Clinical

PHM16’s Visual Diagnosis: Signs and Why They Matter session led by Dr. Kenneth Roberts and guest presenters was a review of case presentations in which visual clues were vital to establishing a diagnosis. Though much of the content was presented with pictures, the emphasis was placed on the importance of correct diagnosis to avoid both misdiagnoses/over-diagnoses and the potential harm that may result from inappropriate treatment. This may also translate into poor utilization of resources and significant financial burden that can result from the unnecessary hospitalization of a patient.

Many of the presented cases (such as the Gianotti-Crosti toddler over-diagnosed as eczema herpeticum, a child with pseudochromhidrosis misdiagnosed as a cyanotic disease, the case of phytophotodermatitis mistaken as child abuse, and a teen treated for 2 years for JIA before diagnosis of hypertrophic osteoarthropathy was made) highlighted examples in which there was extensive workup, hospitalization, subspecialty evaluation, and even incorrect treatment of patients.

In other instances, such as Henoch-Schonlein purpura, Waardenburg syndrome, or McCune-Albright syndrome, the correct diagnosis is necessary to help guide management and future treatment, including subspecialty evaluation.

Many diseases with visual presentations also have a benign course and require no treatment, and acknowledging this is important in providing reassurance to a family that may be very anxious over the physical appearance of their child.

This session underscores the need for experience and exposure to various signs, not only with rare medical conditions, but also in common illnesses such as Kawasaki and scarlet fever that may present similarly.

Key Takeaway:

Providers should have a high index of suspicion and use visual clues to make the correct diagnosis in order to guide treatment, avoid harm in children, and ensure appropriate utilization of resources.

---

Chandani DeZure, MD, FAAP, is a pediatric Hospitalist at Children’s National Health System, Instruction of Pediatrics at George Washington University’s School of Medicine and Health Sciences in Washington, D.C.

PHM16’s Visual Diagnosis: Signs and Why They Matter session led by Dr. Kenneth Roberts and guest presenters was a review of case presentations in which visual clues were vital to establishing a diagnosis. Though much of the content was presented with pictures, the emphasis was placed on the importance of correct diagnosis to avoid both misdiagnoses/over-diagnoses and the potential harm that may result from inappropriate treatment. This may also translate into poor utilization of resources and significant financial burden that can result from the unnecessary hospitalization of a patient.

Many of the presented cases (such as the Gianotti-Crosti toddler over-diagnosed as eczema herpeticum, a child with pseudochromhidrosis misdiagnosed as a cyanotic disease, the case of phytophotodermatitis mistaken as child abuse, and a teen treated for 2 years for JIA before diagnosis of hypertrophic osteoarthropathy was made) highlighted examples in which there was extensive workup, hospitalization, subspecialty evaluation, and even incorrect treatment of patients.

In other instances, such as Henoch-Schonlein purpura, Waardenburg syndrome, or McCune-Albright syndrome, the correct diagnosis is necessary to help guide management and future treatment, including subspecialty evaluation.

Many diseases with visual presentations also have a benign course and require no treatment, and acknowledging this is important in providing reassurance to a family that may be very anxious over the physical appearance of their child.

This session underscores the need for experience and exposure to various signs, not only with rare medical conditions, but also in common illnesses such as Kawasaki and scarlet fever that may present similarly.

Key Takeaway:

Providers should have a high index of suspicion and use visual clues to make the correct diagnosis in order to guide treatment, avoid harm in children, and ensure appropriate utilization of resources.

---

Chandani DeZure, MD, FAAP, is a pediatric Hospitalist at Children’s National Health System, Instruction of Pediatrics at George Washington University’s School of Medicine and Health Sciences in Washington, D.C.

PHM16’s Visual Diagnosis: Signs and Why They Matter session led by Dr. Kenneth Roberts and guest presenters was a review of case presentations in which visual clues were vital to establishing a diagnosis. Though much of the content was presented with pictures, the emphasis was placed on the importance of correct diagnosis to avoid both misdiagnoses/over-diagnoses and the potential harm that may result from inappropriate treatment. This may also translate into poor utilization of resources and significant financial burden that can result from the unnecessary hospitalization of a patient.

Many of the presented cases (such as the Gianotti-Crosti toddler over-diagnosed as eczema herpeticum, a child with pseudochromhidrosis misdiagnosed as a cyanotic disease, the case of phytophotodermatitis mistaken as child abuse, and a teen treated for 2 years for JIA before diagnosis of hypertrophic osteoarthropathy was made) highlighted examples in which there was extensive workup, hospitalization, subspecialty evaluation, and even incorrect treatment of patients.

In other instances, such as Henoch-Schonlein purpura, Waardenburg syndrome, or McCune-Albright syndrome, the correct diagnosis is necessary to help guide management and future treatment, including subspecialty evaluation.

Many diseases with visual presentations also have a benign course and require no treatment, and acknowledging this is important in providing reassurance to a family that may be very anxious over the physical appearance of their child.

This session underscores the need for experience and exposure to various signs, not only with rare medical conditions, but also in common illnesses such as Kawasaki and scarlet fever that may present similarly.

Key Takeaway:

Providers should have a high index of suspicion and use visual clues to make the correct diagnosis in order to guide treatment, avoid harm in children, and ensure appropriate utilization of resources.

---

Chandani DeZure, MD, FAAP, is a pediatric Hospitalist at Children’s National Health System, Instruction of Pediatrics at George Washington University’s School of Medicine and Health Sciences in Washington, D.C.

One of PHM16’s most highly-attended sessions was an update on the anticipated AAP guidelines for febrile infants between ages 7-90 days given by Dr. Kenneth Roberts. The goal is to give evidence-based guidelines, not rules, from the most recent literature available. It also stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The inclusion criteria for infants for this upcoming algorithm require an infant to be full-term (37-43 weeks gestation), aged 7-90 days, well-appearing, and presenting with a temperature of 38 degrees Celsius.

Exclusion criteria include perinatal/prenatal/neonatal: maternal fever, infection, or antimicrobial treatment, the presence of any evident infection, being technology-dependent, and the presence of congenital anomalies.

The updated guideline will aim to stratify management by age 7-28 days, 29-60 days, and 61 to 90 days to provide the most appropriate and directed treatment.

It will also include a role for inflammatory markers, and allow for a “kinder, gentler” approach to the management of febrile infants aged 7-90 days including withholding certain treatments and procedures if infants are at low risk of infection. An active, not passive, need for observation may be appropriate for certain infants as well. These guidelines should be tailored for individual patients to provide the best care possible while minimizing risk in this population.

Key Takeaway:

An updated AAP Practice guideline algorithm for the management of well-appearing febrile infants 7-28 days, 29-60 days, and 60-90 days will be coming in the near future that will help standardize care in this population, but should not be used as a substitute for clinical judgment.

---

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System, Instruction of Pediatrics at George Washington University’s School of Medicine and Health Sciences in Washington, D.C.

One of PHM16’s most highly-attended sessions was an update on the anticipated AAP guidelines for febrile infants between ages 7-90 days given by Dr. Kenneth Roberts. The goal is to give evidence-based guidelines, not rules, from the most recent literature available. It also stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The inclusion criteria for infants for this upcoming algorithm require an infant to be full-term (37-43 weeks gestation), aged 7-90 days, well-appearing, and presenting with a temperature of 38 degrees Celsius.

Exclusion criteria include perinatal/prenatal/neonatal: maternal fever, infection, or antimicrobial treatment, the presence of any evident infection, being technology-dependent, and the presence of congenital anomalies.

The updated guideline will aim to stratify management by age 7-28 days, 29-60 days, and 61 to 90 days to provide the most appropriate and directed treatment.

It will also include a role for inflammatory markers, and allow for a “kinder, gentler” approach to the management of febrile infants aged 7-90 days including withholding certain treatments and procedures if infants are at low risk of infection. An active, not passive, need for observation may be appropriate for certain infants as well. These guidelines should be tailored for individual patients to provide the best care possible while minimizing risk in this population.

Key Takeaway:

An updated AAP Practice guideline algorithm for the management of well-appearing febrile infants 7-28 days, 29-60 days, and 60-90 days will be coming in the near future that will help standardize care in this population, but should not be used as a substitute for clinical judgment.

---

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System, Instruction of Pediatrics at George Washington University’s School of Medicine and Health Sciences in Washington, D.C.

One of PHM16’s most highly-attended sessions was an update on the anticipated AAP guidelines for febrile infants between ages 7-90 days given by Dr. Kenneth Roberts. The goal is to give evidence-based guidelines, not rules, from the most recent literature available. It also stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The inclusion criteria for infants for this upcoming algorithm require an infant to be full-term (37-43 weeks gestation), aged 7-90 days, well-appearing, and presenting with a temperature of 38 degrees Celsius.

Exclusion criteria include perinatal/prenatal/neonatal: maternal fever, infection, or antimicrobial treatment, the presence of any evident infection, being technology-dependent, and the presence of congenital anomalies.

The updated guideline will aim to stratify management by age 7-28 days, 29-60 days, and 61 to 90 days to provide the most appropriate and directed treatment.

It will also include a role for inflammatory markers, and allow for a “kinder, gentler” approach to the management of febrile infants aged 7-90 days including withholding certain treatments and procedures if infants are at low risk of infection. An active, not passive, need for observation may be appropriate for certain infants as well. These guidelines should be tailored for individual patients to provide the best care possible while minimizing risk in this population.

Key Takeaway:

An updated AAP Practice guideline algorithm for the management of well-appearing febrile infants 7-28 days, 29-60 days, and 60-90 days will be coming in the near future that will help standardize care in this population, but should not be used as a substitute for clinical judgment.

---

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System, Instruction of Pediatrics at George Washington University’s School of Medicine and Health Sciences in Washington, D.C.

CHICAGO - A study examining the genes of more than 120,000 people from Europe, Asia, Africa and the Americas has offered the clearest picture yet of the genes that drive type 2 diabetes.

The study, published July 11 in the journal Nature, puts to rest a decades-long debate over the genetics that influence the risk of diabetes, which affects one in 10 people over the course of their lifetime.

And it has identified more than a dozen specific genes directly involved in the development of type 2 diabetes that might serve as potential drug targets.

"There was a whole furious debate that arose about this," said Dr. Francis Collins, director of the National Institutes of Health, one of more than 300 scientists collaborating on the work.

Prior studies turned up more than 80 spots in the genome associated with the development of adult-onset diabetes, but most of these genetic errors were common, meaning they occurred frequently in the population, and they explained only a small fraction of disease risk.

These discoveries were based on genome-wide association studies or GWAS, which used gene chips that scan thousands of genes at a time. Researchers used these to scan DNA from large populations of individuals with a specific disease and compare them with DNA from similar groups of healthy people.

Critics, including geneticist Dr. David Goldstein at Columbia University, argued that such studies were a waste of resources because they only found common variants that explained just a small fraction of the risk for disease.

He said the really important drivers of common diseases such as diabetes and schizophrenia were more likely to be found in extremely rare genes, those occurring in individuals or in families, not those shared by large populations of people.

Goldstein "argued very persuasively that it was all about rare variants and we were all going down the wrong road looking at the common ones," Collins said in a telephone interview.

The new study took a deeper look, using next-generation sequencing to search the entire genetic code of 2,657 people with and without diabetes to assess the contribution of both rare and common genes driving diabetes.

They also sequenced all of the protein-making genes in 12,940 people, and used statistical methods to estimate risk in another 111,548 people with less complete DNA data.

They found that, indeed, most of the genetic risk for type 2 diabetes is caused by common mistakes in the genetic code, with each mistake contributing only a small portion of an individual's risk for developing the disease.

"What this study says quite definitively for diabetes is the vast majority of hereditary risk variants are in fact these common ones, and the rare ones, while they pop up here and there, are a much smaller contribution," Collins said.

The study also turned up more than a dozen examples where variants alter the way proteins are made, suggesting that these gene variants have some direct impact on the development of type 2 diabetes.

"These represent promising avenues for efforts to design new ways to treat or prevent the disease," said Mark McCarthy, a senior author of the study from Oxford University.

All of the data will be made publicly available online through the Accelerating Medicines Partnership, a public-private partnership between the NIH, the U.S. Food and Drug Administration, 10 drug companies and several nonprofits.

Goldstein said the work was "a careful, solid investigation" that does not change his view much overall, adding that it was time to "quit arguing."

"What I care about now is finding the exact variants that infer risk, and understanding how they do so," he said.

SOURCE: http://go.nature.com/29DlL5i

Nature 2016.

CHICAGO - A study examining the genes of more than 120,000 people from Europe, Asia, Africa and the Americas has offered the clearest picture yet of the genes that drive type 2 diabetes.

The study, published July 11 in the journal Nature, puts to rest a decades-long debate over the genetics that influence the risk of diabetes, which affects one in 10 people over the course of their lifetime.

And it has identified more than a dozen specific genes directly involved in the development of type 2 diabetes that might serve as potential drug targets.

"There was a whole furious debate that arose about this," said Dr. Francis Collins, director of the National Institutes of Health, one of more than 300 scientists collaborating on the work.

Prior studies turned up more than 80 spots in the genome associated with the development of adult-onset diabetes, but most of these genetic errors were common, meaning they occurred frequently in the population, and they explained only a small fraction of disease risk.

These discoveries were based on genome-wide association studies or GWAS, which used gene chips that scan thousands of genes at a time. Researchers used these to scan DNA from large populations of individuals with a specific disease and compare them with DNA from similar groups of healthy people.

Critics, including geneticist Dr. David Goldstein at Columbia University, argued that such studies were a waste of resources because they only found common variants that explained just a small fraction of the risk for disease.

He said the really important drivers of common diseases such as diabetes and schizophrenia were more likely to be found in extremely rare genes, those occurring in individuals or in families, not those shared by large populations of people.

Goldstein "argued very persuasively that it was all about rare variants and we were all going down the wrong road looking at the common ones," Collins said in a telephone interview.

The new study took a deeper look, using next-generation sequencing to search the entire genetic code of 2,657 people with and without diabetes to assess the contribution of both rare and common genes driving diabetes.

They also sequenced all of the protein-making genes in 12,940 people, and used statistical methods to estimate risk in another 111,548 people with less complete DNA data.

They found that, indeed, most of the genetic risk for type 2 diabetes is caused by common mistakes in the genetic code, with each mistake contributing only a small portion of an individual's risk for developing the disease.

"What this study says quite definitively for diabetes is the vast majority of hereditary risk variants are in fact these common ones, and the rare ones, while they pop up here and there, are a much smaller contribution," Collins said.

The study also turned up more than a dozen examples where variants alter the way proteins are made, suggesting that these gene variants have some direct impact on the development of type 2 diabetes.

"These represent promising avenues for efforts to design new ways to treat or prevent the disease," said Mark McCarthy, a senior author of the study from Oxford University.

All of the data will be made publicly available online through the Accelerating Medicines Partnership, a public-private partnership between the NIH, the U.S. Food and Drug Administration, 10 drug companies and several nonprofits.

Goldstein said the work was "a careful, solid investigation" that does not change his view much overall, adding that it was time to "quit arguing."

"What I care about now is finding the exact variants that infer risk, and understanding how they do so," he said.

SOURCE: http://go.nature.com/29DlL5i

Nature 2016.

CHICAGO - A study examining the genes of more than 120,000 people from Europe, Asia, Africa and the Americas has offered the clearest picture yet of the genes that drive type 2 diabetes.

The study, published July 11 in the journal Nature, puts to rest a decades-long debate over the genetics that influence the risk of diabetes, which affects one in 10 people over the course of their lifetime.

And it has identified more than a dozen specific genes directly involved in the development of type 2 diabetes that might serve as potential drug targets.

"There was a whole furious debate that arose about this," said Dr. Francis Collins, director of the National Institutes of Health, one of more than 300 scientists collaborating on the work.

Prior studies turned up more than 80 spots in the genome associated with the development of adult-onset diabetes, but most of these genetic errors were common, meaning they occurred frequently in the population, and they explained only a small fraction of disease risk.

These discoveries were based on genome-wide association studies or GWAS, which used gene chips that scan thousands of genes at a time. Researchers used these to scan DNA from large populations of individuals with a specific disease and compare them with DNA from similar groups of healthy people.

Critics, including geneticist Dr. David Goldstein at Columbia University, argued that such studies were a waste of resources because they only found common variants that explained just a small fraction of the risk for disease.

He said the really important drivers of common diseases such as diabetes and schizophrenia were more likely to be found in extremely rare genes, those occurring in individuals or in families, not those shared by large populations of people.

Goldstein "argued very persuasively that it was all about rare variants and we were all going down the wrong road looking at the common ones," Collins said in a telephone interview.

The new study took a deeper look, using next-generation sequencing to search the entire genetic code of 2,657 people with and without diabetes to assess the contribution of both rare and common genes driving diabetes.

They also sequenced all of the protein-making genes in 12,940 people, and used statistical methods to estimate risk in another 111,548 people with less complete DNA data.

They found that, indeed, most of the genetic risk for type 2 diabetes is caused by common mistakes in the genetic code, with each mistake contributing only a small portion of an individual's risk for developing the disease.

"What this study says quite definitively for diabetes is the vast majority of hereditary risk variants are in fact these common ones, and the rare ones, while they pop up here and there, are a much smaller contribution," Collins said.

The study also turned up more than a dozen examples where variants alter the way proteins are made, suggesting that these gene variants have some direct impact on the development of type 2 diabetes.

"These represent promising avenues for efforts to design new ways to treat or prevent the disease," said Mark McCarthy, a senior author of the study from Oxford University.

All of the data will be made publicly available online through the Accelerating Medicines Partnership, a public-private partnership between the NIH, the U.S. Food and Drug Administration, 10 drug companies and several nonprofits.

Goldstein said the work was "a careful, solid investigation" that does not change his view much overall, adding that it was time to "quit arguing."

"What I care about now is finding the exact variants that infer risk, and understanding how they do so," he said.

SOURCE: http://go.nature.com/29DlL5i

Nature 2016.

NEW YORK - Greater access to alcohol is linked with more atrial fibrillation but less myocardial infarction and congestive heart failure, researchers report.

Dr. Gregory M. Marcus, from the Division of Cardiology at the University of California, San Francisco, and colleagues conducted an observational cohort study of differences in health outcomes based on alcohol sales laws by county in Texas.

All patients were residents of Texas, 21 years old or older, and were admitted to hospitals in Texas between 2005 and 2010. More than 1 million patients were included in the analysis.

Of the counties, 47 were wet (no restrictions on the sale of alcohol) and 29 were dry (prohibition of alcohol sales). Seven of them changed from dry to wet during the study period.

The main cardiovascular outcomes were atrial fibrillation, acute myocardial infarction, and congestive heart failure.

After multivariable adjustment, wet county residents had a greater prevalence (odds ratio 1.05, p=0.007) and incidence (HR 1.07, p=0.014) of atrial fibrillation.

Prevalence of myocardial infarction was lower (OR 0.83, p<0.001), as was its incidence (HR 0.91, p=0.019). Prevalence of congestive heart failure was also lower (OR 0.87, p<0.001).

In the seven dry counties that changed their status to wet, the post-conversion interval (from dry to wet county status) was associated with greater odds of hospitalization for atrial fibrillation (OR 1.07, p=0.001) and congestive heart failure (OR 1.07, p<0.001).

The researchers found no difference in acute myocardial infarction (OR 0.99, p=0.746).

"Cardiovascular disease is the most common cause of death worldwide, and alcohol is the most widely consumed drug in the United States," said Dr. Rory Brett Weiner, a cardiologist at Massachusetts General Hospital in Boston.

He said that studying the impact of alcohol intake on incident cardiovascular disease is important for its public health implications.

"Differences in laws affecting access to alcohol are associated with changes in health outcomes, both harmful and protective," said Dr. Marcus, "but the study's findings shouldn't be used to change any specific legislation."

Dr. Weiner agreed. "The study design minimizes confounders commonly seen in prior research that relied on self-report," he said, "but it still doesn't provide conclusive evidence with regard to the use of alcohol and incident cardiovascular disease."

Dr. Weiner said that the study did not contain information on the level of individual alcohol exposure, and therefore, the impact of the 'dose' of alcohol on cardiovascular outcomes could not be ascertained.

"Based on the question at hand -- the impact of alcohol -- it's unlikely that a randomized controlled study will ever be performed," he said, "so analyses like the current one are important."

According to Dr. Marcus, "We still don't understand the mechanisms underlying the relationship between alcohol and cardiovascular disease, and have a long way to go to achieve the sort of personalized medicine needed to figure out how to counsel an individual patient on their particular "prescribed" amount, if any, of alcohol."

The National Institute on Alcohol Abuse and Alcoholism supported this research. Dr. Marcus reported research support from Medtronic and Pfizer and equity interest in InCarda.

SOURCE: http://bit.ly/1tlx1cx

BMJ 2016

NEW YORK - Greater access to alcohol is linked with more atrial fibrillation but less myocardial infarction and congestive heart failure, researchers report.

Dr. Gregory M. Marcus, from the Division of Cardiology at the University of California, San Francisco, and colleagues conducted an observational cohort study of differences in health outcomes based on alcohol sales laws by county in Texas.

All patients were residents of Texas, 21 years old or older, and were admitted to hospitals in Texas between 2005 and 2010. More than 1 million patients were included in the analysis.

Of the counties, 47 were wet (no restrictions on the sale of alcohol) and 29 were dry (prohibition of alcohol sales). Seven of them changed from dry to wet during the study period.

The main cardiovascular outcomes were atrial fibrillation, acute myocardial infarction, and congestive heart failure.

After multivariable adjustment, wet county residents had a greater prevalence (odds ratio 1.05, p=0.007) and incidence (HR 1.07, p=0.014) of atrial fibrillation.

Prevalence of myocardial infarction was lower (OR 0.83, p<0.001), as was its incidence (HR 0.91, p=0.019). Prevalence of congestive heart failure was also lower (OR 0.87, p<0.001).

In the seven dry counties that changed their status to wet, the post-conversion interval (from dry to wet county status) was associated with greater odds of hospitalization for atrial fibrillation (OR 1.07, p=0.001) and congestive heart failure (OR 1.07, p<0.001).

The researchers found no difference in acute myocardial infarction (OR 0.99, p=0.746).

"Cardiovascular disease is the most common cause of death worldwide, and alcohol is the most widely consumed drug in the United States," said Dr. Rory Brett Weiner, a cardiologist at Massachusetts General Hospital in Boston.

He said that studying the impact of alcohol intake on incident cardiovascular disease is important for its public health implications.

"Differences in laws affecting access to alcohol are associated with changes in health outcomes, both harmful and protective," said Dr. Marcus, "but the study's findings shouldn't be used to change any specific legislation."

Dr. Weiner agreed. "The study design minimizes confounders commonly seen in prior research that relied on self-report," he said, "but it still doesn't provide conclusive evidence with regard to the use of alcohol and incident cardiovascular disease."

Dr. Weiner said that the study did not contain information on the level of individual alcohol exposure, and therefore, the impact of the 'dose' of alcohol on cardiovascular outcomes could not be ascertained.

"Based on the question at hand -- the impact of alcohol -- it's unlikely that a randomized controlled study will ever be performed," he said, "so analyses like the current one are important."

According to Dr. Marcus, "We still don't understand the mechanisms underlying the relationship between alcohol and cardiovascular disease, and have a long way to go to achieve the sort of personalized medicine needed to figure out how to counsel an individual patient on their particular "prescribed" amount, if any, of alcohol."

The National Institute on Alcohol Abuse and Alcoholism supported this research. Dr. Marcus reported research support from Medtronic and Pfizer and equity interest in InCarda.

SOURCE: http://bit.ly/1tlx1cx

BMJ 2016

NEW YORK - Greater access to alcohol is linked with more atrial fibrillation but less myocardial infarction and congestive heart failure, researchers report.

Dr. Gregory M. Marcus, from the Division of Cardiology at the University of California, San Francisco, and colleagues conducted an observational cohort study of differences in health outcomes based on alcohol sales laws by county in Texas.

All patients were residents of Texas, 21 years old or older, and were admitted to hospitals in Texas between 2005 and 2010. More than 1 million patients were included in the analysis.

Of the counties, 47 were wet (no restrictions on the sale of alcohol) and 29 were dry (prohibition of alcohol sales). Seven of them changed from dry to wet during the study period.

The main cardiovascular outcomes were atrial fibrillation, acute myocardial infarction, and congestive heart failure.

After multivariable adjustment, wet county residents had a greater prevalence (odds ratio 1.05, p=0.007) and incidence (HR 1.07, p=0.014) of atrial fibrillation.

Prevalence of myocardial infarction was lower (OR 0.83, p<0.001), as was its incidence (HR 0.91, p=0.019). Prevalence of congestive heart failure was also lower (OR 0.87, p<0.001).

In the seven dry counties that changed their status to wet, the post-conversion interval (from dry to wet county status) was associated with greater odds of hospitalization for atrial fibrillation (OR 1.07, p=0.001) and congestive heart failure (OR 1.07, p<0.001).

The researchers found no difference in acute myocardial infarction (OR 0.99, p=0.746).

"Cardiovascular disease is the most common cause of death worldwide, and alcohol is the most widely consumed drug in the United States," said Dr. Rory Brett Weiner, a cardiologist at Massachusetts General Hospital in Boston.

He said that studying the impact of alcohol intake on incident cardiovascular disease is important for its public health implications.

"Differences in laws affecting access to alcohol are associated with changes in health outcomes, both harmful and protective," said Dr. Marcus, "but the study's findings shouldn't be used to change any specific legislation."

Dr. Weiner agreed. "The study design minimizes confounders commonly seen in prior research that relied on self-report," he said, "but it still doesn't provide conclusive evidence with regard to the use of alcohol and incident cardiovascular disease."

Dr. Weiner said that the study did not contain information on the level of individual alcohol exposure, and therefore, the impact of the 'dose' of alcohol on cardiovascular outcomes could not be ascertained.

"Based on the question at hand -- the impact of alcohol -- it's unlikely that a randomized controlled study will ever be performed," he said, "so analyses like the current one are important."

According to Dr. Marcus, "We still don't understand the mechanisms underlying the relationship between alcohol and cardiovascular disease, and have a long way to go to achieve the sort of personalized medicine needed to figure out how to counsel an individual patient on their particular "prescribed" amount, if any, of alcohol."

The National Institute on Alcohol Abuse and Alcoholism supported this research. Dr. Marcus reported research support from Medtronic and Pfizer and equity interest in InCarda.

SOURCE: http://bit.ly/1tlx1cx

BMJ 2016

Since hospital medicine’s early days, hospitalist physicians have worked alongside physician assistants (PAs) and nurse practitioners (NPs). Some PAs and NPs have ascended to positions of leadership in their HM groups or health systems, in some cases even supervising the physicians.

The Hospitalist connected with six PA and NP leaders in hospital medicine to discuss their career paths as well as the nature and scope of their jobs. They described leadership as a complex, multidimensional concept, with often more of a collaborative model than a clear-cut supervisory relationship with clinicians. Most said they don’t try to be the “boss” of their group and have found ways to impact key decisions.

They also emphasized that PAs and NPs bring special skills and perspectives to team building. Many have supplemented frontline clinical experience with leadership training. And when it comes to decision making, their responsibilities can include hiring, scheduling, training, mentoring, information technology, quality improvement, and other essential functions of the group.

Edwin Lopez, MBA, PA-C

Facility medical director, St. Elizabeth Hospital, Enumclaw, Wash.

Workplace: St. Elizabeth is a 25-bed critical-access hospital serving a semi-rural bedroom community of 11,000 people an hour southeast of Seattle. It belongs to the nine-hospital CHI Franciscan Health system, and the HM group includes four physicians and four PAs providing 24-hour coverage. The physicians and PAs work in paired teams in the hospital and an 80-bed skilled nursing facility (SNF) across the street. Lopez heads St. Elizabeth’s HM group and is associate medical director of the SNF.

Background: Lopez graduated from the PA program at the University of Washington in 1982 and spent seven years as a PA with a cardiothoracic surgery practice in Tacoma. Then he established his own firm providing PA staffing services for six cardiac surgery programs in western Washington. In 1997, he co-founded an MD/PA hospitalist service covering three hospitals for a Seattle insurance company. That program grew into a larger group that was acquired by CHI Franciscan.

Lopez took time off to earn his MBA in health policy at the University of Washington and Harvard Kennedy School in Boston.

Eight years ago as part of an acquisition, CHI Franciscan asked Lopez to launch an HM program at St. Elizabeth. From the start, he developed the program as a collaborative model. The HM group now covers almost 90% of hospital admissions, manages the ICU, takes calls to admit patients from the ED, and rounds daily on patients in a small hospital that doesn’t have access to a lot of medical specialists.

St. Elizabeth’s has since flourished to become one of the health system’s top performers on quality metrics like HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores. However, Lopez admits readmission rates remain high. He noticed that a big part of the readmission problem was coming from the facility across the street, so he proposed the HM group start providing daily coverage to the SNF. In the group’s first year covering the SNF, the hospital’s readmission rate dropped to 5% from 35%.

Listen: Edwin Lopez, PA-C, discusses post-acute Care in the U.S. health system

Responsibilities: Lopez spends roughly half his time seeing patients, which he considers the most satisfying half. The other half is managing and setting clinical and administrative direction for the group.

“My responsibility is to ensure that there is appropriate physician and PA coverage 24-7 in both facilities,” he says, adding he also handles hiring and personnel issue. “We have an understanding here. I help guide, mentor, and direct the team, with the support of our regional medical director.”

 

The story: Lopez credits his current position to Joe Wilczek, a visionary CEO who came to the health system 18 years ago and retired in 2015.

“Joe and Franciscan’s chief medical officer and system director of hospital medicine came to me and said, ‘We’d like you to go over there and see what you can do at St. Elizabeth.’ There was a definite mandate, with markers they wanted me to reach. They said, ‘If you succeed, we will build you a new hospital building.’”

The new building opened in 2012.

Lopez says he has spent much of his career in quiet oblivion.

“It took five or six years here before people started noticing that our quality and performance were among the highest in the system,” he says. “For my entire 33-year career in medicine, I was never driven by the money. I grew up believing in service and got into medicine to make a difference, to leave a place better than I found it.”

He occasionally fields questions about his role as a PA group leader, which he tries to overcome by building trust, just as he overcame initial resistance to the hospital medicine program at St. Elizabeth from community physicians.

“I am very clear, we as a team are very clear, that we’re all worker bees here. We build strong relationships. We consider ourselves family,” he says. “When family issues come up, we need to sit down and talk about them, even when it may be uncomfortable.”

Laurie Benton, RN, MPAS, PhD, PA-C, DFAAPA

System director of advanced practice professionals (APPs), Baylor Scott & White Health, Dallas; medical/surgical hospitalist, Scott & White Memorial Hospital, Temple, Texas.

Workplace: Baylor Scott & White Health is the largest nonprofit health system in Texas, with 46 hospitals and 500 multispecialty clinics. Scott & White Memorial Hospital is a 636-bed specialty care and teaching hospital. Its hospital medicine program includes 40 physicians and 34 NP/PAs caring for an average daily census of 240 patients. They cover an observation service, consult service, and long-term acute-care service.

Background: Benton has a PhD in health administration. She has practiced hospital medicine at Scott & White Memorial Hospital since 2000 and before that at Emanuel Hospital in Portland, Ore. Currently an orthopedic hospitalist PA, she has worked in cardiothoracic surgery, critical care, and nephrology settings.

She became the system director for APPs in September 2013. In that role, she leads and represents 428 APPs, including hospitalist, intensivist, and cardiology PAs, in the system’s 26-hospital Central Region. She sits on the board of directors of the American Academy of Physician Assistants and has been on workforce committees for the National Commission on Certification of Physician Assistants and on the CME committee of the National Kidney Foundation.

Responsibilities: Benton coordinates everything, including PAs, advanced practice nurses, and nurse anesthetists, in settings across the healthcare continuum.

“I was appointed by our hospital medicine board and administration to be the APP leader. I report to the chief medical officer,” she says. “But I still see patients; it’s my passion. I’m not ready to give it up completely.”

Benton’s schedule includes two 10-hour clinical shifts per week. The other three days she works on administrative tasks. She attends board meetings as well as regular meetings with the system’s top executives and officers, including the chair of the board and the senior vice president for medical affairs.

“I have a seat on staff credentialing, benefits, and compensation committees, and I’m part of continuing medical education and disaster planning. Pretty much any of the committees we have here, I’m invited to be on,” she says. “I make sure I’m up-to-date on all of the new regulations and have information on any policies that have to do with APPs.”

 

The story: Benton says her PA training, including mentorship from Edwin Lopez, placed a strong emphasis on helping students develop leadership skills and interests.

“While I was working in nephrology, my supervising physician mentored me and encouraged me to move forward with my education,” she says. Along the way, she participated in a yearlong executive-education program and taught at the University of Texas McCombs School of Business. “Right off, it was not easy because while people saw me as a very strong, very confident provider, they didn’t see me as an administrator. When I worked with administrators, they were speaking a different language. I’d speak medicine, and they’d speak administration. It took a while to learn how to communicate with them.”

She says non-physician professionals traditionally have reported up through a physician and “never had their own voice. … Now that we have our leadership ladder here, it’s still new to some administrators,” she says. “I want to make sure PAs are part of the solution to high-quality healthcare.

“When I’m at the leadership table, we’re working together. The physicians respect my opinion, giving me the opportunity to interact like anyone else at the table.”

Catherine Boyd, MS, PA-C

Director of clinical operations, Essex Inpatient Physicians, Boxford, Mass.

Workplace: Essex is a private hospitalist group founded in 2007 by James Tollman, MD, FHM, who remains its CEO. It has 34 clinical members, including 16 physicians, 12 PAs, and six NPs. It began providing hospitalist medical care to several hospitals on Massachusetts’ North Shore under contract, then to a psychiatric hospital and a detox treatment center. In recent years, it has expanded into the post-acute arena, providing coverage to 14 SNFs, which now constitute the majority of its business. It also is active with two accountable-care organization networks.

Background: After three years as a respiratory therapist, Boyd enrolled in a PA program at Massachusetts College of Pharmacy and Health Sciences. After graduating in 2005, she worked as a hospitalist and intensivist, including as team leader for the medical emergency team at Lahey Health & Medical Center in Burlington, Mass., and in the PACE (Program of All-Inclusive Care for the Elderly) Internal Medical Department with Partners HealthCare until mid-2014, when she was invited to join Essex.

Responsibilities: “This job is not one thing; I dabble in everything,” says Boyd, who describes herself as the group’s chief operating officer for professional affairs. “I provide direct supervision to our PAs and NPs but also to our independent contractors, including moonlighting physicians. And I help to supervise the full-time physicians.”

She works on system issues, on-site training and mentorship, and implementation of a new electronic health record (EHR) and charge capture system while trying to improve bed flow and quality and decrease clinicians’ job frustrations. She also monitors developments in Medicare regulations.

“I check in with every one of our full-time providers weekly, and I try to offset some of the minutiae of their workday so that they can focus on their patients,” she explains. “Dr. Tollman and I feel that we bring a healthy work-lifestyle balance to the group. We encourage that in our staff. If they are happy in their jobs, it makes quality of care better.”

Boyd also maintains a clinical practice as a hospitalist, with her clinical duties flexing up and down based on patient demand and management needs.

The story: When Boyd was a respiratory therapist at a small community hospital, she worked one-on-one with a physician assistant who inspired her to change careers.

“I really liked what she did. As a PA, I worked to broaden my skill set on a critical care service for seven years,” she says. “But then my two kids got older and I wanted a more flexible schedule. Dr. Tollman came across my résumé when he was looking for a clinician to run operations for Essex.”

 

Building on 10 years of clinical experience, Boyd has tried to earn the trust of the other clinicians.

“They know they can come to me with questions. I like to think I practice active listening. When there is a problem, I do a case review and try to get all the facts,” she says. “When you earn their trust, the credentials tend to fall away, especially with the doctors I work with on a daily basis.”

Daniel Ladd, PA-C, DFAAPA

Chief clinical officer, iNDIGO Health Partners, Traverse City, Mich.

Workplace: Founded in 1993 as Hospitalists of Northern Michigan, iNDIGO Health Partners is one of the country’s largest private hospitalist companies, employing 150 physicians, PAs, and NPs who practice at seven hospitals across the state. The program also provides nighttime hospitalist services via telehealth and pediatric hospital medicine. It recently added 10 post-acute providers to work in SNFs and assisted living facilities.

Background: While working as a nurse’s aide, meeting and being inspired by some of the earliest PAs in Michigan, Ladd pursued PA training at Mercy College in Detroit. After graduating in 1984, he was hired by a cardiology practice at Detroit Medical Center. When he moved upstate to Traverse City in 1997, he landed a position as lead PA at another cardiology practice, acting as its liaison to PAs in the hospital. He joined iNDIGO in 2006.

“Jim Levy, one of the first PA hospitalists in Michigan, was an integral part of founding iNDIGO and now is our vice president of human resources,” Ladd says. “He asked me to join iNDIGO, and I jumped at the chance. Hospital medicine was a new opportunity for me and one with more opportunities for PAs to advance than cardiology.”

In 2009, when the company reorganized, the firm’s leadership recognized the need to establish a liaison group as a buffer between the providers and the company. Ladd became president of its new board of managers.

“From there, my position evolved to what it is today,” he says.

Levy calls Ladd a role model and leader, with great credibility among site program directors, hospital CMOs, and providers.

Responsibilities: Ladd gave up his clinical practice as a hospitalist in 2014 in response to growing management responsibilities.

“I do and I don’t miss it,” he says. “I miss the camaraderie of clinical practice, the foxhole mentality on the front lines. But I feel where I am now that I am able to help our providers give better care.

“Concretely, what I do is to help our practitioners and our medical directors at the clinical sites, some of whom are PAs and NPs, supporting them with leadership and education. I listen to their issues, translating and bringing to bear the resources of our company.”

Those resources include staffing, working conditions, office space, and the application of mobile medical technology for billing and clinical decision support.

“A lot of my communication is via email. I feel I am able to make a point without being inflammatory, by stating my purpose—the rationale for my position—and asking for what I need,” Ladd says. “This role is very accepted at iNDIGO. The corollary is that physician leaders who report to me are also comfortable in our relationship. It’s not about me being a PA and them being physicians but about us being colleagues in medicine.

“I’m in a position where I understand their world and am able to help them.”

The story: Encouraged by what he calls “visionary” leaders, Ladd has taken a number of steps to ascend to his current position as chief clinical officer.

 

“Even going back to the Boy Scouts, I was always one to step forward and volunteer for leadership,” he says. “I was president of my PA class in college and involved with the state association of PAs, as well as taking leadership training through the American Academy of Physician Assistants. I had the good fortune to be hired by a brilliant cardiologist at Detroit Medical Center. … He was the first to encourage me to be not just an excellent clinician but also a leader. He got me involved in implementing the EHR and in medication reconciliation. He promoted me as a PA to his patients and allowed me to become the face of our clinical practice, running the clinical side of the practice.”

Ladd also credits iNDIGO’s leaders for an approach of hiring the best people regardless of degree.

“If they happen to be PAs, great. The company’s vision is to have people with vision and skills to lead, not just based on credentials,” he says. “They established that as a baseline, and now it’s the culture here. We have PAs who are key drivers of the efficiency of this program.”

It hasn’t eliminated the occasional “I’m the physician, I’m delegating to you, and you have to do what I say,” Ladd admits. But he knows handling those situations is part of his job as a practice leader.

“It requires patience and understanding and the ability to see the issue from multiple perspectives,” he says, “and then synthesize all of that into a reasonable solution for all concerned.”

Arnold Facklam III, MSN, FNP-BC, FHM

Nocturnist, hospitalist, and director of advanced practice providers, United Memorial Medical Center, Batavia, N.Y.; medical executive committee member, Medical Staff Organization (MSO) of Kaleida Health, Buffalo, N.Y.

Workplace: United Memorial has 100 beds and is part of the four-hospital Rochester Regional Health System. Kaleida Health has four acute-care hospitals in western New York. Based an hour apart, they compete, but both now get hospitalist services from Infinity Health Hospitalists of Western New York, a hospitalist group of 30 to 35 providers privately owned by local hospitalist John Patti, MD.

Background: Facklam has been a nocturnist since 2009, when he completed an NP program at D’Youville College in Buffalo. He worked 15 to 17 night shifts a month, first at Kaleida’s DeGraff Memorial Hospital and then at United Memorial, starting in 2013 as a per diem and vacation fill-in, then full-time since 2015. He now works for Infinity Health Hospitalists.

While working as a hospitalist, Facklam became involved with the MSO of Kaleida Health, starting on its Advanced Practice Provider Committee, which represents more than 600 NPs and PAs. Now chair of the committee, he leads change in the scope of practice for NPs and PAs and acts as liaison between APPs and the hospitals and health system.

Responsibilities: As a full-time nocturnist, Facklam has to squeeze in time for his role as director of advanced practice providers. He offers guidance and oversight, under the direction of the vice president of medical affairs, to all NPs, PAs, nurse midwives, and nurse anesthetists. He also is in charge of its rapid response and code blue team coverage at night, plus provides clinical education to family practice medical students and residents overnight in the hospital. He has worked on hospital quality improvement projects since 2012.

Facklam, who acknowledges type A personality tendencies, also maintains two to three night shifts per month at Kaleida’s Millard Suburban Hospital.

In 2012, he became a member, eventually a voting member, of Kaleida’s system-wide MSO Medical Executive Committee, which is responsible for rule making, disciplinary action, and the provision of medical care within the system.

 

“The MSO is the mechanism for accountability for professional practice,” he says. He is also active in SHM’s NP/PA Committee and now sits on SHM’s Public Policy Committee.

The story: “Working as a nocturnist has given me the flexibility to look into advanced management training,” he says, including Six Sigma green belt course work and certificate training. While at DeGraff, he heard about a call for membership on the NP/PA committee.

“They quickly realized the benefits of having someone with a background like mine on board,” he said. “As a nocturnist, I started going to more meetings and getting involved when the easier thing to do might have been to drive home and go to bed.”

Along the way, he learned a lot about hospital systems and how they work.

“Having been in healthcare for 23 years, I know the hierarchical approach,” Facklam says. “But the times are changing. As medicine becomes broader and more difficult to manage, it has to become more of a team approach. If you look at the data, there won’t be enough physicians in the near future. PAs and NPs can help fill that need.”

Crystal Therrien, MS, ACNP-BC

Lead nurse practitioner, affiliate practitioner coordinator, Department of Hospital Medicine, University of Massachusetts Memorial Medical Center, Worcester.

Workplace: UMass Medical Center encompasses three campuses in central Massachusetts, including University, Memorial, and Marlborough. The hospital medicine division covers all three campuses with 40 to 45 FTEs of physicians and 20 of APPs. Therrien has been with the department since October 2009—her first job after completing NP training—and assumed her leadership role in June 2012.

Responsibilities: Therrien supervises the UMass hospital medicine division’s Affiliate Practitioner Group. She works with physicians on the executive council, coordinates the medicine service, and coordinates cross-coverage with other services in the hospital, including urology, neurology, surgery, GI, interventional radiology, and bone marrow transplants.

Hospitalist staff work 12-hour shifts, providing 24-hour coverage in the hospital, with one physician and two APPs scheduled at night.

“Because we are available 24-7 in house, I work closely with our scheduler. There is also a lot of coordination with subspecialty services in the hospital and on the observation unit,” she says. “I’m also responsible for interviewing and hiring AP candidates, including credentialing, and with the mentorship program. I chair the rapid response program and host our monthly staff meetings,” which involve both business and didactic presentations. She also serves on the hospital’s NP advisory council.

Before Therrien became the lead NP, her predecessor was assigned at 5% administrative.

“I started out 25% administrative because the program has expanded so quickly,” she says, noting that now she is 50% clinic and 50% administrative. “To be a good leader, I think I need to keep my feet on the ground in patient care.”

The story: Therrien worked as an EMT, a volunteer firefighter, and an ED tech before pursuing a degree in nursing.

“I grew up in a house where my dad was a firefighter and my mom was an EMT,” she says. “We were taught the importance of helping others and being selfless. I always had a leadership mentality.”

Therrien credits her physician colleagues for their commitment and support.

“It can be a little more difficult outside of our department,” she says. “They don’t always understand my role. Some of the attendings have not worked with affiliated providers before, but they have worked with residents. So there’s an interesting dynamic for them to learn how to work with us.”

Kimberly Eisenstock, MD, FHM, the clinical chief of hospital medicine, says that when she was looking for someone new to lead the affiliated practitioners, she wanted “a leader who understood their training and where they could be best utilized. Crystal volunteered. Boy, did she! She was the most experienced and enthusiastic candidate, with the most people-oriented skills.”

 

Dr. Eisenstock says she doesn’t start new roles or programs for the affiliated practitioners without getting the green light from Therrien.

“Crystal now represents the voice for how the division decides to employ APPs and the strategies we use to fill various roles,” she says. TH

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Larry Beresford is a freelance writer in Alameda, Calif.

Since hospital medicine’s early days, hospitalist physicians have worked alongside physician assistants (PAs) and nurse practitioners (NPs). Some PAs and NPs have ascended to positions of leadership in their HM groups or health systems, in some cases even supervising the physicians.

The Hospitalist connected with six PA and NP leaders in hospital medicine to discuss their career paths as well as the nature and scope of their jobs. They described leadership as a complex, multidimensional concept, with often more of a collaborative model than a clear-cut supervisory relationship with clinicians. Most said they don’t try to be the “boss” of their group and have found ways to impact key decisions.

They also emphasized that PAs and NPs bring special skills and perspectives to team building. Many have supplemented frontline clinical experience with leadership training. And when it comes to decision making, their responsibilities can include hiring, scheduling, training, mentoring, information technology, quality improvement, and other essential functions of the group.

Edwin Lopez, MBA, PA-C

Facility medical director, St. Elizabeth Hospital, Enumclaw, Wash.

Workplace: St. Elizabeth is a 25-bed critical-access hospital serving a semi-rural bedroom community of 11,000 people an hour southeast of Seattle. It belongs to the nine-hospital CHI Franciscan Health system, and the HM group includes four physicians and four PAs providing 24-hour coverage. The physicians and PAs work in paired teams in the hospital and an 80-bed skilled nursing facility (SNF) across the street. Lopez heads St. Elizabeth’s HM group and is associate medical director of the SNF.

Background: Lopez graduated from the PA program at the University of Washington in 1982 and spent seven years as a PA with a cardiothoracic surgery practice in Tacoma. Then he established his own firm providing PA staffing services for six cardiac surgery programs in western Washington. In 1997, he co-founded an MD/PA hospitalist service covering three hospitals for a Seattle insurance company. That program grew into a larger group that was acquired by CHI Franciscan.

Lopez took time off to earn his MBA in health policy at the University of Washington and Harvard Kennedy School in Boston.

Eight years ago as part of an acquisition, CHI Franciscan asked Lopez to launch an HM program at St. Elizabeth. From the start, he developed the program as a collaborative model. The HM group now covers almost 90% of hospital admissions, manages the ICU, takes calls to admit patients from the ED, and rounds daily on patients in a small hospital that doesn’t have access to a lot of medical specialists.

St. Elizabeth’s has since flourished to become one of the health system’s top performers on quality metrics like HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores. However, Lopez admits readmission rates remain high. He noticed that a big part of the readmission problem was coming from the facility across the street, so he proposed the HM group start providing daily coverage to the SNF. In the group’s first year covering the SNF, the hospital’s readmission rate dropped to 5% from 35%.

Listen: Edwin Lopez, PA-C, discusses post-acute Care in the U.S. health system

Responsibilities: Lopez spends roughly half his time seeing patients, which he considers the most satisfying half. The other half is managing and setting clinical and administrative direction for the group.

“My responsibility is to ensure that there is appropriate physician and PA coverage 24-7 in both facilities,” he says, adding he also handles hiring and personnel issue. “We have an understanding here. I help guide, mentor, and direct the team, with the support of our regional medical director.”

 

The story: Lopez credits his current position to Joe Wilczek, a visionary CEO who came to the health system 18 years ago and retired in 2015.

“Joe and Franciscan’s chief medical officer and system director of hospital medicine came to me and said, ‘We’d like you to go over there and see what you can do at St. Elizabeth.’ There was a definite mandate, with markers they wanted me to reach. They said, ‘If you succeed, we will build you a new hospital building.’”

The new building opened in 2012.

Lopez says he has spent much of his career in quiet oblivion.

“It took five or six years here before people started noticing that our quality and performance were among the highest in the system,” he says. “For my entire 33-year career in medicine, I was never driven by the money. I grew up believing in service and got into medicine to make a difference, to leave a place better than I found it.”

He occasionally fields questions about his role as a PA group leader, which he tries to overcome by building trust, just as he overcame initial resistance to the hospital medicine program at St. Elizabeth from community physicians.

“I am very clear, we as a team are very clear, that we’re all worker bees here. We build strong relationships. We consider ourselves family,” he says. “When family issues come up, we need to sit down and talk about them, even when it may be uncomfortable.”

Laurie Benton, RN, MPAS, PhD, PA-C, DFAAPA

System director of advanced practice professionals (APPs), Baylor Scott & White Health, Dallas; medical/surgical hospitalist, Scott & White Memorial Hospital, Temple, Texas.

Workplace: Baylor Scott & White Health is the largest nonprofit health system in Texas, with 46 hospitals and 500 multispecialty clinics. Scott & White Memorial Hospital is a 636-bed specialty care and teaching hospital. Its hospital medicine program includes 40 physicians and 34 NP/PAs caring for an average daily census of 240 patients. They cover an observation service, consult service, and long-term acute-care service.

Background: Benton has a PhD in health administration. She has practiced hospital medicine at Scott & White Memorial Hospital since 2000 and before that at Emanuel Hospital in Portland, Ore. Currently an orthopedic hospitalist PA, she has worked in cardiothoracic surgery, critical care, and nephrology settings.

She became the system director for APPs in September 2013. In that role, she leads and represents 428 APPs, including hospitalist, intensivist, and cardiology PAs, in the system’s 26-hospital Central Region. She sits on the board of directors of the American Academy of Physician Assistants and has been on workforce committees for the National Commission on Certification of Physician Assistants and on the CME committee of the National Kidney Foundation.

Responsibilities: Benton coordinates everything, including PAs, advanced practice nurses, and nurse anesthetists, in settings across the healthcare continuum.

“I was appointed by our hospital medicine board and administration to be the APP leader. I report to the chief medical officer,” she says. “But I still see patients; it’s my passion. I’m not ready to give it up completely.”

Benton’s schedule includes two 10-hour clinical shifts per week. The other three days she works on administrative tasks. She attends board meetings as well as regular meetings with the system’s top executives and officers, including the chair of the board and the senior vice president for medical affairs.

“I have a seat on staff credentialing, benefits, and compensation committees, and I’m part of continuing medical education and disaster planning. Pretty much any of the committees we have here, I’m invited to be on,” she says. “I make sure I’m up-to-date on all of the new regulations and have information on any policies that have to do with APPs.”

 

The story: Benton says her PA training, including mentorship from Edwin Lopez, placed a strong emphasis on helping students develop leadership skills and interests.

“While I was working in nephrology, my supervising physician mentored me and encouraged me to move forward with my education,” she says. Along the way, she participated in a yearlong executive-education program and taught at the University of Texas McCombs School of Business. “Right off, it was not easy because while people saw me as a very strong, very confident provider, they didn’t see me as an administrator. When I worked with administrators, they were speaking a different language. I’d speak medicine, and they’d speak administration. It took a while to learn how to communicate with them.”

She says non-physician professionals traditionally have reported up through a physician and “never had their own voice. … Now that we have our leadership ladder here, it’s still new to some administrators,” she says. “I want to make sure PAs are part of the solution to high-quality healthcare.

“When I’m at the leadership table, we’re working together. The physicians respect my opinion, giving me the opportunity to interact like anyone else at the table.”

Catherine Boyd, MS, PA-C

Director of clinical operations, Essex Inpatient Physicians, Boxford, Mass.

Workplace: Essex is a private hospitalist group founded in 2007 by James Tollman, MD, FHM, who remains its CEO. It has 34 clinical members, including 16 physicians, 12 PAs, and six NPs. It began providing hospitalist medical care to several hospitals on Massachusetts’ North Shore under contract, then to a psychiatric hospital and a detox treatment center. In recent years, it has expanded into the post-acute arena, providing coverage to 14 SNFs, which now constitute the majority of its business. It also is active with two accountable-care organization networks.

Background: After three years as a respiratory therapist, Boyd enrolled in a PA program at Massachusetts College of Pharmacy and Health Sciences. After graduating in 2005, she worked as a hospitalist and intensivist, including as team leader for the medical emergency team at Lahey Health & Medical Center in Burlington, Mass., and in the PACE (Program of All-Inclusive Care for the Elderly) Internal Medical Department with Partners HealthCare until mid-2014, when she was invited to join Essex.

Responsibilities: “This job is not one thing; I dabble in everything,” says Boyd, who describes herself as the group’s chief operating officer for professional affairs. “I provide direct supervision to our PAs and NPs but also to our independent contractors, including moonlighting physicians. And I help to supervise the full-time physicians.”

She works on system issues, on-site training and mentorship, and implementation of a new electronic health record (EHR) and charge capture system while trying to improve bed flow and quality and decrease clinicians’ job frustrations. She also monitors developments in Medicare regulations.

“I check in with every one of our full-time providers weekly, and I try to offset some of the minutiae of their workday so that they can focus on their patients,” she explains. “Dr. Tollman and I feel that we bring a healthy work-lifestyle balance to the group. We encourage that in our staff. If they are happy in their jobs, it makes quality of care better.”

Boyd also maintains a clinical practice as a hospitalist, with her clinical duties flexing up and down based on patient demand and management needs.

The story: When Boyd was a respiratory therapist at a small community hospital, she worked one-on-one with a physician assistant who inspired her to change careers.

“I really liked what she did. As a PA, I worked to broaden my skill set on a critical care service for seven years,” she says. “But then my two kids got older and I wanted a more flexible schedule. Dr. Tollman came across my résumé when he was looking for a clinician to run operations for Essex.”

 

Building on 10 years of clinical experience, Boyd has tried to earn the trust of the other clinicians.

“They know they can come to me with questions. I like to think I practice active listening. When there is a problem, I do a case review and try to get all the facts,” she says. “When you earn their trust, the credentials tend to fall away, especially with the doctors I work with on a daily basis.”

Daniel Ladd, PA-C, DFAAPA

Chief clinical officer, iNDIGO Health Partners, Traverse City, Mich.

Workplace: Founded in 1993 as Hospitalists of Northern Michigan, iNDIGO Health Partners is one of the country’s largest private hospitalist companies, employing 150 physicians, PAs, and NPs who practice at seven hospitals across the state. The program also provides nighttime hospitalist services via telehealth and pediatric hospital medicine. It recently added 10 post-acute providers to work in SNFs and assisted living facilities.

Background: While working as a nurse’s aide, meeting and being inspired by some of the earliest PAs in Michigan, Ladd pursued PA training at Mercy College in Detroit. After graduating in 1984, he was hired by a cardiology practice at Detroit Medical Center. When he moved upstate to Traverse City in 1997, he landed a position as lead PA at another cardiology practice, acting as its liaison to PAs in the hospital. He joined iNDIGO in 2006.

“Jim Levy, one of the first PA hospitalists in Michigan, was an integral part of founding iNDIGO and now is our vice president of human resources,” Ladd says. “He asked me to join iNDIGO, and I jumped at the chance. Hospital medicine was a new opportunity for me and one with more opportunities for PAs to advance than cardiology.”

In 2009, when the company reorganized, the firm’s leadership recognized the need to establish a liaison group as a buffer between the providers and the company. Ladd became president of its new board of managers.

“From there, my position evolved to what it is today,” he says.

Levy calls Ladd a role model and leader, with great credibility among site program directors, hospital CMOs, and providers.

Responsibilities: Ladd gave up his clinical practice as a hospitalist in 2014 in response to growing management responsibilities.

“I do and I don’t miss it,” he says. “I miss the camaraderie of clinical practice, the foxhole mentality on the front lines. But I feel where I am now that I am able to help our providers give better care.

“Concretely, what I do is to help our practitioners and our medical directors at the clinical sites, some of whom are PAs and NPs, supporting them with leadership and education. I listen to their issues, translating and bringing to bear the resources of our company.”

Those resources include staffing, working conditions, office space, and the application of mobile medical technology for billing and clinical decision support.

“A lot of my communication is via email. I feel I am able to make a point without being inflammatory, by stating my purpose—the rationale for my position—and asking for what I need,” Ladd says. “This role is very accepted at iNDIGO. The corollary is that physician leaders who report to me are also comfortable in our relationship. It’s not about me being a PA and them being physicians but about us being colleagues in medicine.

“I’m in a position where I understand their world and am able to help them.”

The story: Encouraged by what he calls “visionary” leaders, Ladd has taken a number of steps to ascend to his current position as chief clinical officer.

 

“Even going back to the Boy Scouts, I was always one to step forward and volunteer for leadership,” he says. “I was president of my PA class in college and involved with the state association of PAs, as well as taking leadership training through the American Academy of Physician Assistants. I had the good fortune to be hired by a brilliant cardiologist at Detroit Medical Center. … He was the first to encourage me to be not just an excellent clinician but also a leader. He got me involved in implementing the EHR and in medication reconciliation. He promoted me as a PA to his patients and allowed me to become the face of our clinical practice, running the clinical side of the practice.”

Ladd also credits iNDIGO’s leaders for an approach of hiring the best people regardless of degree.

“If they happen to be PAs, great. The company’s vision is to have people with vision and skills to lead, not just based on credentials,” he says. “They established that as a baseline, and now it’s the culture here. We have PAs who are key drivers of the efficiency of this program.”

It hasn’t eliminated the occasional “I’m the physician, I’m delegating to you, and you have to do what I say,” Ladd admits. But he knows handling those situations is part of his job as a practice leader.

“It requires patience and understanding and the ability to see the issue from multiple perspectives,” he says, “and then synthesize all of that into a reasonable solution for all concerned.”

Arnold Facklam III, MSN, FNP-BC, FHM

Nocturnist, hospitalist, and director of advanced practice providers, United Memorial Medical Center, Batavia, N.Y.; medical executive committee member, Medical Staff Organization (MSO) of Kaleida Health, Buffalo, N.Y.

Workplace: United Memorial has 100 beds and is part of the four-hospital Rochester Regional Health System. Kaleida Health has four acute-care hospitals in western New York. Based an hour apart, they compete, but both now get hospitalist services from Infinity Health Hospitalists of Western New York, a hospitalist group of 30 to 35 providers privately owned by local hospitalist John Patti, MD.

Background: Facklam has been a nocturnist since 2009, when he completed an NP program at D’Youville College in Buffalo. He worked 15 to 17 night shifts a month, first at Kaleida’s DeGraff Memorial Hospital and then at United Memorial, starting in 2013 as a per diem and vacation fill-in, then full-time since 2015. He now works for Infinity Health Hospitalists.

While working as a hospitalist, Facklam became involved with the MSO of Kaleida Health, starting on its Advanced Practice Provider Committee, which represents more than 600 NPs and PAs. Now chair of the committee, he leads change in the scope of practice for NPs and PAs and acts as liaison between APPs and the hospitals and health system.

Responsibilities: As a full-time nocturnist, Facklam has to squeeze in time for his role as director of advanced practice providers. He offers guidance and oversight, under the direction of the vice president of medical affairs, to all NPs, PAs, nurse midwives, and nurse anesthetists. He also is in charge of its rapid response and code blue team coverage at night, plus provides clinical education to family practice medical students and residents overnight in the hospital. He has worked on hospital quality improvement projects since 2012.

Facklam, who acknowledges type A personality tendencies, also maintains two to three night shifts per month at Kaleida’s Millard Suburban Hospital.

In 2012, he became a member, eventually a voting member, of Kaleida’s system-wide MSO Medical Executive Committee, which is responsible for rule making, disciplinary action, and the provision of medical care within the system.

 

“The MSO is the mechanism for accountability for professional practice,” he says. He is also active in SHM’s NP/PA Committee and now sits on SHM’s Public Policy Committee.

The story: “Working as a nocturnist has given me the flexibility to look into advanced management training,” he says, including Six Sigma green belt course work and certificate training. While at DeGraff, he heard about a call for membership on the NP/PA committee.

“They quickly realized the benefits of having someone with a background like mine on board,” he said. “As a nocturnist, I started going to more meetings and getting involved when the easier thing to do might have been to drive home and go to bed.”

Along the way, he learned a lot about hospital systems and how they work.

“Having been in healthcare for 23 years, I know the hierarchical approach,” Facklam says. “But the times are changing. As medicine becomes broader and more difficult to manage, it has to become more of a team approach. If you look at the data, there won’t be enough physicians in the near future. PAs and NPs can help fill that need.”

Crystal Therrien, MS, ACNP-BC

Lead nurse practitioner, affiliate practitioner coordinator, Department of Hospital Medicine, University of Massachusetts Memorial Medical Center, Worcester.

Workplace: UMass Medical Center encompasses three campuses in central Massachusetts, including University, Memorial, and Marlborough. The hospital medicine division covers all three campuses with 40 to 45 FTEs of physicians and 20 of APPs. Therrien has been with the department since October 2009—her first job after completing NP training—and assumed her leadership role in June 2012.

Responsibilities: Therrien supervises the UMass hospital medicine division’s Affiliate Practitioner Group. She works with physicians on the executive council, coordinates the medicine service, and coordinates cross-coverage with other services in the hospital, including urology, neurology, surgery, GI, interventional radiology, and bone marrow transplants.

Hospitalist staff work 12-hour shifts, providing 24-hour coverage in the hospital, with one physician and two APPs scheduled at night.

“Because we are available 24-7 in house, I work closely with our scheduler. There is also a lot of coordination with subspecialty services in the hospital and on the observation unit,” she says. “I’m also responsible for interviewing and hiring AP candidates, including credentialing, and with the mentorship program. I chair the rapid response program and host our monthly staff meetings,” which involve both business and didactic presentations. She also serves on the hospital’s NP advisory council.

Before Therrien became the lead NP, her predecessor was assigned at 5% administrative.

“I started out 25% administrative because the program has expanded so quickly,” she says, noting that now she is 50% clinic and 50% administrative. “To be a good leader, I think I need to keep my feet on the ground in patient care.”

The story: Therrien worked as an EMT, a volunteer firefighter, and an ED tech before pursuing a degree in nursing.

“I grew up in a house where my dad was a firefighter and my mom was an EMT,” she says. “We were taught the importance of helping others and being selfless. I always had a leadership mentality.”

Therrien credits her physician colleagues for their commitment and support.

“It can be a little more difficult outside of our department,” she says. “They don’t always understand my role. Some of the attendings have not worked with affiliated providers before, but they have worked with residents. So there’s an interesting dynamic for them to learn how to work with us.”

Kimberly Eisenstock, MD, FHM, the clinical chief of hospital medicine, says that when she was looking for someone new to lead the affiliated practitioners, she wanted “a leader who understood their training and where they could be best utilized. Crystal volunteered. Boy, did she! She was the most experienced and enthusiastic candidate, with the most people-oriented skills.”

 

Dr. Eisenstock says she doesn’t start new roles or programs for the affiliated practitioners without getting the green light from Therrien.

“Crystal now represents the voice for how the division decides to employ APPs and the strategies we use to fill various roles,” she says. TH

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Larry Beresford is a freelance writer in Alameda, Calif.

Since hospital medicine’s early days, hospitalist physicians have worked alongside physician assistants (PAs) and nurse practitioners (NPs). Some PAs and NPs have ascended to positions of leadership in their HM groups or health systems, in some cases even supervising the physicians.

The Hospitalist connected with six PA and NP leaders in hospital medicine to discuss their career paths as well as the nature and scope of their jobs. They described leadership as a complex, multidimensional concept, with often more of a collaborative model than a clear-cut supervisory relationship with clinicians. Most said they don’t try to be the “boss” of their group and have found ways to impact key decisions.

They also emphasized that PAs and NPs bring special skills and perspectives to team building. Many have supplemented frontline clinical experience with leadership training. And when it comes to decision making, their responsibilities can include hiring, scheduling, training, mentoring, information technology, quality improvement, and other essential functions of the group.

Edwin Lopez, MBA, PA-C

Facility medical director, St. Elizabeth Hospital, Enumclaw, Wash.

Workplace: St. Elizabeth is a 25-bed critical-access hospital serving a semi-rural bedroom community of 11,000 people an hour southeast of Seattle. It belongs to the nine-hospital CHI Franciscan Health system, and the HM group includes four physicians and four PAs providing 24-hour coverage. The physicians and PAs work in paired teams in the hospital and an 80-bed skilled nursing facility (SNF) across the street. Lopez heads St. Elizabeth’s HM group and is associate medical director of the SNF.

Background: Lopez graduated from the PA program at the University of Washington in 1982 and spent seven years as a PA with a cardiothoracic surgery practice in Tacoma. Then he established his own firm providing PA staffing services for six cardiac surgery programs in western Washington. In 1997, he co-founded an MD/PA hospitalist service covering three hospitals for a Seattle insurance company. That program grew into a larger group that was acquired by CHI Franciscan.

Lopez took time off to earn his MBA in health policy at the University of Washington and Harvard Kennedy School in Boston.

Eight years ago as part of an acquisition, CHI Franciscan asked Lopez to launch an HM program at St. Elizabeth. From the start, he developed the program as a collaborative model. The HM group now covers almost 90% of hospital admissions, manages the ICU, takes calls to admit patients from the ED, and rounds daily on patients in a small hospital that doesn’t have access to a lot of medical specialists.

St. Elizabeth’s has since flourished to become one of the health system’s top performers on quality metrics like HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores. However, Lopez admits readmission rates remain high. He noticed that a big part of the readmission problem was coming from the facility across the street, so he proposed the HM group start providing daily coverage to the SNF. In the group’s first year covering the SNF, the hospital’s readmission rate dropped to 5% from 35%.

Listen: Edwin Lopez, PA-C, discusses post-acute Care in the U.S. health system

Responsibilities: Lopez spends roughly half his time seeing patients, which he considers the most satisfying half. The other half is managing and setting clinical and administrative direction for the group.

“My responsibility is to ensure that there is appropriate physician and PA coverage 24-7 in both facilities,” he says, adding he also handles hiring and personnel issue. “We have an understanding here. I help guide, mentor, and direct the team, with the support of our regional medical director.”

 

The story: Lopez credits his current position to Joe Wilczek, a visionary CEO who came to the health system 18 years ago and retired in 2015.

“Joe and Franciscan’s chief medical officer and system director of hospital medicine came to me and said, ‘We’d like you to go over there and see what you can do at St. Elizabeth.’ There was a definite mandate, with markers they wanted me to reach. They said, ‘If you succeed, we will build you a new hospital building.’”

The new building opened in 2012.

Lopez says he has spent much of his career in quiet oblivion.

“It took five or six years here before people started noticing that our quality and performance were among the highest in the system,” he says. “For my entire 33-year career in medicine, I was never driven by the money. I grew up believing in service and got into medicine to make a difference, to leave a place better than I found it.”

He occasionally fields questions about his role as a PA group leader, which he tries to overcome by building trust, just as he overcame initial resistance to the hospital medicine program at St. Elizabeth from community physicians.

“I am very clear, we as a team are very clear, that we’re all worker bees here. We build strong relationships. We consider ourselves family,” he says. “When family issues come up, we need to sit down and talk about them, even when it may be uncomfortable.”

Laurie Benton, RN, MPAS, PhD, PA-C, DFAAPA

System director of advanced practice professionals (APPs), Baylor Scott & White Health, Dallas; medical/surgical hospitalist, Scott & White Memorial Hospital, Temple, Texas.

Workplace: Baylor Scott & White Health is the largest nonprofit health system in Texas, with 46 hospitals and 500 multispecialty clinics. Scott & White Memorial Hospital is a 636-bed specialty care and teaching hospital. Its hospital medicine program includes 40 physicians and 34 NP/PAs caring for an average daily census of 240 patients. They cover an observation service, consult service, and long-term acute-care service.

Background: Benton has a PhD in health administration. She has practiced hospital medicine at Scott & White Memorial Hospital since 2000 and before that at Emanuel Hospital in Portland, Ore. Currently an orthopedic hospitalist PA, she has worked in cardiothoracic surgery, critical care, and nephrology settings.

She became the system director for APPs in September 2013. In that role, she leads and represents 428 APPs, including hospitalist, intensivist, and cardiology PAs, in the system’s 26-hospital Central Region. She sits on the board of directors of the American Academy of Physician Assistants and has been on workforce committees for the National Commission on Certification of Physician Assistants and on the CME committee of the National Kidney Foundation.

Responsibilities: Benton coordinates everything, including PAs, advanced practice nurses, and nurse anesthetists, in settings across the healthcare continuum.

“I was appointed by our hospital medicine board and administration to be the APP leader. I report to the chief medical officer,” she says. “But I still see patients; it’s my passion. I’m not ready to give it up completely.”

Benton’s schedule includes two 10-hour clinical shifts per week. The other three days she works on administrative tasks. She attends board meetings as well as regular meetings with the system’s top executives and officers, including the chair of the board and the senior vice president for medical affairs.

“I have a seat on staff credentialing, benefits, and compensation committees, and I’m part of continuing medical education and disaster planning. Pretty much any of the committees we have here, I’m invited to be on,” she says. “I make sure I’m up-to-date on all of the new regulations and have information on any policies that have to do with APPs.”

 

The story: Benton says her PA training, including mentorship from Edwin Lopez, placed a strong emphasis on helping students develop leadership skills and interests.

“While I was working in nephrology, my supervising physician mentored me and encouraged me to move forward with my education,” she says. Along the way, she participated in a yearlong executive-education program and taught at the University of Texas McCombs School of Business. “Right off, it was not easy because while people saw me as a very strong, very confident provider, they didn’t see me as an administrator. When I worked with administrators, they were speaking a different language. I’d speak medicine, and they’d speak administration. It took a while to learn how to communicate with them.”

She says non-physician professionals traditionally have reported up through a physician and “never had their own voice. … Now that we have our leadership ladder here, it’s still new to some administrators,” she says. “I want to make sure PAs are part of the solution to high-quality healthcare.

“When I’m at the leadership table, we’re working together. The physicians respect my opinion, giving me the opportunity to interact like anyone else at the table.”

Catherine Boyd, MS, PA-C

Director of clinical operations, Essex Inpatient Physicians, Boxford, Mass.

Workplace: Essex is a private hospitalist group founded in 2007 by James Tollman, MD, FHM, who remains its CEO. It has 34 clinical members, including 16 physicians, 12 PAs, and six NPs. It began providing hospitalist medical care to several hospitals on Massachusetts’ North Shore under contract, then to a psychiatric hospital and a detox treatment center. In recent years, it has expanded into the post-acute arena, providing coverage to 14 SNFs, which now constitute the majority of its business. It also is active with two accountable-care organization networks.

Background: After three years as a respiratory therapist, Boyd enrolled in a PA program at Massachusetts College of Pharmacy and Health Sciences. After graduating in 2005, she worked as a hospitalist and intensivist, including as team leader for the medical emergency team at Lahey Health & Medical Center in Burlington, Mass., and in the PACE (Program of All-Inclusive Care for the Elderly) Internal Medical Department with Partners HealthCare until mid-2014, when she was invited to join Essex.

Responsibilities: “This job is not one thing; I dabble in everything,” says Boyd, who describes herself as the group’s chief operating officer for professional affairs. “I provide direct supervision to our PAs and NPs but also to our independent contractors, including moonlighting physicians. And I help to supervise the full-time physicians.”

She works on system issues, on-site training and mentorship, and implementation of a new electronic health record (EHR) and charge capture system while trying to improve bed flow and quality and decrease clinicians’ job frustrations. She also monitors developments in Medicare regulations.

“I check in with every one of our full-time providers weekly, and I try to offset some of the minutiae of their workday so that they can focus on their patients,” she explains. “Dr. Tollman and I feel that we bring a healthy work-lifestyle balance to the group. We encourage that in our staff. If they are happy in their jobs, it makes quality of care better.”

Boyd also maintains a clinical practice as a hospitalist, with her clinical duties flexing up and down based on patient demand and management needs.

The story: When Boyd was a respiratory therapist at a small community hospital, she worked one-on-one with a physician assistant who inspired her to change careers.

“I really liked what she did. As a PA, I worked to broaden my skill set on a critical care service for seven years,” she says. “But then my two kids got older and I wanted a more flexible schedule. Dr. Tollman came across my résumé when he was looking for a clinician to run operations for Essex.”

 

Building on 10 years of clinical experience, Boyd has tried to earn the trust of the other clinicians.

“They know they can come to me with questions. I like to think I practice active listening. When there is a problem, I do a case review and try to get all the facts,” she says. “When you earn their trust, the credentials tend to fall away, especially with the doctors I work with on a daily basis.”

Daniel Ladd, PA-C, DFAAPA

Chief clinical officer, iNDIGO Health Partners, Traverse City, Mich.

Workplace: Founded in 1993 as Hospitalists of Northern Michigan, iNDIGO Health Partners is one of the country’s largest private hospitalist companies, employing 150 physicians, PAs, and NPs who practice at seven hospitals across the state. The program also provides nighttime hospitalist services via telehealth and pediatric hospital medicine. It recently added 10 post-acute providers to work in SNFs and assisted living facilities.

Background: While working as a nurse’s aide, meeting and being inspired by some of the earliest PAs in Michigan, Ladd pursued PA training at Mercy College in Detroit. After graduating in 1984, he was hired by a cardiology practice at Detroit Medical Center. When he moved upstate to Traverse City in 1997, he landed a position as lead PA at another cardiology practice, acting as its liaison to PAs in the hospital. He joined iNDIGO in 2006.

“Jim Levy, one of the first PA hospitalists in Michigan, was an integral part of founding iNDIGO and now is our vice president of human resources,” Ladd says. “He asked me to join iNDIGO, and I jumped at the chance. Hospital medicine was a new opportunity for me and one with more opportunities for PAs to advance than cardiology.”

In 2009, when the company reorganized, the firm’s leadership recognized the need to establish a liaison group as a buffer between the providers and the company. Ladd became president of its new board of managers.

“From there, my position evolved to what it is today,” he says.

Levy calls Ladd a role model and leader, with great credibility among site program directors, hospital CMOs, and providers.

Responsibilities: Ladd gave up his clinical practice as a hospitalist in 2014 in response to growing management responsibilities.

“I do and I don’t miss it,” he says. “I miss the camaraderie of clinical practice, the foxhole mentality on the front lines. But I feel where I am now that I am able to help our providers give better care.

“Concretely, what I do is to help our practitioners and our medical directors at the clinical sites, some of whom are PAs and NPs, supporting them with leadership and education. I listen to their issues, translating and bringing to bear the resources of our company.”

Those resources include staffing, working conditions, office space, and the application of mobile medical technology for billing and clinical decision support.

“A lot of my communication is via email. I feel I am able to make a point without being inflammatory, by stating my purpose—the rationale for my position—and asking for what I need,” Ladd says. “This role is very accepted at iNDIGO. The corollary is that physician leaders who report to me are also comfortable in our relationship. It’s not about me being a PA and them being physicians but about us being colleagues in medicine.

“I’m in a position where I understand their world and am able to help them.”

The story: Encouraged by what he calls “visionary” leaders, Ladd has taken a number of steps to ascend to his current position as chief clinical officer.

 

“Even going back to the Boy Scouts, I was always one to step forward and volunteer for leadership,” he says. “I was president of my PA class in college and involved with the state association of PAs, as well as taking leadership training through the American Academy of Physician Assistants. I had the good fortune to be hired by a brilliant cardiologist at Detroit Medical Center. … He was the first to encourage me to be not just an excellent clinician but also a leader. He got me involved in implementing the EHR and in medication reconciliation. He promoted me as a PA to his patients and allowed me to become the face of our clinical practice, running the clinical side of the practice.”

Ladd also credits iNDIGO’s leaders for an approach of hiring the best people regardless of degree.

“If they happen to be PAs, great. The company’s vision is to have people with vision and skills to lead, not just based on credentials,” he says. “They established that as a baseline, and now it’s the culture here. We have PAs who are key drivers of the efficiency of this program.”

It hasn’t eliminated the occasional “I’m the physician, I’m delegating to you, and you have to do what I say,” Ladd admits. But he knows handling those situations is part of his job as a practice leader.

“It requires patience and understanding and the ability to see the issue from multiple perspectives,” he says, “and then synthesize all of that into a reasonable solution for all concerned.”

Arnold Facklam III, MSN, FNP-BC, FHM

Nocturnist, hospitalist, and director of advanced practice providers, United Memorial Medical Center, Batavia, N.Y.; medical executive committee member, Medical Staff Organization (MSO) of Kaleida Health, Buffalo, N.Y.

Workplace: United Memorial has 100 beds and is part of the four-hospital Rochester Regional Health System. Kaleida Health has four acute-care hospitals in western New York. Based an hour apart, they compete, but both now get hospitalist services from Infinity Health Hospitalists of Western New York, a hospitalist group of 30 to 35 providers privately owned by local hospitalist John Patti, MD.

Background: Facklam has been a nocturnist since 2009, when he completed an NP program at D’Youville College in Buffalo. He worked 15 to 17 night shifts a month, first at Kaleida’s DeGraff Memorial Hospital and then at United Memorial, starting in 2013 as a per diem and vacation fill-in, then full-time since 2015. He now works for Infinity Health Hospitalists.

While working as a hospitalist, Facklam became involved with the MSO of Kaleida Health, starting on its Advanced Practice Provider Committee, which represents more than 600 NPs and PAs. Now chair of the committee, he leads change in the scope of practice for NPs and PAs and acts as liaison between APPs and the hospitals and health system.

Responsibilities: As a full-time nocturnist, Facklam has to squeeze in time for his role as director of advanced practice providers. He offers guidance and oversight, under the direction of the vice president of medical affairs, to all NPs, PAs, nurse midwives, and nurse anesthetists. He also is in charge of its rapid response and code blue team coverage at night, plus provides clinical education to family practice medical students and residents overnight in the hospital. He has worked on hospital quality improvement projects since 2012.

Facklam, who acknowledges type A personality tendencies, also maintains two to three night shifts per month at Kaleida’s Millard Suburban Hospital.

In 2012, he became a member, eventually a voting member, of Kaleida’s system-wide MSO Medical Executive Committee, which is responsible for rule making, disciplinary action, and the provision of medical care within the system.

 

“The MSO is the mechanism for accountability for professional practice,” he says. He is also active in SHM’s NP/PA Committee and now sits on SHM’s Public Policy Committee.

The story: “Working as a nocturnist has given me the flexibility to look into advanced management training,” he says, including Six Sigma green belt course work and certificate training. While at DeGraff, he heard about a call for membership on the NP/PA committee.

“They quickly realized the benefits of having someone with a background like mine on board,” he said. “As a nocturnist, I started going to more meetings and getting involved when the easier thing to do might have been to drive home and go to bed.”

Along the way, he learned a lot about hospital systems and how they work.

“Having been in healthcare for 23 years, I know the hierarchical approach,” Facklam says. “But the times are changing. As medicine becomes broader and more difficult to manage, it has to become more of a team approach. If you look at the data, there won’t be enough physicians in the near future. PAs and NPs can help fill that need.”

Crystal Therrien, MS, ACNP-BC

Lead nurse practitioner, affiliate practitioner coordinator, Department of Hospital Medicine, University of Massachusetts Memorial Medical Center, Worcester.

Workplace: UMass Medical Center encompasses three campuses in central Massachusetts, including University, Memorial, and Marlborough. The hospital medicine division covers all three campuses with 40 to 45 FTEs of physicians and 20 of APPs. Therrien has been with the department since October 2009—her first job after completing NP training—and assumed her leadership role in June 2012.

Responsibilities: Therrien supervises the UMass hospital medicine division’s Affiliate Practitioner Group. She works with physicians on the executive council, coordinates the medicine service, and coordinates cross-coverage with other services in the hospital, including urology, neurology, surgery, GI, interventional radiology, and bone marrow transplants.

Hospitalist staff work 12-hour shifts, providing 24-hour coverage in the hospital, with one physician and two APPs scheduled at night.

“Because we are available 24-7 in house, I work closely with our scheduler. There is also a lot of coordination with subspecialty services in the hospital and on the observation unit,” she says. “I’m also responsible for interviewing and hiring AP candidates, including credentialing, and with the mentorship program. I chair the rapid response program and host our monthly staff meetings,” which involve both business and didactic presentations. She also serves on the hospital’s NP advisory council.

Before Therrien became the lead NP, her predecessor was assigned at 5% administrative.

“I started out 25% administrative because the program has expanded so quickly,” she says, noting that now she is 50% clinic and 50% administrative. “To be a good leader, I think I need to keep my feet on the ground in patient care.”

The story: Therrien worked as an EMT, a volunteer firefighter, and an ED tech before pursuing a degree in nursing.

“I grew up in a house where my dad was a firefighter and my mom was an EMT,” she says. “We were taught the importance of helping others and being selfless. I always had a leadership mentality.”

Therrien credits her physician colleagues for their commitment and support.

“It can be a little more difficult outside of our department,” she says. “They don’t always understand my role. Some of the attendings have not worked with affiliated providers before, but they have worked with residents. So there’s an interesting dynamic for them to learn how to work with us.”

Kimberly Eisenstock, MD, FHM, the clinical chief of hospital medicine, says that when she was looking for someone new to lead the affiliated practitioners, she wanted “a leader who understood their training and where they could be best utilized. Crystal volunteered. Boy, did she! She was the most experienced and enthusiastic candidate, with the most people-oriented skills.”

 

Dr. Eisenstock says she doesn’t start new roles or programs for the affiliated practitioners without getting the green light from Therrien.

“Crystal now represents the voice for how the division decides to employ APPs and the strategies we use to fill various roles,” she says. TH

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Larry Beresford is a freelance writer in Alameda, Calif.

NEW YORK - CT scans identify all clinically significant cervical spine injuries in intoxicated patients with blunt trauma, according to a new study.

"I don't think any of the results were particularly surprising to any of us who regularly do trauma care, but what I do think is remarkable about them is that they dispel several long-held myths about the c-spine, intoxicated patients, and the clearance process," Dr. Matthew J. Martin from Legacy Emanuel Medical Center, Portland, Oregon told Reuters Health.

"I think it again confirms that modern CT scan is highly reliable for identifying significant c-spine injuries, but also that the majority of so called 'intoxicated' patients are examinable enough to determine whether the collar can be removed (when combined with the CT scan)," he said.

Up to half of trauma patients are intoxicated, making clearance of the cervical spine a commonly encountered dilemma with both medical and medicolegal implications. Most guidelines indicate that the cervical spine should not be cleared in such patients, resulting in prolonged immobilization or additional imaging even in the face of a normal CT scan.

Dr. Martin's team examined cervical spine clearance practices for intoxicated trauma patients, examined the reliability of cervical spine CT scans for identifying clinically significant injuries (CSIs), and looked for CSIs that might have been missed by CT scans.

Among 1,429 patients who had an alcohol or drug screen performed, 44.2% were intoxicated, the researchers report in JAMA Surgery, online June 15.

Cervical spine injuries were identified in 11.3% of the sober group, 8.1% of the alcohol-intoxicated group, and 12.0% of the drug-intoxicated group.

CT scans yielded negative predictive values of 99.2% for all injuries and 99.8% for unstable injuries. There were five false-negative CT scans, including four central cord syndromes without associated fractures and one potentially unstable injury in a drug-intoxicated patient who presented with clear quadriplegia on examination.

Half of the intoxicated patients were admitted with continued cervical spine immobilization only on the basis of their intoxication. There were no missed CSIs in this group, and all patients were discharged without evidence of an injury or neurologic deficit. They underwent cervical spine immobilization for an average of 15.1 hours, about four times the average time to cervical spine clearance among sober patients (3.7 hours).

"The finding of how long we are keeping these patients in a c-collar based solely on intoxication should raise some eyebrows, and identifies an easy target for process improvement," Dr. Martin said.

"Cervical collars and immobilization are not therapeutic for the vast majority of c-spine injuries; they are really only to prevent inadvertent motion of an unstable c-spine injury," Dr. Martin said. "This is exceedingly rare in a patient who presents with no gross motor deficit, and a high quality CT scan will identify these unstable injuries very reliably. In addition, there are multiple adverse effects of prolonged immobilization, and even of getting an MRI."

"When these are factored in, I think the risk:benefit analysis falls squarely on the side of early clearance based on CT scan," he concluded.

"A key point is that this should be done by experts who are familiar with not only the global concept (the collar can be removed with a negative CT scan), but also the finer points where you could potentially cause harm, or where you should not remove the collar," Dr. Martin added. "This is where a very clear written protocol comes into play and reduces variation or errors that could cause patient harm."

"The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed," write Dr. Olubode A. Olufajo and Dr. Ali Salim from Brigham and Women's Hospital, Boston, in a related editorial. "However, caution must be taken in making conclusions based on these data."

"Although the authors conducted the study at an institution with high-quality CT technology and well-trained radiologists, they still recorded a false-negative CT report consistent with a misread," they note. "With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars."

 

They wonder, "With our knowledge that intoxicated patients form up to half of the population of trauma patients, is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times?"

Dr. Stephen Asha from the University of New South Wales in Sydney, Australia, who has reported on various aspects of cervical spine imaging, told Reuters Health by email, "I think this study confirms what clinical experience as well as much of the more recent studies on cervical spine CT scanning tells us, which is that if there is nothing abnormal detected on a new generation, multi-slice CT, then the neck can be cleared."

"Of course there were a few missed injuries, but this needs to be put into context: no one just does a test in isolation, it is always combined with a clinical assessment, and a consideration the mechanism of injury," said Dr. Asha, who was not involved in the new work. "In this case there were five injuries not apparent on the CT scan, but all had obvious spinal cord injury on clinical examination before the CT was done, so these injuries were never going to be missed in a real clinical setting."

"MRI use should be carefully considered because the problem with MRI is that it can be over-sensitive, demonstrating abnormal signal suggesting ligamentous injury in patient who simply have a ligamentous 'strain,'" Dr. Asha explained. "The false-positive results then lead to further periods of inappropriate immobilization and testing, with the accompanying costs, inconvenience, and complications."

"In patients in whom the clinical assessment raises no concerns for injury, then a normal CT should herald the end of investigations," he said. "MRI should be reserved for those where the clinical assessment is abnormal or where the CT is abnormal and further evaluation for ligamentous or spinal injury is required."

Dr. Asha concluded, "If the clinical exam is not concerning and the CT is normal, then clear the neck."

SOURCE: http://bit.ly/28MxHxA and http://bit.ly/28MxHO5

JAMA Surg 2016.

NEW YORK - CT scans identify all clinically significant cervical spine injuries in intoxicated patients with blunt trauma, according to a new study.

"I don't think any of the results were particularly surprising to any of us who regularly do trauma care, but what I do think is remarkable about them is that they dispel several long-held myths about the c-spine, intoxicated patients, and the clearance process," Dr. Matthew J. Martin from Legacy Emanuel Medical Center, Portland, Oregon told Reuters Health.

"I think it again confirms that modern CT scan is highly reliable for identifying significant c-spine injuries, but also that the majority of so called 'intoxicated' patients are examinable enough to determine whether the collar can be removed (when combined with the CT scan)," he said.

Up to half of trauma patients are intoxicated, making clearance of the cervical spine a commonly encountered dilemma with both medical and medicolegal implications. Most guidelines indicate that the cervical spine should not be cleared in such patients, resulting in prolonged immobilization or additional imaging even in the face of a normal CT scan.

Dr. Martin's team examined cervical spine clearance practices for intoxicated trauma patients, examined the reliability of cervical spine CT scans for identifying clinically significant injuries (CSIs), and looked for CSIs that might have been missed by CT scans.

Among 1,429 patients who had an alcohol or drug screen performed, 44.2% were intoxicated, the researchers report in JAMA Surgery, online June 15.

Cervical spine injuries were identified in 11.3% of the sober group, 8.1% of the alcohol-intoxicated group, and 12.0% of the drug-intoxicated group.

CT scans yielded negative predictive values of 99.2% for all injuries and 99.8% for unstable injuries. There were five false-negative CT scans, including four central cord syndromes without associated fractures and one potentially unstable injury in a drug-intoxicated patient who presented with clear quadriplegia on examination.

Half of the intoxicated patients were admitted with continued cervical spine immobilization only on the basis of their intoxication. There were no missed CSIs in this group, and all patients were discharged without evidence of an injury or neurologic deficit. They underwent cervical spine immobilization for an average of 15.1 hours, about four times the average time to cervical spine clearance among sober patients (3.7 hours).

"The finding of how long we are keeping these patients in a c-collar based solely on intoxication should raise some eyebrows, and identifies an easy target for process improvement," Dr. Martin said.

"Cervical collars and immobilization are not therapeutic for the vast majority of c-spine injuries; they are really only to prevent inadvertent motion of an unstable c-spine injury," Dr. Martin said. "This is exceedingly rare in a patient who presents with no gross motor deficit, and a high quality CT scan will identify these unstable injuries very reliably. In addition, there are multiple adverse effects of prolonged immobilization, and even of getting an MRI."

"When these are factored in, I think the risk:benefit analysis falls squarely on the side of early clearance based on CT scan," he concluded.

"A key point is that this should be done by experts who are familiar with not only the global concept (the collar can be removed with a negative CT scan), but also the finer points where you could potentially cause harm, or where you should not remove the collar," Dr. Martin added. "This is where a very clear written protocol comes into play and reduces variation or errors that could cause patient harm."

"The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed," write Dr. Olubode A. Olufajo and Dr. Ali Salim from Brigham and Women's Hospital, Boston, in a related editorial. "However, caution must be taken in making conclusions based on these data."

"Although the authors conducted the study at an institution with high-quality CT technology and well-trained radiologists, they still recorded a false-negative CT report consistent with a misread," they note. "With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars."

 

They wonder, "With our knowledge that intoxicated patients form up to half of the population of trauma patients, is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times?"

Dr. Stephen Asha from the University of New South Wales in Sydney, Australia, who has reported on various aspects of cervical spine imaging, told Reuters Health by email, "I think this study confirms what clinical experience as well as much of the more recent studies on cervical spine CT scanning tells us, which is that if there is nothing abnormal detected on a new generation, multi-slice CT, then the neck can be cleared."

"Of course there were a few missed injuries, but this needs to be put into context: no one just does a test in isolation, it is always combined with a clinical assessment, and a consideration the mechanism of injury," said Dr. Asha, who was not involved in the new work. "In this case there were five injuries not apparent on the CT scan, but all had obvious spinal cord injury on clinical examination before the CT was done, so these injuries were never going to be missed in a real clinical setting."

"MRI use should be carefully considered because the problem with MRI is that it can be over-sensitive, demonstrating abnormal signal suggesting ligamentous injury in patient who simply have a ligamentous 'strain,'" Dr. Asha explained. "The false-positive results then lead to further periods of inappropriate immobilization and testing, with the accompanying costs, inconvenience, and complications."

"In patients in whom the clinical assessment raises no concerns for injury, then a normal CT should herald the end of investigations," he said. "MRI should be reserved for those where the clinical assessment is abnormal or where the CT is abnormal and further evaluation for ligamentous or spinal injury is required."

Dr. Asha concluded, "If the clinical exam is not concerning and the CT is normal, then clear the neck."

SOURCE: http://bit.ly/28MxHxA and http://bit.ly/28MxHO5

JAMA Surg 2016.

NEW YORK - CT scans identify all clinically significant cervical spine injuries in intoxicated patients with blunt trauma, according to a new study.

"I don't think any of the results were particularly surprising to any of us who regularly do trauma care, but what I do think is remarkable about them is that they dispel several long-held myths about the c-spine, intoxicated patients, and the clearance process," Dr. Matthew J. Martin from Legacy Emanuel Medical Center, Portland, Oregon told Reuters Health.

"I think it again confirms that modern CT scan is highly reliable for identifying significant c-spine injuries, but also that the majority of so called 'intoxicated' patients are examinable enough to determine whether the collar can be removed (when combined with the CT scan)," he said.

Up to half of trauma patients are intoxicated, making clearance of the cervical spine a commonly encountered dilemma with both medical and medicolegal implications. Most guidelines indicate that the cervical spine should not be cleared in such patients, resulting in prolonged immobilization or additional imaging even in the face of a normal CT scan.

Dr. Martin's team examined cervical spine clearance practices for intoxicated trauma patients, examined the reliability of cervical spine CT scans for identifying clinically significant injuries (CSIs), and looked for CSIs that might have been missed by CT scans.

Among 1,429 patients who had an alcohol or drug screen performed, 44.2% were intoxicated, the researchers report in JAMA Surgery, online June 15.

Cervical spine injuries were identified in 11.3% of the sober group, 8.1% of the alcohol-intoxicated group, and 12.0% of the drug-intoxicated group.

CT scans yielded negative predictive values of 99.2% for all injuries and 99.8% for unstable injuries. There were five false-negative CT scans, including four central cord syndromes without associated fractures and one potentially unstable injury in a drug-intoxicated patient who presented with clear quadriplegia on examination.

Half of the intoxicated patients were admitted with continued cervical spine immobilization only on the basis of their intoxication. There were no missed CSIs in this group, and all patients were discharged without evidence of an injury or neurologic deficit. They underwent cervical spine immobilization for an average of 15.1 hours, about four times the average time to cervical spine clearance among sober patients (3.7 hours).

"The finding of how long we are keeping these patients in a c-collar based solely on intoxication should raise some eyebrows, and identifies an easy target for process improvement," Dr. Martin said.

"Cervical collars and immobilization are not therapeutic for the vast majority of c-spine injuries; they are really only to prevent inadvertent motion of an unstable c-spine injury," Dr. Martin said. "This is exceedingly rare in a patient who presents with no gross motor deficit, and a high quality CT scan will identify these unstable injuries very reliably. In addition, there are multiple adverse effects of prolonged immobilization, and even of getting an MRI."

"When these are factored in, I think the risk:benefit analysis falls squarely on the side of early clearance based on CT scan," he concluded.

"A key point is that this should be done by experts who are familiar with not only the global concept (the collar can be removed with a negative CT scan), but also the finer points where you could potentially cause harm, or where you should not remove the collar," Dr. Martin added. "This is where a very clear written protocol comes into play and reduces variation or errors that could cause patient harm."

"The results of this study suggest that it is unnecessary to delay cervical spine clearance until intoxicated patients are sober or until magnetic resonance imaging is performed," write Dr. Olubode A. Olufajo and Dr. Ali Salim from Brigham and Women's Hospital, Boston, in a related editorial. "However, caution must be taken in making conclusions based on these data."

"Although the authors conducted the study at an institution with high-quality CT technology and well-trained radiologists, they still recorded a false-negative CT report consistent with a misread," they note. "With the higher potential for this nature of error in lower-resourced settings, it becomes important to compare the costs and benefits of early removal of cervical collars."

 

They wonder, "With our knowledge that intoxicated patients form up to half of the population of trauma patients, is it really safe to risk irreversible injuries in 1% of the population to save a few hours in cervical clearance times?"

Dr. Stephen Asha from the University of New South Wales in Sydney, Australia, who has reported on various aspects of cervical spine imaging, told Reuters Health by email, "I think this study confirms what clinical experience as well as much of the more recent studies on cervical spine CT scanning tells us, which is that if there is nothing abnormal detected on a new generation, multi-slice CT, then the neck can be cleared."

"Of course there were a few missed injuries, but this needs to be put into context: no one just does a test in isolation, it is always combined with a clinical assessment, and a consideration the mechanism of injury," said Dr. Asha, who was not involved in the new work. "In this case there were five injuries not apparent on the CT scan, but all had obvious spinal cord injury on clinical examination before the CT was done, so these injuries were never going to be missed in a real clinical setting."

"MRI use should be carefully considered because the problem with MRI is that it can be over-sensitive, demonstrating abnormal signal suggesting ligamentous injury in patient who simply have a ligamentous 'strain,'" Dr. Asha explained. "The false-positive results then lead to further periods of inappropriate immobilization and testing, with the accompanying costs, inconvenience, and complications."

"In patients in whom the clinical assessment raises no concerns for injury, then a normal CT should herald the end of investigations," he said. "MRI should be reserved for those where the clinical assessment is abnormal or where the CT is abnormal and further evaluation for ligamentous or spinal injury is required."

Dr. Asha concluded, "If the clinical exam is not concerning and the CT is normal, then clear the neck."

SOURCE: http://bit.ly/28MxHxA and http://bit.ly/28MxHO5

JAMA Surg 2016.

Case

A 42-year-old female with a history of intravenous (IV) drug use presents with severe neck pain, gait instability, and bilateral C5 motor weakness. A cervical MRI shows inflammation consistent with infection of her cervical spine at C5 and C6 and significant boney destruction. The patient undergoes kyphoplasty and debridement of her cervical spine. Operative cultures are significant for Pseudomonas aeruginosa. Infectious disease consultants recommend parenteral ceftriaxone for six weeks. The patient has no insurance, and efforts to obtain long-term placement are unsuccessful. The patient states that her last use of IV drugs was three months ago, and she insists that she will abstain from illicit IV drug abuse going forward.

Background

Outpatient parenteral antibiotic treatment (OPAT) has proven to be a cost-effective and relatively safe treatment option for most patients.1 For these reasons, it has been encouraged for use among a wide a variety of clinical situations. Intravenous drug users (IDUs) are often underinsured and have few options other than costly treatment in an inpatient acute-care facility.

A history of illicit injection drug use frequently raises questions about the appropriateness of OPAT. Some of our most vulnerable patients are those who abuse illicit drugs. Due to psychiatric, social, and financial factors, their ability to adequately transition to outpatient care may be limited. They are often underinsured, and appropriate options for inpatient post-acute care may not exist. Hospitalists often feel pressure to discharge these patients despite the lack of optimal follow-up care, and they must weigh the risks and benefits in each case.

The enrollment of IDUs into an OPAT service using a peripherally inserted central catheter (PICC) is controversial and often avoided. No clear-cut guidelines concerning the use of OPAT in IDUs by national medical societies exist.2 Consultants are often reluctant to recommend options that deviate from the typical standard of inpatient or directly observed care. The obvious risk is that a PICC line provides easy and tempting access to veins for continued drug abuse. In addition, there is an increased risk of infection and/or thrombosis if the PICC is abused.3

The safety and efficacy of PICC line use for OPAT in IDUs are unknown, and studies addressing these issues are limited. In one study at the National University Hospital of Singapore, 29 IDU patients received OPAT without complications.4 Patients were closely monitored, including by use of a tamper-proof security seal on the PICC. Infective endocarditis was the primary diagnosis in 42% of the cases studied. There were no deaths or cases of PICC abuse reported. In another abstract presentation, 39 IDU patients at Henry Ford Health System in Detroit were discharged to outpatient therapy with a PICC line and demonstrated a high cure rate (73.3%). Nine patients were lost to follow-up.5

No studies have compared OPAT therapy to inpatient therapy in IDU patients.

Back to the Case

Despite multiple attempts and due to financial considerations, no long-term care facility is able to admit the patient for therapy. The frequency of required antibiotics makes outpatient therapy in an infusion center problematic. The primary service is reluctant to discharge the patient home with a PICC line in place due to the potential of abuse and complications. A “Goals of Care” committee, consisting of several physicians from multiple specialties, legal counsel, and case management, is convened to review the case. The committee concludes that, in this particular case, it would be a reasonable option to discharge the patient to home with a PICC line in place to complete OPAT. A patient agreement document is drafted; it describes the complications of PICC line abuse and stipulates that the patient agrees to drug testing throughout the duration of her treatment. A similar agreement is required by the home infusion company. Both documents are signed by the patient, and she is subsequently discharged home.

 

Bottom Line

Our strategy is to deal with each of these cases as unique situations because no policies, procedures, protocols, or guidelines currently exist. One of the guiding principles should be, despite financial pressures, that the primary focus is on appropriate care of this vulnerable population. A type of “Goals of Care” committee (or organizational equivalent) can be utilized to offer assistance in decision making. Unfortunately, the safety and efficacy of OPAT in IDU patients are uncertain, and there is a lack of studies to support definitive protocols. In select cases, OPAT in IDU patients may be considered, but signed consent of the risks and the patient’s responsibilities concerning OPAT should be clearly documented in the medical record by the discharging team. TH

Dr. Conrad is a hospitalist with Ochsner Health System in New Orleans.

References

1. Tice AD, Hoaglund PA, Nolet B, McKinnon PS, Mozaffari E. Cost perspectives for outpatient intravenous antimicrobial therapy. Pharmacotherapy. 2002;22(2, pt 2):63S-70S.
2. Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38(12):1651-1672.
3. Chemaly R, de Parres JB, Rehm SJ, et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179-1183.
4. Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrobial Chemotherapy. 2010;65(12):2641-2644.
5. Papalekas E, Patel N, Neph A, Moreno D, Zervos M, Reyes K. Outpatient parenteral antimicrobial therapy (OPAT) in intravenous drug users (IVDUs): epidemiology and outcomes. Oral abstract presented at: IDWeek; October 2014; Philadelphia.

Case

A 42-year-old female with a history of intravenous (IV) drug use presents with severe neck pain, gait instability, and bilateral C5 motor weakness. A cervical MRI shows inflammation consistent with infection of her cervical spine at C5 and C6 and significant boney destruction. The patient undergoes kyphoplasty and debridement of her cervical spine. Operative cultures are significant for Pseudomonas aeruginosa. Infectious disease consultants recommend parenteral ceftriaxone for six weeks. The patient has no insurance, and efforts to obtain long-term placement are unsuccessful. The patient states that her last use of IV drugs was three months ago, and she insists that she will abstain from illicit IV drug abuse going forward.

Background

Outpatient parenteral antibiotic treatment (OPAT) has proven to be a cost-effective and relatively safe treatment option for most patients.1 For these reasons, it has been encouraged for use among a wide a variety of clinical situations. Intravenous drug users (IDUs) are often underinsured and have few options other than costly treatment in an inpatient acute-care facility.

A history of illicit injection drug use frequently raises questions about the appropriateness of OPAT. Some of our most vulnerable patients are those who abuse illicit drugs. Due to psychiatric, social, and financial factors, their ability to adequately transition to outpatient care may be limited. They are often underinsured, and appropriate options for inpatient post-acute care may not exist. Hospitalists often feel pressure to discharge these patients despite the lack of optimal follow-up care, and they must weigh the risks and benefits in each case.

The enrollment of IDUs into an OPAT service using a peripherally inserted central catheter (PICC) is controversial and often avoided. No clear-cut guidelines concerning the use of OPAT in IDUs by national medical societies exist.2 Consultants are often reluctant to recommend options that deviate from the typical standard of inpatient or directly observed care. The obvious risk is that a PICC line provides easy and tempting access to veins for continued drug abuse. In addition, there is an increased risk of infection and/or thrombosis if the PICC is abused.3

The safety and efficacy of PICC line use for OPAT in IDUs are unknown, and studies addressing these issues are limited. In one study at the National University Hospital of Singapore, 29 IDU patients received OPAT without complications.4 Patients were closely monitored, including by use of a tamper-proof security seal on the PICC. Infective endocarditis was the primary diagnosis in 42% of the cases studied. There were no deaths or cases of PICC abuse reported. In another abstract presentation, 39 IDU patients at Henry Ford Health System in Detroit were discharged to outpatient therapy with a PICC line and demonstrated a high cure rate (73.3%). Nine patients were lost to follow-up.5

No studies have compared OPAT therapy to inpatient therapy in IDU patients.

Back to the Case

Despite multiple attempts and due to financial considerations, no long-term care facility is able to admit the patient for therapy. The frequency of required antibiotics makes outpatient therapy in an infusion center problematic. The primary service is reluctant to discharge the patient home with a PICC line in place due to the potential of abuse and complications. A “Goals of Care” committee, consisting of several physicians from multiple specialties, legal counsel, and case management, is convened to review the case. The committee concludes that, in this particular case, it would be a reasonable option to discharge the patient to home with a PICC line in place to complete OPAT. A patient agreement document is drafted; it describes the complications of PICC line abuse and stipulates that the patient agrees to drug testing throughout the duration of her treatment. A similar agreement is required by the home infusion company. Both documents are signed by the patient, and she is subsequently discharged home.

 

Bottom Line

Our strategy is to deal with each of these cases as unique situations because no policies, procedures, protocols, or guidelines currently exist. One of the guiding principles should be, despite financial pressures, that the primary focus is on appropriate care of this vulnerable population. A type of “Goals of Care” committee (or organizational equivalent) can be utilized to offer assistance in decision making. Unfortunately, the safety and efficacy of OPAT in IDU patients are uncertain, and there is a lack of studies to support definitive protocols. In select cases, OPAT in IDU patients may be considered, but signed consent of the risks and the patient’s responsibilities concerning OPAT should be clearly documented in the medical record by the discharging team. TH

Dr. Conrad is a hospitalist with Ochsner Health System in New Orleans.

References

1. Tice AD, Hoaglund PA, Nolet B, McKinnon PS, Mozaffari E. Cost perspectives for outpatient intravenous antimicrobial therapy. Pharmacotherapy. 2002;22(2, pt 2):63S-70S.
2. Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38(12):1651-1672.
3. Chemaly R, de Parres JB, Rehm SJ, et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179-1183.
4. Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrobial Chemotherapy. 2010;65(12):2641-2644.
5. Papalekas E, Patel N, Neph A, Moreno D, Zervos M, Reyes K. Outpatient parenteral antimicrobial therapy (OPAT) in intravenous drug users (IVDUs): epidemiology and outcomes. Oral abstract presented at: IDWeek; October 2014; Philadelphia.

Case

A 42-year-old female with a history of intravenous (IV) drug use presents with severe neck pain, gait instability, and bilateral C5 motor weakness. A cervical MRI shows inflammation consistent with infection of her cervical spine at C5 and C6 and significant boney destruction. The patient undergoes kyphoplasty and debridement of her cervical spine. Operative cultures are significant for Pseudomonas aeruginosa. Infectious disease consultants recommend parenteral ceftriaxone for six weeks. The patient has no insurance, and efforts to obtain long-term placement are unsuccessful. The patient states that her last use of IV drugs was three months ago, and she insists that she will abstain from illicit IV drug abuse going forward.

Background

Outpatient parenteral antibiotic treatment (OPAT) has proven to be a cost-effective and relatively safe treatment option for most patients.1 For these reasons, it has been encouraged for use among a wide a variety of clinical situations. Intravenous drug users (IDUs) are often underinsured and have few options other than costly treatment in an inpatient acute-care facility.

A history of illicit injection drug use frequently raises questions about the appropriateness of OPAT. Some of our most vulnerable patients are those who abuse illicit drugs. Due to psychiatric, social, and financial factors, their ability to adequately transition to outpatient care may be limited. They are often underinsured, and appropriate options for inpatient post-acute care may not exist. Hospitalists often feel pressure to discharge these patients despite the lack of optimal follow-up care, and they must weigh the risks and benefits in each case.

The enrollment of IDUs into an OPAT service using a peripherally inserted central catheter (PICC) is controversial and often avoided. No clear-cut guidelines concerning the use of OPAT in IDUs by national medical societies exist.2 Consultants are often reluctant to recommend options that deviate from the typical standard of inpatient or directly observed care. The obvious risk is that a PICC line provides easy and tempting access to veins for continued drug abuse. In addition, there is an increased risk of infection and/or thrombosis if the PICC is abused.3

The safety and efficacy of PICC line use for OPAT in IDUs are unknown, and studies addressing these issues are limited. In one study at the National University Hospital of Singapore, 29 IDU patients received OPAT without complications.4 Patients were closely monitored, including by use of a tamper-proof security seal on the PICC. Infective endocarditis was the primary diagnosis in 42% of the cases studied. There were no deaths or cases of PICC abuse reported. In another abstract presentation, 39 IDU patients at Henry Ford Health System in Detroit were discharged to outpatient therapy with a PICC line and demonstrated a high cure rate (73.3%). Nine patients were lost to follow-up.5

No studies have compared OPAT therapy to inpatient therapy in IDU patients.

Back to the Case

Despite multiple attempts and due to financial considerations, no long-term care facility is able to admit the patient for therapy. The frequency of required antibiotics makes outpatient therapy in an infusion center problematic. The primary service is reluctant to discharge the patient home with a PICC line in place due to the potential of abuse and complications. A “Goals of Care” committee, consisting of several physicians from multiple specialties, legal counsel, and case management, is convened to review the case. The committee concludes that, in this particular case, it would be a reasonable option to discharge the patient to home with a PICC line in place to complete OPAT. A patient agreement document is drafted; it describes the complications of PICC line abuse and stipulates that the patient agrees to drug testing throughout the duration of her treatment. A similar agreement is required by the home infusion company. Both documents are signed by the patient, and she is subsequently discharged home.

 

Bottom Line

Our strategy is to deal with each of these cases as unique situations because no policies, procedures, protocols, or guidelines currently exist. One of the guiding principles should be, despite financial pressures, that the primary focus is on appropriate care of this vulnerable population. A type of “Goals of Care” committee (or organizational equivalent) can be utilized to offer assistance in decision making. Unfortunately, the safety and efficacy of OPAT in IDU patients are uncertain, and there is a lack of studies to support definitive protocols. In select cases, OPAT in IDU patients may be considered, but signed consent of the risks and the patient’s responsibilities concerning OPAT should be clearly documented in the medical record by the discharging team. TH

Dr. Conrad is a hospitalist with Ochsner Health System in New Orleans.

References

1. Tice AD, Hoaglund PA, Nolet B, McKinnon PS, Mozaffari E. Cost perspectives for outpatient intravenous antimicrobial therapy. Pharmacotherapy. 2002;22(2, pt 2):63S-70S.
2. Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38(12):1651-1672.
3. Chemaly R, de Parres JB, Rehm SJ, et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179-1183.
4. Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrobial Chemotherapy. 2010;65(12):2641-2644.
5. Papalekas E, Patel N, Neph A, Moreno D, Zervos M, Reyes K. Outpatient parenteral antimicrobial therapy (OPAT) in intravenous drug users (IVDUs): epidemiology and outcomes. Oral abstract presented at: IDWeek; October 2014; Philadelphia.

Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.

POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.

With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.

For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.

POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.

POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.

It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.

Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.

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Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter

Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.

POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.

With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.

For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.

POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.

POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.

It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.

Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.

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Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter

Small devices carried in pockets during rounds can enable hospitalists to make quick decisions at the bedside, enhance and teach physical exam skills, streamline patient flow through the hospital, and potentially avoid the cost and risk of exposure to radiation. Point-of-care (POC) ultrasound enhances both patient satisfaction and the clinician’s professional satisfaction. Hospital medicine will be the next field to rapidly assimilate its use.

POC, or “bedside,” ultrasound has been used by ob-gyns, vascular access, and procedural teams for quite some time. Of late, emergency medicine and critical care physicians have adopted its use. It offers the advantage of gaining immediate information regarding the patient through dynamic imaging and the ability to integrate that information into the clinical picture. This enables providers to make decisions about patient care in real time.

With the advent of affordable handheld devices with quality images, rounding with these devices has become practical for hospitalists. Hospitalists should rapidly embrace this skill set. POC ultrasound can be very useful to quickly improve patient diagnosis, patient satisfaction, patient safety, length of stay, and provider satisfaction.

For example, in patients complaining of dyspnea, for which there is not a clear diagnosis of COPD, congestive heart failure, pulmonary embolism, or pneumonia, a focused cardiac ultrasound can rapidly differentiate between right ventricular dysfunction, left ventricular dysfunction, pericardial effusion, or a hyperdynamic heart. Lung ultrasound with diffuse or focal “B lines,” focal consolidation, and/or pleural effusion can assist in differentiating the cause as well.

POC ultrasound also is a teaching tool that can enhance exam skills. Hospitalists can confirm exam findings and teach as they palpate the liver or percuss the chest. Performing a procedure such as paracentesis or a central line with ultrasound guidance is now considered standard of care in some centers. The literature shows ultrasound guidance is safer even when compared to clinicians skilled in landmark techniques. In addition, many hospitalists and/or trainees will work in areas where 24-7 echo, interventional radiologists, and ultrasound techs are not available. Hospitalists need to know how to use POC ultrasound to serve patients well.

POC ultrasound can also be used in daily care. For heart failure patients, watching the B lines (pulmonary edema), pleural effusions, and inferior vena cava size can avoid over- or under-diuresis and reduce length of stay and cost. The same can be said for patients with percutaneous catheters to ensure proper drainage of the pockets of fluid in the chest or abdomen.

It is important to know the limitations of POC ultrasound. It is best used to answer binary questions (e.g., pericardial effusion present or not). It is a skill to be acquired and honed, and it requires specialized training. There are many one- to two-day courses as well simulators and other means. The basics of image acquisition and interpretation can be found online, and much of it is free. Manufacturers often are willing to provide machines to practice with.

Many patients enjoy seeing the images and having a better understanding of their disease process, which leads to improved patient satisfaction. Overall, there are many benefits for hospitalists.

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Gordon Johnson, MD, hospitalist and president, Oregon/Southwest Washington SHM Chapter

Clinical question: Which medications are most safe and effective at managing type 2 diabetes?

Background: Patients and practitioners need an updated review of the evidence to select the optimal medication for type 2 diabetes management.

Study design: Systematic review.

Synopsis: The authors reviewed 179 trials and 25 observational studies. When comparing metformin to sulfonylureas, metformin was associated with less cardiovascular mortality.

However, when trying to make comparisons based on all-cause mortality or microvascular complications, the evidence is limited. Improvements in hemoglobin A1c levels are similar when comparing different monotherapy options, and low blood sugar was most common with sulfonylureas. The short duration of many trials limits the ability to provide better data on long-term outcomes.

Bottom line: Metformin remains the first-line agent for type 2 diabetes management.

Citation: Maruthur NM, Tseng E, Hutfless S, et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systemic review and meta-analysis. Ann Intern Med. 2016;164(1):740-751.

Short Take

Patients Discharge Readiness May Not Be Adequately Assessed and/or Addressed During Hospitalization

Prospective observational study found unresolved barriers to discharge were common in at least 90% of patients. Patients frequently cited issues including unresolved pain, lack of understanding around discharge plans, and ability to provide self-care.

Citation: Harrison JD, Greysen RS, Jacolbia R, Nguyen A, Auerbach AD. Not ready, not set…discharge: patient-reported barriers to discharge readiness at an academic medical center [published online ahead of print April 15, 2016]. J Hosp Med. doi:10.1002/jhm.2591.

Clinical question: Which medications are most safe and effective at managing type 2 diabetes?

Background: Patients and practitioners need an updated review of the evidence to select the optimal medication for type 2 diabetes management.

Study design: Systematic review.

Synopsis: The authors reviewed 179 trials and 25 observational studies. When comparing metformin to sulfonylureas, metformin was associated with less cardiovascular mortality.

However, when trying to make comparisons based on all-cause mortality or microvascular complications, the evidence is limited. Improvements in hemoglobin A1c levels are similar when comparing different monotherapy options, and low blood sugar was most common with sulfonylureas. The short duration of many trials limits the ability to provide better data on long-term outcomes.

Bottom line: Metformin remains the first-line agent for type 2 diabetes management.

Citation: Maruthur NM, Tseng E, Hutfless S, et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systemic review and meta-analysis. Ann Intern Med. 2016;164(1):740-751.

Short Take

Patients Discharge Readiness May Not Be Adequately Assessed and/or Addressed During Hospitalization

Prospective observational study found unresolved barriers to discharge were common in at least 90% of patients. Patients frequently cited issues including unresolved pain, lack of understanding around discharge plans, and ability to provide self-care.

Citation: Harrison JD, Greysen RS, Jacolbia R, Nguyen A, Auerbach AD. Not ready, not set…discharge: patient-reported barriers to discharge readiness at an academic medical center [published online ahead of print April 15, 2016]. J Hosp Med. doi:10.1002/jhm.2591.

Clinical question: Which medications are most safe and effective at managing type 2 diabetes?

Background: Patients and practitioners need an updated review of the evidence to select the optimal medication for type 2 diabetes management.

Study design: Systematic review.

Synopsis: The authors reviewed 179 trials and 25 observational studies. When comparing metformin to sulfonylureas, metformin was associated with less cardiovascular mortality.

However, when trying to make comparisons based on all-cause mortality or microvascular complications, the evidence is limited. Improvements in hemoglobin A1c levels are similar when comparing different monotherapy options, and low blood sugar was most common with sulfonylureas. The short duration of many trials limits the ability to provide better data on long-term outcomes.

Bottom line: Metformin remains the first-line agent for type 2 diabetes management.

Citation: Maruthur NM, Tseng E, Hutfless S, et al. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systemic review and meta-analysis. Ann Intern Med. 2016;164(1):740-751.

Short Take

Patients Discharge Readiness May Not Be Adequately Assessed and/or Addressed During Hospitalization

Prospective observational study found unresolved barriers to discharge were common in at least 90% of patients. Patients frequently cited issues including unresolved pain, lack of understanding around discharge plans, and ability to provide self-care.

Citation: Harrison JD, Greysen RS, Jacolbia R, Nguyen A, Auerbach AD. Not ready, not set…discharge: patient-reported barriers to discharge readiness at an academic medical center [published online ahead of print April 15, 2016]. J Hosp Med. doi:10.1002/jhm.2591.

Clinical question: What is the prognosis of patients who have a TIA or minor stroke?

Background: Prior studies had estimated the risk in the three months following a TIA or minor stroke of having a stroke or acute coronary syndrome (ACS) as 12% to 20%, but this may not reflect the risk of modern patients receiving the current standards of care.

Study design: Prospective observational registry of patients with recent TIA or minor stroke.

Setting: International, including 21 countries.

Synopsis: Adults with recent TIA or minor stroke were included in this multi-center, international registry, and one-year outcomes were reported. At one year, the Kaplan-Meier estimated event rate for the combined outcome of stroke, ACS, or death from cardiovascular causes was 6.2%. The risk of the cardiovascular events was found to be lower than previously reported, suggesting an improvement in outcomes with current interventions. Elevated ABCD2 score, infarction seen on brain imaging, and large-artery atherosclerosis were each associated with higher risk.

Bottom line: Elevated ABCD2 score, brain imaging findings, and large-artery atherosclerosis suggest increased risk for recurrent stroke.

Citation: Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med. 2016;374(16):1533-1542.

Clinical question: What is the prognosis of patients who have a TIA or minor stroke?

Background: Prior studies had estimated the risk in the three months following a TIA or minor stroke of having a stroke or acute coronary syndrome (ACS) as 12% to 20%, but this may not reflect the risk of modern patients receiving the current standards of care.

Study design: Prospective observational registry of patients with recent TIA or minor stroke.

Setting: International, including 21 countries.

Synopsis: Adults with recent TIA or minor stroke were included in this multi-center, international registry, and one-year outcomes were reported. At one year, the Kaplan-Meier estimated event rate for the combined outcome of stroke, ACS, or death from cardiovascular causes was 6.2%. The risk of the cardiovascular events was found to be lower than previously reported, suggesting an improvement in outcomes with current interventions. Elevated ABCD2 score, infarction seen on brain imaging, and large-artery atherosclerosis were each associated with higher risk.

Bottom line: Elevated ABCD2 score, brain imaging findings, and large-artery atherosclerosis suggest increased risk for recurrent stroke.

Citation: Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med. 2016;374(16):1533-1542.

Clinical question: What is the prognosis of patients who have a TIA or minor stroke?

Background: Prior studies had estimated the risk in the three months following a TIA or minor stroke of having a stroke or acute coronary syndrome (ACS) as 12% to 20%, but this may not reflect the risk of modern patients receiving the current standards of care.

Study design: Prospective observational registry of patients with recent TIA or minor stroke.

Setting: International, including 21 countries.

Synopsis: Adults with recent TIA or minor stroke were included in this multi-center, international registry, and one-year outcomes were reported. At one year, the Kaplan-Meier estimated event rate for the combined outcome of stroke, ACS, or death from cardiovascular causes was 6.2%. The risk of the cardiovascular events was found to be lower than previously reported, suggesting an improvement in outcomes with current interventions. Elevated ABCD2 score, infarction seen on brain imaging, and large-artery atherosclerosis were each associated with higher risk.

Bottom line: Elevated ABCD2 score, brain imaging findings, and large-artery atherosclerosis suggest increased risk for recurrent stroke.

Citation: Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med. 2016;374(16):1533-1542.