significant differences in the proportion of patients who achieved blood pressure and LDL-C level goals.

Bottom line: An interdisciplinary, multi-faceted intervention increased medication compliance in the year after discharge for ACS but did not improve blood pressure or LDL-C levels.

Citation: Ho PM, Lambert-Kerzner A, Carey EP, et al. Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge. JAMA Intern Med. 2014;174(2):186-193.

Edoxaban Is Noninferior to Warfarin in Patients with Atrial Fibrillation

Clinical question: What is the long-term efficacy and safety of edoxaban compared with warfarin in patients with atrial fibrillation (Afib)?

Background: Edoxaban is an oral factor Xa inhibitor approved for use in Japan for the prevention of venous thromboembolism after orthopedic surgery. No specific antidote for edoxaban exists, but hemostatic agents can reverse its anticoagulation effect.

Study design: RCT.

Setting: More than 1,300 centers in 46 countries.

Synopsis: Researchers randomized 21,105 patients in a 1:1:1 ratio to receive warfarin (goal INR of 2-3), low-dose edoxaban, or high-dose edoxoban. All patients received two sets of drugs, either active warfarin with placebo edoxaban or active edoxaban (high- or low-dose) and placebo warfarin (with sham INRs drawn), and were followed for a median of 2.8 years.

The annualized rate of stroke or systemic embolic event was 1.5% in the warfarin group, compared with 1.18% in the high-dose edoxaban group (hazard ratio 0.79; P<0.001) and 1.61% in the low-dose edoxaban group (hazard ratio 1.07; P=0.005). Annualized rate of major bleeding was 3.43% with warfarin, 2.75% with high-dose edoxoban (hazard ratio 0.80; P<0.001), and 1.61% with low-dose edoxaban (hazard ratio 0.47; P<0.001).

Both edoxaban regimens were noninferior to warfarin for the prevention of stroke or systemic emboli. The rates of cardiovascular events, bleeding, or death from any cause was lower with both doses of edoxaban as compared with warfarin.

Bottom line: Once-daily edoxaban is noninferior to warfarin for the prevention of stroke or systemic emboli and is associated with lower rates of bleeding and death.

Citation: Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. New Engl J Med. 2013;369(22):2093-2104.

Beta Blockers Lower Mortality after Acute Myocardial Infarction in COPD Patients

Clinical question: Does the use and timing of beta blockers in COPD patients experiencing a first myocardial infarction (MI) affect survival after the event?

Background: Beta blockers are effective in reducing mortality and reinfarction after an MI; however, concerns regarding the side effects of beta blockers, such as bronchospasm, continue to limit their use in patients with COPD.

Study design: Population-based cohort study.

Setting: The Myocardial Ischemia National Audit Project, linked to the General Practice Research Database, in the United Kingdom.

Synopsis: Researchers identified 1,063 patients over the age of 18 with COPD admitted to the hospital with a first acute MI. Use of beta blockers during hospitalization was associated with increased overall and one-year survival. Initiation of beta blockers during an MI had a mortality-adjusted hazard ratio of 0.50 (95% CI 0.36 to 0.69; P<0.001; median follow-up time=2.9 years).

Patients already on beta blockers prior to the MI had overall survival-adjusted hazard ratio of 0.59 (95% CI 0.44 to 0.79; P<0.001). Both scenarios showed survival benefits compared to COPD patients who were not prescribed beta blockers. Patients given beta blockers with COPD either during the MI hospitalization or before the event were younger and had fewer comorbidities. This may have accounted for some of the survival bias.

Bottom line: The use of beta blockers in patients with COPD started prior to, or at the time of, hospital admission for a first MI is associated with improved survival.

Citation: Quint JK, Herret E, Bhaskaran K, et al. Effect of ß blockers on mortality after myocardial infarction in adults with COPD: population-based cohort study of UK electronic healthcare records. BMJ. 2013;347:f6650.

Neither Low-Dose Dopamine nor Low-Dose Nesiritide Improves Renal Dysfunction in Acute Heart Failure Patients

Clinical question: Does low-dose dopamine or low-dose nesiritide added to diuretic therapy enhance pulmonary volume reduction and preserve renal function in patients with acute heart failure and renal dysfunction, compared to placebo?

Background: Small studies have suggested that low-dose dopamine or low-dose nesiritide may be beneficial in enhancing decongestion and improving renal dysfunction; however, there is ambiguity in overall benefit. Some observational studies suggest that dopamine and nesiritide are associated with higher length of stay, higher costs, and greater mortality.

Study Design: RCT.

Setting: Twenty-six hospital sites in the U.S. and Canada.

Synopsis: Three hundred sixty patients with acute heart failure and renal dysfunction were randomized to receive either nesiritide or dopamine within 24 hours of admission. Within each of these arms, patients were then randomized, in a double-blinded 2:1 fashion, into active treatment versus placebo groups. Treatment groups were compared to the pooled placebo groups.

Two main endpoints were urine output and change in serum cystatin C, from enrollment to 72 hours. Compared with placebo, low-dose dopamine had no significant effect on urine output or serum cystatin C level. Similarly, low-dose nesiritide had no significant effect on 72-hour urine output or serum cystatin C level.

Other studies have shown these drugs to be potentially harmful. Hospitalists should use caution and carefully interpret the relevant evidence when considering their use.

Bottom line: Neither low-dose nesiritide nor low-dose dopamine improved urine output or serum cystatin C levels at 72 hours in patients with acute heart failure and renal dysfunction.

Citation: Chen HH, Anstrom KJ, Givertz MM, et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: The ROSE acute heart failure randomized trial. JAMA. 2013;310(23):2533-2543.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Facecards improve familiarity with physician names, not satisfaction
2. Pre-operative beta-blockers may benefit some cardiac patients
3. Benefit of therapeutic hypothermia after cardiac arrest unclear
4. Patients prefer inpatient boarding to ED boarding
5. Triple rule outs for chest pain
6. Colloids vs. crystalloids for critically ill patients presenting with hypovolemic shock
7. Interdisciplinary intervention improves medication compliance, not blood pressure or LDL-C levels
8. Edoxaban is noninferior to warfarin in Afib patients
9. Beta blockers lower mortality after acute MI in COPD patients
10. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction

Facecards Improve Familiarity with Physician Names but Not Satisfaction

Clinical question: Do facecards improve patients’ familiarity with physicians and increase satisfaction, trust, and agreement with physicians?

Background: Facecards can improve patients’ knowledge of names and roles of physicians, but their impact on other outcomes is unclear. This pilot trial was designed to assess facecards’ impact on patient satisfaction, trust, or agreement with physicians.

Study design: Cluster, randomized controlled trial (RCT).

Setting: A large teaching hospital in the United States.

Synopsis: Patients (n=138) were randomized to receive either facecards with the name and picture of their hospitalists, as well as a brief description of the hospitalist’s role (n=66), or to receive traditional communication (n=72). There were no significant differences in patient age, sex, or race.

Patients who received a facecard were more likely to correctly identify their hospital physician (89.1% vs. 51.1%; P< 0.01) and were more likely to correctly identify the role of their hospital physician than those in the control group (67.4% vs. 16.3%; P<0.01).

Patients who received a facecard rated satisfaction, trust, and agreement slightly higher compared with those who had not received a card, but the results were not statistically significant (P values 0.27, 0.32, 0.37, respectively.) The authors note that larger studies may be needed to see a difference in these areas.

Bottom line: Facecards improve patients’ knowledge of the names and roles of hospital physicians but have no clear impact on satisfaction with, trust of, or agreement with physicians.

Citation: Simons Y, Caprio T, Furiasse N, Kriss, M, Williams MV, O’Leary KJ. The impact of facecards on patients’ knowledge, satisfaction, trust, and agreement with hospitalist physicians: a pilot study. J Hosp Med. 2014;9(3):137-141.

Pre-Operative Beta Blockers May Benefit Some Cardiac Patients

Clinical question: In patients with ischemic heart disease (IHD) undergoing non-cardiac surgery, do pre-operative beta blockers reduce post-operative major cardiovascular events (MACE) or mortality at 30 days?

Background: Peri-operative beta blocker use has become more restricted, as evidence about which patients derive benefit has become clearer. Opinions and practice vary regarding whether all patients with IHD, or only certain populations within this group, benefit from peri-operative beta blockers.

Study design: Retrospective, national registry-based cohort study.

Setting: Denmark, 2004-2009.

Synopsis: No benefit was found for the overall cohort of 28,263 patients. Patients with IHD and heart failure (n=7990) had lower risk of MACE (HR=0.75, 95% CI, 0.70-0.87) and mortality (HR=0.80, 95% CI, 0.70-0.92). Patients with IHD and myocardial infarction within two years (n=1664) had lower risk of MACE (HR=0.54, 95% CI, 0.37-0.78) but not mortality.

Beta blocker dose and compliance were unknown. Whether patients had symptoms or inducible ischemia was not clear.

This study supports the concept that higher-risk patients benefit more from peri-operative beta blockers, but it is not high-grade evidence.

Bottom line: Not all patients with IHD benefit from pre-operative beta blockers; those with concomitant heart failure or recent MI have a lower risk of MACE and/or mortality at 30 days with beta blockers.

Citation: Andersson C, Merie C, Jorgensen M, et al. Association of ß-blocker therapy with risks of adverse cardiovascular events and deaths in patients with ischemic heart disease undergoing non-cardiac surgery: a Danish nationwide cohort study. JAMA Intern Med. 2014;174(3):336-344.

Benefit of Therapeutic Hypothermia after Cardiac Arrest Unclear

Clinical question: Does targeted hypothermia (33°C) after cardiac arrest confer benefits compared with targeted temperature management at 36°C?

Background: Therapeutic hypothermia is a current recommendation in resuscitation guidelines after cardiac arrest. Fever develops in many patients after arrest, and it is unclear if the treatment benefit is due to hypothermia or due to the prevention of fever.

Study design: RCT.

Setting: ICUs in Europe and Australia.

Synopsis: The study authors randomized 950 patients who experienced out-of-hospital cardiac arrest to targeted temperature management at either 36°C or 33°C. The goal of this trial was to prevent fever in both groups during the first 36 hours after cardiac arrest. No statistically significant difference in outcomes between these two approaches was found. In the 33°C group, 54% died or had poor neurologic function, compared with 52% in the 36°C group (risk ratio 1.02; 95% CI 0.88 to 1.16; P=0.78).

Given the wide confidence interval, a trial with either more participants or more events might be able to determine whether a true difference in these management approaches exists.

Bottom line: Therapeutic hypothermia at 33°C after out-of-hospital cardiac arrest did not confer a benefit compared with targeted temperature management at 36°C.

Citation: Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369(23):2197-2206.

Patients Prefer Inpatient Boarding to Emergency Department Boarding

Clinical question: Do patients who experience overcrowding and long waits in the emergency department (ED) prefer boarding within ED hallways or within inpatient medical unit hallways?

Background: Boarding of admitted patients in EDs can be problematic, especially with regard to patient safety and patient satisfaction. Patient satisfaction data comparing boarding in the ED versus boarding in an inpatient unit hallway is limited.

Study design: Post-discharge, structured, telephone satisfaction survey.

Setting: Suburban, university-based teaching hospital.

Synopsis: A group of patients who experienced hallway boarding in the ED and then hallway boarding on the inpatient medical unit were identified. They were contacted by phone and asked to take a survey on their experience; 105 of 110 patients identified agreed. Patients were asked to rate their location preference with regard to various aspects of care. A five-point Likert scale consisting of the following answers was used: ED hallway much better, ED hallway better, no preference, inpatient hallway better, and inpatient hallway much better.

The inpatient hallway was the overall preferred location in 85% of respondents. Respondents preferred inpatient boarding with regard to multiple other parameters: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED.

Patient demographics in this hospital may differ from other settings and should be considered when applying the results. With Hospital Consumer Assessment of Healthcare Providers and Systems scores and ED throughput being publicly reported, further studies in this area would be valuable.

Bottom line: In a post-discharge telephone survey, patients preferred boarding in inpatient unit hallways rather than boarding in the ED.

Citation: Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013;45(6):942-946.

“Triple Rule Outs” for Chest Pain: A Tool to Evaluate the Coronaries but Not Pulmonary Embolism or Aortic Dissection

Clinical question: How does “triple rule out” (TRO) computed tomographic (CT) angiography compare to other imaging modalities in evaluating coronary and other life-threatening etiologies of chest pain, such as pulmonary embolism (PE) and aortic dissection?

Background: TRO CT angiography is a noninvasive technology that evaluates the coronary arteries, thoracic aorta, and pulmonary vasculature simultaneously. Comparison with other tests in the diagnosis of common clinical conditions is useful information for clinical practice.

Study design: Systematic review and meta-analysis.

Setting: Systematic review of 11 studies (one randomized, 10 observational).

Synopsis: Using an enrolled population of 3,539 patients, TRO CT was compared to other imaging modalities on the basis of image quality, diagnostic accuracy, radiation, and contrast volume. When TRO CT was compared to dedicated CT scans, no significant imaging difference was discovered. TRO CT detected CAD with a sensitivity of 94.3% (95% CI, 89.1% to 97.5%, I2=58.2%) and specificity of 97.4% (95% CI, 96.1% to 98.5%, I2=91.2%).

An insufficient number of patients with PE or aortic dissection were studied to generate diagnostic accuracy for these conditions. TRO CT involved greater radiation exposure and contrast exposure than non-TRO CT.

This study reports high accuracy of TRO CT in the diagnosis of coronary artery disease. Due to the low prevalence of patients with PE or aortic dissection (<1%), the data cannot be extrapolated to these conditions.

Bottom line: Although TRO CT is highly accurate for detecting coronary artery disease, there is insufficient data to recommend its use for the diagnosis of PE or aortic dissection.

Citation: Ayaram D, Bellolio MF, Murad MH, et al. Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis. Acad Emerg Med. 2013;20(9):861-871.

Colloids vs. Crystalloids for Critically Ill Patients Presenting with Hypovolemic Shock

Clinical question: In critically ill patients admitted to the ICU with hypovolemic shock, does the use of colloid for fluid resuscitation, compared with crystalloid, improve mortality?

Background: The current Surviving Sepsis Campaign guidelines recommend crystalloids as the preferred fluid for resuscitation of patients with hypovolemic shock; however, evidence supporting the choice of intravenous colloid vs. crystalloid solutions for management of hypovolemic shock is weak.

Study design: RCT.

Setting: International, multi-center study.

Synopsis: Researchers randomized 2,857 adult patients who were admitted to an ICU and required fluid resuscitation for acute hypovolemia to receive either crystalloids or colloids.

At 28 days, there were 359 deaths (25.4%) in the colloids group vs. 390 deaths (27.0%) in the crystalloids group (P=0.26). At 90 days, there were 434 deaths (30.7%) in the colloids group vs. 493 deaths (34.2%) in the crystalloids group (P=0.03).

Renal replacement therapy was used in 11.0% of the colloids group vs. 12.5% of the crystalloids group (P=0.19). There were more days alive without mechanical ventilation in the colloids group vs. the crystalloids group at seven days (P=0.01) and at 28 days (P=0.01), and there were more days alive without vasopressor therapy in the colloids group vs. the crystalloids group at seven days (P=0.04) and at 28 days (P=0.03).

Major limitations of the study included the use of open-labeled fluids during allocation, so the initial investigators were not blinded to the type of fluid. Moreover, the study compared two therapeutic strategies (colloid vs. crystalloids) rather than two types of molecules.

Bottom line: In ICU patients with hypovolemia requiring resuscitation, the use of colloids vs. crystalloids did not result in a significant difference in 28-day mortality; however, 90-day mortality was lower among patients receiving colloids.

Citation: Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality of critically ill patients presenting with hypovolemic shock: the CRISTAL randomization trial. JAMA. 2013;310(17):1809-1817.

Interdisciplinary Intervention Improves Medication Compliance, Not Blood Pressure or LDL-C Levels

Clinical question: Can intervention by pharmacists and physicians improve compliance to cardio-protective medications?

Background: Adherence to cardio-protective medications in the year after hospitalization for acute coronary syndrome is poor.

Study design: RCT.

Setting: Four Department of Veterans Affairs medical centers.

Synopsis: The intervention consisted of pharmacist-led medication reconciliation, patient education, pharmacist and PCP +/- cardiologist collaboration, and voice messaging. The outcome measured was the proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) >0.80 in the year after discharge, using pharmacy refill data for clopidogrel, beta blockers, statins, and ACEI/ARBs.

Two hundred forty-one patients (95.3%) completed the study. In the intervention group, 89.3% of patients were adherent vs. 73.9% in the usual care group (P=0.003). Mean PDC was higher in the intervention group (0.94 vs. 0.87; P<0.001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs. 70.7%; P=0.03), statins (93.2% vs. 71.3%; P<0.001), and ACEI/ARBs (93.1% vs. 81.7%; P=0.03), but not beta blockers (88.1% vs. 84.8%; P=0.59). There were no statistically significant differences in the proportion of patients who achieved blood pressure and LDL-C level goals.

Bottom line: An interdisciplinary, multi-faceted intervention increased medication compliance in the year after discharge for ACS but did not improve blood pressure or LDL-C levels.

Citation: Ho PM, Lambert-Kerzner A, Carey EP, et al. Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge. JAMA Intern Med. 2014;174(2):186-193.

Edoxaban Is Noninferior to Warfarin in Patients with Atrial Fibrillation

Clinical question: What is the long-term efficacy and safety of edoxaban compared with warfarin in patients with atrial fibrillation (Afib)?

Background: Edoxaban is an oral factor Xa inhibitor approved for use in Japan for the prevention of venous thromboembolism after orthopedic surgery. No specific antidote for edoxaban exists, but hemostatic agents can reverse its anticoagulation effect.

Study design: RCT.

Setting: More than 1,300 centers in 46 countries.

Synopsis: Researchers randomized 21,105 patients in a 1:1:1 ratio to receive warfarin (goal INR of 2-3), low-dose edoxaban, or high-dose edoxoban. All patients received two sets of drugs, either active warfarin with placebo edoxaban or active edoxaban (high- or low-dose) and placebo warfarin (with sham INRs drawn), and were followed for a median of 2.8 years.

The annualized rate of stroke or systemic embolic event was 1.5% in the warfarin group, compared with 1.18% in the high-dose edoxaban group (hazard ratio 0.79; P<0.001) and 1.61% in the low-dose edoxaban group (hazard ratio 1.07; P=0.005). Annualized rate of major bleeding was 3.43% with warfarin, 2.75% with high-dose edoxoban (hazard ratio 0.80; P<0.001), and 1.61% with low-dose edoxaban (hazard ratio 0.47; P<0.001).

Both edoxaban regimens were noninferior to warfarin for the prevention of stroke or systemic emboli. The rates of cardiovascular events, bleeding, or death from any cause was lower with both doses of edoxaban as compared with warfarin.

Bottom line: Once-daily edoxaban is noninferior to warfarin for the prevention of stroke or systemic emboli and is associated with lower rates of bleeding and death.

Citation: Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. New Engl J Med. 2013;369(22):2093-2104.

Beta Blockers Lower Mortality after Acute Myocardial Infarction in COPD Patients

Clinical question: Does the use and timing of beta blockers in COPD patients experiencing a first myocardial infarction (MI) affect survival after the event?

Background: Beta blockers are effective in reducing mortality and reinfarction after an MI; however, concerns regarding the side effects of beta blockers, such as bronchospasm, continue to limit their use in patients with COPD.

Study design: Population-based cohort study.

Setting: The Myocardial Ischemia National Audit Project, linked to the General Practice Research Database, in the United Kingdom.

Synopsis: Researchers identified 1,063 patients over the age of 18 with COPD admitted to the hospital with a first acute MI. Use of beta blockers during hospitalization was associated with increased overall and one-year survival. Initiation of beta blockers during an MI had a mortality-adjusted hazard ratio of 0.50 (95% CI 0.36 to 0.69; P<0.001; median follow-up time=2.9 years).

Patients already on beta blockers prior to the MI had overall survival-adjusted hazard ratio of 0.59 (95% CI 0.44 to 0.79; P<0.001). Both scenarios showed survival benefits compared to COPD patients who were not prescribed beta blockers. Patients given beta blockers with COPD either during the MI hospitalization or before the event were younger and had fewer comorbidities. This may have accounted for some of the survival bias.

Bottom line: The use of beta blockers in patients with COPD started prior to, or at the time of, hospital admission for a first MI is associated with improved survival.

Citation: Quint JK, Herret E, Bhaskaran K, et al. Effect of ß blockers on mortality after myocardial infarction in adults with COPD: population-based cohort study of UK electronic healthcare records. BMJ. 2013;347:f6650.

Neither Low-Dose Dopamine nor Low-Dose Nesiritide Improves Renal Dysfunction in Acute Heart Failure Patients

Clinical question: Does low-dose dopamine or low-dose nesiritide added to diuretic therapy enhance pulmonary volume reduction and preserve renal function in patients with acute heart failure and renal dysfunction, compared to placebo?

Background: Small studies have suggested that low-dose dopamine or low-dose nesiritide may be beneficial in enhancing decongestion and improving renal dysfunction; however, there is ambiguity in overall benefit. Some observational studies suggest that dopamine and nesiritide are associated with higher length of stay, higher costs, and greater mortality.

Study Design: RCT.

Setting: Twenty-six hospital sites in the U.S. and Canada.

Synopsis: Three hundred sixty patients with acute heart failure and renal dysfunction were randomized to receive either nesiritide or dopamine within 24 hours of admission. Within each of these arms, patients were then randomized, in a double-blinded 2:1 fashion, into active treatment versus placebo groups. Treatment groups were compared to the pooled placebo groups.

Two main endpoints were urine output and change in serum cystatin C, from enrollment to 72 hours. Compared with placebo, low-dose dopamine had no significant effect on urine output or serum cystatin C level. Similarly, low-dose nesiritide had no significant effect on 72-hour urine output or serum cystatin C level.

Other studies have shown these drugs to be potentially harmful. Hospitalists should use caution and carefully interpret the relevant evidence when considering their use.

Bottom line: Neither low-dose nesiritide nor low-dose dopamine improved urine output or serum cystatin C levels at 72 hours in patients with acute heart failure and renal dysfunction.

Citation: Chen HH, Anstrom KJ, Givertz MM, et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: The ROSE acute heart failure randomized trial. JAMA. 2013;310(23):2533-2543.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Facecards improve familiarity with physician names, not satisfaction
2. Pre-operative beta-blockers may benefit some cardiac patients
3. Benefit of therapeutic hypothermia after cardiac arrest unclear
4. Patients prefer inpatient boarding to ED boarding
5. Triple rule outs for chest pain
6. Colloids vs. crystalloids for critically ill patients presenting with hypovolemic shock
7. Interdisciplinary intervention improves medication compliance, not blood pressure or LDL-C levels
8. Edoxaban is noninferior to warfarin in Afib patients
9. Beta blockers lower mortality after acute MI in COPD patients
10. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction

Facecards Improve Familiarity with Physician Names but Not Satisfaction

Clinical question: Do facecards improve patients’ familiarity with physicians and increase satisfaction, trust, and agreement with physicians?

Background: Facecards can improve patients’ knowledge of names and roles of physicians, but their impact on other outcomes is unclear. This pilot trial was designed to assess facecards’ impact on patient satisfaction, trust, or agreement with physicians.

Study design: Cluster, randomized controlled trial (RCT).

Setting: A large teaching hospital in the United States.

Synopsis: Patients (n=138) were randomized to receive either facecards with the name and picture of their hospitalists, as well as a brief description of the hospitalist’s role (n=66), or to receive traditional communication (n=72). There were no significant differences in patient age, sex, or race.

Patients who received a facecard were more likely to correctly identify their hospital physician (89.1% vs. 51.1%; P< 0.01) and were more likely to correctly identify the role of their hospital physician than those in the control group (67.4% vs. 16.3%; P<0.01).

Patients who received a facecard rated satisfaction, trust, and agreement slightly higher compared with those who had not received a card, but the results were not statistically significant (P values 0.27, 0.32, 0.37, respectively.) The authors note that larger studies may be needed to see a difference in these areas.

Bottom line: Facecards improve patients’ knowledge of the names and roles of hospital physicians but have no clear impact on satisfaction with, trust of, or agreement with physicians.

Citation: Simons Y, Caprio T, Furiasse N, Kriss, M, Williams MV, O’Leary KJ. The impact of facecards on patients’ knowledge, satisfaction, trust, and agreement with hospitalist physicians: a pilot study. J Hosp Med. 2014;9(3):137-141.

Pre-Operative Beta Blockers May Benefit Some Cardiac Patients

Clinical question: In patients with ischemic heart disease (IHD) undergoing non-cardiac surgery, do pre-operative beta blockers reduce post-operative major cardiovascular events (MACE) or mortality at 30 days?

Background: Peri-operative beta blocker use has become more restricted, as evidence about which patients derive benefit has become clearer. Opinions and practice vary regarding whether all patients with IHD, or only certain populations within this group, benefit from peri-operative beta blockers.

Study design: Retrospective, national registry-based cohort study.

Setting: Denmark, 2004-2009.

Synopsis: No benefit was found for the overall cohort of 28,263 patients. Patients with IHD and heart failure (n=7990) had lower risk of MACE (HR=0.75, 95% CI, 0.70-0.87) and mortality (HR=0.80, 95% CI, 0.70-0.92). Patients with IHD and myocardial infarction within two years (n=1664) had lower risk of MACE (HR=0.54, 95% CI, 0.37-0.78) but not mortality.

Beta blocker dose and compliance were unknown. Whether patients had symptoms or inducible ischemia was not clear.

This study supports the concept that higher-risk patients benefit more from peri-operative beta blockers, but it is not high-grade evidence.

Bottom line: Not all patients with IHD benefit from pre-operative beta blockers; those with concomitant heart failure or recent MI have a lower risk of MACE and/or mortality at 30 days with beta blockers.

Citation: Andersson C, Merie C, Jorgensen M, et al. Association of ß-blocker therapy with risks of adverse cardiovascular events and deaths in patients with ischemic heart disease undergoing non-cardiac surgery: a Danish nationwide cohort study. JAMA Intern Med. 2014;174(3):336-344.

Benefit of Therapeutic Hypothermia after Cardiac Arrest Unclear

Clinical question: Does targeted hypothermia (33°C) after cardiac arrest confer benefits compared with targeted temperature management at 36°C?

Background: Therapeutic hypothermia is a current recommendation in resuscitation guidelines after cardiac arrest. Fever develops in many patients after arrest, and it is unclear if the treatment benefit is due to hypothermia or due to the prevention of fever.

Study design: RCT.

Setting: ICUs in Europe and Australia.

Synopsis: The study authors randomized 950 patients who experienced out-of-hospital cardiac arrest to targeted temperature management at either 36°C or 33°C. The goal of this trial was to prevent fever in both groups during the first 36 hours after cardiac arrest. No statistically significant difference in outcomes between these two approaches was found. In the 33°C group, 54% died or had poor neurologic function, compared with 52% in the 36°C group (risk ratio 1.02; 95% CI 0.88 to 1.16; P=0.78).

Given the wide confidence interval, a trial with either more participants or more events might be able to determine whether a true difference in these management approaches exists.

Bottom line: Therapeutic hypothermia at 33°C after out-of-hospital cardiac arrest did not confer a benefit compared with targeted temperature management at 36°C.

Citation: Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369(23):2197-2206.

Patients Prefer Inpatient Boarding to Emergency Department Boarding

Clinical question: Do patients who experience overcrowding and long waits in the emergency department (ED) prefer boarding within ED hallways or within inpatient medical unit hallways?

Background: Boarding of admitted patients in EDs can be problematic, especially with regard to patient safety and patient satisfaction. Patient satisfaction data comparing boarding in the ED versus boarding in an inpatient unit hallway is limited.

Study design: Post-discharge, structured, telephone satisfaction survey.

Setting: Suburban, university-based teaching hospital.

Synopsis: A group of patients who experienced hallway boarding in the ED and then hallway boarding on the inpatient medical unit were identified. They were contacted by phone and asked to take a survey on their experience; 105 of 110 patients identified agreed. Patients were asked to rate their location preference with regard to various aspects of care. A five-point Likert scale consisting of the following answers was used: ED hallway much better, ED hallway better, no preference, inpatient hallway better, and inpatient hallway much better.

The inpatient hallway was the overall preferred location in 85% of respondents. Respondents preferred inpatient boarding with regard to multiple other parameters: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED.

Patient demographics in this hospital may differ from other settings and should be considered when applying the results. With Hospital Consumer Assessment of Healthcare Providers and Systems scores and ED throughput being publicly reported, further studies in this area would be valuable.

Bottom line: In a post-discharge telephone survey, patients preferred boarding in inpatient unit hallways rather than boarding in the ED.

Citation: Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013;45(6):942-946.

“Triple Rule Outs” for Chest Pain: A Tool to Evaluate the Coronaries but Not Pulmonary Embolism or Aortic Dissection

Clinical question: How does “triple rule out” (TRO) computed tomographic (CT) angiography compare to other imaging modalities in evaluating coronary and other life-threatening etiologies of chest pain, such as pulmonary embolism (PE) and aortic dissection?

Background: TRO CT angiography is a noninvasive technology that evaluates the coronary arteries, thoracic aorta, and pulmonary vasculature simultaneously. Comparison with other tests in the diagnosis of common clinical conditions is useful information for clinical practice.

Study design: Systematic review and meta-analysis.

Setting: Systematic review of 11 studies (one randomized, 10 observational).

Synopsis: Using an enrolled population of 3,539 patients, TRO CT was compared to other imaging modalities on the basis of image quality, diagnostic accuracy, radiation, and contrast volume. When TRO CT was compared to dedicated CT scans, no significant imaging difference was discovered. TRO CT detected CAD with a sensitivity of 94.3% (95% CI, 89.1% to 97.5%, I2=58.2%) and specificity of 97.4% (95% CI, 96.1% to 98.5%, I2=91.2%).

An insufficient number of patients with PE or aortic dissection were studied to generate diagnostic accuracy for these conditions. TRO CT involved greater radiation exposure and contrast exposure than non-TRO CT.

This study reports high accuracy of TRO CT in the diagnosis of coronary artery disease. Due to the low prevalence of patients with PE or aortic dissection (<1%), the data cannot be extrapolated to these conditions.

Bottom line: Although TRO CT is highly accurate for detecting coronary artery disease, there is insufficient data to recommend its use for the diagnosis of PE or aortic dissection.

Citation: Ayaram D, Bellolio MF, Murad MH, et al. Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis. Acad Emerg Med. 2013;20(9):861-871.

Colloids vs. Crystalloids for Critically Ill Patients Presenting with Hypovolemic Shock

Clinical question: In critically ill patients admitted to the ICU with hypovolemic shock, does the use of colloid for fluid resuscitation, compared with crystalloid, improve mortality?

Background: The current Surviving Sepsis Campaign guidelines recommend crystalloids as the preferred fluid for resuscitation of patients with hypovolemic shock; however, evidence supporting the choice of intravenous colloid vs. crystalloid solutions for management of hypovolemic shock is weak.

Study design: RCT.

Setting: International, multi-center study.

Synopsis: Researchers randomized 2,857 adult patients who were admitted to an ICU and required fluid resuscitation for acute hypovolemia to receive either crystalloids or colloids.

At 28 days, there were 359 deaths (25.4%) in the colloids group vs. 390 deaths (27.0%) in the crystalloids group (P=0.26). At 90 days, there were 434 deaths (30.7%) in the colloids group vs. 493 deaths (34.2%) in the crystalloids group (P=0.03).

Renal replacement therapy was used in 11.0% of the colloids group vs. 12.5% of the crystalloids group (P=0.19). There were more days alive without mechanical ventilation in the colloids group vs. the crystalloids group at seven days (P=0.01) and at 28 days (P=0.01), and there were more days alive without vasopressor therapy in the colloids group vs. the crystalloids group at seven days (P=0.04) and at 28 days (P=0.03).

Major limitations of the study included the use of open-labeled fluids during allocation, so the initial investigators were not blinded to the type of fluid. Moreover, the study compared two therapeutic strategies (colloid vs. crystalloids) rather than two types of molecules.

Bottom line: In ICU patients with hypovolemia requiring resuscitation, the use of colloids vs. crystalloids did not result in a significant difference in 28-day mortality; however, 90-day mortality was lower among patients receiving colloids.

Citation: Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality of critically ill patients presenting with hypovolemic shock: the CRISTAL randomization trial. JAMA. 2013;310(17):1809-1817.

Interdisciplinary Intervention Improves Medication Compliance, Not Blood Pressure or LDL-C Levels

Clinical question: Can intervention by pharmacists and physicians improve compliance to cardio-protective medications?

Background: Adherence to cardio-protective medications in the year after hospitalization for acute coronary syndrome is poor.

Study design: RCT.

Setting: Four Department of Veterans Affairs medical centers.

Synopsis: The intervention consisted of pharmacist-led medication reconciliation, patient education, pharmacist and PCP +/- cardiologist collaboration, and voice messaging. The outcome measured was the proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) >0.80 in the year after discharge, using pharmacy refill data for clopidogrel, beta blockers, statins, and ACEI/ARBs.

Two hundred forty-one patients (95.3%) completed the study. In the intervention group, 89.3% of patients were adherent vs. 73.9% in the usual care group (P=0.003). Mean PDC was higher in the intervention group (0.94 vs. 0.87; P<0.001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs. 70.7%; P=0.03), statins (93.2% vs. 71.3%; P<0.001), and ACEI/ARBs (93.1% vs. 81.7%; P=0.03), but not beta blockers (88.1% vs. 84.8%; P=0.59). There were no statistically significant differences in the proportion of patients who achieved blood pressure and LDL-C level goals.

Bottom line: An interdisciplinary, multi-faceted intervention increased medication compliance in the year after discharge for ACS but did not improve blood pressure or LDL-C levels.

Citation: Ho PM, Lambert-Kerzner A, Carey EP, et al. Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge. JAMA Intern Med. 2014;174(2):186-193.

Edoxaban Is Noninferior to Warfarin in Patients with Atrial Fibrillation

Clinical question: What is the long-term efficacy and safety of edoxaban compared with warfarin in patients with atrial fibrillation (Afib)?

Background: Edoxaban is an oral factor Xa inhibitor approved for use in Japan for the prevention of venous thromboembolism after orthopedic surgery. No specific antidote for edoxaban exists, but hemostatic agents can reverse its anticoagulation effect.

Study design: RCT.

Setting: More than 1,300 centers in 46 countries.

Synopsis: Researchers randomized 21,105 patients in a 1:1:1 ratio to receive warfarin (goal INR of 2-3), low-dose edoxaban, or high-dose edoxoban. All patients received two sets of drugs, either active warfarin with placebo edoxaban or active edoxaban (high- or low-dose) and placebo warfarin (with sham INRs drawn), and were followed for a median of 2.8 years.

The annualized rate of stroke or systemic embolic event was 1.5% in the warfarin group, compared with 1.18% in the high-dose edoxaban group (hazard ratio 0.79; P<0.001) and 1.61% in the low-dose edoxaban group (hazard ratio 1.07; P=0.005). Annualized rate of major bleeding was 3.43% with warfarin, 2.75% with high-dose edoxoban (hazard ratio 0.80; P<0.001), and 1.61% with low-dose edoxaban (hazard ratio 0.47; P<0.001).

Both edoxaban regimens were noninferior to warfarin for the prevention of stroke or systemic emboli. The rates of cardiovascular events, bleeding, or death from any cause was lower with both doses of edoxaban as compared with warfarin.

Bottom line: Once-daily edoxaban is noninferior to warfarin for the prevention of stroke or systemic emboli and is associated with lower rates of bleeding and death.

Citation: Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. New Engl J Med. 2013;369(22):2093-2104.

Beta Blockers Lower Mortality after Acute Myocardial Infarction in COPD Patients

Clinical question: Does the use and timing of beta blockers in COPD patients experiencing a first myocardial infarction (MI) affect survival after the event?

Background: Beta blockers are effective in reducing mortality and reinfarction after an MI; however, concerns regarding the side effects of beta blockers, such as bronchospasm, continue to limit their use in patients with COPD.

Study design: Population-based cohort study.

Setting: The Myocardial Ischemia National Audit Project, linked to the General Practice Research Database, in the United Kingdom.

Synopsis: Researchers identified 1,063 patients over the age of 18 with COPD admitted to the hospital with a first acute MI. Use of beta blockers during hospitalization was associated with increased overall and one-year survival. Initiation of beta blockers during an MI had a mortality-adjusted hazard ratio of 0.50 (95% CI 0.36 to 0.69; P<0.001; median follow-up time=2.9 years).

Patients already on beta blockers prior to the MI had overall survival-adjusted hazard ratio of 0.59 (95% CI 0.44 to 0.79; P<0.001). Both scenarios showed survival benefits compared to COPD patients who were not prescribed beta blockers. Patients given beta blockers with COPD either during the MI hospitalization or before the event were younger and had fewer comorbidities. This may have accounted for some of the survival bias.

Bottom line: The use of beta blockers in patients with COPD started prior to, or at the time of, hospital admission for a first MI is associated with improved survival.

Citation: Quint JK, Herret E, Bhaskaran K, et al. Effect of ß blockers on mortality after myocardial infarction in adults with COPD: population-based cohort study of UK electronic healthcare records. BMJ. 2013;347:f6650.

Neither Low-Dose Dopamine nor Low-Dose Nesiritide Improves Renal Dysfunction in Acute Heart Failure Patients

Clinical question: Does low-dose dopamine or low-dose nesiritide added to diuretic therapy enhance pulmonary volume reduction and preserve renal function in patients with acute heart failure and renal dysfunction, compared to placebo?

Background: Small studies have suggested that low-dose dopamine or low-dose nesiritide may be beneficial in enhancing decongestion and improving renal dysfunction; however, there is ambiguity in overall benefit. Some observational studies suggest that dopamine and nesiritide are associated with higher length of stay, higher costs, and greater mortality.

Study Design: RCT.

Setting: Twenty-six hospital sites in the U.S. and Canada.

Synopsis: Three hundred sixty patients with acute heart failure and renal dysfunction were randomized to receive either nesiritide or dopamine within 24 hours of admission. Within each of these arms, patients were then randomized, in a double-blinded 2:1 fashion, into active treatment versus placebo groups. Treatment groups were compared to the pooled placebo groups.

Two main endpoints were urine output and change in serum cystatin C, from enrollment to 72 hours. Compared with placebo, low-dose dopamine had no significant effect on urine output or serum cystatin C level. Similarly, low-dose nesiritide had no significant effect on 72-hour urine output or serum cystatin C level.

Other studies have shown these drugs to be potentially harmful. Hospitalists should use caution and carefully interpret the relevant evidence when considering their use.

Bottom line: Neither low-dose nesiritide nor low-dose dopamine improved urine output or serum cystatin C levels at 72 hours in patients with acute heart failure and renal dysfunction.

Citation: Chen HH, Anstrom KJ, Givertz MM, et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: The ROSE acute heart failure randomized trial. JAMA. 2013;310(23):2533-2543.

The use of observation status within hospitals has risen over the last several years, creating the potential for negative financial impacts on patients and mounting headaches for hospitalists. Historically, the intent of observation status was to provide care in designated hospital units for short-stay patients with well-defined diagnoses, according to Medicare; however, as a result of complex federal policy and the realities of hospital care, patients under observation often receive care in general hospital beds, with stays that can extend past the 48-hour benchmark set by the Centers for Medicare & Medicaid Services (CMS).

Almost all hospitalists are familiar with the implications of observation status for their patients, and SHM has taken a leadership role in advocating for positive changes that benefit both the patient and hospitalist workflow.

Today, patients under observation often receive identical care to that received by inpatients but are billed as outpatients under Medicare Part B. This results in high deductibles, additional cost sharing, and out-of-pocket costs for medications. Complicating the issue more, hospitals in most states are not required to notify patients that they are coded as outpatients, leaving them with the impression that they have been admitted, until they receive their hospital bill.

In an attempt to curb the overuse of hospital observation status and clarify guidelines pertaining to inpatient admission decisions, CMS changed the rules for admitting patients in August 2013. Under what is now known as the “Two-Midnight Rule,” if a patient is expected to stay longer than two midnights and their stay is documented as medically necessary, they are an inpatient; fewer than two midnights constitutes outpatient services.

Even though the two-midnight rule is intended to simplify admission decisions, hospitalists have expressed a general apprehension regarding the impact of observation status. If a patient classified as an inpatient is discharged before two midnights, Medicare recovery auditors may deem the inpatient classification unnecessary, potentially resulting in loss of payment for medical services rendered.

For patients, the new rule does not remedy the fact that days spent under observation do not count toward the three-day inpatient stay requirement needed for skill nursing facility (SNF) post-acute care under Medicare. Consequently, thousands of patients classified under outpatient status have no choice but to pay for SNF care themselves, or forego the treatment altogether, creating possible complications in their care and delays in recovery.

Hospitalist concern over this issue has prompted SHM to rank observation status as a priority advocacy issue. Hospitalists are ideally situated to be part of a meaningful solution, and SHM’s Public Policy Committee has set out to do just that.

The first step will be to fully understand the experiences and perspectives regarding observation policy among hospitalists. SHM’s Public Policy Committee and government relations team have developed a survey for a group of randomized members. While individual anecdotal accounts are available, this is the first time the issue will be addressed on an aggregate level. Responses from survey participants will be used to frame the hospitalist perspective, help to bolster advocacy and educational efforts within SHM, and, ultimately, bring about possible policy revisions.

Hospitalists not receiving the survey can help by joining SHM’s Grassroots Network and lending their voice to the effort. To get involved, visit www.hospitalmedicine.org/advocacy.

NaDea Jeter is a member of SHM’s government relations team.

The use of observation status within hospitals has risen over the last several years, creating the potential for negative financial impacts on patients and mounting headaches for hospitalists. Historically, the intent of observation status was to provide care in designated hospital units for short-stay patients with well-defined diagnoses, according to Medicare; however, as a result of complex federal policy and the realities of hospital care, patients under observation often receive care in general hospital beds, with stays that can extend past the 48-hour benchmark set by the Centers for Medicare & Medicaid Services (CMS).

Almost all hospitalists are familiar with the implications of observation status for their patients, and SHM has taken a leadership role in advocating for positive changes that benefit both the patient and hospitalist workflow.

Today, patients under observation often receive identical care to that received by inpatients but are billed as outpatients under Medicare Part B. This results in high deductibles, additional cost sharing, and out-of-pocket costs for medications. Complicating the issue more, hospitals in most states are not required to notify patients that they are coded as outpatients, leaving them with the impression that they have been admitted, until they receive their hospital bill.

In an attempt to curb the overuse of hospital observation status and clarify guidelines pertaining to inpatient admission decisions, CMS changed the rules for admitting patients in August 2013. Under what is now known as the “Two-Midnight Rule,” if a patient is expected to stay longer than two midnights and their stay is documented as medically necessary, they are an inpatient; fewer than two midnights constitutes outpatient services.

Even though the two-midnight rule is intended to simplify admission decisions, hospitalists have expressed a general apprehension regarding the impact of observation status. If a patient classified as an inpatient is discharged before two midnights, Medicare recovery auditors may deem the inpatient classification unnecessary, potentially resulting in loss of payment for medical services rendered.

For patients, the new rule does not remedy the fact that days spent under observation do not count toward the three-day inpatient stay requirement needed for skill nursing facility (SNF) post-acute care under Medicare. Consequently, thousands of patients classified under outpatient status have no choice but to pay for SNF care themselves, or forego the treatment altogether, creating possible complications in their care and delays in recovery.

Hospitalist concern over this issue has prompted SHM to rank observation status as a priority advocacy issue. Hospitalists are ideally situated to be part of a meaningful solution, and SHM’s Public Policy Committee has set out to do just that.

The first step will be to fully understand the experiences and perspectives regarding observation policy among hospitalists. SHM’s Public Policy Committee and government relations team have developed a survey for a group of randomized members. While individual anecdotal accounts are available, this is the first time the issue will be addressed on an aggregate level. Responses from survey participants will be used to frame the hospitalist perspective, help to bolster advocacy and educational efforts within SHM, and, ultimately, bring about possible policy revisions.

Hospitalists not receiving the survey can help by joining SHM’s Grassroots Network and lending their voice to the effort. To get involved, visit www.hospitalmedicine.org/advocacy.

NaDea Jeter is a member of SHM’s government relations team.

The use of observation status within hospitals has risen over the last several years, creating the potential for negative financial impacts on patients and mounting headaches for hospitalists. Historically, the intent of observation status was to provide care in designated hospital units for short-stay patients with well-defined diagnoses, according to Medicare; however, as a result of complex federal policy and the realities of hospital care, patients under observation often receive care in general hospital beds, with stays that can extend past the 48-hour benchmark set by the Centers for Medicare & Medicaid Services (CMS).

Almost all hospitalists are familiar with the implications of observation status for their patients, and SHM has taken a leadership role in advocating for positive changes that benefit both the patient and hospitalist workflow.

Today, patients under observation often receive identical care to that received by inpatients but are billed as outpatients under Medicare Part B. This results in high deductibles, additional cost sharing, and out-of-pocket costs for medications. Complicating the issue more, hospitals in most states are not required to notify patients that they are coded as outpatients, leaving them with the impression that they have been admitted, until they receive their hospital bill.

In an attempt to curb the overuse of hospital observation status and clarify guidelines pertaining to inpatient admission decisions, CMS changed the rules for admitting patients in August 2013. Under what is now known as the “Two-Midnight Rule,” if a patient is expected to stay longer than two midnights and their stay is documented as medically necessary, they are an inpatient; fewer than two midnights constitutes outpatient services.

Even though the two-midnight rule is intended to simplify admission decisions, hospitalists have expressed a general apprehension regarding the impact of observation status. If a patient classified as an inpatient is discharged before two midnights, Medicare recovery auditors may deem the inpatient classification unnecessary, potentially resulting in loss of payment for medical services rendered.

For patients, the new rule does not remedy the fact that days spent under observation do not count toward the three-day inpatient stay requirement needed for skill nursing facility (SNF) post-acute care under Medicare. Consequently, thousands of patients classified under outpatient status have no choice but to pay for SNF care themselves, or forego the treatment altogether, creating possible complications in their care and delays in recovery.

Hospitalist concern over this issue has prompted SHM to rank observation status as a priority advocacy issue. Hospitalists are ideally situated to be part of a meaningful solution, and SHM’s Public Policy Committee has set out to do just that.

The first step will be to fully understand the experiences and perspectives regarding observation policy among hospitalists. SHM’s Public Policy Committee and government relations team have developed a survey for a group of randomized members. While individual anecdotal accounts are available, this is the first time the issue will be addressed on an aggregate level. Responses from survey participants will be used to frame the hospitalist perspective, help to bolster advocacy and educational efforts within SHM, and, ultimately, bring about possible policy revisions.

Hospitalists not receiving the survey can help by joining SHM’s Grassroots Network and lending their voice to the effort. To get involved, visit www.hospitalmedicine.org/advocacy.

NaDea Jeter is a member of SHM’s government relations team.

Former attendees will tell you that SHM’s Leadership Academy (www.hospitalmedicine.org/leadership) is one of the most intense and professionally rewarding experiences in the specialty, so now is the time to mark your calendar for the four-day session. And be sure to book extra time to soak in the Hawaiian sun while much of the rest of the country begins to cool off.

Former attendees will tell you that SHM’s Leadership Academy (www.hospitalmedicine.org/leadership) is one of the most intense and professionally rewarding experiences in the specialty, so now is the time to mark your calendar for the four-day session. And be sure to book extra time to soak in the Hawaiian sun while much of the rest of the country begins to cool off.

Former attendees will tell you that SHM’s Leadership Academy (www.hospitalmedicine.org/leadership) is one of the most intense and professionally rewarding experiences in the specialty, so now is the time to mark your calendar for the four-day session. And be sure to book extra time to soak in the Hawaiian sun while much of the rest of the country begins to cool off.

If you still haven’t registered for Pediatric Hospital Medicine 2014, now is the time to save. The early bird discount can save you up to $150 on your registration fees.

Why come to PHM 2014?

• Enjoy a learning experience customized for you, including nine different concurrent sessions and workshops across seven unique educational tracks.
• Network with pediatric hospitalists from medical institutions across the country.
• Learn from the renowned faculty, hailing from inside and outside of pediatric hospital medicine.

If you still haven’t registered for Pediatric Hospital Medicine 2014, now is the time to save. The early bird discount can save you up to $150 on your registration fees.

Why come to PHM 2014?

• Enjoy a learning experience customized for you, including nine different concurrent sessions and workshops across seven unique educational tracks.
• Network with pediatric hospitalists from medical institutions across the country.
• Learn from the renowned faculty, hailing from inside and outside of pediatric hospital medicine.

If you still haven’t registered for Pediatric Hospital Medicine 2014, now is the time to save. The early bird discount can save you up to $150 on your registration fees.

Why come to PHM 2014?

• Enjoy a learning experience customized for you, including nine different concurrent sessions and workshops across seven unique educational tracks.
• Network with pediatric hospitalists from medical institutions across the country.
• Learn from the renowned faculty, hailing from inside and outside of pediatric hospital medicine.

Quality improvement education is no longer just an elective for trainees, which is why medical educators need the best possible knowledge and tools for teaching quality and safety. SHM and the Alliance for Academic Internal Medicine (AAIM) have teamed up to present the Quality and Safety Educators Academy, to be held May 1-3 in Tempe, Ariz.

There is still time to register. For more information, visit www.hospitalmedicine.org/qsea.

Quality improvement education is no longer just an elective for trainees, which is why medical educators need the best possible knowledge and tools for teaching quality and safety. SHM and the Alliance for Academic Internal Medicine (AAIM) have teamed up to present the Quality and Safety Educators Academy, to be held May 1-3 in Tempe, Ariz.

There is still time to register. For more information, visit www.hospitalmedicine.org/qsea.

Quality improvement education is no longer just an elective for trainees, which is why medical educators need the best possible knowledge and tools for teaching quality and safety. SHM and the Alliance for Academic Internal Medicine (AAIM) have teamed up to present the Quality and Safety Educators Academy, to be held May 1-3 in Tempe, Ariz.

There is still time to register. For more information, visit www.hospitalmedicine.org/qsea.

If you weren’t able to make it to HM14 last month, you can catch up on some of the hottest topics and sessions in the hospitalist movement through On Demand Video from the meeting. HM14 On Demand (www.hospitalmedicine.org/HM14ondemand) is a great way for conference attendees to check out sessions that they missed live, revisit favorite sessions, and share the HM14 experience with colleagues throughout the year.

• Watch sessions that you missed.
• Share your experiences with colleagues.

Revisit your favorite sessions. Topics in HM14 On Demand include:

• Clinical
• Co-Management of Hospitalized Patients
• Bending the Cost Curve
• Rapid Fire Tracks
• Potpourri
• Practice Management
• Quality Improvement

If you weren’t able to make it to HM14 last month, you can catch up on some of the hottest topics and sessions in the hospitalist movement through On Demand Video from the meeting. HM14 On Demand (www.hospitalmedicine.org/HM14ondemand) is a great way for conference attendees to check out sessions that they missed live, revisit favorite sessions, and share the HM14 experience with colleagues throughout the year.

• Watch sessions that you missed.
• Share your experiences with colleagues.

Revisit your favorite sessions. Topics in HM14 On Demand include:

• Clinical
• Co-Management of Hospitalized Patients
• Bending the Cost Curve
• Rapid Fire Tracks
• Potpourri
• Practice Management
• Quality Improvement

If you weren’t able to make it to HM14 last month, you can catch up on some of the hottest topics and sessions in the hospitalist movement through On Demand Video from the meeting. HM14 On Demand (www.hospitalmedicine.org/HM14ondemand) is a great way for conference attendees to check out sessions that they missed live, revisit favorite sessions, and share the HM14 experience with colleagues throughout the year.

• Watch sessions that you missed.
• Share your experiences with colleagues.

Revisit your favorite sessions. Topics in HM14 On Demand include:

• Clinical
• Co-Management of Hospitalized Patients
• Bending the Cost Curve
• Rapid Fire Tracks
• Potpourri
• Practice Management
• Quality Improvement

Many potential Project BOOST candidate sites apply, but not all are accepted into the program. What makes for a successful application? Ask one of the founding members of Project BOOST and a current mentor, Dr. Jeffrey Greenwald.

• A strong letter of support. Qualified candidates can demonstrate that the hospital’s leadership is already behind their interest to reduce readmission rates through a program like Project BOOST.
• Demonstrate the existing support of the team. Good applications show that it’s not just a good idea to a few people. Good Project BOOST candidates can illustrate that their hospital has an “institutional prioritization for transitions of care.”
• An honest assessment on organizing change. Project BOOST has helped high-performing sites and beginners alike, but a thoughtful assessment of your site’s prior experience in organizing change and process improvement helps program leaders better understand your needs.

Apply Now Project BOOST is accepting applications now through August 30. Visit www.hospitalmedicine.org/projectboost.

Many potential Project BOOST candidate sites apply, but not all are accepted into the program. What makes for a successful application? Ask one of the founding members of Project BOOST and a current mentor, Dr. Jeffrey Greenwald.

• A strong letter of support. Qualified candidates can demonstrate that the hospital’s leadership is already behind their interest to reduce readmission rates through a program like Project BOOST.
• Demonstrate the existing support of the team. Good applications show that it’s not just a good idea to a few people. Good Project BOOST candidates can illustrate that their hospital has an “institutional prioritization for transitions of care.”
• An honest assessment on organizing change. Project BOOST has helped high-performing sites and beginners alike, but a thoughtful assessment of your site’s prior experience in organizing change and process improvement helps program leaders better understand your needs.

Apply Now Project BOOST is accepting applications now through August 30. Visit www.hospitalmedicine.org/projectboost.

Many potential Project BOOST candidate sites apply, but not all are accepted into the program. What makes for a successful application? Ask one of the founding members of Project BOOST and a current mentor, Dr. Jeffrey Greenwald.

• A strong letter of support. Qualified candidates can demonstrate that the hospital’s leadership is already behind their interest to reduce readmission rates through a program like Project BOOST.
• Demonstrate the existing support of the team. Good applications show that it’s not just a good idea to a few people. Good Project BOOST candidates can illustrate that their hospital has an “institutional prioritization for transitions of care.”
• An honest assessment on organizing change. Project BOOST has helped high-performing sites and beginners alike, but a thoughtful assessment of your site’s prior experience in organizing change and process improvement helps program leaders better understand your needs.

Apply Now Project BOOST is accepting applications now through August 30. Visit www.hospitalmedicine.org/projectboost.

Change doesn’t always come easily to hospitals, but once a catalyst comes along, one positive change can set the stage for the next one—and the one after that. At least that’s the lesson from Houston Methodist Hospital (HMH) and their work with SHM’s Project BOOST, a yearlong, mentored implementation program designed to help hospitals nationwide reduce readmission rates.

As the saying goes, every journey begins with a single step. For hospitals ready to start their journey to reduce readmissions rates and tackle other quality improvement challenges, the first step is the application to Project BOOST, which is due at the end of August. Details on the application and fees are available at www.hospitalmedicine.org/boost.

At Houston Methodist Hospital—a hospital U.S. News & World Report ranked one of “America’s Best Hospitals” in a dozen specialties and designated as a magnet hospital for excellence in nursing—taking that first step toward reducing readmissions by applying to Project BOOST has been well worth it.

“I recommend Project BOOST enthusiastically and unequivocally. If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers,” says Manasi Kekan, MD, MS, FACP, who serves as HMH’s medical director. “As a hospitalist, at times, I have found it challenging to ration my times between patient contact and documentation to meet the goals set by the healthcare industry. Being involved in BOOST and watching tangible improvements for my patients has provided me with immense personal and professional gratification!”

In fact, Dr. Kekan and her team have been so pleased with the results, both quantitative and qualitative, from their participation in Project BOOST that they enrolled twice: first in 2012 and again in 2013. She cites the program’s adaptability “that would help us develop a higher quality discharge process for our patients.”

Like many fruitful journeys, though, this one did not find Dr. Kekan and the caregivers at HMH alone: They had a guide who made all the difference.

Change implementation can be difficult, says Houston Methodist’s Janice Finder, RN, MSN. “Everyone knows how they want to design the house, so to speak,” she says, “but if you have someone who has done it before and can lead and direct, it goes much smoother.”

That was the true value of their Project BOOST mentor, Jeffrey Greenwald, MD, SFHM, one of the founding developers of Project BOOST.

“Dr. Greenwald gave us great mentorship and guidance,” Finder says. “The guidance about leadership is essential. If you do not have full support and a person who has ‘been there, done that,’ it is hard to envision.”

From his perspective, Dr. Greenwald saw that HMH had many of the critical elements in place to be successful.

“They had a good set of experiences already. They had the will and leadership and skill on the ground in process improvement,” he says, calling HMH an “incredibly well-oiled machine” with buy-in from the kind of inter-professional team that can make Project BOOST a success.

Overall, Dr. Greenwald calls HMH a “good example of a hospital that has married Project BOOST with the hospital’s existing priorities.”

Other Project BOOST sites start at different levels, in terms of basic interventions and process improvement, Dr. Greenwald explains. Many are able to address more advanced challenges, like how to implement change across broader areas in the hospital, working with leadership, addressing political issues, and improving waning interest in groups.

Dr. Greenwald’s interest in mentorship of Project BOOST sites stems from his own experiences early on—and the need for mentors in quality improvement projects.

“I wish I would have had someone like that when I got started,” says Dr. Greenwald, who tries to fill that role for others now. “Hopefully, each group moves down the path of making sure they have the right stakeholders, the right communications styles and skills in how to look at data and work with front-end staff.”

While Project BOOST focuses teams on reducing readmissions rates, Dr. Kekan has found that the skills learned from Project BOOST have created a blueprint that is applicable to many other team-based challenges in the hospital.

“We describe BOOST as a patient-centric quality initiative that mainly helps improve care transitions and encourages patients to stay informed about their health, which, in turn, helps reduce readmissions,” she says. “BOOST can be used as a framework to enhance other disease-specific discharge initiatives, like CHF [congestive heart failure] and delirium.”

Still, the core elements of reducing readmission rates and making a qualitative impact on her, her team, and the hospital resonate the most with Dr. Kekan.

“Providing a good transition plan to our patients provides satisfaction like none other.”

Brendon Shank is SHM’s associate vice president of communications.

Change doesn’t always come easily to hospitals, but once a catalyst comes along, one positive change can set the stage for the next one—and the one after that. At least that’s the lesson from Houston Methodist Hospital (HMH) and their work with SHM’s Project BOOST, a yearlong, mentored implementation program designed to help hospitals nationwide reduce readmission rates.

As the saying goes, every journey begins with a single step. For hospitals ready to start their journey to reduce readmissions rates and tackle other quality improvement challenges, the first step is the application to Project BOOST, which is due at the end of August. Details on the application and fees are available at www.hospitalmedicine.org/boost.

At Houston Methodist Hospital—a hospital U.S. News & World Report ranked one of “America’s Best Hospitals” in a dozen specialties and designated as a magnet hospital for excellence in nursing—taking that first step toward reducing readmissions by applying to Project BOOST has been well worth it.

“I recommend Project BOOST enthusiastically and unequivocally. If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers,” says Manasi Kekan, MD, MS, FACP, who serves as HMH’s medical director. “As a hospitalist, at times, I have found it challenging to ration my times between patient contact and documentation to meet the goals set by the healthcare industry. Being involved in BOOST and watching tangible improvements for my patients has provided me with immense personal and professional gratification!”

In fact, Dr. Kekan and her team have been so pleased with the results, both quantitative and qualitative, from their participation in Project BOOST that they enrolled twice: first in 2012 and again in 2013. She cites the program’s adaptability “that would help us develop a higher quality discharge process for our patients.”

Like many fruitful journeys, though, this one did not find Dr. Kekan and the caregivers at HMH alone: They had a guide who made all the difference.

Change implementation can be difficult, says Houston Methodist’s Janice Finder, RN, MSN. “Everyone knows how they want to design the house, so to speak,” she says, “but if you have someone who has done it before and can lead and direct, it goes much smoother.”

That was the true value of their Project BOOST mentor, Jeffrey Greenwald, MD, SFHM, one of the founding developers of Project BOOST.

“Dr. Greenwald gave us great mentorship and guidance,” Finder says. “The guidance about leadership is essential. If you do not have full support and a person who has ‘been there, done that,’ it is hard to envision.”

From his perspective, Dr. Greenwald saw that HMH had many of the critical elements in place to be successful.

“They had a good set of experiences already. They had the will and leadership and skill on the ground in process improvement,” he says, calling HMH an “incredibly well-oiled machine” with buy-in from the kind of inter-professional team that can make Project BOOST a success.

Overall, Dr. Greenwald calls HMH a “good example of a hospital that has married Project BOOST with the hospital’s existing priorities.”

Other Project BOOST sites start at different levels, in terms of basic interventions and process improvement, Dr. Greenwald explains. Many are able to address more advanced challenges, like how to implement change across broader areas in the hospital, working with leadership, addressing political issues, and improving waning interest in groups.

Dr. Greenwald’s interest in mentorship of Project BOOST sites stems from his own experiences early on—and the need for mentors in quality improvement projects.

“I wish I would have had someone like that when I got started,” says Dr. Greenwald, who tries to fill that role for others now. “Hopefully, each group moves down the path of making sure they have the right stakeholders, the right communications styles and skills in how to look at data and work with front-end staff.”

While Project BOOST focuses teams on reducing readmissions rates, Dr. Kekan has found that the skills learned from Project BOOST have created a blueprint that is applicable to many other team-based challenges in the hospital.

“We describe BOOST as a patient-centric quality initiative that mainly helps improve care transitions and encourages patients to stay informed about their health, which, in turn, helps reduce readmissions,” she says. “BOOST can be used as a framework to enhance other disease-specific discharge initiatives, like CHF [congestive heart failure] and delirium.”

Still, the core elements of reducing readmission rates and making a qualitative impact on her, her team, and the hospital resonate the most with Dr. Kekan.

“Providing a good transition plan to our patients provides satisfaction like none other.”

Brendon Shank is SHM’s associate vice president of communications.

Change doesn’t always come easily to hospitals, but once a catalyst comes along, one positive change can set the stage for the next one—and the one after that. At least that’s the lesson from Houston Methodist Hospital (HMH) and their work with SHM’s Project BOOST, a yearlong, mentored implementation program designed to help hospitals nationwide reduce readmission rates.

As the saying goes, every journey begins with a single step. For hospitals ready to start their journey to reduce readmissions rates and tackle other quality improvement challenges, the first step is the application to Project BOOST, which is due at the end of August. Details on the application and fees are available at www.hospitalmedicine.org/boost.

At Houston Methodist Hospital—a hospital U.S. News & World Report ranked one of “America’s Best Hospitals” in a dozen specialties and designated as a magnet hospital for excellence in nursing—taking that first step toward reducing readmissions by applying to Project BOOST has been well worth it.

“I recommend Project BOOST enthusiastically and unequivocally. If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers,” says Manasi Kekan, MD, MS, FACP, who serves as HMH’s medical director. “As a hospitalist, at times, I have found it challenging to ration my times between patient contact and documentation to meet the goals set by the healthcare industry. Being involved in BOOST and watching tangible improvements for my patients has provided me with immense personal and professional gratification!”

In fact, Dr. Kekan and her team have been so pleased with the results, both quantitative and qualitative, from their participation in Project BOOST that they enrolled twice: first in 2012 and again in 2013. She cites the program’s adaptability “that would help us develop a higher quality discharge process for our patients.”

Like many fruitful journeys, though, this one did not find Dr. Kekan and the caregivers at HMH alone: They had a guide who made all the difference.

Change implementation can be difficult, says Houston Methodist’s Janice Finder, RN, MSN. “Everyone knows how they want to design the house, so to speak,” she says, “but if you have someone who has done it before and can lead and direct, it goes much smoother.”

That was the true value of their Project BOOST mentor, Jeffrey Greenwald, MD, SFHM, one of the founding developers of Project BOOST.

“Dr. Greenwald gave us great mentorship and guidance,” Finder says. “The guidance about leadership is essential. If you do not have full support and a person who has ‘been there, done that,’ it is hard to envision.”

From his perspective, Dr. Greenwald saw that HMH had many of the critical elements in place to be successful.

“They had a good set of experiences already. They had the will and leadership and skill on the ground in process improvement,” he says, calling HMH an “incredibly well-oiled machine” with buy-in from the kind of inter-professional team that can make Project BOOST a success.

Overall, Dr. Greenwald calls HMH a “good example of a hospital that has married Project BOOST with the hospital’s existing priorities.”

Other Project BOOST sites start at different levels, in terms of basic interventions and process improvement, Dr. Greenwald explains. Many are able to address more advanced challenges, like how to implement change across broader areas in the hospital, working with leadership, addressing political issues, and improving waning interest in groups.

Dr. Greenwald’s interest in mentorship of Project BOOST sites stems from his own experiences early on—and the need for mentors in quality improvement projects.

“I wish I would have had someone like that when I got started,” says Dr. Greenwald, who tries to fill that role for others now. “Hopefully, each group moves down the path of making sure they have the right stakeholders, the right communications styles and skills in how to look at data and work with front-end staff.”

While Project BOOST focuses teams on reducing readmissions rates, Dr. Kekan has found that the skills learned from Project BOOST have created a blueprint that is applicable to many other team-based challenges in the hospital.

“We describe BOOST as a patient-centric quality initiative that mainly helps improve care transitions and encourages patients to stay informed about their health, which, in turn, helps reduce readmissions,” she says. “BOOST can be used as a framework to enhance other disease-specific discharge initiatives, like CHF [congestive heart failure] and delirium.”

Still, the core elements of reducing readmission rates and making a qualitative impact on her, her team, and the hospital resonate the most with Dr. Kekan.

“Providing a good transition plan to our patients provides satisfaction like none other.”

Brendon Shank is SHM’s associate vice president of communications.

Lakshmi Halasyamani, MD, SFHM, is the new chief medical officer (CMO) for Cogent Healthcare, which is based in Brentwood, Tenn. A former SHM board member, Dr. Halasyamani comes to Cogent from her role as CMO at St. Joseph Mercy Health System in Ypsilanti, Mich. She has assumed the role left vacant by Ron Greeno, MD, MHM, after Cogent appointed him executive vice president of strategy and innovation.

Dalibor Hradek, MD, has been named the 2013 physician of the year by the Greenville, S.C.-based OB Hospitalist Group (OBHG). Dr. Hradek is an OB/GYN hospitalist at Lakeland Regional Medical Center in Lakeland, Fla. Dr. Hradek received praise for his clinical expertise and dedication to his patients. OBHG staffs more than 250 OB/GYN hospitalists in over 55 programs nationwide.

Abdul Ftesi, MD, has been named the new hospitalist medical director at the University of Oklahoma Medical Center (OUMC) in Oklahoma City, Okla., by the Dallas, Texas-based provider Questcare Hospitalists. In his new role, Dr. Ftesi will lead and coordinate a team of 12 hospitalists.

Alan Dulit, MD, is the new chief medical officer for St. Anthony Summit Medical Center in Frisco, Colo. Dr. Dulit comes to St. Anthony from his role as OB Hospitalist Group’s vice president of medical affairs at St. Mark’s Hospital in Salt Lake City.

Sujesh Pillai, MD, has been named the 2013 Physician of the Year by Huntsville (Texas) Memorial Hospital (HMH). Dr. Pillai currently serves as hospitalist medical director at HMH. Dr. Pillai is noted for his professionalism and his compassion for his patients and their families.

Christine Meagher, RN, is the first to receive the Hospitalist Nursing Service Award from the Physician Hospitalist group at Heywood Hospital in Gardner, Mass. Meagher serves as a nurse in the ICU at the 134-bed acute care facility.

John Larson, MD, has been named Family Physician of the Year for 2013 by the Wisconsin Academy of Family Physicians. Dr. Larson serves as regional assistant medical director for Mayo Clinic Health System and often plays the role of a hospitalist, among many others, as part of his job.

Charles Clair, MD, recently received a service and gratitude award from the Pocatello (Idaho) Free Clinic. Dr. Clair serves as a hospitalist at Portneuf Medical Center in Pocatello, Idaho, and regularly volunteers at the Free Clinic with his wife, who offers her time maintaining the clinic’s website. The Pocatello Free Clinic has been serving patients in the area since 1971.

Felix Cabrera, MD, is the new director of clinical informatics and medical education for Guam Regional Medical City (GRMC) in Dededo, Guam. Dr. Cabrera was previously a hospitalist and associate medical director at Guam Memorial Hospital. GRMC is a brand new, 130-bed acute care facility privately owned by Philippine healthcare firm The Medical City.

Scott Sears, MD, FACP, has been named the new chief clinical officer for the Tacoma, Wash.-based Sound Physicians. Dr. Sears assumes his new role after serving as Sound’s regional chief medical officer for the Northwest Region.

Talbot “Mac” McCormick, MD, has assumed the role of chief executive officer of the Dallas, Texas-based Eagle Hospital Physicians. Dr. McCormick previously served as Eagle’s president and chief operating officer and has been with Eagle in various roles since 2003.

Lakshmi Halasyamani, MD, SFHM, is the new chief medical officer (CMO) for Cogent Healthcare, which is based in Brentwood, Tenn. A former SHM board member, Dr. Halasyamani comes to Cogent from her role as CMO at St. Joseph Mercy Health System in Ypsilanti, Mich. She has assumed the role left vacant by Ron Greeno, MD, MHM, after Cogent appointed him executive vice president of strategy and innovation.

Dalibor Hradek, MD, has been named the 2013 physician of the year by the Greenville, S.C.-based OB Hospitalist Group (OBHG). Dr. Hradek is an OB/GYN hospitalist at Lakeland Regional Medical Center in Lakeland, Fla. Dr. Hradek received praise for his clinical expertise and dedication to his patients. OBHG staffs more than 250 OB/GYN hospitalists in over 55 programs nationwide.

Abdul Ftesi, MD, has been named the new hospitalist medical director at the University of Oklahoma Medical Center (OUMC) in Oklahoma City, Okla., by the Dallas, Texas-based provider Questcare Hospitalists. In his new role, Dr. Ftesi will lead and coordinate a team of 12 hospitalists.

Alan Dulit, MD, is the new chief medical officer for St. Anthony Summit Medical Center in Frisco, Colo. Dr. Dulit comes to St. Anthony from his role as OB Hospitalist Group’s vice president of medical affairs at St. Mark’s Hospital in Salt Lake City.

Sujesh Pillai, MD, has been named the 2013 Physician of the Year by Huntsville (Texas) Memorial Hospital (HMH). Dr. Pillai currently serves as hospitalist medical director at HMH. Dr. Pillai is noted for his professionalism and his compassion for his patients and their families.

Christine Meagher, RN, is the first to receive the Hospitalist Nursing Service Award from the Physician Hospitalist group at Heywood Hospital in Gardner, Mass. Meagher serves as a nurse in the ICU at the 134-bed acute care facility.

John Larson, MD, has been named Family Physician of the Year for 2013 by the Wisconsin Academy of Family Physicians. Dr. Larson serves as regional assistant medical director for Mayo Clinic Health System and often plays the role of a hospitalist, among many others, as part of his job.

Charles Clair, MD, recently received a service and gratitude award from the Pocatello (Idaho) Free Clinic. Dr. Clair serves as a hospitalist at Portneuf Medical Center in Pocatello, Idaho, and regularly volunteers at the Free Clinic with his wife, who offers her time maintaining the clinic’s website. The Pocatello Free Clinic has been serving patients in the area since 1971.

Felix Cabrera, MD, is the new director of clinical informatics and medical education for Guam Regional Medical City (GRMC) in Dededo, Guam. Dr. Cabrera was previously a hospitalist and associate medical director at Guam Memorial Hospital. GRMC is a brand new, 130-bed acute care facility privately owned by Philippine healthcare firm The Medical City.

Scott Sears, MD, FACP, has been named the new chief clinical officer for the Tacoma, Wash.-based Sound Physicians. Dr. Sears assumes his new role after serving as Sound’s regional chief medical officer for the Northwest Region.

Talbot “Mac” McCormick, MD, has assumed the role of chief executive officer of the Dallas, Texas-based Eagle Hospital Physicians. Dr. McCormick previously served as Eagle’s president and chief operating officer and has been with Eagle in various roles since 2003.

Lakshmi Halasyamani, MD, SFHM, is the new chief medical officer (CMO) for Cogent Healthcare, which is based in Brentwood, Tenn. A former SHM board member, Dr. Halasyamani comes to Cogent from her role as CMO at St. Joseph Mercy Health System in Ypsilanti, Mich. She has assumed the role left vacant by Ron Greeno, MD, MHM, after Cogent appointed him executive vice president of strategy and innovation.

Dalibor Hradek, MD, has been named the 2013 physician of the year by the Greenville, S.C.-based OB Hospitalist Group (OBHG). Dr. Hradek is an OB/GYN hospitalist at Lakeland Regional Medical Center in Lakeland, Fla. Dr. Hradek received praise for his clinical expertise and dedication to his patients. OBHG staffs more than 250 OB/GYN hospitalists in over 55 programs nationwide.

Abdul Ftesi, MD, has been named the new hospitalist medical director at the University of Oklahoma Medical Center (OUMC) in Oklahoma City, Okla., by the Dallas, Texas-based provider Questcare Hospitalists. In his new role, Dr. Ftesi will lead and coordinate a team of 12 hospitalists.

Alan Dulit, MD, is the new chief medical officer for St. Anthony Summit Medical Center in Frisco, Colo. Dr. Dulit comes to St. Anthony from his role as OB Hospitalist Group’s vice president of medical affairs at St. Mark’s Hospital in Salt Lake City.

Sujesh Pillai, MD, has been named the 2013 Physician of the Year by Huntsville (Texas) Memorial Hospital (HMH). Dr. Pillai currently serves as hospitalist medical director at HMH. Dr. Pillai is noted for his professionalism and his compassion for his patients and their families.

Christine Meagher, RN, is the first to receive the Hospitalist Nursing Service Award from the Physician Hospitalist group at Heywood Hospital in Gardner, Mass. Meagher serves as a nurse in the ICU at the 134-bed acute care facility.

John Larson, MD, has been named Family Physician of the Year for 2013 by the Wisconsin Academy of Family Physicians. Dr. Larson serves as regional assistant medical director for Mayo Clinic Health System and often plays the role of a hospitalist, among many others, as part of his job.

Charles Clair, MD, recently received a service and gratitude award from the Pocatello (Idaho) Free Clinic. Dr. Clair serves as a hospitalist at Portneuf Medical Center in Pocatello, Idaho, and regularly volunteers at the Free Clinic with his wife, who offers her time maintaining the clinic’s website. The Pocatello Free Clinic has been serving patients in the area since 1971.

Felix Cabrera, MD, is the new director of clinical informatics and medical education for Guam Regional Medical City (GRMC) in Dededo, Guam. Dr. Cabrera was previously a hospitalist and associate medical director at Guam Memorial Hospital. GRMC is a brand new, 130-bed acute care facility privately owned by Philippine healthcare firm The Medical City.

Scott Sears, MD, FACP, has been named the new chief clinical officer for the Tacoma, Wash.-based Sound Physicians. Dr. Sears assumes his new role after serving as Sound’s regional chief medical officer for the Northwest Region.

Talbot “Mac” McCormick, MD, has assumed the role of chief executive officer of the Dallas, Texas-based Eagle Hospital Physicians. Dr. McCormick previously served as Eagle’s president and chief operating officer and has been with Eagle in various roles since 2003.

Hospitalist Group Leaders Need Not Work Clinical Shifts to Achieve Respect

The “Survey Insights” article by Dr. Rachel Lovins (“Physician Practice Leaders,” November 2013) makes excellent points about the importance of leadership in hospital medicine groups but perpetuates a fallacy that undercuts the effectiveness of physician leaders. Dr. Lovins states that hospitalist leaders need to work as clinical hospitalists to achieve respect. Consider the example of professional sports, where athletes are highly skilled and earn more than doctors, but the concept of a player/coach has essentially disappeared. The difference is that athletes understand that they are playing on a team that needs a cohesive vision to succeed. They value the insights of a coach who can watch their performance from the sidelines and help them improve, even though that person’s own playing skills may have been undistinguished.

Dr. Lovins states that hospitalist leaders need to experience firsthand the frustrations of hospital practice. Would it not be better to replace anecdotal evidence with systematic communication and analysis of experiences from the entire group? The demand by physicians that their leaders be active clinicians is really a way to ensure that those individuals are unable to secure the time and perspective needed to become effective coaches, and it encroaches upon the autonomy of the individuals.

HM cannot achieve its potential until it develops leaders who can move beyond the level of chief resident and engage meaningfully with the concerns of senior hospital leaders to drive the performance of their teams. Hospitalists must understand that they are part of an organization that will be led by persons with different skill sets than those required to diagnose and treat disease.

—Richard Rohr, MD, SFHM, team leader, United Health Group, Broomall, Pa.

Hospitalist Group Leaders Need Not Work Clinical Shifts to Achieve Respect

The “Survey Insights” article by Dr. Rachel Lovins (“Physician Practice Leaders,” November 2013) makes excellent points about the importance of leadership in hospital medicine groups but perpetuates a fallacy that undercuts the effectiveness of physician leaders. Dr. Lovins states that hospitalist leaders need to work as clinical hospitalists to achieve respect. Consider the example of professional sports, where athletes are highly skilled and earn more than doctors, but the concept of a player/coach has essentially disappeared. The difference is that athletes understand that they are playing on a team that needs a cohesive vision to succeed. They value the insights of a coach who can watch their performance from the sidelines and help them improve, even though that person’s own playing skills may have been undistinguished.

Dr. Lovins states that hospitalist leaders need to experience firsthand the frustrations of hospital practice. Would it not be better to replace anecdotal evidence with systematic communication and analysis of experiences from the entire group? The demand by physicians that their leaders be active clinicians is really a way to ensure that those individuals are unable to secure the time and perspective needed to become effective coaches, and it encroaches upon the autonomy of the individuals.

HM cannot achieve its potential until it develops leaders who can move beyond the level of chief resident and engage meaningfully with the concerns of senior hospital leaders to drive the performance of their teams. Hospitalists must understand that they are part of an organization that will be led by persons with different skill sets than those required to diagnose and treat disease.

—Richard Rohr, MD, SFHM, team leader, United Health Group, Broomall, Pa.

Hospitalist Group Leaders Need Not Work Clinical Shifts to Achieve Respect

The “Survey Insights” article by Dr. Rachel Lovins (“Physician Practice Leaders,” November 2013) makes excellent points about the importance of leadership in hospital medicine groups but perpetuates a fallacy that undercuts the effectiveness of physician leaders. Dr. Lovins states that hospitalist leaders need to work as clinical hospitalists to achieve respect. Consider the example of professional sports, where athletes are highly skilled and earn more than doctors, but the concept of a player/coach has essentially disappeared. The difference is that athletes understand that they are playing on a team that needs a cohesive vision to succeed. They value the insights of a coach who can watch their performance from the sidelines and help them improve, even though that person’s own playing skills may have been undistinguished.

Dr. Lovins states that hospitalist leaders need to experience firsthand the frustrations of hospital practice. Would it not be better to replace anecdotal evidence with systematic communication and analysis of experiences from the entire group? The demand by physicians that their leaders be active clinicians is really a way to ensure that those individuals are unable to secure the time and perspective needed to become effective coaches, and it encroaches upon the autonomy of the individuals.

HM cannot achieve its potential until it develops leaders who can move beyond the level of chief resident and engage meaningfully with the concerns of senior hospital leaders to drive the performance of their teams. Hospitalists must understand that they are part of an organization that will be led by persons with different skill sets than those required to diagnose and treat disease.

—Richard Rohr, MD, SFHM, team leader, United Health Group, Broomall, Pa.