CME: Coming to a Screen Near You Hospitalists often turn to

SHM for continuing medical education (CME) credits. Soon, SHM members will have even more options for earning and tracking CME through its new Learning Portal.

Due to launch in May, the Learning Portal will give hospitalists new online content for hospitalist-specific CME credits. It will offer personalized portfolios to track CME credits earned through the Learning Portal and other CME sources.

For more on the portal, visit www.hospitalmedicine.org in May.

HMX: Expanding the Conversation with More Than 1,400 Hospitalists

More and more hospitalists are turning to HMX, SHM's online collaboration and discussion site, for questions and answers from their HM colleagues. More than 1,400 hospitalists have logged into HMX; earlier this year, HMX notched its 10,000th log-in.

For topics ranging from paid time off to working with post-discharge clinics to reduce readmissions, HMX has quickly become the source for practical, up-to-date information from hospitalists in the know. Plus, HMX users have posted dozens of helpful documents and other resources to more than three dozen active, topic-based communities on HMX. Others have used HMX to connect with other hospitalists directly through the HMX directory.

Are you ready to connect? Visit www.hmxchange.org.

Project BOOST: It's Not Too Early to Apply

The best hospital discharge processes start at admission. And, as with planning for patient discharges, applying for SHM's Project BOOST is best done in advance. SHM will be accepting applications for its 2013 cohort through June, but the process requires a letter of support from an executive sponsor and an application, so April is a great time to get started.

Just ask Jean Range of The Joint Commission: "Project BOOST provides a clear plan of action for hospitals who want to improve the discharge process for their older patients. Utilizing the free resources that BOOST provides will result in decreased rehospitalization and better patient outcomes—a win-win situation for all involved."

For more information, visit www.hospitalmedicine.org/boost.

Hospitalists Can Lead by Following (and Friending)

SHM's presence is growing. More than 1,600 hospitalists and others interested in HM are getting the latest updates about hospital medicine from @SHMLive, SHM's Twitter feed. And SHM's Facebook page has received nearly 2,200 "likes."

To join the HM movement through social media, visit SHM's profiles on:

• Twitter: www.twitter.com/shmlive
• Facebook: www.facebook.com/Hospitalists
• LinkedIn: www.linkedin.com/company/society-of-hospital-medicine
• YouTube: www.youtube.com/user/SHMLive

CME: Coming to a Screen Near You Hospitalists often turn to

SHM for continuing medical education (CME) credits. Soon, SHM members will have even more options for earning and tracking CME through its new Learning Portal.

Due to launch in May, the Learning Portal will give hospitalists new online content for hospitalist-specific CME credits. It will offer personalized portfolios to track CME credits earned through the Learning Portal and other CME sources.

For more on the portal, visit www.hospitalmedicine.org in May.

HMX: Expanding the Conversation with More Than 1,400 Hospitalists

More and more hospitalists are turning to HMX, SHM's online collaboration and discussion site, for questions and answers from their HM colleagues. More than 1,400 hospitalists have logged into HMX; earlier this year, HMX notched its 10,000th log-in.

For topics ranging from paid time off to working with post-discharge clinics to reduce readmissions, HMX has quickly become the source for practical, up-to-date information from hospitalists in the know. Plus, HMX users have posted dozens of helpful documents and other resources to more than three dozen active, topic-based communities on HMX. Others have used HMX to connect with other hospitalists directly through the HMX directory.

Are you ready to connect? Visit www.hmxchange.org.

Project BOOST: It's Not Too Early to Apply

The best hospital discharge processes start at admission. And, as with planning for patient discharges, applying for SHM's Project BOOST is best done in advance. SHM will be accepting applications for its 2013 cohort through June, but the process requires a letter of support from an executive sponsor and an application, so April is a great time to get started.

Just ask Jean Range of The Joint Commission: "Project BOOST provides a clear plan of action for hospitals who want to improve the discharge process for their older patients. Utilizing the free resources that BOOST provides will result in decreased rehospitalization and better patient outcomes—a win-win situation for all involved."

For more information, visit www.hospitalmedicine.org/boost.

Hospitalists Can Lead by Following (and Friending)

SHM's presence is growing. More than 1,600 hospitalists and others interested in HM are getting the latest updates about hospital medicine from @SHMLive, SHM's Twitter feed. And SHM's Facebook page has received nearly 2,200 "likes."

To join the HM movement through social media, visit SHM's profiles on:

• Twitter: www.twitter.com/shmlive
• Facebook: www.facebook.com/Hospitalists
• LinkedIn: www.linkedin.com/company/society-of-hospital-medicine
• YouTube: www.youtube.com/user/SHMLive

CME: Coming to a Screen Near You Hospitalists often turn to

SHM for continuing medical education (CME) credits. Soon, SHM members will have even more options for earning and tracking CME through its new Learning Portal.

Due to launch in May, the Learning Portal will give hospitalists new online content for hospitalist-specific CME credits. It will offer personalized portfolios to track CME credits earned through the Learning Portal and other CME sources.

For more on the portal, visit www.hospitalmedicine.org in May.

HMX: Expanding the Conversation with More Than 1,400 Hospitalists

More and more hospitalists are turning to HMX, SHM's online collaboration and discussion site, for questions and answers from their HM colleagues. More than 1,400 hospitalists have logged into HMX; earlier this year, HMX notched its 10,000th log-in.

For topics ranging from paid time off to working with post-discharge clinics to reduce readmissions, HMX has quickly become the source for practical, up-to-date information from hospitalists in the know. Plus, HMX users have posted dozens of helpful documents and other resources to more than three dozen active, topic-based communities on HMX. Others have used HMX to connect with other hospitalists directly through the HMX directory.

Are you ready to connect? Visit www.hmxchange.org.

Project BOOST: It's Not Too Early to Apply

The best hospital discharge processes start at admission. And, as with planning for patient discharges, applying for SHM's Project BOOST is best done in advance. SHM will be accepting applications for its 2013 cohort through June, but the process requires a letter of support from an executive sponsor and an application, so April is a great time to get started.

Just ask Jean Range of The Joint Commission: "Project BOOST provides a clear plan of action for hospitals who want to improve the discharge process for their older patients. Utilizing the free resources that BOOST provides will result in decreased rehospitalization and better patient outcomes—a win-win situation for all involved."

For more information, visit www.hospitalmedicine.org/boost.

Hospitalists Can Lead by Following (and Friending)

SHM's presence is growing. More than 1,600 hospitalists and others interested in HM are getting the latest updates about hospital medicine from @SHMLive, SHM's Twitter feed. And SHM's Facebook page has received nearly 2,200 "likes."

To join the HM movement through social media, visit SHM's profiles on:

• Twitter: www.twitter.com/shmlive
• Facebook: www.facebook.com/Hospitalists
• LinkedIn: www.linkedin.com/company/society-of-hospital-medicine
• YouTube: www.youtube.com/user/SHMLive

SHM’s Boston area chapter is looking to award a $1,000 scholarship to a resident who has been accepted to present a research, innovation, or clinical vignette (RIV) poster at HM13 in May at the Gaylord National Resort and Conference Center just outside Washington, D.C. The scholarship is to help defray travel expenses to attend the four-day annual meeting.

“We want to encourage our trainees to be productive in academic work and contribute to the body of knowledge about hospital medicine,” says Joseph Ming Wah Li, MD SFHM FACP, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston and past president of SHM, adding chapter organizers hope the scholarship will further the awardees’ interest in the HM and provide the resident the opportunity to meet and share ideas with leaders in the field. “Any resident in training in the state of Massachusetts whose abstract was accepted for poster presentation at HM13 is eligible,” he says.

The application [PDF] deadline is April 8. Interested applicants should contact Dr. Li. The 2013 RIV poster sessions are Friday, May 16, and Saturday, May 17.

SHM’s Maryland chapter also awards annual meeting scholarships, and SHM leaders are looking to broaden the effort in years to come.

The Maryland chapter periodically solicits RIV abstracts from early-career hospitalists, residents, nurse practitioners, and physician assistants, inviting four or five to make oral presentations at a chapter meeting and then selecting a winner. Preeti Mehrotra, MD, internal medicine-pediatrics resident at the University of Maryland Medical Center in Baltimore, and Jameka Riley, PA-C, physician assistant with Physician Inpatient Care Specialists in Annapolis, won the latest Maryland chapter contest and will have their HM13 registration fees covered.

Visit the SHM website for more information about chapters.

SHM’s Boston area chapter is looking to award a $1,000 scholarship to a resident who has been accepted to present a research, innovation, or clinical vignette (RIV) poster at HM13 in May at the Gaylord National Resort and Conference Center just outside Washington, D.C. The scholarship is to help defray travel expenses to attend the four-day annual meeting.

“We want to encourage our trainees to be productive in academic work and contribute to the body of knowledge about hospital medicine,” says Joseph Ming Wah Li, MD SFHM FACP, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston and past president of SHM, adding chapter organizers hope the scholarship will further the awardees’ interest in the HM and provide the resident the opportunity to meet and share ideas with leaders in the field. “Any resident in training in the state of Massachusetts whose abstract was accepted for poster presentation at HM13 is eligible,” he says.

The application [PDF] deadline is April 8. Interested applicants should contact Dr. Li. The 2013 RIV poster sessions are Friday, May 16, and Saturday, May 17.

SHM’s Maryland chapter also awards annual meeting scholarships, and SHM leaders are looking to broaden the effort in years to come.

The Maryland chapter periodically solicits RIV abstracts from early-career hospitalists, residents, nurse practitioners, and physician assistants, inviting four or five to make oral presentations at a chapter meeting and then selecting a winner. Preeti Mehrotra, MD, internal medicine-pediatrics resident at the University of Maryland Medical Center in Baltimore, and Jameka Riley, PA-C, physician assistant with Physician Inpatient Care Specialists in Annapolis, won the latest Maryland chapter contest and will have their HM13 registration fees covered.

Visit the SHM website for more information about chapters.

SHM’s Boston area chapter is looking to award a $1,000 scholarship to a resident who has been accepted to present a research, innovation, or clinical vignette (RIV) poster at HM13 in May at the Gaylord National Resort and Conference Center just outside Washington, D.C. The scholarship is to help defray travel expenses to attend the four-day annual meeting.

“We want to encourage our trainees to be productive in academic work and contribute to the body of knowledge about hospital medicine,” says Joseph Ming Wah Li, MD SFHM FACP, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston and past president of SHM, adding chapter organizers hope the scholarship will further the awardees’ interest in the HM and provide the resident the opportunity to meet and share ideas with leaders in the field. “Any resident in training in the state of Massachusetts whose abstract was accepted for poster presentation at HM13 is eligible,” he says.

The application [PDF] deadline is April 8. Interested applicants should contact Dr. Li. The 2013 RIV poster sessions are Friday, May 16, and Saturday, May 17.

SHM’s Maryland chapter also awards annual meeting scholarships, and SHM leaders are looking to broaden the effort in years to come.

The Maryland chapter periodically solicits RIV abstracts from early-career hospitalists, residents, nurse practitioners, and physician assistants, inviting four or five to make oral presentations at a chapter meeting and then selecting a winner. Preeti Mehrotra, MD, internal medicine-pediatrics resident at the University of Maryland Medical Center in Baltimore, and Jameka Riley, PA-C, physician assistant with Physician Inpatient Care Specialists in Annapolis, won the latest Maryland chapter contest and will have their HM13 registration fees covered.

Visit the SHM website for more information about chapters.

Look no further than SHM’s Web application for HM13 at www.eventmobi.com/hm13.

This year, SHM is introducing the HM13 at Hand app as the sole source for HM13 content, including session presentations and speaker information for all of the conference. In previous years, attendees have used the meeting’s “paperless site” as the online location for all of the meeting’s content.

At HM13, attendees can get all of the content seamlessly on their tablets or smartphones in real time through the HM13 At Hand app.

HM13 At Hand puts HM13 in your hands with meeting content and tools:

• Presentations
• Speaker information
• HM13 schedule and planner
• “Scan to Win” contest
• Real-time alerts and updates
• Links to other HM13 resources and social media

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Look no further than SHM’s Web application for HM13 at www.eventmobi.com/hm13.

This year, SHM is introducing the HM13 at Hand app as the sole source for HM13 content, including session presentations and speaker information for all of the conference. In previous years, attendees have used the meeting’s “paperless site” as the online location for all of the meeting’s content.

At HM13, attendees can get all of the content seamlessly on their tablets or smartphones in real time through the HM13 At Hand app.

HM13 At Hand puts HM13 in your hands with meeting content and tools:

• Presentations
• Speaker information
• HM13 schedule and planner
• “Scan to Win” contest
• Real-time alerts and updates
• Links to other HM13 resources and social media

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

Look no further than SHM’s Web application for HM13 at www.eventmobi.com/hm13.

This year, SHM is introducing the HM13 at Hand app as the sole source for HM13 content, including session presentations and speaker information for all of the conference. In previous years, attendees have used the meeting’s “paperless site” as the online location for all of the meeting’s content.

At HM13, attendees can get all of the content seamlessly on their tablets or smartphones in real time through the HM13 At Hand app.

HM13 At Hand puts HM13 in your hands with meeting content and tools:

• Presentations
• Speaker information
• HM13 schedule and planner
• “Scan to Win” contest
• Real-time alerts and updates
• Links to other HM13 resources and social media

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

How do you go from being an early-career hospitalist to a leader in healthcare? Are there opportunities to do quality-improvement (QI) programs as a hospitalist?

Medical students and residents often have lots of questions about the many career paths available to hospitalists, and a special lunch at HM13 is designed to help answer many of them. This year’s lunch is May 17, the first day of the full HM13 program. It will link the specialty’s future hospitalists with leaders in the field.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

How do you go from being an early-career hospitalist to a leader in healthcare? Are there opportunities to do quality-improvement (QI) programs as a hospitalist?

Medical students and residents often have lots of questions about the many career paths available to hospitalists, and a special lunch at HM13 is designed to help answer many of them. This year’s lunch is May 17, the first day of the full HM13 program. It will link the specialty’s future hospitalists with leaders in the field.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

How do you go from being an early-career hospitalist to a leader in healthcare? Are there opportunities to do quality-improvement (QI) programs as a hospitalist?

Medical students and residents often have lots of questions about the many career paths available to hospitalists, and a special lunch at HM13 is designed to help answer many of them. This year’s lunch is May 17, the first day of the full HM13 program. It will link the specialty’s future hospitalists with leaders in the field.

Check out our 6-minute feature video: "Five Reasons You Should Attend HM13"

SHM Sections offer opportunities for members to connect with communities of their peers who share specialties or interests. At present, SHM Sections include:

• Med-Peds
• International
• Global Health and Human Rights
• Rural Hospitalists
• Practice Administrators

SHM Section of the Month

Seeing as how the focused-practice pathway for hospitalists is a first of its kind for physician credentialing boards, the ABIM is planning a “fairly significant” research effort tracking participants’ experience, Dr. Holmboe says.

Global Health and Human Rights is one of the newest SHM Sections, and represents a growing passion among hospitalists as increasing numbers of internal-medicine physicians express interest in overseas placements in resource-limited settings. SHM also recognizes the need for mentored training in global health.

Over the last decade, interest in global health has grown significantly amongst trainees, faculty, and staff. Current priorities for global health include: health-system strengthening, workforce training, QI and patient safety. These priorities align to core strengths of hospital medicine, which is therefore well suited to meet these global health challenges.

For more information about this and other Sections, visit www.hospitalmedicine.org/membership.

SHM Sections offer opportunities for members to connect with communities of their peers who share specialties or interests. At present, SHM Sections include:

• Med-Peds
• International
• Global Health and Human Rights
• Rural Hospitalists
• Practice Administrators

SHM Section of the Month

Seeing as how the focused-practice pathway for hospitalists is a first of its kind for physician credentialing boards, the ABIM is planning a “fairly significant” research effort tracking participants’ experience, Dr. Holmboe says.

Global Health and Human Rights is one of the newest SHM Sections, and represents a growing passion among hospitalists as increasing numbers of internal-medicine physicians express interest in overseas placements in resource-limited settings. SHM also recognizes the need for mentored training in global health.

Over the last decade, interest in global health has grown significantly amongst trainees, faculty, and staff. Current priorities for global health include: health-system strengthening, workforce training, QI and patient safety. These priorities align to core strengths of hospital medicine, which is therefore well suited to meet these global health challenges.

For more information about this and other Sections, visit www.hospitalmedicine.org/membership.

SHM Sections offer opportunities for members to connect with communities of their peers who share specialties or interests. At present, SHM Sections include:

• Med-Peds
• International
• Global Health and Human Rights
• Rural Hospitalists
• Practice Administrators

SHM Section of the Month

Seeing as how the focused-practice pathway for hospitalists is a first of its kind for physician credentialing boards, the ABIM is planning a “fairly significant” research effort tracking participants’ experience, Dr. Holmboe says.

Global Health and Human Rights is one of the newest SHM Sections, and represents a growing passion among hospitalists as increasing numbers of internal-medicine physicians express interest in overseas placements in resource-limited settings. SHM also recognizes the need for mentored training in global health.

Over the last decade, interest in global health has grown significantly amongst trainees, faculty, and staff. Current priorities for global health include: health-system strengthening, workforce training, QI and patient safety. These priorities align to core strengths of hospital medicine, which is therefore well suited to meet these global health challenges.

For more information about this and other Sections, visit www.hospitalmedicine.org/membership.

On the Move

Nasim Afsar, MD, SFHM

Russell Holman, MD, MHM

Kurt Krupnick, MD

John M. Little Jr., MD, MBA

Nasim Afsar, MD, SFHM, has been named associate chief medical officer of UCLA Hospitals in Los Angeles. She comes to this position from her role as associate medical director of quality and safety at UCLA Hospitals.

Dr. Afsar serves on the SHM board of directors and is an active member of the hospitalist community. In addition to hospital medicine, she also specializes in neurosurgery.

Russell Holman, MD, MHM, is the new chief medical officer of LifePoint Hospitals, based in Brentwood, Tenn. Dr. Holman formerly was chief clinical officer at Cogent HMG. In 2002, he received the SHM Award for Outstanding Service in Hospital Medicine and is a former SHM president.

Charles Edwards, MBA, MD, FACP, has been appointed vice chair of clinical operations and quality assurance at the University of South Florida Department of Internal Medicine in Tampa. Dr. Edwards is director of the USF Morsani College of Medicine’s division of hospital medicine, of which he is a founding member.

Kurt Krupnick, MD, has been named physician of the year at Yavapai Regional Medical Center (YRMC) in Prescott, Ariz. Dr. Krupnick has been a YRMC hospitalist since 2009.

John M. Little Jr., MD, MBA, is the new chief payor development officer at national hospitalist management company Cogent HMG, based in Brentwood, Tenn. Dr. Little previously was vice president of healthcare services and chief medical officer for the South Carolina division of Blue Cross and Blue Shield. He previously practiced family medicine full time.

Business Moves

Fort Lauderdale, Fla.-based TeamHealth will provide hospitalist services at West Boca Medical Center in Raton, Fla.; Lincoln Medical Center in Fayetteville, Tenn.; Roane Medical Center in Harriman, Tenn.; and Morristown-Hamblen Healthcare System in Morristown, Tenn. TeamHealth was founded in 1979 and now provides hospitalist management services in 10 states across the country.

IPC: The Hospitalist Company Inc., based in North Hollywood, Calif., announced its acquisition of Morristown, N.J.-based Internal Medicine Consultants (IMC). IMC currently serves nearly 18,000 patients per year. IPC manages hospitalist services in 28 states across the U.S.

Sound Physicians, based in Tacoma, Wash., is overseeing hospitalist services at Saint Joseph Regional Medical Center (SJRMC) in Mishawaka, Ind. SJRMC is part of the Livonia, Mich.-based Trinity Health hospital system, the fourth-largest Catholic healthcare system in the U.S. Sound Physicians currently employs more than 500 doctors in more than 70 hospitals nationwide.

On the Move

Nasim Afsar, MD, SFHM

Russell Holman, MD, MHM

Kurt Krupnick, MD

John M. Little Jr., MD, MBA

Nasim Afsar, MD, SFHM, has been named associate chief medical officer of UCLA Hospitals in Los Angeles. She comes to this position from her role as associate medical director of quality and safety at UCLA Hospitals.

Dr. Afsar serves on the SHM board of directors and is an active member of the hospitalist community. In addition to hospital medicine, she also specializes in neurosurgery.

Russell Holman, MD, MHM, is the new chief medical officer of LifePoint Hospitals, based in Brentwood, Tenn. Dr. Holman formerly was chief clinical officer at Cogent HMG. In 2002, he received the SHM Award for Outstanding Service in Hospital Medicine and is a former SHM president.

Charles Edwards, MBA, MD, FACP, has been appointed vice chair of clinical operations and quality assurance at the University of South Florida Department of Internal Medicine in Tampa. Dr. Edwards is director of the USF Morsani College of Medicine’s division of hospital medicine, of which he is a founding member.

Kurt Krupnick, MD, has been named physician of the year at Yavapai Regional Medical Center (YRMC) in Prescott, Ariz. Dr. Krupnick has been a YRMC hospitalist since 2009.

John M. Little Jr., MD, MBA, is the new chief payor development officer at national hospitalist management company Cogent HMG, based in Brentwood, Tenn. Dr. Little previously was vice president of healthcare services and chief medical officer for the South Carolina division of Blue Cross and Blue Shield. He previously practiced family medicine full time.

Business Moves

Fort Lauderdale, Fla.-based TeamHealth will provide hospitalist services at West Boca Medical Center in Raton, Fla.; Lincoln Medical Center in Fayetteville, Tenn.; Roane Medical Center in Harriman, Tenn.; and Morristown-Hamblen Healthcare System in Morristown, Tenn. TeamHealth was founded in 1979 and now provides hospitalist management services in 10 states across the country.

IPC: The Hospitalist Company Inc., based in North Hollywood, Calif., announced its acquisition of Morristown, N.J.-based Internal Medicine Consultants (IMC). IMC currently serves nearly 18,000 patients per year. IPC manages hospitalist services in 28 states across the U.S.

Sound Physicians, based in Tacoma, Wash., is overseeing hospitalist services at Saint Joseph Regional Medical Center (SJRMC) in Mishawaka, Ind. SJRMC is part of the Livonia, Mich.-based Trinity Health hospital system, the fourth-largest Catholic healthcare system in the U.S. Sound Physicians currently employs more than 500 doctors in more than 70 hospitals nationwide.

On the Move

Nasim Afsar, MD, SFHM

Russell Holman, MD, MHM

Kurt Krupnick, MD

John M. Little Jr., MD, MBA

Nasim Afsar, MD, SFHM, has been named associate chief medical officer of UCLA Hospitals in Los Angeles. She comes to this position from her role as associate medical director of quality and safety at UCLA Hospitals.

Dr. Afsar serves on the SHM board of directors and is an active member of the hospitalist community. In addition to hospital medicine, she also specializes in neurosurgery.

Russell Holman, MD, MHM, is the new chief medical officer of LifePoint Hospitals, based in Brentwood, Tenn. Dr. Holman formerly was chief clinical officer at Cogent HMG. In 2002, he received the SHM Award for Outstanding Service in Hospital Medicine and is a former SHM president.

Charles Edwards, MBA, MD, FACP, has been appointed vice chair of clinical operations and quality assurance at the University of South Florida Department of Internal Medicine in Tampa. Dr. Edwards is director of the USF Morsani College of Medicine’s division of hospital medicine, of which he is a founding member.

Kurt Krupnick, MD, has been named physician of the year at Yavapai Regional Medical Center (YRMC) in Prescott, Ariz. Dr. Krupnick has been a YRMC hospitalist since 2009.

John M. Little Jr., MD, MBA, is the new chief payor development officer at national hospitalist management company Cogent HMG, based in Brentwood, Tenn. Dr. Little previously was vice president of healthcare services and chief medical officer for the South Carolina division of Blue Cross and Blue Shield. He previously practiced family medicine full time.

Business Moves

Fort Lauderdale, Fla.-based TeamHealth will provide hospitalist services at West Boca Medical Center in Raton, Fla.; Lincoln Medical Center in Fayetteville, Tenn.; Roane Medical Center in Harriman, Tenn.; and Morristown-Hamblen Healthcare System in Morristown, Tenn. TeamHealth was founded in 1979 and now provides hospitalist management services in 10 states across the country.

IPC: The Hospitalist Company Inc., based in North Hollywood, Calif., announced its acquisition of Morristown, N.J.-based Internal Medicine Consultants (IMC). IMC currently serves nearly 18,000 patients per year. IPC manages hospitalist services in 28 states across the U.S.

Sound Physicians, based in Tacoma, Wash., is overseeing hospitalist services at Saint Joseph Regional Medical Center (SJRMC) in Mishawaka, Ind. SJRMC is part of the Livonia, Mich.-based Trinity Health hospital system, the fourth-largest Catholic healthcare system in the U.S. Sound Physicians currently employs more than 500 doctors in more than 70 hospitals nationwide.

Clinical question: What are the long-term outcomes of pediatric pleural empyema?

Background: Hospitalizations for complicated pneumonia have increased in recent years. In the U.S., early intervention—commonly video-assisted thorascopic surgery (VATS)—has become popular. Although short-term outcomes appear cost-effective with this approach, long-term comparative-effectiveness outcomes are not entirely clear.

Study design: Prospective observational study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a two-year period, 82 patients were enrolled and available for at least one follow-up visit in a 12-month period. Chest drain was used in 62% of children; fibrinolytics were used in 78% of those cases. All patients received antibiotics. Six patients (7%) were readmitted in the first month, with three patients requiring a chest drain. At 12 months, four patients (5%) had mildly abnormal spirometric or radiographic abnormalities but were asymptomatic with normal quality-of-life scores.

This prospective observational study is notable for the relatively conservative approach (antibiotics alone or chest drainage, without VATS) employed in all subjects. The results provide a comprehensive summary of outcomes at 12 months in this population. Unfortunately, comparative-effectiveness data for VATS are not available in a generalizable form. Nevertheless, this single-center snapshot suggests that long-term outcomes are good with a conservative approach.

Given these findings, and the low likelihood that significant advantages of VATS will be demonstrated in the absence of a large multicenter trial, better understanding of parental preferences will become critical to making the right decision for each patient.

Bottom line: Conservative management of pediatric pleural empyema yields good long-term outcomes.

Citation: Cohen E, Mahant S, Dell SD, et al. The long-term outcomes of pediatric pleural empyema: a prospective study. Arch Pediatr Adolesc Med. 2012;166(11):999-1004.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What are the long-term outcomes of pediatric pleural empyema?

Background: Hospitalizations for complicated pneumonia have increased in recent years. In the U.S., early intervention—commonly video-assisted thorascopic surgery (VATS)—has become popular. Although short-term outcomes appear cost-effective with this approach, long-term comparative-effectiveness outcomes are not entirely clear.

Study design: Prospective observational study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a two-year period, 82 patients were enrolled and available for at least one follow-up visit in a 12-month period. Chest drain was used in 62% of children; fibrinolytics were used in 78% of those cases. All patients received antibiotics. Six patients (7%) were readmitted in the first month, with three patients requiring a chest drain. At 12 months, four patients (5%) had mildly abnormal spirometric or radiographic abnormalities but were asymptomatic with normal quality-of-life scores.

This prospective observational study is notable for the relatively conservative approach (antibiotics alone or chest drainage, without VATS) employed in all subjects. The results provide a comprehensive summary of outcomes at 12 months in this population. Unfortunately, comparative-effectiveness data for VATS are not available in a generalizable form. Nevertheless, this single-center snapshot suggests that long-term outcomes are good with a conservative approach.

Given these findings, and the low likelihood that significant advantages of VATS will be demonstrated in the absence of a large multicenter trial, better understanding of parental preferences will become critical to making the right decision for each patient.

Bottom line: Conservative management of pediatric pleural empyema yields good long-term outcomes.

Citation: Cohen E, Mahant S, Dell SD, et al. The long-term outcomes of pediatric pleural empyema: a prospective study. Arch Pediatr Adolesc Med. 2012;166(11):999-1004.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What are the long-term outcomes of pediatric pleural empyema?

Background: Hospitalizations for complicated pneumonia have increased in recent years. In the U.S., early intervention—commonly video-assisted thorascopic surgery (VATS)—has become popular. Although short-term outcomes appear cost-effective with this approach, long-term comparative-effectiveness outcomes are not entirely clear.

Study design: Prospective observational study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a two-year period, 82 patients were enrolled and available for at least one follow-up visit in a 12-month period. Chest drain was used in 62% of children; fibrinolytics were used in 78% of those cases. All patients received antibiotics. Six patients (7%) were readmitted in the first month, with three patients requiring a chest drain. At 12 months, four patients (5%) had mildly abnormal spirometric or radiographic abnormalities but were asymptomatic with normal quality-of-life scores.

This prospective observational study is notable for the relatively conservative approach (antibiotics alone or chest drainage, without VATS) employed in all subjects. The results provide a comprehensive summary of outcomes at 12 months in this population. Unfortunately, comparative-effectiveness data for VATS are not available in a generalizable form. Nevertheless, this single-center snapshot suggests that long-term outcomes are good with a conservative approach.

Given these findings, and the low likelihood that significant advantages of VATS will be demonstrated in the absence of a large multicenter trial, better understanding of parental preferences will become critical to making the right decision for each patient.

Bottom line: Conservative management of pediatric pleural empyema yields good long-term outcomes.

Citation: Cohen E, Mahant S, Dell SD, et al. The long-term outcomes of pediatric pleural empyema: a prospective study. Arch Pediatr Adolesc Med. 2012;166(11):999-1004.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Value of routine preoperative urine screening assessed
2. Impact of hospitalist-led intermediate care on patient survival
3. Risks of blood transfusion to treat upper GI bleeding
4. Low-dose steroids and increased mortality in sepsis
5. Reduced length of stay and hospital readmission rates
6. Restrictive blood transfusion strategies better for acute myocardial infarction
7. Trends in GI illnesses and their associated costs
8. Apixaban as a stand-alone anticoagulant in patients with VTE
9. Guidelines for upper endoscopy use in gastroesophageal reflux disease

Avoid Preoperative Urine Culture in Nonurologic Surgical Procedures

Clinical question: Is routine preoperative urine screening beneficial?

Background: The value of preoperative urine screening is unproven, except before urologic procedures. Furthermore, treatment of asymptomatic bacteriuria may lead to adverse events, including diarrhea, allergic reactions, and Clostridium difficile infection (CDI).

Study design: Retrospective chart review.

Setting: Patients who underwent cardiothoracic, orthopedic, and vascular surgeries at the Minneapolis Veterans Affairs Medical Center in 2010.

Synopsis: A total of 1,934 procedures were performed on 1,699 patients, most of which were orthopedics procedures (1,291 in 1,115 patients). A urine culture was obtained before 25% of procedures with significant variation by service (cardiothoracic, 85%; vascular, 48%; orthopedic, 4%). Bacteriuria was detected in 11% of urine cultures (54 of 489), but antimicrobial drugs were dispensed to just 16 patients.

To identify correlates of preoperative urine culture use, patients with and without urine cultures were compared. The rate of surgical-site infection was similar for both groups. Postoperative UTI was more frequent among patients with bacteriuria. Rates of diarrhea, allergy, and CDI did not differ. Paradoxically, patients treated for preoperative UTI were more likely to develop surgical-site infections (45% vs. 14%; P=0.03). Postoperative UTI was also more frequent among treated patients versus untreated patients (18% vs. 7%).

Bottom line: This is the largest study to assess outcomes for routine preoperative urine cultures. These findings demonstrate that preoperative screening for, and treatment of, asymptomatic bacteriuria should be avoided in patients undergoing nonurologic surgical procedures.

Citation: Drekonja DM, Zarmbinski B, Johnson JR. Preoperative urine culture at a veterans affairs medical center. JAMA Intern Med. 2013;173(1):71-72.

Intermediate Care Staffed by Hospitalists: Impact on Mortality, Comanagement, and Teaching

Clinical question: Does a hospitalist-led intermediate-care unit improve patient survival?

Background: Hospitalized patients are complex, and institutions often have to balance matching patient acuity to either an ICU or a regular ward. However, an intermediate-care setting might be an attractive strategy to provide rational care according to patient needs while expanding comanagement and teaching services.

Study design: Retrospective observational study.

Setting: Intermediate-care unit of a single academic hospital.

Synopsis: In-hospital mortality in this intermediate-care unit was 20.6%, whereas the expected mortality was 23.2% based on Simplified Acute Physiology Score II (SAPS II) score. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (P<0.001). Comanagement was performed with several medical and surgical teams, with an increase in perioperative comanagement of 22.7% (P=0.014). The number of training residents in the intermediate-care unit increased to 30.4% from 4.3% (P=0.002).

Bottom line: An intermediate-care unit led by hospitalists showed encouraging results in patient mortality, as well as comanagement and teaching opportunities.

Citation: Lucena JF, Alegre F, Rodil R, et al. Results of a retrospective observational study of intermediate care staffed by hospitalists: impact on mortality, co-management, and teaching. J Hosp Med. 2012;7(5):411-415.

Blood Transfusion Associated with Increased Risk of Rebleeding in Patients with Nonvariceal Upper GI Bleeding

Clinical question: Does more liberal use of blood transfusions in the setting of nonvariceal upper GI bleeding result in patient harm?

Background: Randomized controlled trials have demonstrated that a more liberal approach to blood transfusions for patients in the medical intensive-care unit results in higher mortality. However, the potential harmful effect of blood transfusions in the setting of GI bleeding has not been demonstrated.

Study design: Retrospective cohort study.

Setting: Canadian hospitals.

Synopsis: Based on a retrospective analysis of the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), the authors determined there was a statistically significant association between patients who received a blood transfusion for the management of nonvariceal upper GI bleeding and the risk of rebleeding. The rate of rebleeding in patients who received a blood transfusion was 23.6% compared with 11.3% in patients who were not transfused (P<0.01). There was no statistically significant difference in mortality.

Although this was a reasonably large observational study that included 1,677 patients with nonvariceal upper GI bleeding, it is vulnerable to confounding. It suggests the need to further study potential harm of blood transfusion in the setting of GI bleeding, but it should not result in a change in clinical practice at this time.

Bottom line: Prospective randomized studies are needed to determine if there are harmful effects of blood transfusions in the setting of GI bleeding and to better define a threshold for transfusion.

Citation: Restellini S, Kherad O, Jairath V, Martel M, Barkun AN. Red blood cell transfusion is associated with increased rebleeding in patients with nonvariceal upper gastrointestinal bleeding. Aliment Pharmacol Ther. 2013;37:316-322.

Low-Dose Steroids in Sepsis Associated with Increase in Mortality

Clinical question: What is the role of steroids in the treatment of adult patients with sepsis?

Background: The Surviving Sepsis Campaign guidelines have previously recommended administering steroids to patients with septic shock not responsive to fluid resuscitation and who require vasopressors. However, prior randomized clinical trials studying the use of steroids in these settings have produced conflicting results.

Study design: Retrospective cohort study.

Setting: Two hundred fifty-two hospitals in North America, South America, and Europe.

Synopsis: The Surviving Sepsis Campaign management bundle has been shown to reduce mortality in patients with sepsis. However, it is not known which particular elements of the management bundle result in improved mortality. The Surviving Sepsis Campaign database included 17,847 patients who required vasopressor therapy after adequate fluid resuscitation. This subgroup was analyzed to see if there was a difference in mortality between patients who received low-dose steroids versus those who did not receive steroids. The mortality rate among those who received steroids was statistically higher (with odds ratio of 1.18 and P<0.001) compared with those who did not receive steroids. This finding adds to the body of evidence that calls into question the commonplace practice of administrating steroids to septic patients on vasopressor therapy.

The most recent campaign guidelines recommend the use of steroids in septic patients only if both adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability.

Bottom line: Further studies are needed to better define the role of steroids in the treatment of sepsis.

Citation: Casserly B, Gerlach H, Phillips GS, et al. Low-dose steroids in adult septic shock: results of the Surviving Sepsis Campaign. Intensive Care Med. 2012;38:1946-1954.

Link Between Length of Stay and Readmission Rates

Clinical question: How has reducing length of stay affected hospital readmission rates?

Background: There are ongoing concerns that improving a hospital’s efficiency by reducing length of stay (LOS) could be associated with higher hospital readmission rates. However, no studies evaluating the relationship between LOS and readmission rates have been done using recent data.

Study design: Retrospective observational study.

Setting: All acute-care Veterans Affairs (VA) hospitals in the U.S.

Synopsis: A total of 4,124,907 index admissions were included in the final sample from all acute medical admissions in 129 acute-care VA hospitals from October 1996 to September 2010. The primary outcomes were the hospital LOS and the 30-day readmission rate. Index admissions for heart failure, chronic obstructive pulmonary disease (COPD), acute myocardial infarction (AMI), community-acquired pneumonia, and gastrointestinal hemorrhage were also analyzed separately.

The risk-adjusted analysis of LOS demonstrated significant reductions for all admissions over the 14-year period, to 3.98 days from 5.44 days, and for all of the individual conditions with reductions ranging from 1.40 days for gastrointestinal hemorrhage to 2.85 days for AMI. There were similar significant reductions in 30-day readmission rates for all admissions to 13.8% from 16.5% and within the individual conditions ranging from 0.9% in community-acquired pneumonia to 3.3% in COPD. These results show that the reductions in LOS did not increase the risk of readmissions. The major limitation of the study was that these data are only from a single healthcare system.

Bottom line: Data from VA hospitals show that reductions in LOS do not have adverse effects on 30-day readmission rates; instead, both LOS and readmission rates improved over the same time period.

Citation: Kaboli PJ, Go JT, Hockenberry J, et al. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med. 2012;157:837-845.

Better to Restrict Blood Transfusions in Acute Myocardial Infarction

Clinical question: Is a liberal or restrictive blood transfusion strategy better in patients with anemia and acute myocardial infarction?

Background: Patients with acute myocardial infarction (AMI) are often given therapies that can increase their risk for bleeding and anemia, and it is known that AMI patients have a worse prognosis if they have concomitant anemia. No clear consensus exists on the benefit or harm of blood transfusions in AMI patients.

Study design: Systematic review and meta-analysis.

Setting: Ten articles included in the qualitative and quantitative analyses out of 729 screened articles from Jan. 1, 1966, to March 31, 2012, using the search terms “transfusion,” “myocardial infarction,” and “mortality” in English language.

Synopsis: A total of 203,665 study participants were identified from the 10 studies (one randomized and nine observational) that met the inclusion and exclusion criteria. All-cause mortality was significantly higher in AMI patients who received a blood transfusion compared with those who did not (18.2% vs. 10.2%). However, this difference was not statistically significant in patients that had a STEMI or in patients with a baseline hematocrit less than 30%. A multivariate meta-regression with several covariates, excluding demographics, also showed that blood transfusion was associated with higher mortality and higher risk for subsequent myocardial infarction. There was significant heterogeneity in all results, but no single study was found as the source of the heterogeneity, and no significant publication bias was identified. The major limitations to this study are that there is a paucity of randomized trials available that pertain to this specific topic and the authors did not have patient-level covariates to include in their analyses.

Bottom line: There appears to be an increased risk of mortality and subsequent myocardial infarction in AMI patients who receive blood transfusions versus those who do not.

Citation: Chatterjee S, Wetterslev J, Sharma A, Lichstein E, Mukherjee D. Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis. JAMA Intern Med. 2013;173(2):132-139.

Trends in GI Illnesses and Their Associated Costs

Clinical question: What are the new trends in GI illnesses and their associated costs?

Background: The frequency of illnesses and their treatment costs have changed over the last decade. In order to help healthcare providers focus their attention on these new trends, a new compilation of data is needed.

Study design: Epidemiological analysis.

Setting: Various governmental and private databases representing outpatient clinics, hospitals, and death certificates from multiple regions of the U.S.

Synopsis: The analysis was blinded to patient identifiers but represented multiple regions of the U.S. Symptoms were abstracted from patient surveys, and the rest of the data were collected from record review. The most common reported symptoms were abdominal pain, followed by nausea, vomiting, diarrhea, constipation, and heartburn. The most common clinic diagnoses were reflux, abdominal pain, enteritis/dyspepsia, and constipation. The most common inpatient discharge primary diagnoses included acute pancreatitis, cholecystitis, and diverticulitis. Impressive increases were seen in the number of morbidly obese, C. diff, and fatty liver diagnoses.

Colon cancer was the most common GI malignancy and had the highest mortality. C. diff was the ninth-leading cause of GI-related deaths. All types of scopes (except endoscopic retrograde cholangiopancreatography) were performed more commonly now than in the past, with colonoscopy being the most common. The most common indication for an upper endoscopy was reflux, which was also the most common outpatient GI diagnosis.

Bottom line: Healthcare providers need to be aware of new GI illness trends and their associated costs.

Citation: Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterol. 2012;143:1179-1187.

Is Apixaban a Good Stand-Alone Anticoagulant for Extended Treatment in VTE Patients?

Clinical question: Is apixaban an option for the extended treatment of VTE in a simple, fixed-dose regimen?

Background: Apixaban is an oral factor Xa inhibitor that is administered in fixed doses without the need for laboratory monitoring. In the Apixaban after the Initial Management of Pulmonary Embolism and Deep Vein Thrombosis with First-Line Therapy—Extended Treatment (AMPLIFY-EXT) study, investigators compared the efficacy and safety of two doses of apixaban (2.5 mg and 5 mg) with those of placebo in patients with VTE who had completed six to 12 months of anticoagulation therapy and for whom treating physicians were uncertain about continuing therapy. Additional aims of the study were to determine whether the lower dose of apixaban was effective and whether it was associated with less bleeding than the higher dose, and to examine the effect of treatment on arterial thrombotic outcomes.

Study design: Randomized, double-blind study.

Synopsis: A total of 2,486 patients underwent randomization, 2,482 of whom were included in the intention-to-treat analyses. Symptomatic recurrent VTE or death from VTE occurred in 73 of the 829 patients (8.8%) who were receiving placebo, compared with 14 of the 840 patients (1.7%) who were receiving 2.5 mg of apixaban (a difference of 7.2 percentage points; 95% confidence interval [CI], 5.0 to 9.3) and 14 of the 813 patients (1.7%) who were receiving 5 mg of apixaban (a difference of 7.0 percentage points; 95% CI, 4.9 to 9.1) (P<0.001 for both comparisons). The rates of major bleeding were 0.5% in the placebo group, 0.2% in the 2.5-mg apixaban group, and 0.1% in the 5-mg apixaban group. The rates of clinically relevant nonmajor bleeding were 2.3% in the placebo group, 3.0% in the 2.5-mg apixaban group, and 4.2% in the 5-mg apixaban group. The rate of death from any cause was 1.7% in the placebo group, compared with 0.8% in the 2.5-mg apixaban group and 0.5% in the 5-mg apixaban group.

Bottom line: Apixaban is a safe and effective anticoagulant for extended anticoagulation in patients with VTE initially treated with six to 12 months of warfarin.

Citation: Agnelli GM, Buller HR, Cohen A, et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med. 2013;368(8):699-708.

ACP Guideline Review: Upper Endoscopy for Gastroesophageal Reflux Disease

Clinical question: What are the indications of upper endoscopy in the setting of gastroesophageal reflux disease (GERD)?

Background: GERD is a common condition. Upper endoscopy is widely available and routinely used for diagnosis and management of GERD and its complications. The indications for this procedure are not clearly defined. Overuse of upper endoscopy contributes to higher healthcare costs without improving patient outcomes.

Study design: Literature review and comparison of clinical guidelines from professional organizations by a team of general internists, gastroenterologists, and clinical epidemiologists. The document was not based on a formal systemic review but was intended to provide practical advice based on the best available evidence.

Synopsis: Best practice advice No. 1: Upper endoscopy is indicated in men and women with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting).

Best practice advice No. 2: Upper endoscopy is indicated in men and women with typical GERD symptoms that persist despite a therapeutic trial of four to eight weeks of twice-daily proton-pump inhibitor therapy, severe erosive esophagitis after a two-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett esophagus, and history of esophageal stricture who have recurrent symptoms of dysphagia.

Best practice advice No. 3: Upper endoscopy might be indicated in men older than 50 with chronic GERD symptoms (symptoms for more than five years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett esophagus. It might also be indicated for surveillance evaluation in men and women with a history of Barrett esophagus. In men and women with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than three to five years. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia.

Bottom line: Use upper endoscopy selectively for patients with GERD.

Citation: Shaheen NJ, Weinberg DS, Denberg TD, et al. Upper endoscopy for gastroesophageal reflux disease: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2012;157(11):808-816.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Value of routine preoperative urine screening assessed
2. Impact of hospitalist-led intermediate care on patient survival
3. Risks of blood transfusion to treat upper GI bleeding
4. Low-dose steroids and increased mortality in sepsis
5. Reduced length of stay and hospital readmission rates
6. Restrictive blood transfusion strategies better for acute myocardial infarction
7. Trends in GI illnesses and their associated costs
8. Apixaban as a stand-alone anticoagulant in patients with VTE
9. Guidelines for upper endoscopy use in gastroesophageal reflux disease

Avoid Preoperative Urine Culture in Nonurologic Surgical Procedures

Clinical question: Is routine preoperative urine screening beneficial?

Background: The value of preoperative urine screening is unproven, except before urologic procedures. Furthermore, treatment of asymptomatic bacteriuria may lead to adverse events, including diarrhea, allergic reactions, and Clostridium difficile infection (CDI).

Study design: Retrospective chart review.

Setting: Patients who underwent cardiothoracic, orthopedic, and vascular surgeries at the Minneapolis Veterans Affairs Medical Center in 2010.

Synopsis: A total of 1,934 procedures were performed on 1,699 patients, most of which were orthopedics procedures (1,291 in 1,115 patients). A urine culture was obtained before 25% of procedures with significant variation by service (cardiothoracic, 85%; vascular, 48%; orthopedic, 4%). Bacteriuria was detected in 11% of urine cultures (54 of 489), but antimicrobial drugs were dispensed to just 16 patients.

To identify correlates of preoperative urine culture use, patients with and without urine cultures were compared. The rate of surgical-site infection was similar for both groups. Postoperative UTI was more frequent among patients with bacteriuria. Rates of diarrhea, allergy, and CDI did not differ. Paradoxically, patients treated for preoperative UTI were more likely to develop surgical-site infections (45% vs. 14%; P=0.03). Postoperative UTI was also more frequent among treated patients versus untreated patients (18% vs. 7%).

Bottom line: This is the largest study to assess outcomes for routine preoperative urine cultures. These findings demonstrate that preoperative screening for, and treatment of, asymptomatic bacteriuria should be avoided in patients undergoing nonurologic surgical procedures.

Citation: Drekonja DM, Zarmbinski B, Johnson JR. Preoperative urine culture at a veterans affairs medical center. JAMA Intern Med. 2013;173(1):71-72.

Intermediate Care Staffed by Hospitalists: Impact on Mortality, Comanagement, and Teaching

Clinical question: Does a hospitalist-led intermediate-care unit improve patient survival?

Background: Hospitalized patients are complex, and institutions often have to balance matching patient acuity to either an ICU or a regular ward. However, an intermediate-care setting might be an attractive strategy to provide rational care according to patient needs while expanding comanagement and teaching services.

Study design: Retrospective observational study.

Setting: Intermediate-care unit of a single academic hospital.

Synopsis: In-hospital mortality in this intermediate-care unit was 20.6%, whereas the expected mortality was 23.2% based on Simplified Acute Physiology Score II (SAPS II) score. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (P<0.001). Comanagement was performed with several medical and surgical teams, with an increase in perioperative comanagement of 22.7% (P=0.014). The number of training residents in the intermediate-care unit increased to 30.4% from 4.3% (P=0.002).

Bottom line: An intermediate-care unit led by hospitalists showed encouraging results in patient mortality, as well as comanagement and teaching opportunities.

Citation: Lucena JF, Alegre F, Rodil R, et al. Results of a retrospective observational study of intermediate care staffed by hospitalists: impact on mortality, co-management, and teaching. J Hosp Med. 2012;7(5):411-415.

Blood Transfusion Associated with Increased Risk of Rebleeding in Patients with Nonvariceal Upper GI Bleeding

Clinical question: Does more liberal use of blood transfusions in the setting of nonvariceal upper GI bleeding result in patient harm?

Background: Randomized controlled trials have demonstrated that a more liberal approach to blood transfusions for patients in the medical intensive-care unit results in higher mortality. However, the potential harmful effect of blood transfusions in the setting of GI bleeding has not been demonstrated.

Study design: Retrospective cohort study.

Setting: Canadian hospitals.

Synopsis: Based on a retrospective analysis of the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), the authors determined there was a statistically significant association between patients who received a blood transfusion for the management of nonvariceal upper GI bleeding and the risk of rebleeding. The rate of rebleeding in patients who received a blood transfusion was 23.6% compared with 11.3% in patients who were not transfused (P<0.01). There was no statistically significant difference in mortality.

Although this was a reasonably large observational study that included 1,677 patients with nonvariceal upper GI bleeding, it is vulnerable to confounding. It suggests the need to further study potential harm of blood transfusion in the setting of GI bleeding, but it should not result in a change in clinical practice at this time.

Bottom line: Prospective randomized studies are needed to determine if there are harmful effects of blood transfusions in the setting of GI bleeding and to better define a threshold for transfusion.

Citation: Restellini S, Kherad O, Jairath V, Martel M, Barkun AN. Red blood cell transfusion is associated with increased rebleeding in patients with nonvariceal upper gastrointestinal bleeding. Aliment Pharmacol Ther. 2013;37:316-322.

Low-Dose Steroids in Sepsis Associated with Increase in Mortality

Clinical question: What is the role of steroids in the treatment of adult patients with sepsis?

Background: The Surviving Sepsis Campaign guidelines have previously recommended administering steroids to patients with septic shock not responsive to fluid resuscitation and who require vasopressors. However, prior randomized clinical trials studying the use of steroids in these settings have produced conflicting results.

Study design: Retrospective cohort study.

Setting: Two hundred fifty-two hospitals in North America, South America, and Europe.

Synopsis: The Surviving Sepsis Campaign management bundle has been shown to reduce mortality in patients with sepsis. However, it is not known which particular elements of the management bundle result in improved mortality. The Surviving Sepsis Campaign database included 17,847 patients who required vasopressor therapy after adequate fluid resuscitation. This subgroup was analyzed to see if there was a difference in mortality between patients who received low-dose steroids versus those who did not receive steroids. The mortality rate among those who received steroids was statistically higher (with odds ratio of 1.18 and P<0.001) compared with those who did not receive steroids. This finding adds to the body of evidence that calls into question the commonplace practice of administrating steroids to septic patients on vasopressor therapy.

The most recent campaign guidelines recommend the use of steroids in septic patients only if both adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability.

Bottom line: Further studies are needed to better define the role of steroids in the treatment of sepsis.

Citation: Casserly B, Gerlach H, Phillips GS, et al. Low-dose steroids in adult septic shock: results of the Surviving Sepsis Campaign. Intensive Care Med. 2012;38:1946-1954.

Link Between Length of Stay and Readmission Rates

Clinical question: How has reducing length of stay affected hospital readmission rates?

Background: There are ongoing concerns that improving a hospital’s efficiency by reducing length of stay (LOS) could be associated with higher hospital readmission rates. However, no studies evaluating the relationship between LOS and readmission rates have been done using recent data.

Study design: Retrospective observational study.

Setting: All acute-care Veterans Affairs (VA) hospitals in the U.S.

Synopsis: A total of 4,124,907 index admissions were included in the final sample from all acute medical admissions in 129 acute-care VA hospitals from October 1996 to September 2010. The primary outcomes were the hospital LOS and the 30-day readmission rate. Index admissions for heart failure, chronic obstructive pulmonary disease (COPD), acute myocardial infarction (AMI), community-acquired pneumonia, and gastrointestinal hemorrhage were also analyzed separately.

The risk-adjusted analysis of LOS demonstrated significant reductions for all admissions over the 14-year period, to 3.98 days from 5.44 days, and for all of the individual conditions with reductions ranging from 1.40 days for gastrointestinal hemorrhage to 2.85 days for AMI. There were similar significant reductions in 30-day readmission rates for all admissions to 13.8% from 16.5% and within the individual conditions ranging from 0.9% in community-acquired pneumonia to 3.3% in COPD. These results show that the reductions in LOS did not increase the risk of readmissions. The major limitation of the study was that these data are only from a single healthcare system.

Bottom line: Data from VA hospitals show that reductions in LOS do not have adverse effects on 30-day readmission rates; instead, both LOS and readmission rates improved over the same time period.

Citation: Kaboli PJ, Go JT, Hockenberry J, et al. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med. 2012;157:837-845.

Better to Restrict Blood Transfusions in Acute Myocardial Infarction

Clinical question: Is a liberal or restrictive blood transfusion strategy better in patients with anemia and acute myocardial infarction?

Background: Patients with acute myocardial infarction (AMI) are often given therapies that can increase their risk for bleeding and anemia, and it is known that AMI patients have a worse prognosis if they have concomitant anemia. No clear consensus exists on the benefit or harm of blood transfusions in AMI patients.

Study design: Systematic review and meta-analysis.

Setting: Ten articles included in the qualitative and quantitative analyses out of 729 screened articles from Jan. 1, 1966, to March 31, 2012, using the search terms “transfusion,” “myocardial infarction,” and “mortality” in English language.

Synopsis: A total of 203,665 study participants were identified from the 10 studies (one randomized and nine observational) that met the inclusion and exclusion criteria. All-cause mortality was significantly higher in AMI patients who received a blood transfusion compared with those who did not (18.2% vs. 10.2%). However, this difference was not statistically significant in patients that had a STEMI or in patients with a baseline hematocrit less than 30%. A multivariate meta-regression with several covariates, excluding demographics, also showed that blood transfusion was associated with higher mortality and higher risk for subsequent myocardial infarction. There was significant heterogeneity in all results, but no single study was found as the source of the heterogeneity, and no significant publication bias was identified. The major limitations to this study are that there is a paucity of randomized trials available that pertain to this specific topic and the authors did not have patient-level covariates to include in their analyses.

Bottom line: There appears to be an increased risk of mortality and subsequent myocardial infarction in AMI patients who receive blood transfusions versus those who do not.

Citation: Chatterjee S, Wetterslev J, Sharma A, Lichstein E, Mukherjee D. Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis. JAMA Intern Med. 2013;173(2):132-139.

Trends in GI Illnesses and Their Associated Costs

Clinical question: What are the new trends in GI illnesses and their associated costs?

Background: The frequency of illnesses and their treatment costs have changed over the last decade. In order to help healthcare providers focus their attention on these new trends, a new compilation of data is needed.

Study design: Epidemiological analysis.

Setting: Various governmental and private databases representing outpatient clinics, hospitals, and death certificates from multiple regions of the U.S.

Synopsis: The analysis was blinded to patient identifiers but represented multiple regions of the U.S. Symptoms were abstracted from patient surveys, and the rest of the data were collected from record review. The most common reported symptoms were abdominal pain, followed by nausea, vomiting, diarrhea, constipation, and heartburn. The most common clinic diagnoses were reflux, abdominal pain, enteritis/dyspepsia, and constipation. The most common inpatient discharge primary diagnoses included acute pancreatitis, cholecystitis, and diverticulitis. Impressive increases were seen in the number of morbidly obese, C. diff, and fatty liver diagnoses.

Colon cancer was the most common GI malignancy and had the highest mortality. C. diff was the ninth-leading cause of GI-related deaths. All types of scopes (except endoscopic retrograde cholangiopancreatography) were performed more commonly now than in the past, with colonoscopy being the most common. The most common indication for an upper endoscopy was reflux, which was also the most common outpatient GI diagnosis.

Bottom line: Healthcare providers need to be aware of new GI illness trends and their associated costs.

Citation: Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterol. 2012;143:1179-1187.

Is Apixaban a Good Stand-Alone Anticoagulant for Extended Treatment in VTE Patients?

Clinical question: Is apixaban an option for the extended treatment of VTE in a simple, fixed-dose regimen?

Background: Apixaban is an oral factor Xa inhibitor that is administered in fixed doses without the need for laboratory monitoring. In the Apixaban after the Initial Management of Pulmonary Embolism and Deep Vein Thrombosis with First-Line Therapy—Extended Treatment (AMPLIFY-EXT) study, investigators compared the efficacy and safety of two doses of apixaban (2.5 mg and 5 mg) with those of placebo in patients with VTE who had completed six to 12 months of anticoagulation therapy and for whom treating physicians were uncertain about continuing therapy. Additional aims of the study were to determine whether the lower dose of apixaban was effective and whether it was associated with less bleeding than the higher dose, and to examine the effect of treatment on arterial thrombotic outcomes.

Study design: Randomized, double-blind study.

Synopsis: A total of 2,486 patients underwent randomization, 2,482 of whom were included in the intention-to-treat analyses. Symptomatic recurrent VTE or death from VTE occurred in 73 of the 829 patients (8.8%) who were receiving placebo, compared with 14 of the 840 patients (1.7%) who were receiving 2.5 mg of apixaban (a difference of 7.2 percentage points; 95% confidence interval [CI], 5.0 to 9.3) and 14 of the 813 patients (1.7%) who were receiving 5 mg of apixaban (a difference of 7.0 percentage points; 95% CI, 4.9 to 9.1) (P<0.001 for both comparisons). The rates of major bleeding were 0.5% in the placebo group, 0.2% in the 2.5-mg apixaban group, and 0.1% in the 5-mg apixaban group. The rates of clinically relevant nonmajor bleeding were 2.3% in the placebo group, 3.0% in the 2.5-mg apixaban group, and 4.2% in the 5-mg apixaban group. The rate of death from any cause was 1.7% in the placebo group, compared with 0.8% in the 2.5-mg apixaban group and 0.5% in the 5-mg apixaban group.

Bottom line: Apixaban is a safe and effective anticoagulant for extended anticoagulation in patients with VTE initially treated with six to 12 months of warfarin.

Citation: Agnelli GM, Buller HR, Cohen A, et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med. 2013;368(8):699-708.

ACP Guideline Review: Upper Endoscopy for Gastroesophageal Reflux Disease

Clinical question: What are the indications of upper endoscopy in the setting of gastroesophageal reflux disease (GERD)?

Background: GERD is a common condition. Upper endoscopy is widely available and routinely used for diagnosis and management of GERD and its complications. The indications for this procedure are not clearly defined. Overuse of upper endoscopy contributes to higher healthcare costs without improving patient outcomes.

Study design: Literature review and comparison of clinical guidelines from professional organizations by a team of general internists, gastroenterologists, and clinical epidemiologists. The document was not based on a formal systemic review but was intended to provide practical advice based on the best available evidence.

Synopsis: Best practice advice No. 1: Upper endoscopy is indicated in men and women with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting).

Best practice advice No. 2: Upper endoscopy is indicated in men and women with typical GERD symptoms that persist despite a therapeutic trial of four to eight weeks of twice-daily proton-pump inhibitor therapy, severe erosive esophagitis after a two-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett esophagus, and history of esophageal stricture who have recurrent symptoms of dysphagia.

Best practice advice No. 3: Upper endoscopy might be indicated in men older than 50 with chronic GERD symptoms (symptoms for more than five years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett esophagus. It might also be indicated for surveillance evaluation in men and women with a history of Barrett esophagus. In men and women with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than three to five years. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia.

Bottom line: Use upper endoscopy selectively for patients with GERD.

Citation: Shaheen NJ, Weinberg DS, Denberg TD, et al. Upper endoscopy for gastroesophageal reflux disease: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2012;157(11):808-816.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Value of routine preoperative urine screening assessed
2. Impact of hospitalist-led intermediate care on patient survival
3. Risks of blood transfusion to treat upper GI bleeding
4. Low-dose steroids and increased mortality in sepsis
5. Reduced length of stay and hospital readmission rates
6. Restrictive blood transfusion strategies better for acute myocardial infarction
7. Trends in GI illnesses and their associated costs
8. Apixaban as a stand-alone anticoagulant in patients with VTE
9. Guidelines for upper endoscopy use in gastroesophageal reflux disease

Avoid Preoperative Urine Culture in Nonurologic Surgical Procedures

Clinical question: Is routine preoperative urine screening beneficial?

Background: The value of preoperative urine screening is unproven, except before urologic procedures. Furthermore, treatment of asymptomatic bacteriuria may lead to adverse events, including diarrhea, allergic reactions, and Clostridium difficile infection (CDI).

Study design: Retrospective chart review.

Setting: Patients who underwent cardiothoracic, orthopedic, and vascular surgeries at the Minneapolis Veterans Affairs Medical Center in 2010.

Synopsis: A total of 1,934 procedures were performed on 1,699 patients, most of which were orthopedics procedures (1,291 in 1,115 patients). A urine culture was obtained before 25% of procedures with significant variation by service (cardiothoracic, 85%; vascular, 48%; orthopedic, 4%). Bacteriuria was detected in 11% of urine cultures (54 of 489), but antimicrobial drugs were dispensed to just 16 patients.

To identify correlates of preoperative urine culture use, patients with and without urine cultures were compared. The rate of surgical-site infection was similar for both groups. Postoperative UTI was more frequent among patients with bacteriuria. Rates of diarrhea, allergy, and CDI did not differ. Paradoxically, patients treated for preoperative UTI were more likely to develop surgical-site infections (45% vs. 14%; P=0.03). Postoperative UTI was also more frequent among treated patients versus untreated patients (18% vs. 7%).

Bottom line: This is the largest study to assess outcomes for routine preoperative urine cultures. These findings demonstrate that preoperative screening for, and treatment of, asymptomatic bacteriuria should be avoided in patients undergoing nonurologic surgical procedures.

Citation: Drekonja DM, Zarmbinski B, Johnson JR. Preoperative urine culture at a veterans affairs medical center. JAMA Intern Med. 2013;173(1):71-72.

Intermediate Care Staffed by Hospitalists: Impact on Mortality, Comanagement, and Teaching

Clinical question: Does a hospitalist-led intermediate-care unit improve patient survival?

Background: Hospitalized patients are complex, and institutions often have to balance matching patient acuity to either an ICU or a regular ward. However, an intermediate-care setting might be an attractive strategy to provide rational care according to patient needs while expanding comanagement and teaching services.

Study design: Retrospective observational study.

Setting: Intermediate-care unit of a single academic hospital.

Synopsis: In-hospital mortality in this intermediate-care unit was 20.6%, whereas the expected mortality was 23.2% based on Simplified Acute Physiology Score II (SAPS II) score. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (P<0.001). Comanagement was performed with several medical and surgical teams, with an increase in perioperative comanagement of 22.7% (P=0.014). The number of training residents in the intermediate-care unit increased to 30.4% from 4.3% (P=0.002).

Bottom line: An intermediate-care unit led by hospitalists showed encouraging results in patient mortality, as well as comanagement and teaching opportunities.

Citation: Lucena JF, Alegre F, Rodil R, et al. Results of a retrospective observational study of intermediate care staffed by hospitalists: impact on mortality, co-management, and teaching. J Hosp Med. 2012;7(5):411-415.

Blood Transfusion Associated with Increased Risk of Rebleeding in Patients with Nonvariceal Upper GI Bleeding

Clinical question: Does more liberal use of blood transfusions in the setting of nonvariceal upper GI bleeding result in patient harm?

Background: Randomized controlled trials have demonstrated that a more liberal approach to blood transfusions for patients in the medical intensive-care unit results in higher mortality. However, the potential harmful effect of blood transfusions in the setting of GI bleeding has not been demonstrated.

Study design: Retrospective cohort study.

Setting: Canadian hospitals.

Synopsis: Based on a retrospective analysis of the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), the authors determined there was a statistically significant association between patients who received a blood transfusion for the management of nonvariceal upper GI bleeding and the risk of rebleeding. The rate of rebleeding in patients who received a blood transfusion was 23.6% compared with 11.3% in patients who were not transfused (P<0.01). There was no statistically significant difference in mortality.

Although this was a reasonably large observational study that included 1,677 patients with nonvariceal upper GI bleeding, it is vulnerable to confounding. It suggests the need to further study potential harm of blood transfusion in the setting of GI bleeding, but it should not result in a change in clinical practice at this time.

Bottom line: Prospective randomized studies are needed to determine if there are harmful effects of blood transfusions in the setting of GI bleeding and to better define a threshold for transfusion.

Citation: Restellini S, Kherad O, Jairath V, Martel M, Barkun AN. Red blood cell transfusion is associated with increased rebleeding in patients with nonvariceal upper gastrointestinal bleeding. Aliment Pharmacol Ther. 2013;37:316-322.

Low-Dose Steroids in Sepsis Associated with Increase in Mortality

Clinical question: What is the role of steroids in the treatment of adult patients with sepsis?

Background: The Surviving Sepsis Campaign guidelines have previously recommended administering steroids to patients with septic shock not responsive to fluid resuscitation and who require vasopressors. However, prior randomized clinical trials studying the use of steroids in these settings have produced conflicting results.

Study design: Retrospective cohort study.

Setting: Two hundred fifty-two hospitals in North America, South America, and Europe.

Synopsis: The Surviving Sepsis Campaign management bundle has been shown to reduce mortality in patients with sepsis. However, it is not known which particular elements of the management bundle result in improved mortality. The Surviving Sepsis Campaign database included 17,847 patients who required vasopressor therapy after adequate fluid resuscitation. This subgroup was analyzed to see if there was a difference in mortality between patients who received low-dose steroids versus those who did not receive steroids. The mortality rate among those who received steroids was statistically higher (with odds ratio of 1.18 and P<0.001) compared with those who did not receive steroids. This finding adds to the body of evidence that calls into question the commonplace practice of administrating steroids to septic patients on vasopressor therapy.

The most recent campaign guidelines recommend the use of steroids in septic patients only if both adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability.

Bottom line: Further studies are needed to better define the role of steroids in the treatment of sepsis.

Citation: Casserly B, Gerlach H, Phillips GS, et al. Low-dose steroids in adult septic shock: results of the Surviving Sepsis Campaign. Intensive Care Med. 2012;38:1946-1954.

Link Between Length of Stay and Readmission Rates

Clinical question: How has reducing length of stay affected hospital readmission rates?

Background: There are ongoing concerns that improving a hospital’s efficiency by reducing length of stay (LOS) could be associated with higher hospital readmission rates. However, no studies evaluating the relationship between LOS and readmission rates have been done using recent data.

Study design: Retrospective observational study.

Setting: All acute-care Veterans Affairs (VA) hospitals in the U.S.

Synopsis: A total of 4,124,907 index admissions were included in the final sample from all acute medical admissions in 129 acute-care VA hospitals from October 1996 to September 2010. The primary outcomes were the hospital LOS and the 30-day readmission rate. Index admissions for heart failure, chronic obstructive pulmonary disease (COPD), acute myocardial infarction (AMI), community-acquired pneumonia, and gastrointestinal hemorrhage were also analyzed separately.

The risk-adjusted analysis of LOS demonstrated significant reductions for all admissions over the 14-year period, to 3.98 days from 5.44 days, and for all of the individual conditions with reductions ranging from 1.40 days for gastrointestinal hemorrhage to 2.85 days for AMI. There were similar significant reductions in 30-day readmission rates for all admissions to 13.8% from 16.5% and within the individual conditions ranging from 0.9% in community-acquired pneumonia to 3.3% in COPD. These results show that the reductions in LOS did not increase the risk of readmissions. The major limitation of the study was that these data are only from a single healthcare system.

Bottom line: Data from VA hospitals show that reductions in LOS do not have adverse effects on 30-day readmission rates; instead, both LOS and readmission rates improved over the same time period.

Citation: Kaboli PJ, Go JT, Hockenberry J, et al. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med. 2012;157:837-845.

Better to Restrict Blood Transfusions in Acute Myocardial Infarction

Clinical question: Is a liberal or restrictive blood transfusion strategy better in patients with anemia and acute myocardial infarction?

Background: Patients with acute myocardial infarction (AMI) are often given therapies that can increase their risk for bleeding and anemia, and it is known that AMI patients have a worse prognosis if they have concomitant anemia. No clear consensus exists on the benefit or harm of blood transfusions in AMI patients.

Study design: Systematic review and meta-analysis.

Setting: Ten articles included in the qualitative and quantitative analyses out of 729 screened articles from Jan. 1, 1966, to March 31, 2012, using the search terms “transfusion,” “myocardial infarction,” and “mortality” in English language.

Synopsis: A total of 203,665 study participants were identified from the 10 studies (one randomized and nine observational) that met the inclusion and exclusion criteria. All-cause mortality was significantly higher in AMI patients who received a blood transfusion compared with those who did not (18.2% vs. 10.2%). However, this difference was not statistically significant in patients that had a STEMI or in patients with a baseline hematocrit less than 30%. A multivariate meta-regression with several covariates, excluding demographics, also showed that blood transfusion was associated with higher mortality and higher risk for subsequent myocardial infarction. There was significant heterogeneity in all results, but no single study was found as the source of the heterogeneity, and no significant publication bias was identified. The major limitations to this study are that there is a paucity of randomized trials available that pertain to this specific topic and the authors did not have patient-level covariates to include in their analyses.

Bottom line: There appears to be an increased risk of mortality and subsequent myocardial infarction in AMI patients who receive blood transfusions versus those who do not.

Citation: Chatterjee S, Wetterslev J, Sharma A, Lichstein E, Mukherjee D. Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis. JAMA Intern Med. 2013;173(2):132-139.

Trends in GI Illnesses and Their Associated Costs

Clinical question: What are the new trends in GI illnesses and their associated costs?

Background: The frequency of illnesses and their treatment costs have changed over the last decade. In order to help healthcare providers focus their attention on these new trends, a new compilation of data is needed.

Study design: Epidemiological analysis.

Setting: Various governmental and private databases representing outpatient clinics, hospitals, and death certificates from multiple regions of the U.S.

Synopsis: The analysis was blinded to patient identifiers but represented multiple regions of the U.S. Symptoms were abstracted from patient surveys, and the rest of the data were collected from record review. The most common reported symptoms were abdominal pain, followed by nausea, vomiting, diarrhea, constipation, and heartburn. The most common clinic diagnoses were reflux, abdominal pain, enteritis/dyspepsia, and constipation. The most common inpatient discharge primary diagnoses included acute pancreatitis, cholecystitis, and diverticulitis. Impressive increases were seen in the number of morbidly obese, C. diff, and fatty liver diagnoses.

Colon cancer was the most common GI malignancy and had the highest mortality. C. diff was the ninth-leading cause of GI-related deaths. All types of scopes (except endoscopic retrograde cholangiopancreatography) were performed more commonly now than in the past, with colonoscopy being the most common. The most common indication for an upper endoscopy was reflux, which was also the most common outpatient GI diagnosis.

Bottom line: Healthcare providers need to be aware of new GI illness trends and their associated costs.

Citation: Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterol. 2012;143:1179-1187.

Is Apixaban a Good Stand-Alone Anticoagulant for Extended Treatment in VTE Patients?

Clinical question: Is apixaban an option for the extended treatment of VTE in a simple, fixed-dose regimen?

Background: Apixaban is an oral factor Xa inhibitor that is administered in fixed doses without the need for laboratory monitoring. In the Apixaban after the Initial Management of Pulmonary Embolism and Deep Vein Thrombosis with First-Line Therapy—Extended Treatment (AMPLIFY-EXT) study, investigators compared the efficacy and safety of two doses of apixaban (2.5 mg and 5 mg) with those of placebo in patients with VTE who had completed six to 12 months of anticoagulation therapy and for whom treating physicians were uncertain about continuing therapy. Additional aims of the study were to determine whether the lower dose of apixaban was effective and whether it was associated with less bleeding than the higher dose, and to examine the effect of treatment on arterial thrombotic outcomes.

Study design: Randomized, double-blind study.

Synopsis: A total of 2,486 patients underwent randomization, 2,482 of whom were included in the intention-to-treat analyses. Symptomatic recurrent VTE or death from VTE occurred in 73 of the 829 patients (8.8%) who were receiving placebo, compared with 14 of the 840 patients (1.7%) who were receiving 2.5 mg of apixaban (a difference of 7.2 percentage points; 95% confidence interval [CI], 5.0 to 9.3) and 14 of the 813 patients (1.7%) who were receiving 5 mg of apixaban (a difference of 7.0 percentage points; 95% CI, 4.9 to 9.1) (P<0.001 for both comparisons). The rates of major bleeding were 0.5% in the placebo group, 0.2% in the 2.5-mg apixaban group, and 0.1% in the 5-mg apixaban group. The rates of clinically relevant nonmajor bleeding were 2.3% in the placebo group, 3.0% in the 2.5-mg apixaban group, and 4.2% in the 5-mg apixaban group. The rate of death from any cause was 1.7% in the placebo group, compared with 0.8% in the 2.5-mg apixaban group and 0.5% in the 5-mg apixaban group.

Bottom line: Apixaban is a safe and effective anticoagulant for extended anticoagulation in patients with VTE initially treated with six to 12 months of warfarin.

Citation: Agnelli GM, Buller HR, Cohen A, et al. Apixaban for extended treatment of venous thromboembolism. N Engl J Med. 2013;368(8):699-708.

ACP Guideline Review: Upper Endoscopy for Gastroesophageal Reflux Disease

Clinical question: What are the indications of upper endoscopy in the setting of gastroesophageal reflux disease (GERD)?

Background: GERD is a common condition. Upper endoscopy is widely available and routinely used for diagnosis and management of GERD and its complications. The indications for this procedure are not clearly defined. Overuse of upper endoscopy contributes to higher healthcare costs without improving patient outcomes.

Study design: Literature review and comparison of clinical guidelines from professional organizations by a team of general internists, gastroenterologists, and clinical epidemiologists. The document was not based on a formal systemic review but was intended to provide practical advice based on the best available evidence.

Synopsis: Best practice advice No. 1: Upper endoscopy is indicated in men and women with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting).

Best practice advice No. 2: Upper endoscopy is indicated in men and women with typical GERD symptoms that persist despite a therapeutic trial of four to eight weeks of twice-daily proton-pump inhibitor therapy, severe erosive esophagitis after a two-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett esophagus, and history of esophageal stricture who have recurrent symptoms of dysphagia.

Best practice advice No. 3: Upper endoscopy might be indicated in men older than 50 with chronic GERD symptoms (symptoms for more than five years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett esophagus. It might also be indicated for surveillance evaluation in men and women with a history of Barrett esophagus. In men and women with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than three to five years. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia.

Bottom line: Use upper endoscopy selectively for patients with GERD.

Citation: Shaheen NJ, Weinberg DS, Denberg TD, et al. Upper endoscopy for gastroesophageal reflux disease: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2012;157(11):808-816.