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When one patient decompensates, others on the ward may follow
Clinical question: How does the clinical decompensation of a ward patient affect the likelihood of another patient’s decompensation?
Background: Previous research has attempted to identify patient-specific characteristics for risk of decompensation, but there may be environmental factors that contribute.
Setting: Thirteen geographically distinct, adult medical-surgical wards at an academic medical center.
Synopsis: Of 83,723 admissions to medical-surgical wards, 4,286 patients experienced cardiac arrest (179) or were transferred to the ICU (4,107). When one or more of these events occurred, other patients on the same ward had an increased risk for either event over the subsequent 6 (OR 1.18; CI, 1.07-1.31) and 12 hours and the risk was higher if more than one event occurred. Importantly, for patients exposed to other patients on the same ward decompensating, there were no differences in the severity of illness for patients transferred to ICU or in overall mortality.
Intuitively, when one patient becomes critically ill, other patients receive less attention. Though the effect was small, this study highlights that diversion of resources may increase other patients to greater risk. Surprisingly, the increased risk was not significant during night-time hours, when resources are more limited, but data collection may have been also affected.
Bottom Line: When a patient becomes critically ill, another patient on the same ward is more likely to decompensate within the next 6-12 hours, but the effect is small.
Citations: Volchenboum SL, Mayampurath A, Göksu-Gürsoy G, et al. Association between in-hospital critical illness events and outcomes in patients on the same ward. JAMA. 2016;316(24):2674-5.
Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical question: How does the clinical decompensation of a ward patient affect the likelihood of another patient’s decompensation?
Background: Previous research has attempted to identify patient-specific characteristics for risk of decompensation, but there may be environmental factors that contribute.
Setting: Thirteen geographically distinct, adult medical-surgical wards at an academic medical center.
Synopsis: Of 83,723 admissions to medical-surgical wards, 4,286 patients experienced cardiac arrest (179) or were transferred to the ICU (4,107). When one or more of these events occurred, other patients on the same ward had an increased risk for either event over the subsequent 6 (OR 1.18; CI, 1.07-1.31) and 12 hours and the risk was higher if more than one event occurred. Importantly, for patients exposed to other patients on the same ward decompensating, there were no differences in the severity of illness for patients transferred to ICU or in overall mortality.
Intuitively, when one patient becomes critically ill, other patients receive less attention. Though the effect was small, this study highlights that diversion of resources may increase other patients to greater risk. Surprisingly, the increased risk was not significant during night-time hours, when resources are more limited, but data collection may have been also affected.
Bottom Line: When a patient becomes critically ill, another patient on the same ward is more likely to decompensate within the next 6-12 hours, but the effect is small.
Citations: Volchenboum SL, Mayampurath A, Göksu-Gürsoy G, et al. Association between in-hospital critical illness events and outcomes in patients on the same ward. JAMA. 2016;316(24):2674-5.
Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical question: How does the clinical decompensation of a ward patient affect the likelihood of another patient’s decompensation?
Background: Previous research has attempted to identify patient-specific characteristics for risk of decompensation, but there may be environmental factors that contribute.
Setting: Thirteen geographically distinct, adult medical-surgical wards at an academic medical center.
Synopsis: Of 83,723 admissions to medical-surgical wards, 4,286 patients experienced cardiac arrest (179) or were transferred to the ICU (4,107). When one or more of these events occurred, other patients on the same ward had an increased risk for either event over the subsequent 6 (OR 1.18; CI, 1.07-1.31) and 12 hours and the risk was higher if more than one event occurred. Importantly, for patients exposed to other patients on the same ward decompensating, there were no differences in the severity of illness for patients transferred to ICU or in overall mortality.
Intuitively, when one patient becomes critically ill, other patients receive less attention. Though the effect was small, this study highlights that diversion of resources may increase other patients to greater risk. Surprisingly, the increased risk was not significant during night-time hours, when resources are more limited, but data collection may have been also affected.
Bottom Line: When a patient becomes critically ill, another patient on the same ward is more likely to decompensate within the next 6-12 hours, but the effect is small.
Citations: Volchenboum SL, Mayampurath A, Göksu-Gürsoy G, et al. Association between in-hospital critical illness events and outcomes in patients on the same ward. JAMA. 2016;316(24):2674-5.
Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Principles learned from a successful improvement program can increase compliance and reduce hospital acquired VTEs (HA-VTEs) across multiple institutions
Clinical question: Can a single institution’s VTE prophylaxis program be scaled to increase prophylaxis and reduce HA-VTEs across multiple institutions?
Study design: prospective, unblinded, open-intervention study
Setting: Inpatient medical and surgical services at five independent, cooperating academic hospitals
Synopsis: Each site used common principles to develop their own multi-pronged VTE prophylaxis program including structured order-sets, simplified risk-assessment, feedback to providers, and education programs.
306,906 inpatient discharges were evaluated with average VTE prophylaxis bundle compliance reaching 89% across all institutions. HA-VTE rates declined from 0.90% to 0.69% (RR, 0.76; CI, 0.68-0.85) – equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. Of note, HA-VTE rates only declined at three of the five institutions with the greatest improvement at those with the highest baseline rates. Further, while HA-VTE rates improved across all patient populations, the incidence reduction was statistically significant in Oncologic and Surgical populations.
Bottom Line: Hospital systems can reduce HA-VTE and increase VTE prophylaxis by implementing a bundle of interventions and these efforts are highest yield for Oncologic and Surgical populations.
Citations: Jenkins IH, White RH, Amin AN, et al. Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: findings from five University of California medical centers. J Hosp Med. 2016;11:S22-8.
Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical question: Can a single institution’s VTE prophylaxis program be scaled to increase prophylaxis and reduce HA-VTEs across multiple institutions?
Study design: prospective, unblinded, open-intervention study
Setting: Inpatient medical and surgical services at five independent, cooperating academic hospitals
Synopsis: Each site used common principles to develop their own multi-pronged VTE prophylaxis program including structured order-sets, simplified risk-assessment, feedback to providers, and education programs.
306,906 inpatient discharges were evaluated with average VTE prophylaxis bundle compliance reaching 89% across all institutions. HA-VTE rates declined from 0.90% to 0.69% (RR, 0.76; CI, 0.68-0.85) – equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. Of note, HA-VTE rates only declined at three of the five institutions with the greatest improvement at those with the highest baseline rates. Further, while HA-VTE rates improved across all patient populations, the incidence reduction was statistically significant in Oncologic and Surgical populations.
Bottom Line: Hospital systems can reduce HA-VTE and increase VTE prophylaxis by implementing a bundle of interventions and these efforts are highest yield for Oncologic and Surgical populations.
Citations: Jenkins IH, White RH, Amin AN, et al. Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: findings from five University of California medical centers. J Hosp Med. 2016;11:S22-8.
Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical question: Can a single institution’s VTE prophylaxis program be scaled to increase prophylaxis and reduce HA-VTEs across multiple institutions?
Study design: prospective, unblinded, open-intervention study
Setting: Inpatient medical and surgical services at five independent, cooperating academic hospitals
Synopsis: Each site used common principles to develop their own multi-pronged VTE prophylaxis program including structured order-sets, simplified risk-assessment, feedback to providers, and education programs.
306,906 inpatient discharges were evaluated with average VTE prophylaxis bundle compliance reaching 89% across all institutions. HA-VTE rates declined from 0.90% to 0.69% (RR, 0.76; CI, 0.68-0.85) – equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. Of note, HA-VTE rates only declined at three of the five institutions with the greatest improvement at those with the highest baseline rates. Further, while HA-VTE rates improved across all patient populations, the incidence reduction was statistically significant in Oncologic and Surgical populations.
Bottom Line: Hospital systems can reduce HA-VTE and increase VTE prophylaxis by implementing a bundle of interventions and these efforts are highest yield for Oncologic and Surgical populations.
Citations: Jenkins IH, White RH, Amin AN, et al. Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: findings from five University of California medical centers. J Hosp Med. 2016;11:S22-8.
Dr. Anstett is Hospital Medicine Fellow in Quality and Systems Leadership, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Preoperative VTEs occurred in 10% of cancer patients
SEATTLE – Venous thromboembolism (VTE) is common in cancer, but 10% of asymptomatic patients undergoing major oncologic surgery have a preoperative VTE, according to findings presented at the annual Society of Surgical Oncology Cancer Symposium.
The incidence of preoperative VTE was associated with increasing age, a history of previous VTE, and a diagnosis of sepsis 1 month prior to undergoing oncologic surgery.
Surprisingly, noted study author Dr. Melanie Gainsbury of Cedar’s Sinai Medical Center, Los Angeles, it was not associated with oncologic factors such as locally recurrent disease, metastatic disease, or the receipt of neoadjuvant therapy.
“One may argue that patients undergoing oncologic surgery should receive preoperative lower-extremity duplex screening,” especially those who appear to be at high risk, she said.
About one in five cases of VTE is cancer related, and postoperative VTE is a leading cause of morbidity in cancer patients. However, Dr. Gainsbury noted, the incidence of preoperative VTE has not been well established or studied.
In this study, she and her colleagues evaluated the prevalence and risk factors associated with preoperative VTE in asymptomatic patients who were undergoing major oncologic surgery at an academic medical center.
In their retrospective analysis, the investigators identified 412 patients from the hospital’s database who underwent open abdominopelvic oncologic surgery between 2009 to 2016. All patients in the cohort had received a preoperative lower-extremity venous duplex scan (VDS).
The authors found that the overall incidence of preoperative VTE detected on VDS in this asymptomatic population was 10.1%. Of this group, 48.6% of the VTEs were acute, 42.9% were chronic, and a small subset (8.5%) was classified as subacute.
The majority of VTEs (62.9%) were located below the knee, and all of those patients with above-the-knee VTEs (37.1%) received inferior vena cava filters prior to surgery.
None of the patients in this cohort experienced a postoperative pulmonary embolism.
The investigators also looked at various risk factors that could predispose patients to a higher risk of developing a VTE. They did not find any statistically significant differences between those with a preoperative VTE and those without one when looking at gender, body mass index, or cancer type.
There was, however, a statistically significant difference in age, with older age being significantly associated with preoperative VTE. Further analysis showed that patients were 1.3 times more likely to have a preoperative DVT for every 5-year increase in age (odds ratio, 1.3; 95% confidence interval, 1.1-1.6).
In addition, patients with preoperative VTEs were significantly more likely to experience postoperative complications, with an almost twofold increased incidence (25.7% vs. 13.2%, P = .046).
“Patients with preoperative VTE were 1.95 times more likely to develop a postoperative complication than patients without a preoperative VTE,” Dr. Gainsbury said.
In terms of comorbidities, there was no statistically significant difference in regards to history of a known lung disease, varicose veins, a known coagulation mutation, congestive heart failure, and inflammatory bowel disease.
There were also no statistical differences between hormone use or anticoagulants in patients with and without VTEs.
Of note, a recent history of sepsis appeared to be an important factor that put patients at risk for a subsequent VTE. “The preoperative VTE group had a higher rate of diagnosed sepsis during the month prior to surgery,” she said. “We believe that the preoperative diagnosis of sepsis represents a prior hospitalization and perhaps a sicker population at risk for VTEs.”
There was no funding source disclosed in the abstract. Dr. Gainsbury and her coauthors had no disclosures.
SEATTLE – Venous thromboembolism (VTE) is common in cancer, but 10% of asymptomatic patients undergoing major oncologic surgery have a preoperative VTE, according to findings presented at the annual Society of Surgical Oncology Cancer Symposium.
The incidence of preoperative VTE was associated with increasing age, a history of previous VTE, and a diagnosis of sepsis 1 month prior to undergoing oncologic surgery.
Surprisingly, noted study author Dr. Melanie Gainsbury of Cedar’s Sinai Medical Center, Los Angeles, it was not associated with oncologic factors such as locally recurrent disease, metastatic disease, or the receipt of neoadjuvant therapy.
“One may argue that patients undergoing oncologic surgery should receive preoperative lower-extremity duplex screening,” especially those who appear to be at high risk, she said.
About one in five cases of VTE is cancer related, and postoperative VTE is a leading cause of morbidity in cancer patients. However, Dr. Gainsbury noted, the incidence of preoperative VTE has not been well established or studied.
In this study, she and her colleagues evaluated the prevalence and risk factors associated with preoperative VTE in asymptomatic patients who were undergoing major oncologic surgery at an academic medical center.
In their retrospective analysis, the investigators identified 412 patients from the hospital’s database who underwent open abdominopelvic oncologic surgery between 2009 to 2016. All patients in the cohort had received a preoperative lower-extremity venous duplex scan (VDS).
The authors found that the overall incidence of preoperative VTE detected on VDS in this asymptomatic population was 10.1%. Of this group, 48.6% of the VTEs were acute, 42.9% were chronic, and a small subset (8.5%) was classified as subacute.
The majority of VTEs (62.9%) were located below the knee, and all of those patients with above-the-knee VTEs (37.1%) received inferior vena cava filters prior to surgery.
None of the patients in this cohort experienced a postoperative pulmonary embolism.
The investigators also looked at various risk factors that could predispose patients to a higher risk of developing a VTE. They did not find any statistically significant differences between those with a preoperative VTE and those without one when looking at gender, body mass index, or cancer type.
There was, however, a statistically significant difference in age, with older age being significantly associated with preoperative VTE. Further analysis showed that patients were 1.3 times more likely to have a preoperative DVT for every 5-year increase in age (odds ratio, 1.3; 95% confidence interval, 1.1-1.6).
In addition, patients with preoperative VTEs were significantly more likely to experience postoperative complications, with an almost twofold increased incidence (25.7% vs. 13.2%, P = .046).
“Patients with preoperative VTE were 1.95 times more likely to develop a postoperative complication than patients without a preoperative VTE,” Dr. Gainsbury said.
In terms of comorbidities, there was no statistically significant difference in regards to history of a known lung disease, varicose veins, a known coagulation mutation, congestive heart failure, and inflammatory bowel disease.
There were also no statistical differences between hormone use or anticoagulants in patients with and without VTEs.
Of note, a recent history of sepsis appeared to be an important factor that put patients at risk for a subsequent VTE. “The preoperative VTE group had a higher rate of diagnosed sepsis during the month prior to surgery,” she said. “We believe that the preoperative diagnosis of sepsis represents a prior hospitalization and perhaps a sicker population at risk for VTEs.”
There was no funding source disclosed in the abstract. Dr. Gainsbury and her coauthors had no disclosures.
SEATTLE – Venous thromboembolism (VTE) is common in cancer, but 10% of asymptomatic patients undergoing major oncologic surgery have a preoperative VTE, according to findings presented at the annual Society of Surgical Oncology Cancer Symposium.
The incidence of preoperative VTE was associated with increasing age, a history of previous VTE, and a diagnosis of sepsis 1 month prior to undergoing oncologic surgery.
Surprisingly, noted study author Dr. Melanie Gainsbury of Cedar’s Sinai Medical Center, Los Angeles, it was not associated with oncologic factors such as locally recurrent disease, metastatic disease, or the receipt of neoadjuvant therapy.
“One may argue that patients undergoing oncologic surgery should receive preoperative lower-extremity duplex screening,” especially those who appear to be at high risk, she said.
About one in five cases of VTE is cancer related, and postoperative VTE is a leading cause of morbidity in cancer patients. However, Dr. Gainsbury noted, the incidence of preoperative VTE has not been well established or studied.
In this study, she and her colleagues evaluated the prevalence and risk factors associated with preoperative VTE in asymptomatic patients who were undergoing major oncologic surgery at an academic medical center.
In their retrospective analysis, the investigators identified 412 patients from the hospital’s database who underwent open abdominopelvic oncologic surgery between 2009 to 2016. All patients in the cohort had received a preoperative lower-extremity venous duplex scan (VDS).
The authors found that the overall incidence of preoperative VTE detected on VDS in this asymptomatic population was 10.1%. Of this group, 48.6% of the VTEs were acute, 42.9% were chronic, and a small subset (8.5%) was classified as subacute.
The majority of VTEs (62.9%) were located below the knee, and all of those patients with above-the-knee VTEs (37.1%) received inferior vena cava filters prior to surgery.
None of the patients in this cohort experienced a postoperative pulmonary embolism.
The investigators also looked at various risk factors that could predispose patients to a higher risk of developing a VTE. They did not find any statistically significant differences between those with a preoperative VTE and those without one when looking at gender, body mass index, or cancer type.
There was, however, a statistically significant difference in age, with older age being significantly associated with preoperative VTE. Further analysis showed that patients were 1.3 times more likely to have a preoperative DVT for every 5-year increase in age (odds ratio, 1.3; 95% confidence interval, 1.1-1.6).
In addition, patients with preoperative VTEs were significantly more likely to experience postoperative complications, with an almost twofold increased incidence (25.7% vs. 13.2%, P = .046).
“Patients with preoperative VTE were 1.95 times more likely to develop a postoperative complication than patients without a preoperative VTE,” Dr. Gainsbury said.
In terms of comorbidities, there was no statistically significant difference in regards to history of a known lung disease, varicose veins, a known coagulation mutation, congestive heart failure, and inflammatory bowel disease.
There were also no statistical differences between hormone use or anticoagulants in patients with and without VTEs.
Of note, a recent history of sepsis appeared to be an important factor that put patients at risk for a subsequent VTE. “The preoperative VTE group had a higher rate of diagnosed sepsis during the month prior to surgery,” she said. “We believe that the preoperative diagnosis of sepsis represents a prior hospitalization and perhaps a sicker population at risk for VTEs.”
There was no funding source disclosed in the abstract. Dr. Gainsbury and her coauthors had no disclosures.
AT SSO 2017
Key clinical point: 10% of asymptomatic cancer patients undergoing major cancer surgery have preoperative venous thromboembolism.
Major finding: Patients with preoperative VTEs were significantly more likely to experience postoperative complications, with an almost twofold increased incidence (25.7% vs. 13.2%, P = .046).
Data source: Retrospective analysis that included 412 who underwent open abdominopelvic oncologic surgery at a single academic center.
Disclosures: There was no funding source disclosed in the abstract. Dr. Gainsbury and her coauthors had no disclosures.
Alpha blockers may facilitate the expulsion of larger ureteric stones
Clinical Question: Are alpha blockers efficacious in patients with ureteric stones?
Background: A multicenter, randomized controlled trial by Pickard and colleagues demonstrated an alpha blocker to be no more efficacious than placebo as medical expulsive therapy. There are no systematic reviews that include this recent study.
Setting: Randomized controlled trials (RCTs); most conducted in Europe and Asia.
Synopsis: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.
Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.
Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.
The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.
Bottom Line: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.
Citations: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: Are alpha blockers efficacious in patients with ureteric stones?
Background: A multicenter, randomized controlled trial by Pickard and colleagues demonstrated an alpha blocker to be no more efficacious than placebo as medical expulsive therapy. There are no systematic reviews that include this recent study.
Setting: Randomized controlled trials (RCTs); most conducted in Europe and Asia.
Synopsis: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.
Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.
Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.
The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.
Bottom Line: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.
Citations: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: Are alpha blockers efficacious in patients with ureteric stones?
Background: A multicenter, randomized controlled trial by Pickard and colleagues demonstrated an alpha blocker to be no more efficacious than placebo as medical expulsive therapy. There are no systematic reviews that include this recent study.
Setting: Randomized controlled trials (RCTs); most conducted in Europe and Asia.
Synopsis: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.
Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.
Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.
The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.
Bottom Line: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.
Citations: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Interventions, especially those that are organization-directed, reduce burnout in physicians
Clinical Question: How efficacious are interventions to reduce burnout in physicians?
Background: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.
Setting: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.
Synopsis: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.
Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.
The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.
Bottom Line: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.
Citations: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: How efficacious are interventions to reduce burnout in physicians?
Background: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.
Setting: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.
Synopsis: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.
Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.
The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.
Bottom Line: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.
Citations: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: How efficacious are interventions to reduce burnout in physicians?
Background: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.
Setting: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.
Synopsis: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.
Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.
The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.
Bottom Line: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.
Citations: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Perioperative statin associated with reduction in all-cause perioperative mortality in noncardiac surgery
CLINICAL QUESTION: Does perioperative statin use reduce 30-day mortality in noncardiac surgery?
BACKGROUND: Current perioperative guidelines focus on continuation of existing therapy in long-term statin users with weak recommendations of potential efficacy in reducing perioperative complications.
STUDY DESIGN: Retrospective, observational cohort analysis.
SETTING: Veterans’ Affairs Hospitals.
SYNOPSIS: Using the Veterans Affairs Surgical Quality Improvement Program database, 96,486 patients were studied who were undergoing elective or emergent noncardiac surgery (vascular, general, orthopedic, neurosurgery, otolaryngology, and urology). 96.3% were men. Patients who died the day of the surgery or the day after were excluded, as were patients with multiple surgeries during the assessment period. Statin exposure on the day of or the day after surgery was compared with no statin use. The primary outcome was 30-day mortality and the secondary outcomes were significant reduction in any other complication.
Statin exposure was associated with reduced 30-day all-cause mortality with a marginally favorable effect with longer-term statin use (6 months to 1 year before admission). For the secondary outcomes, there was significant risk reduction in cardiac, infectious, respiratory, and renal complications but no significant change in central nervous system or nonatherosclerotic thrombotic complications.
Statin exposure may be associated with adherence to medical treatment and follow-up thus causing a selection bias.
BOTTOM LINE: Perioperative statin use was associated with a reduction in 30-day mortality and other complications.
CITATIONS: London MJ, Schwartz GG, Hur K, Henderson WG. Association of perioperative statin use with mortality and morbidity after major noncardiac surgery. JAMA Intern Med. 2017 Feb 1;177(2):231-42.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Does perioperative statin use reduce 30-day mortality in noncardiac surgery?
BACKGROUND: Current perioperative guidelines focus on continuation of existing therapy in long-term statin users with weak recommendations of potential efficacy in reducing perioperative complications.
STUDY DESIGN: Retrospective, observational cohort analysis.
SETTING: Veterans’ Affairs Hospitals.
SYNOPSIS: Using the Veterans Affairs Surgical Quality Improvement Program database, 96,486 patients were studied who were undergoing elective or emergent noncardiac surgery (vascular, general, orthopedic, neurosurgery, otolaryngology, and urology). 96.3% were men. Patients who died the day of the surgery or the day after were excluded, as were patients with multiple surgeries during the assessment period. Statin exposure on the day of or the day after surgery was compared with no statin use. The primary outcome was 30-day mortality and the secondary outcomes were significant reduction in any other complication.
Statin exposure was associated with reduced 30-day all-cause mortality with a marginally favorable effect with longer-term statin use (6 months to 1 year before admission). For the secondary outcomes, there was significant risk reduction in cardiac, infectious, respiratory, and renal complications but no significant change in central nervous system or nonatherosclerotic thrombotic complications.
Statin exposure may be associated with adherence to medical treatment and follow-up thus causing a selection bias.
BOTTOM LINE: Perioperative statin use was associated with a reduction in 30-day mortality and other complications.
CITATIONS: London MJ, Schwartz GG, Hur K, Henderson WG. Association of perioperative statin use with mortality and morbidity after major noncardiac surgery. JAMA Intern Med. 2017 Feb 1;177(2):231-42.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Does perioperative statin use reduce 30-day mortality in noncardiac surgery?
BACKGROUND: Current perioperative guidelines focus on continuation of existing therapy in long-term statin users with weak recommendations of potential efficacy in reducing perioperative complications.
STUDY DESIGN: Retrospective, observational cohort analysis.
SETTING: Veterans’ Affairs Hospitals.
SYNOPSIS: Using the Veterans Affairs Surgical Quality Improvement Program database, 96,486 patients were studied who were undergoing elective or emergent noncardiac surgery (vascular, general, orthopedic, neurosurgery, otolaryngology, and urology). 96.3% were men. Patients who died the day of the surgery or the day after were excluded, as were patients with multiple surgeries during the assessment period. Statin exposure on the day of or the day after surgery was compared with no statin use. The primary outcome was 30-day mortality and the secondary outcomes were significant reduction in any other complication.
Statin exposure was associated with reduced 30-day all-cause mortality with a marginally favorable effect with longer-term statin use (6 months to 1 year before admission). For the secondary outcomes, there was significant risk reduction in cardiac, infectious, respiratory, and renal complications but no significant change in central nervous system or nonatherosclerotic thrombotic complications.
Statin exposure may be associated with adherence to medical treatment and follow-up thus causing a selection bias.
BOTTOM LINE: Perioperative statin use was associated with a reduction in 30-day mortality and other complications.
CITATIONS: London MJ, Schwartz GG, Hur K, Henderson WG. Association of perioperative statin use with mortality and morbidity after major noncardiac surgery. JAMA Intern Med. 2017 Feb 1;177(2):231-42.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Male vs. female hospitalists, a comparison in mortality and readmission rate for Medicare patients
Clinical Question: Does physician sex affect hospitalized patient outcomes?
Background: Previous studies had suggested different practice patterns between male and female physicians in process measure of quality. No prior evaluation of patient outcomes examining those differences was studied in the past.
Setting: U.S. national sample (20%) of Medicare beneficiaries aged 65 years or older, hospitalized with acute medical conditions.
Synopsis: This observational study assessed the difference in patients’ outcomes that were treated by a male or female physician. 30-days mortality rate was analyzed from 1,583,028 hospitalizations. The mortality rate of patients cared for by female physicians was lower and statistically significant: 11.07% vs. 11.49% (adjusted risk difference, –0.43%; 95% CI, –0.57% to –0.28%; P less than .001). The difference did not change after considering patient and physician characteristics as well as when looking at hospital fixed effects (that is, hospital indicators). In order to prevent one death, a female physician needs to treat 233 patients.
Also, 30-day readmission rate, after adjustment readmissions (from 1,540,797 hospitalizations) was 15.02% vs. 15.57% (adjusted risk difference, –0.55%; 95% confidence interval, –0.71% to 0.39%; P less than .001) showing that the care provided by a female physician can reduce one readmission when treating 182 patients.
Bottom line: Patients older than 65 years have lower 30-day mortality and readmission rates when receiving inpatient care from a female internist, compared with care by a male internist.
Citations: Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs. female physicians. JAMA Intern Med. 2017 Feb;177(2):206-13.
Dr. Orjuela is assistant professor of neurology at the University of Colorado School of Medicine, Aurora.
Clinical Question: Does physician sex affect hospitalized patient outcomes?
Background: Previous studies had suggested different practice patterns between male and female physicians in process measure of quality. No prior evaluation of patient outcomes examining those differences was studied in the past.
Setting: U.S. national sample (20%) of Medicare beneficiaries aged 65 years or older, hospitalized with acute medical conditions.
Synopsis: This observational study assessed the difference in patients’ outcomes that were treated by a male or female physician. 30-days mortality rate was analyzed from 1,583,028 hospitalizations. The mortality rate of patients cared for by female physicians was lower and statistically significant: 11.07% vs. 11.49% (adjusted risk difference, –0.43%; 95% CI, –0.57% to –0.28%; P less than .001). The difference did not change after considering patient and physician characteristics as well as when looking at hospital fixed effects (that is, hospital indicators). In order to prevent one death, a female physician needs to treat 233 patients.
Also, 30-day readmission rate, after adjustment readmissions (from 1,540,797 hospitalizations) was 15.02% vs. 15.57% (adjusted risk difference, –0.55%; 95% confidence interval, –0.71% to 0.39%; P less than .001) showing that the care provided by a female physician can reduce one readmission when treating 182 patients.
Bottom line: Patients older than 65 years have lower 30-day mortality and readmission rates when receiving inpatient care from a female internist, compared with care by a male internist.
Citations: Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs. female physicians. JAMA Intern Med. 2017 Feb;177(2):206-13.
Dr. Orjuela is assistant professor of neurology at the University of Colorado School of Medicine, Aurora.
Clinical Question: Does physician sex affect hospitalized patient outcomes?
Background: Previous studies had suggested different practice patterns between male and female physicians in process measure of quality. No prior evaluation of patient outcomes examining those differences was studied in the past.
Setting: U.S. national sample (20%) of Medicare beneficiaries aged 65 years or older, hospitalized with acute medical conditions.
Synopsis: This observational study assessed the difference in patients’ outcomes that were treated by a male or female physician. 30-days mortality rate was analyzed from 1,583,028 hospitalizations. The mortality rate of patients cared for by female physicians was lower and statistically significant: 11.07% vs. 11.49% (adjusted risk difference, –0.43%; 95% CI, –0.57% to –0.28%; P less than .001). The difference did not change after considering patient and physician characteristics as well as when looking at hospital fixed effects (that is, hospital indicators). In order to prevent one death, a female physician needs to treat 233 patients.
Also, 30-day readmission rate, after adjustment readmissions (from 1,540,797 hospitalizations) was 15.02% vs. 15.57% (adjusted risk difference, –0.55%; 95% confidence interval, –0.71% to 0.39%; P less than .001) showing that the care provided by a female physician can reduce one readmission when treating 182 patients.
Bottom line: Patients older than 65 years have lower 30-day mortality and readmission rates when receiving inpatient care from a female internist, compared with care by a male internist.
Citations: Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs. female physicians. JAMA Intern Med. 2017 Feb;177(2):206-13.
Dr. Orjuela is assistant professor of neurology at the University of Colorado School of Medicine, Aurora.
End-of-rotation resident transition in care and mortality among hospitalized patients
Clinical Question: Are hospitalized patients experiencing an increased mortality risk at the end-rotation resident transition in care and is this association related to the Accreditation Council for Graduate Medical Education (ACGME) 2011 duty-hour regulations?
Background: Prior studies of physicians’ transitions in care were associated with potential adverse patient events and outcomes. A higher mortality risk was suggested among patients with a complex hospital course or prolonged length of stay in association to house-staff transitions of care.
Setting: 10 University-affiliated U.S. Veterans Health Administration hospitals.
Synopsis: 230,701 patient discharges (mean age, 65.6 years; 95.8% male sex; median length of stay, 3 days) were included. The transition group included patients admitted at any time prior to an end-of-rotation who were either discharged or deceased within 7 days of transition. All other discharges were considered controls.
The primary outcome was in-hospital mortality rate; secondary outcomes included 30-day and 90-day mortality and readmission rates. An absolute increase of 1.5% to 1.9% in a unadjusted in-hospitality risk was found. The 30-day and 90-day mortality odds ratios were 1.10 and 1.21, respectively. A possible stronger association was found among interns’ transitions in care and the in-hospital and after-discharge mortality post-ACGME 2011 duty hour regulations. The latter raises questions about the interns’ inexperience and their amount of shift-to-shift handoffs. An adjusted analysis of the readmission rates at 30-day and 90-day was not significantly different between transition vs. control patients.
Bottom line: Elevated in-hospital mortality was seen among patients admitted to the inpatient medicine service at the end-of-rotation resident transitions in care. The association was stronger after the duty-hour ACGME (2011) regulations.
Citations: Denson JL, Jensen A, Saag HS, et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA. 2016 Dec 6;316(21):2204-13.
Dr. Orjuela is assistant professor of neurology at the University of Colorado School of Medicine, Aurora.
Clinical Question: Are hospitalized patients experiencing an increased mortality risk at the end-rotation resident transition in care and is this association related to the Accreditation Council for Graduate Medical Education (ACGME) 2011 duty-hour regulations?
Background: Prior studies of physicians’ transitions in care were associated with potential adverse patient events and outcomes. A higher mortality risk was suggested among patients with a complex hospital course or prolonged length of stay in association to house-staff transitions of care.
Setting: 10 University-affiliated U.S. Veterans Health Administration hospitals.
Synopsis: 230,701 patient discharges (mean age, 65.6 years; 95.8% male sex; median length of stay, 3 days) were included. The transition group included patients admitted at any time prior to an end-of-rotation who were either discharged or deceased within 7 days of transition. All other discharges were considered controls.
The primary outcome was in-hospital mortality rate; secondary outcomes included 30-day and 90-day mortality and readmission rates. An absolute increase of 1.5% to 1.9% in a unadjusted in-hospitality risk was found. The 30-day and 90-day mortality odds ratios were 1.10 and 1.21, respectively. A possible stronger association was found among interns’ transitions in care and the in-hospital and after-discharge mortality post-ACGME 2011 duty hour regulations. The latter raises questions about the interns’ inexperience and their amount of shift-to-shift handoffs. An adjusted analysis of the readmission rates at 30-day and 90-day was not significantly different between transition vs. control patients.
Bottom line: Elevated in-hospital mortality was seen among patients admitted to the inpatient medicine service at the end-of-rotation resident transitions in care. The association was stronger after the duty-hour ACGME (2011) regulations.
Citations: Denson JL, Jensen A, Saag HS, et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA. 2016 Dec 6;316(21):2204-13.
Dr. Orjuela is assistant professor of neurology at the University of Colorado School of Medicine, Aurora.
Clinical Question: Are hospitalized patients experiencing an increased mortality risk at the end-rotation resident transition in care and is this association related to the Accreditation Council for Graduate Medical Education (ACGME) 2011 duty-hour regulations?
Background: Prior studies of physicians’ transitions in care were associated with potential adverse patient events and outcomes. A higher mortality risk was suggested among patients with a complex hospital course or prolonged length of stay in association to house-staff transitions of care.
Setting: 10 University-affiliated U.S. Veterans Health Administration hospitals.
Synopsis: 230,701 patient discharges (mean age, 65.6 years; 95.8% male sex; median length of stay, 3 days) were included. The transition group included patients admitted at any time prior to an end-of-rotation who were either discharged or deceased within 7 days of transition. All other discharges were considered controls.
The primary outcome was in-hospital mortality rate; secondary outcomes included 30-day and 90-day mortality and readmission rates. An absolute increase of 1.5% to 1.9% in a unadjusted in-hospitality risk was found. The 30-day and 90-day mortality odds ratios were 1.10 and 1.21, respectively. A possible stronger association was found among interns’ transitions in care and the in-hospital and after-discharge mortality post-ACGME 2011 duty hour regulations. The latter raises questions about the interns’ inexperience and their amount of shift-to-shift handoffs. An adjusted analysis of the readmission rates at 30-day and 90-day was not significantly different between transition vs. control patients.
Bottom line: Elevated in-hospital mortality was seen among patients admitted to the inpatient medicine service at the end-of-rotation resident transitions in care. The association was stronger after the duty-hour ACGME (2011) regulations.
Citations: Denson JL, Jensen A, Saag HS, et al. Association between end-of-rotation resident transition in care and mortality among hospitalized patients. JAMA. 2016 Dec 6;316(21):2204-13.
Dr. Orjuela is assistant professor of neurology at the University of Colorado School of Medicine, Aurora.
Using shock index in the ED to predict hospital admission and inpatient mortality
CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?
BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.
SETTING: Academic tertiary care center.
SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.
This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.
BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.
CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?
BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.
SETTING: Academic tertiary care center.
SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.
This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.
BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.
CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?
BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.
SETTING: Academic tertiary care center.
SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.
This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.
BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.
CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Sneak Peek: Journal of Hospital Medicine
BACKGROUND: Readmissions after hospitalization for pneumonia are common, but the few risk-prediction models have poor to modest predictive ability. Data routinely collected in the EHR may improve prediction.
DESIGN: Observational cohort study using backward-stepwise selection and cross validation.
SUBJECTS: Consecutive pneumonia hospitalizations from six diverse hospitals in north Texas from 2009 to 2010.
MEASURES: All-cause, nonelective, 30-day readmissions, ascertained from 75 regional hospitals.
RESULTS: Of 1,463 patients, 13.6% were readmitted. The first-day, pneumonia-specific model included sociodemographic factors, prior hospitalizations, thrombocytosis, and a modified pneumonia severity index. The full-stay model included disposition status, vital sign instabilities on discharge, and an updated pneumonia severity index calculated using values from the day of discharge as additional predictors. The full-stay, pneumonia-specific model outperformed the first-day model (C-statistic, 0.731 vs. 0.695; P = .02; net reclassification index = 0.08). Compared with a validated multicondition readmission model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores, the full-stay pneumonia-specific model had better discrimination (C-statistic, 0.604-0.681; P less than 0.01 for all comparisons), predicted a broader range of risk, and better reclassified individuals by their true risk (net reclassification index range, 0.09-0.18).
CONCLUSIONS: EHR data collected from the entire hospitalization can accurately predict readmission risk among patients hospitalized for pneumonia. This approach outperforms a first-day, pneumonia-specific model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores.
Also In JHM This Month
Evaluating automated rules for rapid response system alarm triggers in medical and surgical patients
AUTHORS: Santiago Romero-Brufau, MD; Bruce W. Morlan, MS; Matthew Johnson, MPH; Joel Hickman; Lisa L. Kirkland, MD; James M. Naessens, ScD; Jeanne Huddleston, MD, FACP, FHM
Prognosticating with the Hospital-Patient One-year Mortality Risk score using information abstracted from the medical record
AUTHORS: Genevieve Casey, MD, and Carl van Walraven, MD, FRCPC, MSc
Automating venous thromboembolism risk calculation using electronic health record data upon hospital admission: The Automated Padua Prediction Score
AUTHORS: Pierre Elias, MD; Raman Khanna, MD; Adams Dudley, MD, MBA; Jason Davies, MD, PhD; Ronald Jacolbia, MSN; Kara McArthur, BA; Andrew D. Auerbach, MD, MPH, SFHM
The value of ultrasound in cellulitis to rule out deep venous thrombosis
AUTHORS: Hyung J. Cho, MD, and Andrew S. Dunn, MD, SFHM
Hospital medicine and perioperative care: A framework for high quality, high value collaborative care
AUTHORS: Rachel E. Thompson, MD, MPH, SFHM; Kurt Pfeifer, MD, FHM; Paul Grant, MD, SFHM; Cornelia Taylor, MD; Barbara Slawski, MD, FACP, MS, SFHM; Christopher Whinney, MD, FACP, FHM; Laurence Wellikson, MD, MHM; Amir K. Jaffer, MD, MBA, SFHM
BACKGROUND: Readmissions after hospitalization for pneumonia are common, but the few risk-prediction models have poor to modest predictive ability. Data routinely collected in the EHR may improve prediction.
DESIGN: Observational cohort study using backward-stepwise selection and cross validation.
SUBJECTS: Consecutive pneumonia hospitalizations from six diverse hospitals in north Texas from 2009 to 2010.
MEASURES: All-cause, nonelective, 30-day readmissions, ascertained from 75 regional hospitals.
RESULTS: Of 1,463 patients, 13.6% were readmitted. The first-day, pneumonia-specific model included sociodemographic factors, prior hospitalizations, thrombocytosis, and a modified pneumonia severity index. The full-stay model included disposition status, vital sign instabilities on discharge, and an updated pneumonia severity index calculated using values from the day of discharge as additional predictors. The full-stay, pneumonia-specific model outperformed the first-day model (C-statistic, 0.731 vs. 0.695; P = .02; net reclassification index = 0.08). Compared with a validated multicondition readmission model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores, the full-stay pneumonia-specific model had better discrimination (C-statistic, 0.604-0.681; P less than 0.01 for all comparisons), predicted a broader range of risk, and better reclassified individuals by their true risk (net reclassification index range, 0.09-0.18).
CONCLUSIONS: EHR data collected from the entire hospitalization can accurately predict readmission risk among patients hospitalized for pneumonia. This approach outperforms a first-day, pneumonia-specific model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores.
Also In JHM This Month
Evaluating automated rules for rapid response system alarm triggers in medical and surgical patients
AUTHORS: Santiago Romero-Brufau, MD; Bruce W. Morlan, MS; Matthew Johnson, MPH; Joel Hickman; Lisa L. Kirkland, MD; James M. Naessens, ScD; Jeanne Huddleston, MD, FACP, FHM
Prognosticating with the Hospital-Patient One-year Mortality Risk score using information abstracted from the medical record
AUTHORS: Genevieve Casey, MD, and Carl van Walraven, MD, FRCPC, MSc
Automating venous thromboembolism risk calculation using electronic health record data upon hospital admission: The Automated Padua Prediction Score
AUTHORS: Pierre Elias, MD; Raman Khanna, MD; Adams Dudley, MD, MBA; Jason Davies, MD, PhD; Ronald Jacolbia, MSN; Kara McArthur, BA; Andrew D. Auerbach, MD, MPH, SFHM
The value of ultrasound in cellulitis to rule out deep venous thrombosis
AUTHORS: Hyung J. Cho, MD, and Andrew S. Dunn, MD, SFHM
Hospital medicine and perioperative care: A framework for high quality, high value collaborative care
AUTHORS: Rachel E. Thompson, MD, MPH, SFHM; Kurt Pfeifer, MD, FHM; Paul Grant, MD, SFHM; Cornelia Taylor, MD; Barbara Slawski, MD, FACP, MS, SFHM; Christopher Whinney, MD, FACP, FHM; Laurence Wellikson, MD, MHM; Amir K. Jaffer, MD, MBA, SFHM
BACKGROUND: Readmissions after hospitalization for pneumonia are common, but the few risk-prediction models have poor to modest predictive ability. Data routinely collected in the EHR may improve prediction.
DESIGN: Observational cohort study using backward-stepwise selection and cross validation.
SUBJECTS: Consecutive pneumonia hospitalizations from six diverse hospitals in north Texas from 2009 to 2010.
MEASURES: All-cause, nonelective, 30-day readmissions, ascertained from 75 regional hospitals.
RESULTS: Of 1,463 patients, 13.6% were readmitted. The first-day, pneumonia-specific model included sociodemographic factors, prior hospitalizations, thrombocytosis, and a modified pneumonia severity index. The full-stay model included disposition status, vital sign instabilities on discharge, and an updated pneumonia severity index calculated using values from the day of discharge as additional predictors. The full-stay, pneumonia-specific model outperformed the first-day model (C-statistic, 0.731 vs. 0.695; P = .02; net reclassification index = 0.08). Compared with a validated multicondition readmission model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores, the full-stay pneumonia-specific model had better discrimination (C-statistic, 0.604-0.681; P less than 0.01 for all comparisons), predicted a broader range of risk, and better reclassified individuals by their true risk (net reclassification index range, 0.09-0.18).
CONCLUSIONS: EHR data collected from the entire hospitalization can accurately predict readmission risk among patients hospitalized for pneumonia. This approach outperforms a first-day, pneumonia-specific model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores.
Also In JHM This Month
Evaluating automated rules for rapid response system alarm triggers in medical and surgical patients
AUTHORS: Santiago Romero-Brufau, MD; Bruce W. Morlan, MS; Matthew Johnson, MPH; Joel Hickman; Lisa L. Kirkland, MD; James M. Naessens, ScD; Jeanne Huddleston, MD, FACP, FHM
Prognosticating with the Hospital-Patient One-year Mortality Risk score using information abstracted from the medical record
AUTHORS: Genevieve Casey, MD, and Carl van Walraven, MD, FRCPC, MSc
Automating venous thromboembolism risk calculation using electronic health record data upon hospital admission: The Automated Padua Prediction Score
AUTHORS: Pierre Elias, MD; Raman Khanna, MD; Adams Dudley, MD, MBA; Jason Davies, MD, PhD; Ronald Jacolbia, MSN; Kara McArthur, BA; Andrew D. Auerbach, MD, MPH, SFHM
The value of ultrasound in cellulitis to rule out deep venous thrombosis
AUTHORS: Hyung J. Cho, MD, and Andrew S. Dunn, MD, SFHM
Hospital medicine and perioperative care: A framework for high quality, high value collaborative care
AUTHORS: Rachel E. Thompson, MD, MPH, SFHM; Kurt Pfeifer, MD, FHM; Paul Grant, MD, SFHM; Cornelia Taylor, MD; Barbara Slawski, MD, FACP, MS, SFHM; Christopher Whinney, MD, FACP, FHM; Laurence Wellikson, MD, MHM; Amir K. Jaffer, MD, MBA, SFHM
