Clinical

Clinical Question: What are current recommendations for diagnosis, management, and prevention of acute gastrointestinal infection in immune-competent adults?

Background: Acute diarrheal infection is a leading cause of healthcare visits and lost quality of life. The Centers for Disease Control and Prevention estimates there are 47.8 million cases annually, with a healthcare economy burden of $150 million.

Study Design: American College of Gastroenterology (ACG) practice guideline.

Setting: Expert panel.

Synopsis: Stool diagnostic studies may be used for dysentery with moderate-severe disease and symptoms lasting more than seven days (strong recommendation, low level of evidence). Traditional diagnostic methods in most cases fail to reveal etiology (strong recommendation, low level of evidence). Treatment with probiotics or prebiotics is not recommended (strong recommendation, moderate level of evidence). Bismuth subsalicylates may be considered for prophylaxis against traveler’s diarrhea (strong recommendation, high level of evidence). Short-term antibiotic chemoprophylaxis also may be considered for high-risk groups (strong recommendation, high level of evidence). Empiric antimicrobial therapy is not recommended except in cases of traveler’s diarrhea (strong recommendation, high level of evidence). Loperamide may be used as an adjunct to antibiotics for traveler’s diarrhea (strong recommendation, moderate level of evidence).

Bottom Line: ACG acute diarrheal illness guidelines have been updated. Few recommendations are strong, and very few have high levels of evidence.

Citation: Riddle MS, DuPont HL, Conner BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016;111(5):602-622.

Clinical Question: What are current recommendations for diagnosis, management, and prevention of acute gastrointestinal infection in immune-competent adults?

Background: Acute diarrheal infection is a leading cause of healthcare visits and lost quality of life. The Centers for Disease Control and Prevention estimates there are 47.8 million cases annually, with a healthcare economy burden of $150 million.

Study Design: American College of Gastroenterology (ACG) practice guideline.

Setting: Expert panel.

Synopsis: Stool diagnostic studies may be used for dysentery with moderate-severe disease and symptoms lasting more than seven days (strong recommendation, low level of evidence). Traditional diagnostic methods in most cases fail to reveal etiology (strong recommendation, low level of evidence). Treatment with probiotics or prebiotics is not recommended (strong recommendation, moderate level of evidence). Bismuth subsalicylates may be considered for prophylaxis against traveler’s diarrhea (strong recommendation, high level of evidence). Short-term antibiotic chemoprophylaxis also may be considered for high-risk groups (strong recommendation, high level of evidence). Empiric antimicrobial therapy is not recommended except in cases of traveler’s diarrhea (strong recommendation, high level of evidence). Loperamide may be used as an adjunct to antibiotics for traveler’s diarrhea (strong recommendation, moderate level of evidence).

Bottom Line: ACG acute diarrheal illness guidelines have been updated. Few recommendations are strong, and very few have high levels of evidence.

Citation: Riddle MS, DuPont HL, Conner BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016;111(5):602-622.

Clinical Question: What are current recommendations for diagnosis, management, and prevention of acute gastrointestinal infection in immune-competent adults?

Background: Acute diarrheal infection is a leading cause of healthcare visits and lost quality of life. The Centers for Disease Control and Prevention estimates there are 47.8 million cases annually, with a healthcare economy burden of $150 million.

Study Design: American College of Gastroenterology (ACG) practice guideline.

Setting: Expert panel.

Synopsis: Stool diagnostic studies may be used for dysentery with moderate-severe disease and symptoms lasting more than seven days (strong recommendation, low level of evidence). Traditional diagnostic methods in most cases fail to reveal etiology (strong recommendation, low level of evidence). Treatment with probiotics or prebiotics is not recommended (strong recommendation, moderate level of evidence). Bismuth subsalicylates may be considered for prophylaxis against traveler’s diarrhea (strong recommendation, high level of evidence). Short-term antibiotic chemoprophylaxis also may be considered for high-risk groups (strong recommendation, high level of evidence). Empiric antimicrobial therapy is not recommended except in cases of traveler’s diarrhea (strong recommendation, high level of evidence). Loperamide may be used as an adjunct to antibiotics for traveler’s diarrhea (strong recommendation, moderate level of evidence).

Bottom Line: ACG acute diarrheal illness guidelines have been updated. Few recommendations are strong, and very few have high levels of evidence.

Citation: Riddle MS, DuPont HL, Conner BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016;111(5):602-622.

Clinical Question: Do risk-assessment models (RAMs) accurately predict which hospitalized medical patients are at risk for venous thromboembolism (VTE)?

Background: Predicting which patients are at high risk for VTE is important. Several models exist, but limited data support their generalizability and accuracy in medical inpatients.

Study Design: Retrospective cohort.

Setting: Hospitals participating in the Michigan Hospital Medicine Safety Consortium (MHMSC).

Synopsis: Data collected through MHMSC for selected medical patients were used in the Kucher, Padua, predictive IMPROVE, and Intermountain DVT risk-assessment models. Patients were classified as “low risk” or “at risk” based on each RAM. Follow-up data came from chart extraction (100% of patients) and 90-day post-discharge telephone calls (58% of patients). The primary outcome was image-confirmed hospital associated VTE, including proximal upper- or proximal lower-extremity DVT or pulmonary embolism. These RAMs classified less than 20% of patients as “at risk.” The incidence of VTE was less than 1%. In this external validation study, the Kucher RAM was the least discriminate and the Intermountain was the best, but none yielded results equivalent to the original studies.

This study was limited by the retrospective design, subjectivity of some risk factors (such as immobility), and inability to obtain 90-day telephone follow-up in all patients. Lastly, the binary approach (“at risk” versus “low risk”) may not align with the original derivation studies in which each factor was evaluated independently.

Bottom Line: The incidence of VTE is low in medical inpatients, and current RAMs may not accurately identify at-risk patients.

Citation: Greene MT, Spyropoulos AC, Chopra V, et al. Validation of risk assessment models of venous thromboembolism in hospitalized medical patients. Am J Med. 2016;129(9):1001.e9-1001.e18. doi:10.1016/j.amjmed.2016.03.031.

Clinical Question: Do risk-assessment models (RAMs) accurately predict which hospitalized medical patients are at risk for venous thromboembolism (VTE)?

Background: Predicting which patients are at high risk for VTE is important. Several models exist, but limited data support their generalizability and accuracy in medical inpatients.

Study Design: Retrospective cohort.

Setting: Hospitals participating in the Michigan Hospital Medicine Safety Consortium (MHMSC).

Synopsis: Data collected through MHMSC for selected medical patients were used in the Kucher, Padua, predictive IMPROVE, and Intermountain DVT risk-assessment models. Patients were classified as “low risk” or “at risk” based on each RAM. Follow-up data came from chart extraction (100% of patients) and 90-day post-discharge telephone calls (58% of patients). The primary outcome was image-confirmed hospital associated VTE, including proximal upper- or proximal lower-extremity DVT or pulmonary embolism. These RAMs classified less than 20% of patients as “at risk.” The incidence of VTE was less than 1%. In this external validation study, the Kucher RAM was the least discriminate and the Intermountain was the best, but none yielded results equivalent to the original studies.

This study was limited by the retrospective design, subjectivity of some risk factors (such as immobility), and inability to obtain 90-day telephone follow-up in all patients. Lastly, the binary approach (“at risk” versus “low risk”) may not align with the original derivation studies in which each factor was evaluated independently.

Bottom Line: The incidence of VTE is low in medical inpatients, and current RAMs may not accurately identify at-risk patients.

Citation: Greene MT, Spyropoulos AC, Chopra V, et al. Validation of risk assessment models of venous thromboembolism in hospitalized medical patients. Am J Med. 2016;129(9):1001.e9-1001.e18. doi:10.1016/j.amjmed.2016.03.031.

Clinical Question: Do risk-assessment models (RAMs) accurately predict which hospitalized medical patients are at risk for venous thromboembolism (VTE)?

Background: Predicting which patients are at high risk for VTE is important. Several models exist, but limited data support their generalizability and accuracy in medical inpatients.

Study Design: Retrospective cohort.

Setting: Hospitals participating in the Michigan Hospital Medicine Safety Consortium (MHMSC).

Synopsis: Data collected through MHMSC for selected medical patients were used in the Kucher, Padua, predictive IMPROVE, and Intermountain DVT risk-assessment models. Patients were classified as “low risk” or “at risk” based on each RAM. Follow-up data came from chart extraction (100% of patients) and 90-day post-discharge telephone calls (58% of patients). The primary outcome was image-confirmed hospital associated VTE, including proximal upper- or proximal lower-extremity DVT or pulmonary embolism. These RAMs classified less than 20% of patients as “at risk.” The incidence of VTE was less than 1%. In this external validation study, the Kucher RAM was the least discriminate and the Intermountain was the best, but none yielded results equivalent to the original studies.

This study was limited by the retrospective design, subjectivity of some risk factors (such as immobility), and inability to obtain 90-day telephone follow-up in all patients. Lastly, the binary approach (“at risk” versus “low risk”) may not align with the original derivation studies in which each factor was evaluated independently.

Bottom Line: The incidence of VTE is low in medical inpatients, and current RAMs may not accurately identify at-risk patients.

Citation: Greene MT, Spyropoulos AC, Chopra V, et al. Validation of risk assessment models of venous thromboembolism in hospitalized medical patients. Am J Med. 2016;129(9):1001.e9-1001.e18. doi:10.1016/j.amjmed.2016.03.031.

Clinical Question: How common are neurologic findings in acute HIV infection?

Background: The incidence of neurologic findings with acute HIV is unknown.

Study Design: Cohort study.

Setting: Bangkok, Thailand.

Synopsis: In this study, 134 patients were identified after presenting for voluntary HIV testing. Five others were enrolled through an ongoing local study. All 139 participants underwent structured neurologic evaluations at enrollment (median of 19 days after presumed exposure), then at four and 12 weeks. Combination antiretroviral therapy (cART) was initiated immediately after initial evaluation.

The cohort was 93% male. Mean age was younger than 30 years. Fifty-three percent of participants experienced some neurologic finding within 12 weeks of diagnosis. One-third (33%) were cognitive symptoms, predominantly problems of concentration (24% of patients) and memory (16% of patients). One-third (34%) were motor findings, and 11% were neuropathy. Forty-nine percent of the neurologic issues were present at diagnosis. Symptoms were mostly mild, although one patient developed fulminant Guillain-Barré syndrome. Patients with neurologic findings had higher viral loads at diagnosis (mean plasma log10 HIV RNA 5.9 versus 5.4; P = 0.006). Participants with and without neurologic findings had similar cerebral spinal fluid viral loads (mean log10 HIV RNA 3.7 versus 3.1, P = 0.14) and serum CD4 counts (339 versus 381 cells/mm3; P = 0.46). Neurologic findings resolved within one month of cART treatment in 90% of patients. Study limitations include lack of a control cohort and potential confounding from illicit drug use among participants.

Bottom Line: Acute HIV infection commonly causes mild neurologic problems, which remit with treatment.

Citation: Hellmuth J, Fletcher JL, Valcour V, et al. Neurologic signs and symptoms frequently manifest in acute HIV infection. Neurology. 2016;87(2):148-154.

Clinical Question: How common are neurologic findings in acute HIV infection?

Background: The incidence of neurologic findings with acute HIV is unknown.

Study Design: Cohort study.

Setting: Bangkok, Thailand.

Synopsis: In this study, 134 patients were identified after presenting for voluntary HIV testing. Five others were enrolled through an ongoing local study. All 139 participants underwent structured neurologic evaluations at enrollment (median of 19 days after presumed exposure), then at four and 12 weeks. Combination antiretroviral therapy (cART) was initiated immediately after initial evaluation.

The cohort was 93% male. Mean age was younger than 30 years. Fifty-three percent of participants experienced some neurologic finding within 12 weeks of diagnosis. One-third (33%) were cognitive symptoms, predominantly problems of concentration (24% of patients) and memory (16% of patients). One-third (34%) were motor findings, and 11% were neuropathy. Forty-nine percent of the neurologic issues were present at diagnosis. Symptoms were mostly mild, although one patient developed fulminant Guillain-Barré syndrome. Patients with neurologic findings had higher viral loads at diagnosis (mean plasma log10 HIV RNA 5.9 versus 5.4; P = 0.006). Participants with and without neurologic findings had similar cerebral spinal fluid viral loads (mean log10 HIV RNA 3.7 versus 3.1, P = 0.14) and serum CD4 counts (339 versus 381 cells/mm3; P = 0.46). Neurologic findings resolved within one month of cART treatment in 90% of patients. Study limitations include lack of a control cohort and potential confounding from illicit drug use among participants.

Bottom Line: Acute HIV infection commonly causes mild neurologic problems, which remit with treatment.

Citation: Hellmuth J, Fletcher JL, Valcour V, et al. Neurologic signs and symptoms frequently manifest in acute HIV infection. Neurology. 2016;87(2):148-154.

Clinical Question: How common are neurologic findings in acute HIV infection?

Background: The incidence of neurologic findings with acute HIV is unknown.

Study Design: Cohort study.

Setting: Bangkok, Thailand.

Synopsis: In this study, 134 patients were identified after presenting for voluntary HIV testing. Five others were enrolled through an ongoing local study. All 139 participants underwent structured neurologic evaluations at enrollment (median of 19 days after presumed exposure), then at four and 12 weeks. Combination antiretroviral therapy (cART) was initiated immediately after initial evaluation.

The cohort was 93% male. Mean age was younger than 30 years. Fifty-three percent of participants experienced some neurologic finding within 12 weeks of diagnosis. One-third (33%) were cognitive symptoms, predominantly problems of concentration (24% of patients) and memory (16% of patients). One-third (34%) were motor findings, and 11% were neuropathy. Forty-nine percent of the neurologic issues were present at diagnosis. Symptoms were mostly mild, although one patient developed fulminant Guillain-Barré syndrome. Patients with neurologic findings had higher viral loads at diagnosis (mean plasma log10 HIV RNA 5.9 versus 5.4; P = 0.006). Participants with and without neurologic findings had similar cerebral spinal fluid viral loads (mean log10 HIV RNA 3.7 versus 3.1, P = 0.14) and serum CD4 counts (339 versus 381 cells/mm3; P = 0.46). Neurologic findings resolved within one month of cART treatment in 90% of patients. Study limitations include lack of a control cohort and potential confounding from illicit drug use among participants.

Bottom Line: Acute HIV infection commonly causes mild neurologic problems, which remit with treatment.

Citation: Hellmuth J, Fletcher JL, Valcour V, et al. Neurologic signs and symptoms frequently manifest in acute HIV infection. Neurology. 2016;87(2):148-154.

Clinical Question: Is the 10-point cognitive screener (10-CS) effective in screening for delirium in older adults with hip fracture?

Background: Delirium in elderly hip fracture patients has been established as a significant comorbidity. There is, however, no agreement on the most appropriate and practical screening tool. Commonly used screening methods, which focus on the detection of cognitive impairment as a surrogate, are time-consuming, insensitive for mild impairment, and limited in their application to patients with impaired dexterity and poor education.

Study Design: Prospective cohort study.

Setting: Tertiary referral hospital in São Paulo, Brazil.

Synopsis: In the study, 147 consecutive hip fracture patients over age 60 were screened using the 10-CS. This test stratifies patients into three categories: normal, possible, and probable cognitive impairment. Development of in-hospital delirium was evaluated by daily Confusion Assessment Method testing administered by a geriatrician. Patients categorized as probable cognitive impairment were more likely to develop delirium (hazard ratio, 7.48; 95% CI, 2.2–25.4).

Hospitalists involved in perioperative care should consider using this simple screening tool. With an area under ROC curve of 0.83 (95% CI, 0.76–0.89), it effectively detects delirium in this high-risk population. Independently, patients who developed delirium had a longer length of stay (median 11.0 versus 7.0; P < 0.001). This serves as a reminder of the importance of screening and preventing delirium in this population.

Bottom Line: The 10-CS tool is practical in its application and effective in identifying elderly hip fracture patients at risk for delirium.

Citation: Fortes-Filho SQ, Apolinario D, Melo JA, Suzuki I, Sitta MD, Garcez-Leme LE. Predicting delirium after hip fracture with a 2-min cognitive screen: prospective cohort study [published online ahead of print May 17, 2016]. Age Ageing. pii:afw084.

Clinical Question: Is the 10-point cognitive screener (10-CS) effective in screening for delirium in older adults with hip fracture?

Background: Delirium in elderly hip fracture patients has been established as a significant comorbidity. There is, however, no agreement on the most appropriate and practical screening tool. Commonly used screening methods, which focus on the detection of cognitive impairment as a surrogate, are time-consuming, insensitive for mild impairment, and limited in their application to patients with impaired dexterity and poor education.

Study Design: Prospective cohort study.

Setting: Tertiary referral hospital in São Paulo, Brazil.

Synopsis: In the study, 147 consecutive hip fracture patients over age 60 were screened using the 10-CS. This test stratifies patients into three categories: normal, possible, and probable cognitive impairment. Development of in-hospital delirium was evaluated by daily Confusion Assessment Method testing administered by a geriatrician. Patients categorized as probable cognitive impairment were more likely to develop delirium (hazard ratio, 7.48; 95% CI, 2.2–25.4).

Hospitalists involved in perioperative care should consider using this simple screening tool. With an area under ROC curve of 0.83 (95% CI, 0.76–0.89), it effectively detects delirium in this high-risk population. Independently, patients who developed delirium had a longer length of stay (median 11.0 versus 7.0; P < 0.001). This serves as a reminder of the importance of screening and preventing delirium in this population.

Bottom Line: The 10-CS tool is practical in its application and effective in identifying elderly hip fracture patients at risk for delirium.

Citation: Fortes-Filho SQ, Apolinario D, Melo JA, Suzuki I, Sitta MD, Garcez-Leme LE. Predicting delirium after hip fracture with a 2-min cognitive screen: prospective cohort study [published online ahead of print May 17, 2016]. Age Ageing. pii:afw084.

Clinical Question: Is the 10-point cognitive screener (10-CS) effective in screening for delirium in older adults with hip fracture?

Background: Delirium in elderly hip fracture patients has been established as a significant comorbidity. There is, however, no agreement on the most appropriate and practical screening tool. Commonly used screening methods, which focus on the detection of cognitive impairment as a surrogate, are time-consuming, insensitive for mild impairment, and limited in their application to patients with impaired dexterity and poor education.

Study Design: Prospective cohort study.

Setting: Tertiary referral hospital in São Paulo, Brazil.

Synopsis: In the study, 147 consecutive hip fracture patients over age 60 were screened using the 10-CS. This test stratifies patients into three categories: normal, possible, and probable cognitive impairment. Development of in-hospital delirium was evaluated by daily Confusion Assessment Method testing administered by a geriatrician. Patients categorized as probable cognitive impairment were more likely to develop delirium (hazard ratio, 7.48; 95% CI, 2.2–25.4).

Hospitalists involved in perioperative care should consider using this simple screening tool. With an area under ROC curve of 0.83 (95% CI, 0.76–0.89), it effectively detects delirium in this high-risk population. Independently, patients who developed delirium had a longer length of stay (median 11.0 versus 7.0; P < 0.001). This serves as a reminder of the importance of screening and preventing delirium in this population.

Bottom Line: The 10-CS tool is practical in its application and effective in identifying elderly hip fracture patients at risk for delirium.

Citation: Fortes-Filho SQ, Apolinario D, Melo JA, Suzuki I, Sitta MD, Garcez-Leme LE. Predicting delirium after hip fracture with a 2-min cognitive screen: prospective cohort study [published online ahead of print May 17, 2016]. Age Ageing. pii:afw084.

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

Hospitalist groups and their stakeholders must continually adapt to evolving reimbursement models and their attendant financial foci on quality. Even in the midst of care models that rely less heavily on volume of care as a marker for reimbursement, the use of criteria by insurers to separate hospital stays into inpatient or observation status remains widespread. Hospitalist groups vary in the reimbursement model environment they work in, and different reimbursement models can drive hospitalist group behavior in different ways.

SHM’s 2016 State of Hospital Medicine Report revisits the issue of observation status utilization raised in previous surveys.1 The 2012 survey’s methodology reports admissions classified as observation status based on CPT coding.2 The 2016 survey continues the 2014 survey methodology of using discharges classified as observation status based on CPT coding, along with same-day admission and discharge reported as a third hospitalization status category. In groups serving adults only, observation discharges accounted for 21.2% of all discharges, which represents an increase from 16.1% in the 2014 survey3 and a general return to the 2012-reported percentage of 20%. If same-day admissions and discharges, many of which are likely classified as observation status, are added, then observation status use in the 2016 survey may be as high as 24% of all admissions. This represents a considerable increase from the combined 19.6% rate in 2014.

Changes in non-academic status hospitalist groups largely account for this increase. Academic hospitalist groups reported an observation status utilization rate of 15.3% of admissions in 2012 and 19.4% in 2014, with a subsequent decrease to 17.5% reported in the 2016 survey. Inclusion of same-day admission and discharge with reported observation status use also reveals a decrease from 22.8% in 2014 to 20.8% in the new survey. In contrast, non-academic hospitalist groups now report a substantial change in observation status utilization, up to 21.4% in the 2016 survey from 15.6% in 2014 and similar to the 2012 level of 20.4%. When same-day admission and discharge codes are also included, the totals for non-academic hospitalist groups also evidence an increase, to 24.3% in the new survey from 19.2% in 2014.

I postulated in 2015 that the comparative increase in observation status utilization by academic groups as compared with non-academic groups in the 2014 survey may have been associated with greater proficiency in documentation and related billing inherent in a bedside clinical workforce entirely composed of physicians who have completed postgraduate training. Other phenomena may now potentially explain the increase in observation status use we see in the 2016 survey. These include adoption of the two-midnight rule by the Centers for Medicare & Medicaid Services, use of readmission rates in hospitalist group incentive structures, sharing of cost savings between hospitalist groups and healthcare organizations mutually engaged in third-party bundled payment arrangements, or risk-avoidant strategies executed by clinicians and institutional coders perhaps in excess of their institutions’ needs for risk avoidance. For many of these events, the 2016 State of Hospital Medicine Report provides further benchmark data, in a national and regional context, to inform understanding for hospitalist groups facing challenges associated with observation status utilization.

G. Randy Smith Jr., MD, MS, FRCP(Edin), SFHM, is an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago.

References

1. 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
2. 2012 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
3. 2014 State of Hospital Medicine Report. Society of Hospital Medicine website.

   Accessed September 11, 2016.

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

Hospitalist groups and their stakeholders must continually adapt to evolving reimbursement models and their attendant financial foci on quality. Even in the midst of care models that rely less heavily on volume of care as a marker for reimbursement, the use of criteria by insurers to separate hospital stays into inpatient or observation status remains widespread. Hospitalist groups vary in the reimbursement model environment they work in, and different reimbursement models can drive hospitalist group behavior in different ways.

SHM’s 2016 State of Hospital Medicine Report revisits the issue of observation status utilization raised in previous surveys.1 The 2012 survey’s methodology reports admissions classified as observation status based on CPT coding.2 The 2016 survey continues the 2014 survey methodology of using discharges classified as observation status based on CPT coding, along with same-day admission and discharge reported as a third hospitalization status category. In groups serving adults only, observation discharges accounted for 21.2% of all discharges, which represents an increase from 16.1% in the 2014 survey3 and a general return to the 2012-reported percentage of 20%. If same-day admissions and discharges, many of which are likely classified as observation status, are added, then observation status use in the 2016 survey may be as high as 24% of all admissions. This represents a considerable increase from the combined 19.6% rate in 2014.

Changes in non-academic status hospitalist groups largely account for this increase. Academic hospitalist groups reported an observation status utilization rate of 15.3% of admissions in 2012 and 19.4% in 2014, with a subsequent decrease to 17.5% reported in the 2016 survey. Inclusion of same-day admission and discharge with reported observation status use also reveals a decrease from 22.8% in 2014 to 20.8% in the new survey. In contrast, non-academic hospitalist groups now report a substantial change in observation status utilization, up to 21.4% in the 2016 survey from 15.6% in 2014 and similar to the 2012 level of 20.4%. When same-day admission and discharge codes are also included, the totals for non-academic hospitalist groups also evidence an increase, to 24.3% in the new survey from 19.2% in 2014.

I postulated in 2015 that the comparative increase in observation status utilization by academic groups as compared with non-academic groups in the 2014 survey may have been associated with greater proficiency in documentation and related billing inherent in a bedside clinical workforce entirely composed of physicians who have completed postgraduate training. Other phenomena may now potentially explain the increase in observation status use we see in the 2016 survey. These include adoption of the two-midnight rule by the Centers for Medicare & Medicaid Services, use of readmission rates in hospitalist group incentive structures, sharing of cost savings between hospitalist groups and healthcare organizations mutually engaged in third-party bundled payment arrangements, or risk-avoidant strategies executed by clinicians and institutional coders perhaps in excess of their institutions’ needs for risk avoidance. For many of these events, the 2016 State of Hospital Medicine Report provides further benchmark data, in a national and regional context, to inform understanding for hospitalist groups facing challenges associated with observation status utilization.

G. Randy Smith Jr., MD, MS, FRCP(Edin), SFHM, is an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago.

References

1. 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
2. 2012 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
3. 2014 State of Hospital Medicine Report. Society of Hospital Medicine website.

   Accessed September 11, 2016.

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

Hospitalist groups and their stakeholders must continually adapt to evolving reimbursement models and their attendant financial foci on quality. Even in the midst of care models that rely less heavily on volume of care as a marker for reimbursement, the use of criteria by insurers to separate hospital stays into inpatient or observation status remains widespread. Hospitalist groups vary in the reimbursement model environment they work in, and different reimbursement models can drive hospitalist group behavior in different ways.

SHM’s 2016 State of Hospital Medicine Report revisits the issue of observation status utilization raised in previous surveys.1 The 2012 survey’s methodology reports admissions classified as observation status based on CPT coding.2 The 2016 survey continues the 2014 survey methodology of using discharges classified as observation status based on CPT coding, along with same-day admission and discharge reported as a third hospitalization status category. In groups serving adults only, observation discharges accounted for 21.2% of all discharges, which represents an increase from 16.1% in the 2014 survey3 and a general return to the 2012-reported percentage of 20%. If same-day admissions and discharges, many of which are likely classified as observation status, are added, then observation status use in the 2016 survey may be as high as 24% of all admissions. This represents a considerable increase from the combined 19.6% rate in 2014.

Changes in non-academic status hospitalist groups largely account for this increase. Academic hospitalist groups reported an observation status utilization rate of 15.3% of admissions in 2012 and 19.4% in 2014, with a subsequent decrease to 17.5% reported in the 2016 survey. Inclusion of same-day admission and discharge with reported observation status use also reveals a decrease from 22.8% in 2014 to 20.8% in the new survey. In contrast, non-academic hospitalist groups now report a substantial change in observation status utilization, up to 21.4% in the 2016 survey from 15.6% in 2014 and similar to the 2012 level of 20.4%. When same-day admission and discharge codes are also included, the totals for non-academic hospitalist groups also evidence an increase, to 24.3% in the new survey from 19.2% in 2014.

I postulated in 2015 that the comparative increase in observation status utilization by academic groups as compared with non-academic groups in the 2014 survey may have been associated with greater proficiency in documentation and related billing inherent in a bedside clinical workforce entirely composed of physicians who have completed postgraduate training. Other phenomena may now potentially explain the increase in observation status use we see in the 2016 survey. These include adoption of the two-midnight rule by the Centers for Medicare & Medicaid Services, use of readmission rates in hospitalist group incentive structures, sharing of cost savings between hospitalist groups and healthcare organizations mutually engaged in third-party bundled payment arrangements, or risk-avoidant strategies executed by clinicians and institutional coders perhaps in excess of their institutions’ needs for risk avoidance. For many of these events, the 2016 State of Hospital Medicine Report provides further benchmark data, in a national and regional context, to inform understanding for hospitalist groups facing challenges associated with observation status utilization.

G. Randy Smith Jr., MD, MS, FRCP(Edin), SFHM, is an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago.

References

1. 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
2. 2012 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed September 11, 2016.
3. 2014 State of Hospital Medicine Report. Society of Hospital Medicine website.

   Accessed September 11, 2016.

NEW YORK (Reuters Health) - The American Academy of Pediatrics (AAP) today released six clinical reports and one policy statement covering a range of timely topics relevant to the health and care of children. Here is a snapshot.

1) Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. 

This report focuses on the issues relevant to children and adolescents presenting to the emergency department (ED) or primary care clinic with a mental health condition or emergency and covers the following topics: medical clearance of pediatric psychiatric patients; suicidal ideation and suicide attempts; involuntary hospitalization; restraint of the agitated patient (verbal restraint, chemical restraint and physical restraint); coordination with the medical home.

2) Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms. 

This clinical report focuses on the challenges a pediatrician may face when evaluating patients with a mental health condition, which may be contributing to or complicating a medical or indeterminate clinical presentation. Topics include somatic symptom and related disorders; adverse effects of psychiatric medications (antipsychotic adverse effects, neuroleptic malignant syndrome, serotonin syndrome); children with special needs in the ED (autism spectrum and developmental disorders); mental health screening in the ED.

Both reports are from the AAP Committee on Pediatric Emergency Medicine and the American College of Emergency Physicians Pediatric Emergency Medicine Committee and include an executive summary.

3) Mind-Body Therapies in Children and Youth

From the AAP Section on Integrative Medicine, this report notes that a "growing body of evidence supports the effectiveness and safety of mind-body therapies in pediatrics. This clinical report outlines popular mind-body therapies for children and youth and examines the best-available evidence for a variety of mind-body therapies and practices, including biofeedback, clinical hypnosis, guided imagery, meditation, and yoga. The report is intended to help health care professionals guide their patients to nonpharmacologic approaches to improve concentration, help decrease pain, control discomfort, or ease anxiety."

4) Preventing Obesity and Eating Disorders in Adolescents 

This report, from the AAP Committee on Nutrition, Committee on Adolescence, Section on Obesity, notes that "messages from pediatricians addressing obesity and reviewing constructive ways to manage weight can be safely and supportively incorporated into health care visits. Avoiding certain weight-based language and using motivational interviewing (MI) techniques may improve communication and promote successful outcomes when providing weight-management counseling. This clinical report addresses the interaction between obesity prevention and eating disorders (EDs) in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs."

5) Parental Presence During Treatment of Ebola or Other Highly Consequential Infection 

From the AAP Committee on Infectious Diseases, this report offers "guidance to health care providers and hospitals on options to consider regarding parental presence at the bedside while caring for a child with suspected or proven Ebola virus disease (Ebola) or other highly consequential infection. Options are presented to help meet the needs of the patient and the family while also posing the least risk to providers and health care organizations."

6) Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns 

This report, from the Committee on Fetus and Newborn, Task Force on Sudden Infant Death Syndrome, notes that skin-to-skin care (SSC) and rooming-in are now common in the newborn period for healthy newborns with the implementation of maternity care practices that support breastfeeding as outlined in the World Health Organization's "Ten Steps to Successful Breastfeeding." The evidence indicates that implementation of these practices "increases overall and exclusive breastfeeding, safer and healthier transitions, and improved maternal-infant bonding. In some cases, however, the practice of SSC and rooming-in may pose safety concerns, particularly with regard to sleep. This clinical report is intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies."

The policy statement - Medication-Assisted Treatment of Adolescents With Opioid Use Disorders - is from the Committee on Substance Use and Prevention. It notes that opioid use disorder is "a leading cause of morbidity and mortality among US youth. Effective treatments, both medications and substance use disorder counseling, are available but underused, and access to developmentally appropriate treatment is severely restricted for adolescents and young adults. Resources to disseminate available therapies and to develop new treatments specifically for this age group are needed to save and improve lives of youth with opioid addiction."

"The AAP recommends that pediatricians consider offering medication-assisted treatment to their adolescent and young adult patients with severe opioid use disorders or discuss referrals to other providers for this service," the statement advises.

The six clinical reports and one policy statement are published in the September issue of Pediatrics and were released online August 22.

SOURCE: http://bit.ly/2bfNEj8

Pediatrics 2016.

(c) Copyright Thomson Reuters 2016.

NEW YORK (Reuters Health) - The American Academy of Pediatrics (AAP) today released six clinical reports and one policy statement covering a range of timely topics relevant to the health and care of children. Here is a snapshot.

1) Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. 

This report focuses on the issues relevant to children and adolescents presenting to the emergency department (ED) or primary care clinic with a mental health condition or emergency and covers the following topics: medical clearance of pediatric psychiatric patients; suicidal ideation and suicide attempts; involuntary hospitalization; restraint of the agitated patient (verbal restraint, chemical restraint and physical restraint); coordination with the medical home.

2) Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms. 

This clinical report focuses on the challenges a pediatrician may face when evaluating patients with a mental health condition, which may be contributing to or complicating a medical or indeterminate clinical presentation. Topics include somatic symptom and related disorders; adverse effects of psychiatric medications (antipsychotic adverse effects, neuroleptic malignant syndrome, serotonin syndrome); children with special needs in the ED (autism spectrum and developmental disorders); mental health screening in the ED.

Both reports are from the AAP Committee on Pediatric Emergency Medicine and the American College of Emergency Physicians Pediatric Emergency Medicine Committee and include an executive summary.

3) Mind-Body Therapies in Children and Youth

From the AAP Section on Integrative Medicine, this report notes that a "growing body of evidence supports the effectiveness and safety of mind-body therapies in pediatrics. This clinical report outlines popular mind-body therapies for children and youth and examines the best-available evidence for a variety of mind-body therapies and practices, including biofeedback, clinical hypnosis, guided imagery, meditation, and yoga. The report is intended to help health care professionals guide their patients to nonpharmacologic approaches to improve concentration, help decrease pain, control discomfort, or ease anxiety."

4) Preventing Obesity and Eating Disorders in Adolescents 

This report, from the AAP Committee on Nutrition, Committee on Adolescence, Section on Obesity, notes that "messages from pediatricians addressing obesity and reviewing constructive ways to manage weight can be safely and supportively incorporated into health care visits. Avoiding certain weight-based language and using motivational interviewing (MI) techniques may improve communication and promote successful outcomes when providing weight-management counseling. This clinical report addresses the interaction between obesity prevention and eating disorders (EDs) in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs."

5) Parental Presence During Treatment of Ebola or Other Highly Consequential Infection 

From the AAP Committee on Infectious Diseases, this report offers "guidance to health care providers and hospitals on options to consider regarding parental presence at the bedside while caring for a child with suspected or proven Ebola virus disease (Ebola) or other highly consequential infection. Options are presented to help meet the needs of the patient and the family while also posing the least risk to providers and health care organizations."

6) Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns 

This report, from the Committee on Fetus and Newborn, Task Force on Sudden Infant Death Syndrome, notes that skin-to-skin care (SSC) and rooming-in are now common in the newborn period for healthy newborns with the implementation of maternity care practices that support breastfeeding as outlined in the World Health Organization's "Ten Steps to Successful Breastfeeding." The evidence indicates that implementation of these practices "increases overall and exclusive breastfeeding, safer and healthier transitions, and improved maternal-infant bonding. In some cases, however, the practice of SSC and rooming-in may pose safety concerns, particularly with regard to sleep. This clinical report is intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies."

The policy statement - Medication-Assisted Treatment of Adolescents With Opioid Use Disorders - is from the Committee on Substance Use and Prevention. It notes that opioid use disorder is "a leading cause of morbidity and mortality among US youth. Effective treatments, both medications and substance use disorder counseling, are available but underused, and access to developmentally appropriate treatment is severely restricted for adolescents and young adults. Resources to disseminate available therapies and to develop new treatments specifically for this age group are needed to save and improve lives of youth with opioid addiction."

"The AAP recommends that pediatricians consider offering medication-assisted treatment to their adolescent and young adult patients with severe opioid use disorders or discuss referrals to other providers for this service," the statement advises.

The six clinical reports and one policy statement are published in the September issue of Pediatrics and were released online August 22.

SOURCE: http://bit.ly/2bfNEj8

Pediatrics 2016.

(c) Copyright Thomson Reuters 2016.

NEW YORK (Reuters Health) - The American Academy of Pediatrics (AAP) today released six clinical reports and one policy statement covering a range of timely topics relevant to the health and care of children. Here is a snapshot.

1) Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. 

This report focuses on the issues relevant to children and adolescents presenting to the emergency department (ED) or primary care clinic with a mental health condition or emergency and covers the following topics: medical clearance of pediatric psychiatric patients; suicidal ideation and suicide attempts; involuntary hospitalization; restraint of the agitated patient (verbal restraint, chemical restraint and physical restraint); coordination with the medical home.

2) Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms. 

This clinical report focuses on the challenges a pediatrician may face when evaluating patients with a mental health condition, which may be contributing to or complicating a medical or indeterminate clinical presentation. Topics include somatic symptom and related disorders; adverse effects of psychiatric medications (antipsychotic adverse effects, neuroleptic malignant syndrome, serotonin syndrome); children with special needs in the ED (autism spectrum and developmental disorders); mental health screening in the ED.

Both reports are from the AAP Committee on Pediatric Emergency Medicine and the American College of Emergency Physicians Pediatric Emergency Medicine Committee and include an executive summary.

3) Mind-Body Therapies in Children and Youth

From the AAP Section on Integrative Medicine, this report notes that a "growing body of evidence supports the effectiveness and safety of mind-body therapies in pediatrics. This clinical report outlines popular mind-body therapies for children and youth and examines the best-available evidence for a variety of mind-body therapies and practices, including biofeedback, clinical hypnosis, guided imagery, meditation, and yoga. The report is intended to help health care professionals guide their patients to nonpharmacologic approaches to improve concentration, help decrease pain, control discomfort, or ease anxiety."

4) Preventing Obesity and Eating Disorders in Adolescents 

This report, from the AAP Committee on Nutrition, Committee on Adolescence, Section on Obesity, notes that "messages from pediatricians addressing obesity and reviewing constructive ways to manage weight can be safely and supportively incorporated into health care visits. Avoiding certain weight-based language and using motivational interviewing (MI) techniques may improve communication and promote successful outcomes when providing weight-management counseling. This clinical report addresses the interaction between obesity prevention and eating disorders (EDs) in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs."

5) Parental Presence During Treatment of Ebola or Other Highly Consequential Infection 

From the AAP Committee on Infectious Diseases, this report offers "guidance to health care providers and hospitals on options to consider regarding parental presence at the bedside while caring for a child with suspected or proven Ebola virus disease (Ebola) or other highly consequential infection. Options are presented to help meet the needs of the patient and the family while also posing the least risk to providers and health care organizations."

6) Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns 

This report, from the Committee on Fetus and Newborn, Task Force on Sudden Infant Death Syndrome, notes that skin-to-skin care (SSC) and rooming-in are now common in the newborn period for healthy newborns with the implementation of maternity care practices that support breastfeeding as outlined in the World Health Organization's "Ten Steps to Successful Breastfeeding." The evidence indicates that implementation of these practices "increases overall and exclusive breastfeeding, safer and healthier transitions, and improved maternal-infant bonding. In some cases, however, the practice of SSC and rooming-in may pose safety concerns, particularly with regard to sleep. This clinical report is intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies."

The policy statement - Medication-Assisted Treatment of Adolescents With Opioid Use Disorders - is from the Committee on Substance Use and Prevention. It notes that opioid use disorder is "a leading cause of morbidity and mortality among US youth. Effective treatments, both medications and substance use disorder counseling, are available but underused, and access to developmentally appropriate treatment is severely restricted for adolescents and young adults. Resources to disseminate available therapies and to develop new treatments specifically for this age group are needed to save and improve lives of youth with opioid addiction."

"The AAP recommends that pediatricians consider offering medication-assisted treatment to their adolescent and young adult patients with severe opioid use disorders or discuss referrals to other providers for this service," the statement advises.

The six clinical reports and one policy statement are published in the September issue of Pediatrics and were released online August 22.

SOURCE: http://bit.ly/2bfNEj8

Pediatrics 2016.

(c) Copyright Thomson Reuters 2016.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

Background: Service handovers contribute to discontinuity of care in hospitalized patients. Research on hospitalist service handovers is limited, and no previous study has examined the service handover from the patient’s perspective.

Study design: Interview-based, qualitative analysis.

Setting: Urban academic medical center.

Synopsis: Researchers interviewed 40 hospitalized patients using a semi-structured nine-question interview regarding their attending hospitalist service change. The constant comparative method was used to identify recurrent themes in patient responses. The research team identified six themes representative of patient concerns during service change: physician-patient communication, transparency in communication, hospitalist-specialist communication, new opportunities due to transition, bedside manner, and indifference toward the transition.

Authors used the six themes to develop a model for the ideal service handover, utilizing open lines of communication, facilitated by multiple modalities and disciplines, and recognizing the patient’s role as the primary stakeholder in the transition of care.

Bottom line: Incorporating patients’ perspective presents an opportunity to improve communication and efficiency during hospitalist service transitions.

Citation: Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients’ experience with hospitalist service handovers [published online ahead of print May 11, 2016]. J Hosp Med. doi:10.1002/jhm.2608.

Background: Service handovers contribute to discontinuity of care in hospitalized patients. Research on hospitalist service handovers is limited, and no previous study has examined the service handover from the patient’s perspective.

Study design: Interview-based, qualitative analysis.

Setting: Urban academic medical center.

Synopsis: Researchers interviewed 40 hospitalized patients using a semi-structured nine-question interview regarding their attending hospitalist service change. The constant comparative method was used to identify recurrent themes in patient responses. The research team identified six themes representative of patient concerns during service change: physician-patient communication, transparency in communication, hospitalist-specialist communication, new opportunities due to transition, bedside manner, and indifference toward the transition.

Authors used the six themes to develop a model for the ideal service handover, utilizing open lines of communication, facilitated by multiple modalities and disciplines, and recognizing the patient’s role as the primary stakeholder in the transition of care.

Bottom line: Incorporating patients’ perspective presents an opportunity to improve communication and efficiency during hospitalist service transitions.

Citation: Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients’ experience with hospitalist service handovers [published online ahead of print May 11, 2016]. J Hosp Med. doi:10.1002/jhm.2608.

Background: Service handovers contribute to discontinuity of care in hospitalized patients. Research on hospitalist service handovers is limited, and no previous study has examined the service handover from the patient’s perspective.

Study design: Interview-based, qualitative analysis.

Setting: Urban academic medical center.

Synopsis: Researchers interviewed 40 hospitalized patients using a semi-structured nine-question interview regarding their attending hospitalist service change. The constant comparative method was used to identify recurrent themes in patient responses. The research team identified six themes representative of patient concerns during service change: physician-patient communication, transparency in communication, hospitalist-specialist communication, new opportunities due to transition, bedside manner, and indifference toward the transition.

Authors used the six themes to develop a model for the ideal service handover, utilizing open lines of communication, facilitated by multiple modalities and disciplines, and recognizing the patient’s role as the primary stakeholder in the transition of care.

Bottom line: Incorporating patients’ perspective presents an opportunity to improve communication and efficiency during hospitalist service transitions.

Citation: Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients’ experience with hospitalist service handovers [published online ahead of print May 11, 2016]. J Hosp Med. doi:10.1002/jhm.2608.

Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.

Study design: Retrospective cohort study.

Setting: National Health Research Institutes, Taiwan.

Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.

Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.

Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.

Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.

Study design: Retrospective cohort study.

Setting: National Health Research Institutes, Taiwan.

Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.

Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.

Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.

Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.

Study design: Retrospective cohort study.

Setting: National Health Research Institutes, Taiwan.

Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.

Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.

Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.

Background: Older hospitalized patients experience decreased mobility while in the hospital and suffer from impaired function and mobility after they are discharged. The efficacy and safety of inpatient mobility programs are unknown.

Study design: Randomized, single-blinded controlled trial.

Setting: Birmingham Veterans Affairs Medical Center, Alabama.

Synopsis: The study included 100 patients age 65 years and older admitted to general medical wards. Researchers excluded cognitively impaired patients and patients with limited life expectancy. Intervention patients received a standardized hospital mobility protocol, with up to twice daily 15- to 20-minute visits by research personnel. Visits sought to progressively increase mobility from assisted sitting to ambulation. Physical activity was coupled with a behavioral intervention focused on goal setting and mobility barrier resolution. The comparison group received usual care. Outcomes included changes in activities of daily living (ADLs) and community mobility one month after hospital discharge.

One month after hospitalization, there were no differences in ADLs between intervention and control patients. Patients in the mobility protocol arm, however, maintained their prehospital community mobility, whereas usual-care patients had a statistically significant decrease in mobility as measured by the Life-Space Assessment. There was no difference in falls between groups.

Bottom line: A hospital mobility intervention was a safe and effective means of preserving community mobility. Future effectiveness studies are needed to demonstrate feasibility and outcomes in real-world settings.

Citation: Brown CJ, Foley KT, Lowman JD Jr, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Intern Med. 2016;176(7):921-927.

Short Take

Topical NSAIDs Effective for Back Pain

Using ketoprofen gel in addition to intravenous dexketoprofen improves pain relief in patients presenting to the emergency department with low back pain.

Citation: Serinken M, Eken C, Tunay K, Golcuk Y. Ketoprofen gel improves low back pain in addition to IV dexkeoprofen: a randomized placebo-controlled trial. Am J Emerg Med. 2016;34(8):1458-1461.

Background: Older hospitalized patients experience decreased mobility while in the hospital and suffer from impaired function and mobility after they are discharged. The efficacy and safety of inpatient mobility programs are unknown.

Study design: Randomized, single-blinded controlled trial.

Setting: Birmingham Veterans Affairs Medical Center, Alabama.

Synopsis: The study included 100 patients age 65 years and older admitted to general medical wards. Researchers excluded cognitively impaired patients and patients with limited life expectancy. Intervention patients received a standardized hospital mobility protocol, with up to twice daily 15- to 20-minute visits by research personnel. Visits sought to progressively increase mobility from assisted sitting to ambulation. Physical activity was coupled with a behavioral intervention focused on goal setting and mobility barrier resolution. The comparison group received usual care. Outcomes included changes in activities of daily living (ADLs) and community mobility one month after hospital discharge.

One month after hospitalization, there were no differences in ADLs between intervention and control patients. Patients in the mobility protocol arm, however, maintained their prehospital community mobility, whereas usual-care patients had a statistically significant decrease in mobility as measured by the Life-Space Assessment. There was no difference in falls between groups.

Bottom line: A hospital mobility intervention was a safe and effective means of preserving community mobility. Future effectiveness studies are needed to demonstrate feasibility and outcomes in real-world settings.

Citation: Brown CJ, Foley KT, Lowman JD Jr, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Intern Med. 2016;176(7):921-927.

Short Take

Topical NSAIDs Effective for Back Pain

Using ketoprofen gel in addition to intravenous dexketoprofen improves pain relief in patients presenting to the emergency department with low back pain.

Citation: Serinken M, Eken C, Tunay K, Golcuk Y. Ketoprofen gel improves low back pain in addition to IV dexkeoprofen: a randomized placebo-controlled trial. Am J Emerg Med. 2016;34(8):1458-1461.

Background: Older hospitalized patients experience decreased mobility while in the hospital and suffer from impaired function and mobility after they are discharged. The efficacy and safety of inpatient mobility programs are unknown.

Study design: Randomized, single-blinded controlled trial.

Setting: Birmingham Veterans Affairs Medical Center, Alabama.

Synopsis: The study included 100 patients age 65 years and older admitted to general medical wards. Researchers excluded cognitively impaired patients and patients with limited life expectancy. Intervention patients received a standardized hospital mobility protocol, with up to twice daily 15- to 20-minute visits by research personnel. Visits sought to progressively increase mobility from assisted sitting to ambulation. Physical activity was coupled with a behavioral intervention focused on goal setting and mobility barrier resolution. The comparison group received usual care. Outcomes included changes in activities of daily living (ADLs) and community mobility one month after hospital discharge.

One month after hospitalization, there were no differences in ADLs between intervention and control patients. Patients in the mobility protocol arm, however, maintained their prehospital community mobility, whereas usual-care patients had a statistically significant decrease in mobility as measured by the Life-Space Assessment. There was no difference in falls between groups.

Bottom line: A hospital mobility intervention was a safe and effective means of preserving community mobility. Future effectiveness studies are needed to demonstrate feasibility and outcomes in real-world settings.

Citation: Brown CJ, Foley KT, Lowman JD Jr, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Intern Med. 2016;176(7):921-927.

Short Take

Topical NSAIDs Effective for Back Pain

Using ketoprofen gel in addition to intravenous dexketoprofen improves pain relief in patients presenting to the emergency department with low back pain.

Citation: Serinken M, Eken C, Tunay K, Golcuk Y. Ketoprofen gel improves low back pain in addition to IV dexkeoprofen: a randomized placebo-controlled trial. Am J Emerg Med. 2016;34(8):1458-1461.