Clinical

Clinical question: Can physician counseling for asthma care be improved by using low-literacy asthma action plans?

Background: Although asthma action plans are recommended for all children with asthma and have been associated with improved medication adherence, written asthma action plans are given to fewer than half of patients with asthma. Children with asthma whose parents have low health literacy have worse asthma-related outcomes; most asthma action plans do not use principles of health literacy. Researchers sought to investigate if asthma counseling was improved when providers were given a low-literacy asthma action plan versus a standard plan to structure their counseling.

Study design: Randomized controlled trial.

Setting: Two large, academic medical centers.

Synopsis: The study enrolled 126 physicians, of which 119 were randomized, with 61 counseling based on the low-literacy asthma action plan and 58 counseling based on a standard asthma action plan. There were no significant differences between the two groups of physicians in terms of age, gender, frequency in providing asthma care, confidence in asthma counseling, or training category (resident, fellow, attending).

These physicians counseled research assistants acting in the role of parents of children with moderate persistent asthma. The children were on a regimen of daily orally inhaled fluticasone and montelukast by mouth and as-needed albuterol. The low-literacy plan used photographs of medications, pictograms, and colors to delineate asthma severity and was prepopulated with the patient’s regimen. The standard plan was from the American Academy of Allergy, Asthma & Immunology (AAAAI); it required the physician to write in the names and doses of the patient’s medications and had no photos or pictograms. Counseling sessions were recorded and coded for content.

Using health literacy principles, the authors valued plain-language descriptions (e.g., “ribs show when breathing”) over jargon (e.g., “respiratory distress”) and specific times (e.g., “morning and night”) over times-per-day dosing (e.g., “two times a day”).

Physicians using the low-literacy plan were much more likely to use specific time of day rather than doses per day (odds ratio = 27.5; 95% CI, 6.1–123.4), much more likely to mention spacers (odds ratio = 6; 95% CI, 2.8–15), and much more likely to use plain-language descriptors of respiratory distress (odds ratio = 33; 95% CI, 7.4–147.5). These differences were present regardless of physicians’ stated comfort with asthma counseling or experience level. There was no significant difference in duration of counseling between the two plans. Physicians stated a preference for the low-literacy plan.

Bottom line: Use of low-literacy asthma action plans improves the quality of physician counseling for asthma.

Citation: Yin HS, Gupta RS, Tomopoulos S, et al. A low-literacy asthma action plan to improve provider asthma counseling: a randomized study. Pediatrics. 2016;137(1):1-11. doi:10.1542/peds.2015-0468.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: Can physician counseling for asthma care be improved by using low-literacy asthma action plans?

Background: Although asthma action plans are recommended for all children with asthma and have been associated with improved medication adherence, written asthma action plans are given to fewer than half of patients with asthma. Children with asthma whose parents have low health literacy have worse asthma-related outcomes; most asthma action plans do not use principles of health literacy. Researchers sought to investigate if asthma counseling was improved when providers were given a low-literacy asthma action plan versus a standard plan to structure their counseling.

Study design: Randomized controlled trial.

Setting: Two large, academic medical centers.

Synopsis: The study enrolled 126 physicians, of which 119 were randomized, with 61 counseling based on the low-literacy asthma action plan and 58 counseling based on a standard asthma action plan. There were no significant differences between the two groups of physicians in terms of age, gender, frequency in providing asthma care, confidence in asthma counseling, or training category (resident, fellow, attending).

These physicians counseled research assistants acting in the role of parents of children with moderate persistent asthma. The children were on a regimen of daily orally inhaled fluticasone and montelukast by mouth and as-needed albuterol. The low-literacy plan used photographs of medications, pictograms, and colors to delineate asthma severity and was prepopulated with the patient’s regimen. The standard plan was from the American Academy of Allergy, Asthma & Immunology (AAAAI); it required the physician to write in the names and doses of the patient’s medications and had no photos or pictograms. Counseling sessions were recorded and coded for content.

Using health literacy principles, the authors valued plain-language descriptions (e.g., “ribs show when breathing”) over jargon (e.g., “respiratory distress”) and specific times (e.g., “morning and night”) over times-per-day dosing (e.g., “two times a day”).

Physicians using the low-literacy plan were much more likely to use specific time of day rather than doses per day (odds ratio = 27.5; 95% CI, 6.1–123.4), much more likely to mention spacers (odds ratio = 6; 95% CI, 2.8–15), and much more likely to use plain-language descriptors of respiratory distress (odds ratio = 33; 95% CI, 7.4–147.5). These differences were present regardless of physicians’ stated comfort with asthma counseling or experience level. There was no significant difference in duration of counseling between the two plans. Physicians stated a preference for the low-literacy plan.

Bottom line: Use of low-literacy asthma action plans improves the quality of physician counseling for asthma.

Citation: Yin HS, Gupta RS, Tomopoulos S, et al. A low-literacy asthma action plan to improve provider asthma counseling: a randomized study. Pediatrics. 2016;137(1):1-11. doi:10.1542/peds.2015-0468.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: Can physician counseling for asthma care be improved by using low-literacy asthma action plans?

Background: Although asthma action plans are recommended for all children with asthma and have been associated with improved medication adherence, written asthma action plans are given to fewer than half of patients with asthma. Children with asthma whose parents have low health literacy have worse asthma-related outcomes; most asthma action plans do not use principles of health literacy. Researchers sought to investigate if asthma counseling was improved when providers were given a low-literacy asthma action plan versus a standard plan to structure their counseling.

Study design: Randomized controlled trial.

Setting: Two large, academic medical centers.

Synopsis: The study enrolled 126 physicians, of which 119 were randomized, with 61 counseling based on the low-literacy asthma action plan and 58 counseling based on a standard asthma action plan. There were no significant differences between the two groups of physicians in terms of age, gender, frequency in providing asthma care, confidence in asthma counseling, or training category (resident, fellow, attending).

These physicians counseled research assistants acting in the role of parents of children with moderate persistent asthma. The children were on a regimen of daily orally inhaled fluticasone and montelukast by mouth and as-needed albuterol. The low-literacy plan used photographs of medications, pictograms, and colors to delineate asthma severity and was prepopulated with the patient’s regimen. The standard plan was from the American Academy of Allergy, Asthma & Immunology (AAAAI); it required the physician to write in the names and doses of the patient’s medications and had no photos or pictograms. Counseling sessions were recorded and coded for content.

Using health literacy principles, the authors valued plain-language descriptions (e.g., “ribs show when breathing”) over jargon (e.g., “respiratory distress”) and specific times (e.g., “morning and night”) over times-per-day dosing (e.g., “two times a day”).

Physicians using the low-literacy plan were much more likely to use specific time of day rather than doses per day (odds ratio = 27.5; 95% CI, 6.1–123.4), much more likely to mention spacers (odds ratio = 6; 95% CI, 2.8–15), and much more likely to use plain-language descriptors of respiratory distress (odds ratio = 33; 95% CI, 7.4–147.5). These differences were present regardless of physicians’ stated comfort with asthma counseling or experience level. There was no significant difference in duration of counseling between the two plans. Physicians stated a preference for the low-literacy plan.

Bottom line: Use of low-literacy asthma action plans improves the quality of physician counseling for asthma.

Citation: Yin HS, Gupta RS, Tomopoulos S, et al. A low-literacy asthma action plan to improve provider asthma counseling: a randomized study. Pediatrics. 2016;137(1):1-11. doi:10.1542/peds.2015-0468.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

(Reuters Health) - Medicaid, the U.S. health program for the poor, pays far less for common surgical procedures in many states than does Medicare, the federal insurance plan for the elderly, according to a new study.

Some of the discounts are so steep that they may threaten access to care, the authors argue.

Medicaid is the biggest public health program in the U.S. and currently accounts for about $1 out of every $6 spent on medical care. Medicaid expenditures also represent almost half of all federal funds spent by states.

When Medicaid fees are too low relative to payments from Medicare, doctors may refuse to treat Medicaid patients, potentially making it much harder for poor people to get treatment, argue Dr. Charles Mabry of the University of Arkansas in Little Rock and colleagues in a paper released online January 13 in the Journal of the American College of Surgeons.

"Lack of proper payment can cause some Medicaid patients to have needed surgical procedures delayed," Mabry told Reuters Health by email. "Our hope was that by researching and publishing on these wide variations in payment, it would spur states to rethink the methodology for how they determine payment."

Even though the federal government picks up part of the tab for care, Medicaid payment rates as well as enrollment eligibility and covered benefits are determined by individual states.

To assess the degree of variation between Medicare and Medicaid payments for surgery, Mabry and colleagues calculated how much fees varied for some of the most common procedures done by general surgeons in nearly every state across the country.

The analysis excluded only Kansas and Tennessee.

The largest discount they found was in New Jersey, where Medicaid paid $1,011 (about 933 euros) less than Medicare for surgery to remove all or part of the small intestine.

At the other extreme, the biggest premium was in Alaska, which paid $1,382 more for insertion of a tunneled central venous port under Medicaid than Medicare would pay for the procedure.

When they looked at mastectomy, Medicaid paid $226.47 in Connecticut, 69% less than the $725.35 Medicare payment for the same procedure in the same state.

For an enterectomy, New Jersey's Medicaid payment of $332 was 75% less than the $1,343.16 payment under Medicare.

To fix a ventral hernia, Medicaid in New Hampshire pays $300, 61% less than the $762.28 Medicare payment in the state.

The analysis has several limitations, including the narrow focus on a handful of surgical procedures and the reliance on published payment schedules in each state, which may not necessarily reflect what surgeons actually get paid, the authors note. The analysis also lacked data on certain bulk payments or additional funds paid by Medicaid that might minimize the apparent discounts in some cases.

The paper didn't examine how access to care might be adversely affected by steep discounts in Medicaid payments relative to Medicare or private insurance. But, the authors conclude, it's likely some people struggle to find surgeons or experience delays in care as a direct result of low fees that motivate doctors to refuse Medicaid patients.

One woman with sickle-cell disease and Medicaid coverage is a case-in-point for Dr. Constantine Manthous, who retired from Yale University and works in private practice in New London, Connecticut.

He recalled meeting her after she had spent a decade in a wheelchair because she couldn't find a surgeon to repair her hip. She didn't receive surgery until the hip fell out of its socket, requiring constant hospitalization and morphine.

"By that time she was so ill she died of late complications from the decade delay," Manthous, who wasn't involved in the study, said by email. "You and I would have gotten the hip immediately."

(Reuters Health) - Medicaid, the U.S. health program for the poor, pays far less for common surgical procedures in many states than does Medicare, the federal insurance plan for the elderly, according to a new study.

Some of the discounts are so steep that they may threaten access to care, the authors argue.

Medicaid is the biggest public health program in the U.S. and currently accounts for about $1 out of every $6 spent on medical care. Medicaid expenditures also represent almost half of all federal funds spent by states.

When Medicaid fees are too low relative to payments from Medicare, doctors may refuse to treat Medicaid patients, potentially making it much harder for poor people to get treatment, argue Dr. Charles Mabry of the University of Arkansas in Little Rock and colleagues in a paper released online January 13 in the Journal of the American College of Surgeons.

"Lack of proper payment can cause some Medicaid patients to have needed surgical procedures delayed," Mabry told Reuters Health by email. "Our hope was that by researching and publishing on these wide variations in payment, it would spur states to rethink the methodology for how they determine payment."

Even though the federal government picks up part of the tab for care, Medicaid payment rates as well as enrollment eligibility and covered benefits are determined by individual states.

To assess the degree of variation between Medicare and Medicaid payments for surgery, Mabry and colleagues calculated how much fees varied for some of the most common procedures done by general surgeons in nearly every state across the country.

The analysis excluded only Kansas and Tennessee.

The largest discount they found was in New Jersey, where Medicaid paid $1,011 (about 933 euros) less than Medicare for surgery to remove all or part of the small intestine.

At the other extreme, the biggest premium was in Alaska, which paid $1,382 more for insertion of a tunneled central venous port under Medicaid than Medicare would pay for the procedure.

When they looked at mastectomy, Medicaid paid $226.47 in Connecticut, 69% less than the $725.35 Medicare payment for the same procedure in the same state.

For an enterectomy, New Jersey's Medicaid payment of $332 was 75% less than the $1,343.16 payment under Medicare.

To fix a ventral hernia, Medicaid in New Hampshire pays $300, 61% less than the $762.28 Medicare payment in the state.

The analysis has several limitations, including the narrow focus on a handful of surgical procedures and the reliance on published payment schedules in each state, which may not necessarily reflect what surgeons actually get paid, the authors note. The analysis also lacked data on certain bulk payments or additional funds paid by Medicaid that might minimize the apparent discounts in some cases.

The paper didn't examine how access to care might be adversely affected by steep discounts in Medicaid payments relative to Medicare or private insurance. But, the authors conclude, it's likely some people struggle to find surgeons or experience delays in care as a direct result of low fees that motivate doctors to refuse Medicaid patients.

One woman with sickle-cell disease and Medicaid coverage is a case-in-point for Dr. Constantine Manthous, who retired from Yale University and works in private practice in New London, Connecticut.

He recalled meeting her after she had spent a decade in a wheelchair because she couldn't find a surgeon to repair her hip. She didn't receive surgery until the hip fell out of its socket, requiring constant hospitalization and morphine.

"By that time she was so ill she died of late complications from the decade delay," Manthous, who wasn't involved in the study, said by email. "You and I would have gotten the hip immediately."

(Reuters Health) - Medicaid, the U.S. health program for the poor, pays far less for common surgical procedures in many states than does Medicare, the federal insurance plan for the elderly, according to a new study.

Some of the discounts are so steep that they may threaten access to care, the authors argue.

Medicaid is the biggest public health program in the U.S. and currently accounts for about $1 out of every $6 spent on medical care. Medicaid expenditures also represent almost half of all federal funds spent by states.

When Medicaid fees are too low relative to payments from Medicare, doctors may refuse to treat Medicaid patients, potentially making it much harder for poor people to get treatment, argue Dr. Charles Mabry of the University of Arkansas in Little Rock and colleagues in a paper released online January 13 in the Journal of the American College of Surgeons.

"Lack of proper payment can cause some Medicaid patients to have needed surgical procedures delayed," Mabry told Reuters Health by email. "Our hope was that by researching and publishing on these wide variations in payment, it would spur states to rethink the methodology for how they determine payment."

Even though the federal government picks up part of the tab for care, Medicaid payment rates as well as enrollment eligibility and covered benefits are determined by individual states.

To assess the degree of variation between Medicare and Medicaid payments for surgery, Mabry and colleagues calculated how much fees varied for some of the most common procedures done by general surgeons in nearly every state across the country.

The analysis excluded only Kansas and Tennessee.

The largest discount they found was in New Jersey, where Medicaid paid $1,011 (about 933 euros) less than Medicare for surgery to remove all or part of the small intestine.

At the other extreme, the biggest premium was in Alaska, which paid $1,382 more for insertion of a tunneled central venous port under Medicaid than Medicare would pay for the procedure.

When they looked at mastectomy, Medicaid paid $226.47 in Connecticut, 69% less than the $725.35 Medicare payment for the same procedure in the same state.

For an enterectomy, New Jersey's Medicaid payment of $332 was 75% less than the $1,343.16 payment under Medicare.

To fix a ventral hernia, Medicaid in New Hampshire pays $300, 61% less than the $762.28 Medicare payment in the state.

The analysis has several limitations, including the narrow focus on a handful of surgical procedures and the reliance on published payment schedules in each state, which may not necessarily reflect what surgeons actually get paid, the authors note. The analysis also lacked data on certain bulk payments or additional funds paid by Medicaid that might minimize the apparent discounts in some cases.

The paper didn't examine how access to care might be adversely affected by steep discounts in Medicaid payments relative to Medicare or private insurance. But, the authors conclude, it's likely some people struggle to find surgeons or experience delays in care as a direct result of low fees that motivate doctors to refuse Medicaid patients.

One woman with sickle-cell disease and Medicaid coverage is a case-in-point for Dr. Constantine Manthous, who retired from Yale University and works in private practice in New London, Connecticut.

He recalled meeting her after she had spent a decade in a wheelchair because she couldn't find a surgeon to repair her hip. She didn't receive surgery until the hip fell out of its socket, requiring constant hospitalization and morphine.

"By that time she was so ill she died of late complications from the decade delay," Manthous, who wasn't involved in the study, said by email. "You and I would have gotten the hip immediately."

NEW YORK (Reuters Health) - Dabigatran and warfarin offer similar stroke-prevention efficacy in patients with atrial fibrillation (AF), but their side effect profiles differ, according to a systematic review and meta-analysis of real-world clinical practice.

"There could be many reasons for the differences in our findings, such as differences in the quality of evidence of observational studies and randomized controlled trials (RCTs) or differences in the included study populations between the observational studies in our review and the RE-LY trial," Dr. Robert J. Romanelli from Palo Alto Medical Foundation Research Institute, California, told Reuters Health by email.

The RE-LY trial is the only RCT to have evaluated dabigatran in stroke prevention, and RCTs are prone to selection biases less likely to be present in well designed observational studies, Dr. Romanelli and colleagues note in Circulation:Cardiovascular and Quality Outcomes, online January 26.

The team used data from seven retrospective cohort studies to compare the effectiveness and safety of dabigatran and warfarin among more than 348,750 patients with nonvalvular AF.

During an overall mean follow-up of 794 days, dabigatran 150mg or 110 mg was similar to warfarin in ischemic stroke prevention.

Both the higher and lower dabigatran doses had significantly lower hazards of intracranial bleeding compared with warfarin (pooled hazard ratio, 0.44 and 0.49, respectively). But the hazard of gastrointestinal bleeding was significantly greater for dabigatran 150 mg (but not for 110 mg) than for warfarin (pHR, 1.23). The 110 mg dose of dabigatran was only available during the trial; it's now sold in 150 mg or 75 mg capsules.

The increased risk of gastrointestinal bleeding with the higher dose of dabigatran was significant only in older populations (75 years or older).

"Data presented in this review reflect relative risk, which is not always clinically meaningful," the researchers caution. "It is important to bear in mind that event rates for the outcome of interest are low under standard treatment."

"I don't think the findings from this one reviewshould change clinical practice," Dr. Romanelli said. "If anything, this study revealed areas for future research.

NEW YORK (Reuters Health) - Dabigatran and warfarin offer similar stroke-prevention efficacy in patients with atrial fibrillation (AF), but their side effect profiles differ, according to a systematic review and meta-analysis of real-world clinical practice.

"There could be many reasons for the differences in our findings, such as differences in the quality of evidence of observational studies and randomized controlled trials (RCTs) or differences in the included study populations between the observational studies in our review and the RE-LY trial," Dr. Robert J. Romanelli from Palo Alto Medical Foundation Research Institute, California, told Reuters Health by email.

The RE-LY trial is the only RCT to have evaluated dabigatran in stroke prevention, and RCTs are prone to selection biases less likely to be present in well designed observational studies, Dr. Romanelli and colleagues note in Circulation:Cardiovascular and Quality Outcomes, online January 26.

The team used data from seven retrospective cohort studies to compare the effectiveness and safety of dabigatran and warfarin among more than 348,750 patients with nonvalvular AF.

During an overall mean follow-up of 794 days, dabigatran 150mg or 110 mg was similar to warfarin in ischemic stroke prevention.

Both the higher and lower dabigatran doses had significantly lower hazards of intracranial bleeding compared with warfarin (pooled hazard ratio, 0.44 and 0.49, respectively). But the hazard of gastrointestinal bleeding was significantly greater for dabigatran 150 mg (but not for 110 mg) than for warfarin (pHR, 1.23). The 110 mg dose of dabigatran was only available during the trial; it's now sold in 150 mg or 75 mg capsules.

The increased risk of gastrointestinal bleeding with the higher dose of dabigatran was significant only in older populations (75 years or older).

"Data presented in this review reflect relative risk, which is not always clinically meaningful," the researchers caution. "It is important to bear in mind that event rates for the outcome of interest are low under standard treatment."

"I don't think the findings from this one reviewshould change clinical practice," Dr. Romanelli said. "If anything, this study revealed areas for future research.

NEW YORK (Reuters Health) - Dabigatran and warfarin offer similar stroke-prevention efficacy in patients with atrial fibrillation (AF), but their side effect profiles differ, according to a systematic review and meta-analysis of real-world clinical practice.

"There could be many reasons for the differences in our findings, such as differences in the quality of evidence of observational studies and randomized controlled trials (RCTs) or differences in the included study populations between the observational studies in our review and the RE-LY trial," Dr. Robert J. Romanelli from Palo Alto Medical Foundation Research Institute, California, told Reuters Health by email.

The RE-LY trial is the only RCT to have evaluated dabigatran in stroke prevention, and RCTs are prone to selection biases less likely to be present in well designed observational studies, Dr. Romanelli and colleagues note in Circulation:Cardiovascular and Quality Outcomes, online January 26.

The team used data from seven retrospective cohort studies to compare the effectiveness and safety of dabigatran and warfarin among more than 348,750 patients with nonvalvular AF.

During an overall mean follow-up of 794 days, dabigatran 150mg or 110 mg was similar to warfarin in ischemic stroke prevention.

Both the higher and lower dabigatran doses had significantly lower hazards of intracranial bleeding compared with warfarin (pooled hazard ratio, 0.44 and 0.49, respectively). But the hazard of gastrointestinal bleeding was significantly greater for dabigatran 150 mg (but not for 110 mg) than for warfarin (pHR, 1.23). The 110 mg dose of dabigatran was only available during the trial; it's now sold in 150 mg or 75 mg capsules.

The increased risk of gastrointestinal bleeding with the higher dose of dabigatran was significant only in older populations (75 years or older).

"Data presented in this review reflect relative risk, which is not always clinically meaningful," the researchers caution. "It is important to bear in mind that event rates for the outcome of interest are low under standard treatment."

"I don't think the findings from this one reviewshould change clinical practice," Dr. Romanelli said. "If anything, this study revealed areas for future research.

NEW YORK (Reuters Health) - Type 2 diabetes risk appears to be increased in youth who are treated with antipsychotics, according to new research.

"We believe that clinicians should take away from our study that type 2 diabetes is a risk when treating youth with antipsychotics, especially long-term," said senior author Dr. Christoff U. Correll of Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, New York.

"Therefore, antipsychotics should be used judiciously and for as short a period as necessary and possible," he told Reuters Health by email. "Importantly, clinicians should routinely and proactively monitor the efficacy and need for ongoing antipsychotic treatment as well as the potential emergence of adverse effects. Specifically, clinicians and patients, as well as parents, should monitor weight change monthly, and fasting blood work for blood sugar and blood lipids

should be obtained before starting an antipsychotic, three months later, and every six months thereafter."

Dr. Correll and colleagues conducted a systematic review of studies reporting on type 2 diabetes incidence in youth up to 24 years old who were exposed to antipsychotics for at least three months. They did a meta-analysis of thirteen studies involving more than 185,000 youth exposed to antipsychotics, representing some 310,000 patient-years.

Seven studies included psychiatric controls and eight studies included healthy controls.

During a mean follow-up of 1.7 years, the cumulative type 2 diabetes risk was 5.72 per 1,000 patient-years (p<0.001). The overall incidence rate was 3.09 cases per 1,000 patient-years (p<0.001), according to an article online January 20 in JAMA Psychiatry.

Compared with healthy controls, antipsychotic-exposed youth had significantly higher cumulative type 2 diabetes risk (odds ratio, 2.58; p<0.0001) and incidence rate ratio (IRR, 3.02; p<0.0001). Compared with psychiatric controls, they had significantly higher risks (OR 2.09, p<0.0001, IRR 1.79,p<0.0001).

In multivariate regression analysis of 10 studies, diabetes was associated with longer follow-up, use of olanzapine, and male sex. Greater diabetes incidence was tied to use of second-generation antipsychotics, while it was inversely related to diagnosis of autism spectrum disorder.

"Although our findings cannot comment on the individual risk with any specific antipsychotic other than the significantly higher risk associated with olanzapine, other studies equally suggest the much increased cardiovascular risk associates with olanzapine than with other antipsychotics in youth. Based on all of these data, I personally believe that olanzapine should not be used first- or second-line in youth, but likely be reserved or treatment-resistant patients who cannot benefit sufficiently from antipsychotics with lower cardiometabolic risk," Dr. Correll told Reuters Health.

"Clearly, additional research is needed to identify the specific mechanisms of antipsychotic-related weight gain and development of diabetes in order to either counter these effects or develop medications that do not adversely affect cardiometabolic health," he added. "Moreover, research is needed seeking to identify patients who are at particularly high risk for weight gain and diabetes and those who seem to be protected against these antipsychotic-related side effects to help individualize treatment selection."

"Finally," he concluded, "research is required that tests lower-risk pharmacologic and nonpharmacologic interventions that may be used effectively before or instead of an antipsychotic when treating nonpsychotic conditions. This need pertains especially to youth presenting with severe mood or behavioral dysregulation, irritability, and aggression for whom antipsychotics are used a lot, often without even providing psychosocial treatments."

NEW YORK (Reuters Health) - Type 2 diabetes risk appears to be increased in youth who are treated with antipsychotics, according to new research.

"We believe that clinicians should take away from our study that type 2 diabetes is a risk when treating youth with antipsychotics, especially long-term," said senior author Dr. Christoff U. Correll of Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, New York.

"Therefore, antipsychotics should be used judiciously and for as short a period as necessary and possible," he told Reuters Health by email. "Importantly, clinicians should routinely and proactively monitor the efficacy and need for ongoing antipsychotic treatment as well as the potential emergence of adverse effects. Specifically, clinicians and patients, as well as parents, should monitor weight change monthly, and fasting blood work for blood sugar and blood lipids

should be obtained before starting an antipsychotic, three months later, and every six months thereafter."

Dr. Correll and colleagues conducted a systematic review of studies reporting on type 2 diabetes incidence in youth up to 24 years old who were exposed to antipsychotics for at least three months. They did a meta-analysis of thirteen studies involving more than 185,000 youth exposed to antipsychotics, representing some 310,000 patient-years.

Seven studies included psychiatric controls and eight studies included healthy controls.

During a mean follow-up of 1.7 years, the cumulative type 2 diabetes risk was 5.72 per 1,000 patient-years (p<0.001). The overall incidence rate was 3.09 cases per 1,000 patient-years (p<0.001), according to an article online January 20 in JAMA Psychiatry.

Compared with healthy controls, antipsychotic-exposed youth had significantly higher cumulative type 2 diabetes risk (odds ratio, 2.58; p<0.0001) and incidence rate ratio (IRR, 3.02; p<0.0001). Compared with psychiatric controls, they had significantly higher risks (OR 2.09, p<0.0001, IRR 1.79,p<0.0001).

In multivariate regression analysis of 10 studies, diabetes was associated with longer follow-up, use of olanzapine, and male sex. Greater diabetes incidence was tied to use of second-generation antipsychotics, while it was inversely related to diagnosis of autism spectrum disorder.

"Although our findings cannot comment on the individual risk with any specific antipsychotic other than the significantly higher risk associated with olanzapine, other studies equally suggest the much increased cardiovascular risk associates with olanzapine than with other antipsychotics in youth. Based on all of these data, I personally believe that olanzapine should not be used first- or second-line in youth, but likely be reserved or treatment-resistant patients who cannot benefit sufficiently from antipsychotics with lower cardiometabolic risk," Dr. Correll told Reuters Health.

"Clearly, additional research is needed to identify the specific mechanisms of antipsychotic-related weight gain and development of diabetes in order to either counter these effects or develop medications that do not adversely affect cardiometabolic health," he added. "Moreover, research is needed seeking to identify patients who are at particularly high risk for weight gain and diabetes and those who seem to be protected against these antipsychotic-related side effects to help individualize treatment selection."

"Finally," he concluded, "research is required that tests lower-risk pharmacologic and nonpharmacologic interventions that may be used effectively before or instead of an antipsychotic when treating nonpsychotic conditions. This need pertains especially to youth presenting with severe mood or behavioral dysregulation, irritability, and aggression for whom antipsychotics are used a lot, often without even providing psychosocial treatments."

NEW YORK (Reuters Health) - Type 2 diabetes risk appears to be increased in youth who are treated with antipsychotics, according to new research.

"We believe that clinicians should take away from our study that type 2 diabetes is a risk when treating youth with antipsychotics, especially long-term," said senior author Dr. Christoff U. Correll of Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, New York.

"Therefore, antipsychotics should be used judiciously and for as short a period as necessary and possible," he told Reuters Health by email. "Importantly, clinicians should routinely and proactively monitor the efficacy and need for ongoing antipsychotic treatment as well as the potential emergence of adverse effects. Specifically, clinicians and patients, as well as parents, should monitor weight change monthly, and fasting blood work for blood sugar and blood lipids

should be obtained before starting an antipsychotic, three months later, and every six months thereafter."

Dr. Correll and colleagues conducted a systematic review of studies reporting on type 2 diabetes incidence in youth up to 24 years old who were exposed to antipsychotics for at least three months. They did a meta-analysis of thirteen studies involving more than 185,000 youth exposed to antipsychotics, representing some 310,000 patient-years.

Seven studies included psychiatric controls and eight studies included healthy controls.

During a mean follow-up of 1.7 years, the cumulative type 2 diabetes risk was 5.72 per 1,000 patient-years (p<0.001). The overall incidence rate was 3.09 cases per 1,000 patient-years (p<0.001), according to an article online January 20 in JAMA Psychiatry.

Compared with healthy controls, antipsychotic-exposed youth had significantly higher cumulative type 2 diabetes risk (odds ratio, 2.58; p<0.0001) and incidence rate ratio (IRR, 3.02; p<0.0001). Compared with psychiatric controls, they had significantly higher risks (OR 2.09, p<0.0001, IRR 1.79,p<0.0001).

In multivariate regression analysis of 10 studies, diabetes was associated with longer follow-up, use of olanzapine, and male sex. Greater diabetes incidence was tied to use of second-generation antipsychotics, while it was inversely related to diagnosis of autism spectrum disorder.

"Although our findings cannot comment on the individual risk with any specific antipsychotic other than the significantly higher risk associated with olanzapine, other studies equally suggest the much increased cardiovascular risk associates with olanzapine than with other antipsychotics in youth. Based on all of these data, I personally believe that olanzapine should not be used first- or second-line in youth, but likely be reserved or treatment-resistant patients who cannot benefit sufficiently from antipsychotics with lower cardiometabolic risk," Dr. Correll told Reuters Health.

"Clearly, additional research is needed to identify the specific mechanisms of antipsychotic-related weight gain and development of diabetes in order to either counter these effects or develop medications that do not adversely affect cardiometabolic health," he added. "Moreover, research is needed seeking to identify patients who are at particularly high risk for weight gain and diabetes and those who seem to be protected against these antipsychotic-related side effects to help individualize treatment selection."

"Finally," he concluded, "research is required that tests lower-risk pharmacologic and nonpharmacologic interventions that may be used effectively before or instead of an antipsychotic when treating nonpsychotic conditions. This need pertains especially to youth presenting with severe mood or behavioral dysregulation, irritability, and aggression for whom antipsychotics are used a lot, often without even providing psychosocial treatments."

Dear Dr. Hospitalist:

We have several physicians in our large academic group whom I hate to follow when picking up teams. There have only been a few situations when I thought there was a clear knowledge deficit, but the most irritating problem is that they don’t discharge patients. I’ve only been in the group for several years, so I don’t want to come across as a complainer. However, I am concerned about poor patient care and the work left to me to discharge patients. How can I help these physicians improve without damaging my relationship with them?

Dr. Frustrated

Dr. Hospitalist responds:

You bring up a problem that I’m certain many of us in hospital medicine have experienced at some point in our career. Since the “practice” of medicine can often be done with much variability, there are many gray areas that occur during the care of patients. However, we all know it is the transitioning of patients into and out of the hospital that is the most labor-intensive period of their care. If at all possible, the discharge process is best performed by the person with the most longitudinal knowledge of the patient’s hospital course.

Your leadership team has the responsibility to assess the quality and quantity of work of all team members. The periodic assessment of a clinician’s skill and aptitude, as well as the safety of care delivered to patients, can be done in several ways. Typically, the initial assessment is done by focused professional practice evaluations (FPPEs) and later by ongoing professional practice evaluations (OPPEs). The Joint Commission created these tools in 2007 to help determine if the quality of care by clinicians fell below an acceptable level.

FPPEs, as defined by the commission, are “the time limited evaluation of practitioner competence in performing a specific privilege.” They are usually done three to six months after the initial credentialing period, when a new or additional privilege is requested after the initial appointment, or when a condition or issue affecting the delivery of safe and high-quality care is identified.

OPPEs, as the name suggests, are typically done on an ongoing basis (usually annually). These practitioner-specific reports are best utilized as screening tools, and when unusual or aberrant tendencies are observed, a more detailed analysis typically is required.

Although these formal evaluations are carried out by chart review and analysis of data collected by the hospital, they should always be supported by discreet and candid conversations with other frontline team members. It is during these sessions that individuals should take the opportunity to express their opinions regarding the care delivered by their colleagues. From my experience, because of the shared care of patients in hospital medicine, if there is a problem with an individual’s professionalism or clinical abilities, it is usually well-known by others in the group.

If for some reason group leaders are not performing these mandated evaluations (and thus risking regulatory sanctions) or don’t have a formal mechanism in place, I would encourage them to establish one. In the interim, I would discreetly address the individuals and share your concerns. Many times, the problems you mention can be resolved with awareness, mentoring, and/or proctoring, but like any needed corrective actions, they must first be acknowledged.

Good luck! TH

Dear Dr. Hospitalist:

We have several physicians in our large academic group whom I hate to follow when picking up teams. There have only been a few situations when I thought there was a clear knowledge deficit, but the most irritating problem is that they don’t discharge patients. I’ve only been in the group for several years, so I don’t want to come across as a complainer. However, I am concerned about poor patient care and the work left to me to discharge patients. How can I help these physicians improve without damaging my relationship with them?

Dr. Frustrated

Dr. Hospitalist responds:

You bring up a problem that I’m certain many of us in hospital medicine have experienced at some point in our career. Since the “practice” of medicine can often be done with much variability, there are many gray areas that occur during the care of patients. However, we all know it is the transitioning of patients into and out of the hospital that is the most labor-intensive period of their care. If at all possible, the discharge process is best performed by the person with the most longitudinal knowledge of the patient’s hospital course.

Your leadership team has the responsibility to assess the quality and quantity of work of all team members. The periodic assessment of a clinician’s skill and aptitude, as well as the safety of care delivered to patients, can be done in several ways. Typically, the initial assessment is done by focused professional practice evaluations (FPPEs) and later by ongoing professional practice evaluations (OPPEs). The Joint Commission created these tools in 2007 to help determine if the quality of care by clinicians fell below an acceptable level.

FPPEs, as defined by the commission, are “the time limited evaluation of practitioner competence in performing a specific privilege.” They are usually done three to six months after the initial credentialing period, when a new or additional privilege is requested after the initial appointment, or when a condition or issue affecting the delivery of safe and high-quality care is identified.

OPPEs, as the name suggests, are typically done on an ongoing basis (usually annually). These practitioner-specific reports are best utilized as screening tools, and when unusual or aberrant tendencies are observed, a more detailed analysis typically is required.

Although these formal evaluations are carried out by chart review and analysis of data collected by the hospital, they should always be supported by discreet and candid conversations with other frontline team members. It is during these sessions that individuals should take the opportunity to express their opinions regarding the care delivered by their colleagues. From my experience, because of the shared care of patients in hospital medicine, if there is a problem with an individual’s professionalism or clinical abilities, it is usually well-known by others in the group.

If for some reason group leaders are not performing these mandated evaluations (and thus risking regulatory sanctions) or don’t have a formal mechanism in place, I would encourage them to establish one. In the interim, I would discreetly address the individuals and share your concerns. Many times, the problems you mention can be resolved with awareness, mentoring, and/or proctoring, but like any needed corrective actions, they must first be acknowledged.

Good luck! TH

Dear Dr. Hospitalist:

We have several physicians in our large academic group whom I hate to follow when picking up teams. There have only been a few situations when I thought there was a clear knowledge deficit, but the most irritating problem is that they don’t discharge patients. I’ve only been in the group for several years, so I don’t want to come across as a complainer. However, I am concerned about poor patient care and the work left to me to discharge patients. How can I help these physicians improve without damaging my relationship with them?

Dr. Frustrated

Dr. Hospitalist responds:

You bring up a problem that I’m certain many of us in hospital medicine have experienced at some point in our career. Since the “practice” of medicine can often be done with much variability, there are many gray areas that occur during the care of patients. However, we all know it is the transitioning of patients into and out of the hospital that is the most labor-intensive period of their care. If at all possible, the discharge process is best performed by the person with the most longitudinal knowledge of the patient’s hospital course.

Your leadership team has the responsibility to assess the quality and quantity of work of all team members. The periodic assessment of a clinician’s skill and aptitude, as well as the safety of care delivered to patients, can be done in several ways. Typically, the initial assessment is done by focused professional practice evaluations (FPPEs) and later by ongoing professional practice evaluations (OPPEs). The Joint Commission created these tools in 2007 to help determine if the quality of care by clinicians fell below an acceptable level.

FPPEs, as defined by the commission, are “the time limited evaluation of practitioner competence in performing a specific privilege.” They are usually done three to six months after the initial credentialing period, when a new or additional privilege is requested after the initial appointment, or when a condition or issue affecting the delivery of safe and high-quality care is identified.

OPPEs, as the name suggests, are typically done on an ongoing basis (usually annually). These practitioner-specific reports are best utilized as screening tools, and when unusual or aberrant tendencies are observed, a more detailed analysis typically is required.

Although these formal evaluations are carried out by chart review and analysis of data collected by the hospital, they should always be supported by discreet and candid conversations with other frontline team members. It is during these sessions that individuals should take the opportunity to express their opinions regarding the care delivered by their colleagues. From my experience, because of the shared care of patients in hospital medicine, if there is a problem with an individual’s professionalism or clinical abilities, it is usually well-known by others in the group.

If for some reason group leaders are not performing these mandated evaluations (and thus risking regulatory sanctions) or don’t have a formal mechanism in place, I would encourage them to establish one. In the interim, I would discreetly address the individuals and share your concerns. Many times, the problems you mention can be resolved with awareness, mentoring, and/or proctoring, but like any needed corrective actions, they must first be acknowledged.

Good luck! TH

NEW YORK (Reuters Health) - Stent-retriever therapy for the treatment of acute ischemic stroke improves the rate of functional independence at 90 days, according to a systematic

review and meta-analysis.

Stent retrievers are deployed in an occluded vessel, temporarily expanded into the body of a thrombus, and then retracted along with the thrombus.

Dr. Mark J. Eisenberg, from Jewish General Hospital/McGill University, Montreal, Quebec, Canada, and colleagues compared stent retrievers with intravenous recombinant tissue plasminogen activator (rtPA) versus rtPA alone for the treatment of acute ischemic stroke in their systematic review and meta-analysis of five randomized controlled trials (RCTs) with a total of 1,287 patients.

In all five trials, patients randomized to stent-retriever therapy had significantly better functional independence (a modified Rankin Scale (mRS) score of 0-2) at 90 days than did patients randomized to rtPA alone.

Stent-retriever therapy also doubled the likelihood of a one-unit improvement in mRS score at 90 days, according to the January 25 JAMA Neurology online report.

In pooled analyses, there were no significant differences between treatment groups in all-cause mortality, intracranial hemorrhage, or parenchymal hematoma rates at 90 days.

The number needed to treat to achieve an mRS score of 0 to 2 at 90 days was six.

"Given the totality of the evidence regarding the benefits and risks of stent retrievers, our results suggest that the use of these devices in patients with acute ischemic stroke is warranted," the researchers conclude.

Dr. Raphael A. Carandang, from the University of Massachusetts Medical School, Worcester, who wrote an editorial related to this report, told Reuters Health by email, "The data from these five RCTs (as the meta-analysis confirms) provides level 1 class A evidence that in the properly selected patients, stent retriever treatment is superior to the current standard of care with intravenous rtPA and would endorse that it should be considered in all acute ischemic stroke patients that are eligible for it. As with any therapy, proper patient selection is needed, but I do think it changes the landscape of acute stroke treatment going forward. I think that systems of care should be organized in stroke centers around this new therapy."

"The current technology for acute stroke care has reached the point where effective interventional therapies are clearly and unequivocally beneficial in the properly selected patients, but the key takeaway is still that the patients need to be selected properly, and the biggest factor continues to be time to recanalization, which means that all practitioners and systems of care need to focus on getting patients to treatment sooner than ever before," Dr. Carandang concluded.

Dr. Woong Yoon, from Chonnam National University Hospital, Gwangju, Korea, recently found no improvement in outcomes with stent-retriever therapy for patients with acute anterior circulation stroke (http://bit.ly/1OT7M5I). He told Reuters Health by email, "Not all patients with acute ischemic stroke can benefit from this new treatment. Patients with acute stroke due to occlusions of intracranial large vessels such as internal carotid artery, middle cerebral artery, or basilar artery and who presented within six-eight hours of stroke onset can benefit from thrombectomy with stent retrievers."

"We should realize that we are facing the moment of change in the paradigm for acute stroke treatment," Dr. Yoon concluded."Further refinement in the patient selection for stent retrieverthrombectomy is needed in the near future."

Dr. Mayank Goyal, from the University of Calgary, Alberta, Canada, coauthored two of the studies included in the current review. He told Reuters Health by email," There are several additional data coming out on this issue in the near future, which will in fact be more powerful than what is mentioned in this study."

Dr. Goyal said, "However, the key issues going into the future are: how should those patients who were not included in the current trials be treated; how should we as a collective evaluate new devices/technologies; and how do societies/countries who cannot afford stent retrievers implement endovascular stroke treatment."

Dr. Eisenberg was unavailable for comment.

The authors reported no funding. Three coauthors reported disclosures.

NEW YORK (Reuters Health) - Stent-retriever therapy for the treatment of acute ischemic stroke improves the rate of functional independence at 90 days, according to a systematic

review and meta-analysis.

Stent retrievers are deployed in an occluded vessel, temporarily expanded into the body of a thrombus, and then retracted along with the thrombus.

Dr. Mark J. Eisenberg, from Jewish General Hospital/McGill University, Montreal, Quebec, Canada, and colleagues compared stent retrievers with intravenous recombinant tissue plasminogen activator (rtPA) versus rtPA alone for the treatment of acute ischemic stroke in their systematic review and meta-analysis of five randomized controlled trials (RCTs) with a total of 1,287 patients.

In all five trials, patients randomized to stent-retriever therapy had significantly better functional independence (a modified Rankin Scale (mRS) score of 0-2) at 90 days than did patients randomized to rtPA alone.

Stent-retriever therapy also doubled the likelihood of a one-unit improvement in mRS score at 90 days, according to the January 25 JAMA Neurology online report.

In pooled analyses, there were no significant differences between treatment groups in all-cause mortality, intracranial hemorrhage, or parenchymal hematoma rates at 90 days.

The number needed to treat to achieve an mRS score of 0 to 2 at 90 days was six.

"Given the totality of the evidence regarding the benefits and risks of stent retrievers, our results suggest that the use of these devices in patients with acute ischemic stroke is warranted," the researchers conclude.

Dr. Raphael A. Carandang, from the University of Massachusetts Medical School, Worcester, who wrote an editorial related to this report, told Reuters Health by email, "The data from these five RCTs (as the meta-analysis confirms) provides level 1 class A evidence that in the properly selected patients, stent retriever treatment is superior to the current standard of care with intravenous rtPA and would endorse that it should be considered in all acute ischemic stroke patients that are eligible for it. As with any therapy, proper patient selection is needed, but I do think it changes the landscape of acute stroke treatment going forward. I think that systems of care should be organized in stroke centers around this new therapy."

"The current technology for acute stroke care has reached the point where effective interventional therapies are clearly and unequivocally beneficial in the properly selected patients, but the key takeaway is still that the patients need to be selected properly, and the biggest factor continues to be time to recanalization, which means that all practitioners and systems of care need to focus on getting patients to treatment sooner than ever before," Dr. Carandang concluded.

Dr. Woong Yoon, from Chonnam National University Hospital, Gwangju, Korea, recently found no improvement in outcomes with stent-retriever therapy for patients with acute anterior circulation stroke (http://bit.ly/1OT7M5I). He told Reuters Health by email, "Not all patients with acute ischemic stroke can benefit from this new treatment. Patients with acute stroke due to occlusions of intracranial large vessels such as internal carotid artery, middle cerebral artery, or basilar artery and who presented within six-eight hours of stroke onset can benefit from thrombectomy with stent retrievers."

"We should realize that we are facing the moment of change in the paradigm for acute stroke treatment," Dr. Yoon concluded."Further refinement in the patient selection for stent retrieverthrombectomy is needed in the near future."

Dr. Mayank Goyal, from the University of Calgary, Alberta, Canada, coauthored two of the studies included in the current review. He told Reuters Health by email," There are several additional data coming out on this issue in the near future, which will in fact be more powerful than what is mentioned in this study."

Dr. Goyal said, "However, the key issues going into the future are: how should those patients who were not included in the current trials be treated; how should we as a collective evaluate new devices/technologies; and how do societies/countries who cannot afford stent retrievers implement endovascular stroke treatment."

Dr. Eisenberg was unavailable for comment.

The authors reported no funding. Three coauthors reported disclosures.

NEW YORK (Reuters Health) - Stent-retriever therapy for the treatment of acute ischemic stroke improves the rate of functional independence at 90 days, according to a systematic

review and meta-analysis.

Stent retrievers are deployed in an occluded vessel, temporarily expanded into the body of a thrombus, and then retracted along with the thrombus.

Dr. Mark J. Eisenberg, from Jewish General Hospital/McGill University, Montreal, Quebec, Canada, and colleagues compared stent retrievers with intravenous recombinant tissue plasminogen activator (rtPA) versus rtPA alone for the treatment of acute ischemic stroke in their systematic review and meta-analysis of five randomized controlled trials (RCTs) with a total of 1,287 patients.

In all five trials, patients randomized to stent-retriever therapy had significantly better functional independence (a modified Rankin Scale (mRS) score of 0-2) at 90 days than did patients randomized to rtPA alone.

Stent-retriever therapy also doubled the likelihood of a one-unit improvement in mRS score at 90 days, according to the January 25 JAMA Neurology online report.

In pooled analyses, there were no significant differences between treatment groups in all-cause mortality, intracranial hemorrhage, or parenchymal hematoma rates at 90 days.

The number needed to treat to achieve an mRS score of 0 to 2 at 90 days was six.

"Given the totality of the evidence regarding the benefits and risks of stent retrievers, our results suggest that the use of these devices in patients with acute ischemic stroke is warranted," the researchers conclude.

Dr. Raphael A. Carandang, from the University of Massachusetts Medical School, Worcester, who wrote an editorial related to this report, told Reuters Health by email, "The data from these five RCTs (as the meta-analysis confirms) provides level 1 class A evidence that in the properly selected patients, stent retriever treatment is superior to the current standard of care with intravenous rtPA and would endorse that it should be considered in all acute ischemic stroke patients that are eligible for it. As with any therapy, proper patient selection is needed, but I do think it changes the landscape of acute stroke treatment going forward. I think that systems of care should be organized in stroke centers around this new therapy."

"The current technology for acute stroke care has reached the point where effective interventional therapies are clearly and unequivocally beneficial in the properly selected patients, but the key takeaway is still that the patients need to be selected properly, and the biggest factor continues to be time to recanalization, which means that all practitioners and systems of care need to focus on getting patients to treatment sooner than ever before," Dr. Carandang concluded.

Dr. Woong Yoon, from Chonnam National University Hospital, Gwangju, Korea, recently found no improvement in outcomes with stent-retriever therapy for patients with acute anterior circulation stroke (http://bit.ly/1OT7M5I). He told Reuters Health by email, "Not all patients with acute ischemic stroke can benefit from this new treatment. Patients with acute stroke due to occlusions of intracranial large vessels such as internal carotid artery, middle cerebral artery, or basilar artery and who presented within six-eight hours of stroke onset can benefit from thrombectomy with stent retrievers."

"We should realize that we are facing the moment of change in the paradigm for acute stroke treatment," Dr. Yoon concluded."Further refinement in the patient selection for stent retrieverthrombectomy is needed in the near future."

Dr. Mayank Goyal, from the University of Calgary, Alberta, Canada, coauthored two of the studies included in the current review. He told Reuters Health by email," There are several additional data coming out on this issue in the near future, which will in fact be more powerful than what is mentioned in this study."

Dr. Goyal said, "However, the key issues going into the future are: how should those patients who were not included in the current trials be treated; how should we as a collective evaluate new devices/technologies; and how do societies/countries who cannot afford stent retrievers implement endovascular stroke treatment."

Dr. Eisenberg was unavailable for comment.

The authors reported no funding. Three coauthors reported disclosures.

As Karen Smith, MD, SFHM, chief of hospital medicine at Children’s National Health System in Washington, D.C., sees it, communication problems often arise at the first possible opportunity, when she’s trying to find out whom to call when she needs to inform a primary care physician or specialist about a hospitalized patient. Sometimes, that information isn’t readily available.

“Which specialist is on and available to talk?” she says.

Then there’s timing.

“By the time we can set up a time to actually talk to people, it’s after normal business hours,” Dr. Smith says. “People aren’t answering their office phones after five. …Your other choice is going through the answering service, but then you get a variety of people and not the person who knows this patient.”

Dr. Smith spearheaded an effort to reach out in a more reliable fashion to community physicians, with a goal of speaking to—or, more commonly, leaving messages with—at least 90% of hospitalized patients’ physicians. They reached the goal, but it was an eye-opening effort.

“The feedback I got from the hospitalists was it’s ‘just so difficult,’” Dr. Smith says. “I’m sitting on the phone waiting to get ahold of someone. Even trying to use administrative people and have them call and contact us, which is kind of complicated to do.”

Yul Ejnes, MD, MACP, a past chair of the board of regents of the American College of Physicians and an internist at Coastal Medical in R.I., says that if he were grading hospitalist communication with primary care providers on a poor-fair-good-excellent scale, he would give it a “fair.”

“It runs the spectrum from getting nothing—which is rare, I have to say—to getting at least a notification that your patient is in the hospital: ‘Here’s a contact number,’ sometimes with diagnosis,” he says. “And, much less commonly, getting a phone call. That usually occurs when there are questions.”

Dr. Ejnes says consistent communication is not as “robust as I would like it to be.”

“Some institutions do much better than others, in terms of the hospitalist always letting us know patients have come in,” he says. “With others, it doesn’t seem to be part of the institutional culture.”

There has to be a better way.

And, in fact, Dr. Smith and many other hospitalists are developing ways to better use technology to communicate more effectively with primary care, specialists, nurses, and patients. The goal is to make communication more routine, more effective, and more convenient for both parties, all the while—hopefully—improving patient care and strengthening working relationships.

Most of the approaches are not ultra-high tech. Too high tech might, in itself, be a potential barrier to communication for those who might be uncomfortable with new technology. Instead, the initiatives are mostly common sense tweaks to—or new, logical uses of—existing technology.

EHR-Embedded Communication

At Children’s National, Dr. Smith and colleagues use a standardized letter as part of a patient’s electronic health record (EHR). In addition to facts about the patient’s condition, the EHR includes information that makes it easier for physicians to communicate.

“What’s lovely with that is that [the letter] tells the provider the team that they’re on,” she said, adding that teams are divided by letter and color. “It has information on how you can reach the doctor. All of our doctors carry a phone around with them, and so it’s got that number.”

The EHR also includes a note suggesting that physicians avoid calling during rounds and gives them information on how to access the portal, so they can follow along with the patient’s care, should they choose to do so.

The amount of actual contact from primary care physicians? Scarce. Maybe one of 20 pediatricians will actually place a call to the hospitalist, but the response she has received has been positive, Dr. Smith says.

The EHR note also includes a sentence further characterizing the patient’s care, such as: Bobby C. was admitted with bronchiolitis. He’s doing fine; I anticipate he will go home tomorrow.

“Pediatricians have loved that,” she says. “They say, ‘I know exactly what my patient’s there for. I had the ability to call if I want.’”

Smarter Pages

At Vanderbilt University Medical Center in Nashville, Tenn., hospitalists noticed a frequent occurrence with pages: Many times, the hospitalist would only receive a phone number.

“With that, you don’t know which patient it’s about, who called you, how urgent it is, or what they need,” says researcher Sunil Kripalani, MD, MSc, SFHM, associate professor and chief of the section of hospital medicine at Vanderbilt.

It’s a tough spot for a busy hospitalist, who might be on the phone or at a bedside with another patient when three, four, or even five pages come through. The page might just be an FYI requiring no callback. It might be urgent. It might be the same page sent multiple times from different numbers (e.g. nursing moving to various phones). Many times, Dr. Kripalani and his hospitalists have had no way to know.

Now, Vanderbilt has established an online template for text pages, with the following basic information:

• Patient;
• Room number;
• Urgency level;
• Name of the sender;
• Callback number;
• Message; and
• Whether or not a callback is needed.

“That structure is very helpful for allowing physicians to triage which pages to call back and how quickly,” Dr. Kripalani says.

He acknowledges it isn’t “fancy bells and whistles.”

“Sometimes it’s doing the basic things well that makes the difference,” he adds.

The “structured pages” have allowed the nature of pages to be analyzed. Dr. Kripalani and colleagues have found that approximately 5% of pages were about a patient’s dietary status. If the patient was ordered not to receive anything by mouth, pages asked, when did that order expire and what diet should the patient resume?

Now, a prompt for that information is included in the hospital’s order entry system, which has cut the number of pages sent.

Vanderbilt is now looking at other, similar ways to streamline communication.

Patients and iPads

At the University of Colorado Hospital in Denver, researchers had an idea to facilitate communication and patient education: Patients are always inquiring about their discharge status and other facets of their hospitalization; what if they got their own tablet to follow along with everything in real time?1

The only real requirements for the study were that patients had to have Internet access at home and an understanding of how to work a web browser, says Jonathan Pell, MD, SFHM, assistant professor of internal medicine at the University of Colorado in Aurora and a hospitalist at University of Colorado Hospital. Patients were shown how to access their schedule for the day, their medication list and dosing schedule, and test results. Much of the information was delivered in real time, so patients who were told that if a lab result came back at a certain level they could be discharged could perhaps start preparing for that possibility earlier than they might have otherwise.

Researchers found that their patients worried less and reported less confusion. They also found that providing the tablets didn’t cause any increase in workload for doctors or nurses.

Providers and nurses expected that patients would notice medication errors, but that endpoint was not significant. Surprisingly, patients’ understanding of discharge times did not live up to expectations. But the results overall were encouraging enough that the effort will continue.

“We have these mixed results,” Dr. Pell says. “I think it’s good to get something out there in the literature and see what else people may be interested in doing. Our next step is to potentially open up notes to patients and let them see their doctor’s and nurse’s notes during their hospitalization.”

He says that, in some cases, communication with patients is the most crucial channel for hospitalists.

“For the very engaged patient [who has] a busy primary care doctor who’s hard to get in touch with,” he explains, “using the patient, informing them well, and getting them all the information they need is actually the best way to make sure that transition of care is smooth.”

Discharge, Facebook-Style

New England Inpatient Specialists (NEIS), a hospitalist group in North Andover, Mass., has an interesting approach to discharge. Instead of a nurse picking up the phone to make a follow-up appointment for a patient leaving the hospital, a secretary posts a message on “Chatter,” a secure tool similar to Facebook. The technology was developed by Salesforce.com, which offers platforms mainly designed to assist businesses with communication.

The idea behind Chatter is that the primary care office personnel can respond to a post at a time that’s convenient to them.

“All of this is so time-consuming. Why would you want somebody like an RN spending 15 to 20 minutes on the phone setting up an appointment when she could be on the floor?” says Sawad Thotathil, MD, vice president of performance and physician recruitment at NEIS. “Our program secretary will just post a discharge, and then somebody at the practice will look at it when they can and find out what associated information is needed and answer at their own convenience.”

Dr. Thotathil’s group also has been using the Imprivata Cortext secure text messaging system for more than a year, with what he deems “overall positive” results. About 60% of the practices with which NEIS staff need to communicate have signed on to the system.

“That kind of helps in management,” he says. “Sometimes, a patient is in the hospital and you can text the cardiologist, asking if the patient can be taken on for a procedure. That kind of communication, which would have taken longer or would not have happened, is happening now.

“Have we been able to directly link it to better outcomes?” he adds. “No, we haven’t looked at it that way. But what we have seen is that there’s always going to be a variation in how many people in a network actually will use it. ... There are going to be those high users, and there are going to be those providers who are going to be minimally using it.”

Videoconferencing

Pediatric hospitalists at the main hospital at Children’s National have been helping to provide care to children who are seen at five community sites. Dr. Smith says the communication at these sites, mostly from the ED, in which the pediatric hospitalists are helping make medical decisions, has been dramatically enhanced.

“The visual aspect of it changes the whole conversation,” she says. “You could tell them the exact same thing verbally and they are like, ‘OK, that’s fine,’ and there doesn’t seem to be a true understanding of what I’m trying to impart to you. Once people look at the child, all of a sudden there is a true shared mental model of, ‘OK, I understand what you’re doing. What’s going on?’”

Hospitalists also have been spearheading videoconferencing at diabetes clinics, to provide better care at community sites.

“We know what the need is. We know the gap in care,” Dr. Smith says. “We’ve been able to advocate and get those specialists brought out to the community via telemedicine, if it’s too difficult to get out on a regular basis.”

There are no hard data on the effects of the programs, but Dr. Smith says the improvement is noticeable.

“Anecdotally, we’ve seen a decrease in kids coming in with DKA (diabetic ketoacidosis) to the emergency room, so we’ve been able to change some of the trajectory. Many of those kids just didn’t have access to care. [For some], it would be a day’s trip for them to get to one of the academic centers to get follow up. They just wouldn’t go.”

EHR-Facilitated Calls

At Cincinnati Children’s, phone contact with community pediatricians at discharge is established with remarkable consistency: 98% to 99% of the time. The reason? A communication system, “Priority Link,” is connected to the EHR.

When the hospitalist signs a discharge order, the patient’s name is put in a queue. An operator sends out a page to inform the resident that the call is about to be made to the outpatient physician, making sure they’re ready for the call to be made.

“The key innovation was that we were trying to make sure that the inpatient side of it was really ready for the call, so we weren’t placing calls out to doctors and then we weren’t ready,” says Jeffrey Simmons, MD, MSc, associate director of clinical operations and quality in Cincinnati Children’s hospital medicine division.

He says there has been some pushback from pediatricians who feel the calls don’t provide any more value than the discharge summary itself. But the opportunity for questions and for a dialogue makes the calls worthwhile, Dr. Simmons notes. The system could be improved by tailoring communications to the community physicians’ preference—via fax or email, perhaps—and by having the call placed by physicians who are more knowledgeable about the details of the case.

Priority Link also is used to help community physicians with direct admissions for patients who don’t need to go to the ED. The operator coordinates a three-way call among the community physician, the hospitalist, and a nurse familiar with the bed situation.

“That three-way call is really great because we’re big and busy enough that sometimes we need that nurse manager on the phone, too, to No. 1, let us know if there really is a bed and, No. 2, coordinate with the nursing unit,” he says. TH

Tom Collins is a freelance writer in South Florida.

Reference

Pell JM, Mancuso M, Limon S, Oman K, Lin CT. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi: 10.1001/jamainternmed.2015.121.

Sometimes, Communication Outside the Hospital Is the Problem

Yul Ejnes, MD, MACP, an internist at Coastal Medicine in R.I., and a past chair of the American College of Physician’s Board of Regents, points to the ACP’s “High Value Care” toolkit as a model for how primary care-hospitalist communication should take place.

The toolkit includes a suggested “agreement” between PCPs and the hospital care team, which calls for PCPs to provide pertinent information (i.e., reconciled medications lists, medical history, and advanced directives) to hospital teams upon notification of an admission. It also calls for establishing standard communication methods and discharge notifications and encourages hospitalists to keep PCPs updated on new developments, provide appropriate information to patients at discharge, and send a “concise discharge summary” to the PCP within 48 to 72 hours of discharge.

It’s a two-way street, Dr. Ejnes says. He also acknowledges that sometimes the problems are on the community physicians’ side. Phone calls can be highly valuable in this dynamic, but it is often difficult for internists to make or take those calls.

“Sitting where I am, in my office, I am certainly interested in what’s going on with my patients,” he says. “On the other hand, the inertia I have to overcome in order to get that information, when I’m in the middle of seeing a whole bunch of patients during my day, involves getting on the phone, punching some numbers, waiting for a call back, as opposed to having the information available on my screen automatically through some information technology solution.”

He has provided his staff with a list of contacts, including hospitalists, for whom he is to be interrupted in order to take calls.

Jeffrey Simmons, MD, MSc, of Cincinnati Children’s, says that in their effort to boost the reliability of placing calls to PCPs, his hospitalists found that confusion within primary care offices is a stumbling block.

“About half the time when we get complaints about this process, when we investigate, we learn that the major problem has been within the practice,” he says. “We may have made a call to Partner X and had a good conversation … [but] between then and when the patient sees Dr. Y, there’s been very little communication between Partner X and Partner Y.”

Setting up the right system is the key—on both ends, Dr. Ejnes says.

“It’s all about workflow,” he says. “If you can integrate these communications into the regular workflow of the physician, either community-based or hospitalist, it’s more likely to happen. Having the will to do it is the first step. But I think it’s got to be facilitated as much as possible.”

— Thomas R. Collins

As Karen Smith, MD, SFHM, chief of hospital medicine at Children’s National Health System in Washington, D.C., sees it, communication problems often arise at the first possible opportunity, when she’s trying to find out whom to call when she needs to inform a primary care physician or specialist about a hospitalized patient. Sometimes, that information isn’t readily available.

“Which specialist is on and available to talk?” she says.

Then there’s timing.

“By the time we can set up a time to actually talk to people, it’s after normal business hours,” Dr. Smith says. “People aren’t answering their office phones after five. …Your other choice is going through the answering service, but then you get a variety of people and not the person who knows this patient.”

Dr. Smith spearheaded an effort to reach out in a more reliable fashion to community physicians, with a goal of speaking to—or, more commonly, leaving messages with—at least 90% of hospitalized patients’ physicians. They reached the goal, but it was an eye-opening effort.

“The feedback I got from the hospitalists was it’s ‘just so difficult,’” Dr. Smith says. “I’m sitting on the phone waiting to get ahold of someone. Even trying to use administrative people and have them call and contact us, which is kind of complicated to do.”

Yul Ejnes, MD, MACP, a past chair of the board of regents of the American College of Physicians and an internist at Coastal Medical in R.I., says that if he were grading hospitalist communication with primary care providers on a poor-fair-good-excellent scale, he would give it a “fair.”

“It runs the spectrum from getting nothing—which is rare, I have to say—to getting at least a notification that your patient is in the hospital: ‘Here’s a contact number,’ sometimes with diagnosis,” he says. “And, much less commonly, getting a phone call. That usually occurs when there are questions.”

Dr. Ejnes says consistent communication is not as “robust as I would like it to be.”

“Some institutions do much better than others, in terms of the hospitalist always letting us know patients have come in,” he says. “With others, it doesn’t seem to be part of the institutional culture.”

There has to be a better way.

And, in fact, Dr. Smith and many other hospitalists are developing ways to better use technology to communicate more effectively with primary care, specialists, nurses, and patients. The goal is to make communication more routine, more effective, and more convenient for both parties, all the while—hopefully—improving patient care and strengthening working relationships.

Most of the approaches are not ultra-high tech. Too high tech might, in itself, be a potential barrier to communication for those who might be uncomfortable with new technology. Instead, the initiatives are mostly common sense tweaks to—or new, logical uses of—existing technology.

EHR-Embedded Communication

At Children’s National, Dr. Smith and colleagues use a standardized letter as part of a patient’s electronic health record (EHR). In addition to facts about the patient’s condition, the EHR includes information that makes it easier for physicians to communicate.

“What’s lovely with that is that [the letter] tells the provider the team that they’re on,” she said, adding that teams are divided by letter and color. “It has information on how you can reach the doctor. All of our doctors carry a phone around with them, and so it’s got that number.”

The EHR also includes a note suggesting that physicians avoid calling during rounds and gives them information on how to access the portal, so they can follow along with the patient’s care, should they choose to do so.

The amount of actual contact from primary care physicians? Scarce. Maybe one of 20 pediatricians will actually place a call to the hospitalist, but the response she has received has been positive, Dr. Smith says.

The EHR note also includes a sentence further characterizing the patient’s care, such as: Bobby C. was admitted with bronchiolitis. He’s doing fine; I anticipate he will go home tomorrow.

“Pediatricians have loved that,” she says. “They say, ‘I know exactly what my patient’s there for. I had the ability to call if I want.’”

Smarter Pages

At Vanderbilt University Medical Center in Nashville, Tenn., hospitalists noticed a frequent occurrence with pages: Many times, the hospitalist would only receive a phone number.

“With that, you don’t know which patient it’s about, who called you, how urgent it is, or what they need,” says researcher Sunil Kripalani, MD, MSc, SFHM, associate professor and chief of the section of hospital medicine at Vanderbilt.

It’s a tough spot for a busy hospitalist, who might be on the phone or at a bedside with another patient when three, four, or even five pages come through. The page might just be an FYI requiring no callback. It might be urgent. It might be the same page sent multiple times from different numbers (e.g. nursing moving to various phones). Many times, Dr. Kripalani and his hospitalists have had no way to know.

Now, Vanderbilt has established an online template for text pages, with the following basic information:

• Patient;
• Room number;
• Urgency level;
• Name of the sender;
• Callback number;
• Message; and
• Whether or not a callback is needed.

“That structure is very helpful for allowing physicians to triage which pages to call back and how quickly,” Dr. Kripalani says.

He acknowledges it isn’t “fancy bells and whistles.”

“Sometimes it’s doing the basic things well that makes the difference,” he adds.

The “structured pages” have allowed the nature of pages to be analyzed. Dr. Kripalani and colleagues have found that approximately 5% of pages were about a patient’s dietary status. If the patient was ordered not to receive anything by mouth, pages asked, when did that order expire and what diet should the patient resume?

Now, a prompt for that information is included in the hospital’s order entry system, which has cut the number of pages sent.

Vanderbilt is now looking at other, similar ways to streamline communication.

Patients and iPads

At the University of Colorado Hospital in Denver, researchers had an idea to facilitate communication and patient education: Patients are always inquiring about their discharge status and other facets of their hospitalization; what if they got their own tablet to follow along with everything in real time?1

The only real requirements for the study were that patients had to have Internet access at home and an understanding of how to work a web browser, says Jonathan Pell, MD, SFHM, assistant professor of internal medicine at the University of Colorado in Aurora and a hospitalist at University of Colorado Hospital. Patients were shown how to access their schedule for the day, their medication list and dosing schedule, and test results. Much of the information was delivered in real time, so patients who were told that if a lab result came back at a certain level they could be discharged could perhaps start preparing for that possibility earlier than they might have otherwise.

Researchers found that their patients worried less and reported less confusion. They also found that providing the tablets didn’t cause any increase in workload for doctors or nurses.

Providers and nurses expected that patients would notice medication errors, but that endpoint was not significant. Surprisingly, patients’ understanding of discharge times did not live up to expectations. But the results overall were encouraging enough that the effort will continue.

“We have these mixed results,” Dr. Pell says. “I think it’s good to get something out there in the literature and see what else people may be interested in doing. Our next step is to potentially open up notes to patients and let them see their doctor’s and nurse’s notes during their hospitalization.”

He says that, in some cases, communication with patients is the most crucial channel for hospitalists.

“For the very engaged patient [who has] a busy primary care doctor who’s hard to get in touch with,” he explains, “using the patient, informing them well, and getting them all the information they need is actually the best way to make sure that transition of care is smooth.”

Discharge, Facebook-Style

New England Inpatient Specialists (NEIS), a hospitalist group in North Andover, Mass., has an interesting approach to discharge. Instead of a nurse picking up the phone to make a follow-up appointment for a patient leaving the hospital, a secretary posts a message on “Chatter,” a secure tool similar to Facebook. The technology was developed by Salesforce.com, which offers platforms mainly designed to assist businesses with communication.

The idea behind Chatter is that the primary care office personnel can respond to a post at a time that’s convenient to them.

“All of this is so time-consuming. Why would you want somebody like an RN spending 15 to 20 minutes on the phone setting up an appointment when she could be on the floor?” says Sawad Thotathil, MD, vice president of performance and physician recruitment at NEIS. “Our program secretary will just post a discharge, and then somebody at the practice will look at it when they can and find out what associated information is needed and answer at their own convenience.”

Dr. Thotathil’s group also has been using the Imprivata Cortext secure text messaging system for more than a year, with what he deems “overall positive” results. About 60% of the practices with which NEIS staff need to communicate have signed on to the system.

“That kind of helps in management,” he says. “Sometimes, a patient is in the hospital and you can text the cardiologist, asking if the patient can be taken on for a procedure. That kind of communication, which would have taken longer or would not have happened, is happening now.

“Have we been able to directly link it to better outcomes?” he adds. “No, we haven’t looked at it that way. But what we have seen is that there’s always going to be a variation in how many people in a network actually will use it. ... There are going to be those high users, and there are going to be those providers who are going to be minimally using it.”

Videoconferencing

Pediatric hospitalists at the main hospital at Children’s National have been helping to provide care to children who are seen at five community sites. Dr. Smith says the communication at these sites, mostly from the ED, in which the pediatric hospitalists are helping make medical decisions, has been dramatically enhanced.

“The visual aspect of it changes the whole conversation,” she says. “You could tell them the exact same thing verbally and they are like, ‘OK, that’s fine,’ and there doesn’t seem to be a true understanding of what I’m trying to impart to you. Once people look at the child, all of a sudden there is a true shared mental model of, ‘OK, I understand what you’re doing. What’s going on?’”

Hospitalists also have been spearheading videoconferencing at diabetes clinics, to provide better care at community sites.

“We know what the need is. We know the gap in care,” Dr. Smith says. “We’ve been able to advocate and get those specialists brought out to the community via telemedicine, if it’s too difficult to get out on a regular basis.”

There are no hard data on the effects of the programs, but Dr. Smith says the improvement is noticeable.

“Anecdotally, we’ve seen a decrease in kids coming in with DKA (diabetic ketoacidosis) to the emergency room, so we’ve been able to change some of the trajectory. Many of those kids just didn’t have access to care. [For some], it would be a day’s trip for them to get to one of the academic centers to get follow up. They just wouldn’t go.”

EHR-Facilitated Calls

At Cincinnati Children’s, phone contact with community pediatricians at discharge is established with remarkable consistency: 98% to 99% of the time. The reason? A communication system, “Priority Link,” is connected to the EHR.

When the hospitalist signs a discharge order, the patient’s name is put in a queue. An operator sends out a page to inform the resident that the call is about to be made to the outpatient physician, making sure they’re ready for the call to be made.

“The key innovation was that we were trying to make sure that the inpatient side of it was really ready for the call, so we weren’t placing calls out to doctors and then we weren’t ready,” says Jeffrey Simmons, MD, MSc, associate director of clinical operations and quality in Cincinnati Children’s hospital medicine division.

He says there has been some pushback from pediatricians who feel the calls don’t provide any more value than the discharge summary itself. But the opportunity for questions and for a dialogue makes the calls worthwhile, Dr. Simmons notes. The system could be improved by tailoring communications to the community physicians’ preference—via fax or email, perhaps—and by having the call placed by physicians who are more knowledgeable about the details of the case.

Priority Link also is used to help community physicians with direct admissions for patients who don’t need to go to the ED. The operator coordinates a three-way call among the community physician, the hospitalist, and a nurse familiar with the bed situation.

“That three-way call is really great because we’re big and busy enough that sometimes we need that nurse manager on the phone, too, to No. 1, let us know if there really is a bed and, No. 2, coordinate with the nursing unit,” he says. TH

Tom Collins is a freelance writer in South Florida.

Reference

Pell JM, Mancuso M, Limon S, Oman K, Lin CT. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi: 10.1001/jamainternmed.2015.121.

Sometimes, Communication Outside the Hospital Is the Problem

Yul Ejnes, MD, MACP, an internist at Coastal Medicine in R.I., and a past chair of the American College of Physician’s Board of Regents, points to the ACP’s “High Value Care” toolkit as a model for how primary care-hospitalist communication should take place.

The toolkit includes a suggested “agreement” between PCPs and the hospital care team, which calls for PCPs to provide pertinent information (i.e., reconciled medications lists, medical history, and advanced directives) to hospital teams upon notification of an admission. It also calls for establishing standard communication methods and discharge notifications and encourages hospitalists to keep PCPs updated on new developments, provide appropriate information to patients at discharge, and send a “concise discharge summary” to the PCP within 48 to 72 hours of discharge.

It’s a two-way street, Dr. Ejnes says. He also acknowledges that sometimes the problems are on the community physicians’ side. Phone calls can be highly valuable in this dynamic, but it is often difficult for internists to make or take those calls.

“Sitting where I am, in my office, I am certainly interested in what’s going on with my patients,” he says. “On the other hand, the inertia I have to overcome in order to get that information, when I’m in the middle of seeing a whole bunch of patients during my day, involves getting on the phone, punching some numbers, waiting for a call back, as opposed to having the information available on my screen automatically through some information technology solution.”

He has provided his staff with a list of contacts, including hospitalists, for whom he is to be interrupted in order to take calls.

Jeffrey Simmons, MD, MSc, of Cincinnati Children’s, says that in their effort to boost the reliability of placing calls to PCPs, his hospitalists found that confusion within primary care offices is a stumbling block.

“About half the time when we get complaints about this process, when we investigate, we learn that the major problem has been within the practice,” he says. “We may have made a call to Partner X and had a good conversation … [but] between then and when the patient sees Dr. Y, there’s been very little communication between Partner X and Partner Y.”

Setting up the right system is the key—on both ends, Dr. Ejnes says.

“It’s all about workflow,” he says. “If you can integrate these communications into the regular workflow of the physician, either community-based or hospitalist, it’s more likely to happen. Having the will to do it is the first step. But I think it’s got to be facilitated as much as possible.”

— Thomas R. Collins

As Karen Smith, MD, SFHM, chief of hospital medicine at Children’s National Health System in Washington, D.C., sees it, communication problems often arise at the first possible opportunity, when she’s trying to find out whom to call when she needs to inform a primary care physician or specialist about a hospitalized patient. Sometimes, that information isn’t readily available.

“Which specialist is on and available to talk?” she says.

Then there’s timing.

“By the time we can set up a time to actually talk to people, it’s after normal business hours,” Dr. Smith says. “People aren’t answering their office phones after five. …Your other choice is going through the answering service, but then you get a variety of people and not the person who knows this patient.”

Dr. Smith spearheaded an effort to reach out in a more reliable fashion to community physicians, with a goal of speaking to—or, more commonly, leaving messages with—at least 90% of hospitalized patients’ physicians. They reached the goal, but it was an eye-opening effort.

“The feedback I got from the hospitalists was it’s ‘just so difficult,’” Dr. Smith says. “I’m sitting on the phone waiting to get ahold of someone. Even trying to use administrative people and have them call and contact us, which is kind of complicated to do.”

Yul Ejnes, MD, MACP, a past chair of the board of regents of the American College of Physicians and an internist at Coastal Medical in R.I., says that if he were grading hospitalist communication with primary care providers on a poor-fair-good-excellent scale, he would give it a “fair.”

“It runs the spectrum from getting nothing—which is rare, I have to say—to getting at least a notification that your patient is in the hospital: ‘Here’s a contact number,’ sometimes with diagnosis,” he says. “And, much less commonly, getting a phone call. That usually occurs when there are questions.”

Dr. Ejnes says consistent communication is not as “robust as I would like it to be.”

“Some institutions do much better than others, in terms of the hospitalist always letting us know patients have come in,” he says. “With others, it doesn’t seem to be part of the institutional culture.”

There has to be a better way.

And, in fact, Dr. Smith and many other hospitalists are developing ways to better use technology to communicate more effectively with primary care, specialists, nurses, and patients. The goal is to make communication more routine, more effective, and more convenient for both parties, all the while—hopefully—improving patient care and strengthening working relationships.

Most of the approaches are not ultra-high tech. Too high tech might, in itself, be a potential barrier to communication for those who might be uncomfortable with new technology. Instead, the initiatives are mostly common sense tweaks to—or new, logical uses of—existing technology.

EHR-Embedded Communication

At Children’s National, Dr. Smith and colleagues use a standardized letter as part of a patient’s electronic health record (EHR). In addition to facts about the patient’s condition, the EHR includes information that makes it easier for physicians to communicate.

“What’s lovely with that is that [the letter] tells the provider the team that they’re on,” she said, adding that teams are divided by letter and color. “It has information on how you can reach the doctor. All of our doctors carry a phone around with them, and so it’s got that number.”

The EHR also includes a note suggesting that physicians avoid calling during rounds and gives them information on how to access the portal, so they can follow along with the patient’s care, should they choose to do so.

The amount of actual contact from primary care physicians? Scarce. Maybe one of 20 pediatricians will actually place a call to the hospitalist, but the response she has received has been positive, Dr. Smith says.

The EHR note also includes a sentence further characterizing the patient’s care, such as: Bobby C. was admitted with bronchiolitis. He’s doing fine; I anticipate he will go home tomorrow.

“Pediatricians have loved that,” she says. “They say, ‘I know exactly what my patient’s there for. I had the ability to call if I want.’”

Smarter Pages

At Vanderbilt University Medical Center in Nashville, Tenn., hospitalists noticed a frequent occurrence with pages: Many times, the hospitalist would only receive a phone number.

“With that, you don’t know which patient it’s about, who called you, how urgent it is, or what they need,” says researcher Sunil Kripalani, MD, MSc, SFHM, associate professor and chief of the section of hospital medicine at Vanderbilt.

It’s a tough spot for a busy hospitalist, who might be on the phone or at a bedside with another patient when three, four, or even five pages come through. The page might just be an FYI requiring no callback. It might be urgent. It might be the same page sent multiple times from different numbers (e.g. nursing moving to various phones). Many times, Dr. Kripalani and his hospitalists have had no way to know.

Now, Vanderbilt has established an online template for text pages, with the following basic information:

• Patient;
• Room number;
• Urgency level;
• Name of the sender;
• Callback number;
• Message; and
• Whether or not a callback is needed.

“That structure is very helpful for allowing physicians to triage which pages to call back and how quickly,” Dr. Kripalani says.

He acknowledges it isn’t “fancy bells and whistles.”

“Sometimes it’s doing the basic things well that makes the difference,” he adds.

The “structured pages” have allowed the nature of pages to be analyzed. Dr. Kripalani and colleagues have found that approximately 5% of pages were about a patient’s dietary status. If the patient was ordered not to receive anything by mouth, pages asked, when did that order expire and what diet should the patient resume?

Now, a prompt for that information is included in the hospital’s order entry system, which has cut the number of pages sent.

Vanderbilt is now looking at other, similar ways to streamline communication.

Patients and iPads

At the University of Colorado Hospital in Denver, researchers had an idea to facilitate communication and patient education: Patients are always inquiring about their discharge status and other facets of their hospitalization; what if they got their own tablet to follow along with everything in real time?1

The only real requirements for the study were that patients had to have Internet access at home and an understanding of how to work a web browser, says Jonathan Pell, MD, SFHM, assistant professor of internal medicine at the University of Colorado in Aurora and a hospitalist at University of Colorado Hospital. Patients were shown how to access their schedule for the day, their medication list and dosing schedule, and test results. Much of the information was delivered in real time, so patients who were told that if a lab result came back at a certain level they could be discharged could perhaps start preparing for that possibility earlier than they might have otherwise.

Researchers found that their patients worried less and reported less confusion. They also found that providing the tablets didn’t cause any increase in workload for doctors or nurses.

Providers and nurses expected that patients would notice medication errors, but that endpoint was not significant. Surprisingly, patients’ understanding of discharge times did not live up to expectations. But the results overall were encouraging enough that the effort will continue.

“We have these mixed results,” Dr. Pell says. “I think it’s good to get something out there in the literature and see what else people may be interested in doing. Our next step is to potentially open up notes to patients and let them see their doctor’s and nurse’s notes during their hospitalization.”

He says that, in some cases, communication with patients is the most crucial channel for hospitalists.

“For the very engaged patient [who has] a busy primary care doctor who’s hard to get in touch with,” he explains, “using the patient, informing them well, and getting them all the information they need is actually the best way to make sure that transition of care is smooth.”

Discharge, Facebook-Style

New England Inpatient Specialists (NEIS), a hospitalist group in North Andover, Mass., has an interesting approach to discharge. Instead of a nurse picking up the phone to make a follow-up appointment for a patient leaving the hospital, a secretary posts a message on “Chatter,” a secure tool similar to Facebook. The technology was developed by Salesforce.com, which offers platforms mainly designed to assist businesses with communication.

The idea behind Chatter is that the primary care office personnel can respond to a post at a time that’s convenient to them.

“All of this is so time-consuming. Why would you want somebody like an RN spending 15 to 20 minutes on the phone setting up an appointment when she could be on the floor?” says Sawad Thotathil, MD, vice president of performance and physician recruitment at NEIS. “Our program secretary will just post a discharge, and then somebody at the practice will look at it when they can and find out what associated information is needed and answer at their own convenience.”

Dr. Thotathil’s group also has been using the Imprivata Cortext secure text messaging system for more than a year, with what he deems “overall positive” results. About 60% of the practices with which NEIS staff need to communicate have signed on to the system.

“That kind of helps in management,” he says. “Sometimes, a patient is in the hospital and you can text the cardiologist, asking if the patient can be taken on for a procedure. That kind of communication, which would have taken longer or would not have happened, is happening now.

“Have we been able to directly link it to better outcomes?” he adds. “No, we haven’t looked at it that way. But what we have seen is that there’s always going to be a variation in how many people in a network actually will use it. ... There are going to be those high users, and there are going to be those providers who are going to be minimally using it.”

Videoconferencing

Pediatric hospitalists at the main hospital at Children’s National have been helping to provide care to children who are seen at five community sites. Dr. Smith says the communication at these sites, mostly from the ED, in which the pediatric hospitalists are helping make medical decisions, has been dramatically enhanced.

“The visual aspect of it changes the whole conversation,” she says. “You could tell them the exact same thing verbally and they are like, ‘OK, that’s fine,’ and there doesn’t seem to be a true understanding of what I’m trying to impart to you. Once people look at the child, all of a sudden there is a true shared mental model of, ‘OK, I understand what you’re doing. What’s going on?’”

Hospitalists also have been spearheading videoconferencing at diabetes clinics, to provide better care at community sites.

“We know what the need is. We know the gap in care,” Dr. Smith says. “We’ve been able to advocate and get those specialists brought out to the community via telemedicine, if it’s too difficult to get out on a regular basis.”

There are no hard data on the effects of the programs, but Dr. Smith says the improvement is noticeable.

“Anecdotally, we’ve seen a decrease in kids coming in with DKA (diabetic ketoacidosis) to the emergency room, so we’ve been able to change some of the trajectory. Many of those kids just didn’t have access to care. [For some], it would be a day’s trip for them to get to one of the academic centers to get follow up. They just wouldn’t go.”

EHR-Facilitated Calls

At Cincinnati Children’s, phone contact with community pediatricians at discharge is established with remarkable consistency: 98% to 99% of the time. The reason? A communication system, “Priority Link,” is connected to the EHR.

When the hospitalist signs a discharge order, the patient’s name is put in a queue. An operator sends out a page to inform the resident that the call is about to be made to the outpatient physician, making sure they’re ready for the call to be made.

“The key innovation was that we were trying to make sure that the inpatient side of it was really ready for the call, so we weren’t placing calls out to doctors and then we weren’t ready,” says Jeffrey Simmons, MD, MSc, associate director of clinical operations and quality in Cincinnati Children’s hospital medicine division.

He says there has been some pushback from pediatricians who feel the calls don’t provide any more value than the discharge summary itself. But the opportunity for questions and for a dialogue makes the calls worthwhile, Dr. Simmons notes. The system could be improved by tailoring communications to the community physicians’ preference—via fax or email, perhaps—and by having the call placed by physicians who are more knowledgeable about the details of the case.

Priority Link also is used to help community physicians with direct admissions for patients who don’t need to go to the ED. The operator coordinates a three-way call among the community physician, the hospitalist, and a nurse familiar with the bed situation.

“That three-way call is really great because we’re big and busy enough that sometimes we need that nurse manager on the phone, too, to No. 1, let us know if there really is a bed and, No. 2, coordinate with the nursing unit,” he says. TH

Tom Collins is a freelance writer in South Florida.

Reference

Pell JM, Mancuso M, Limon S, Oman K, Lin CT. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi: 10.1001/jamainternmed.2015.121.

Sometimes, Communication Outside the Hospital Is the Problem

Yul Ejnes, MD, MACP, an internist at Coastal Medicine in R.I., and a past chair of the American College of Physician’s Board of Regents, points to the ACP’s “High Value Care” toolkit as a model for how primary care-hospitalist communication should take place.

The toolkit includes a suggested “agreement” between PCPs and the hospital care team, which calls for PCPs to provide pertinent information (i.e., reconciled medications lists, medical history, and advanced directives) to hospital teams upon notification of an admission. It also calls for establishing standard communication methods and discharge notifications and encourages hospitalists to keep PCPs updated on new developments, provide appropriate information to patients at discharge, and send a “concise discharge summary” to the PCP within 48 to 72 hours of discharge.

It’s a two-way street, Dr. Ejnes says. He also acknowledges that sometimes the problems are on the community physicians’ side. Phone calls can be highly valuable in this dynamic, but it is often difficult for internists to make or take those calls.

“Sitting where I am, in my office, I am certainly interested in what’s going on with my patients,” he says. “On the other hand, the inertia I have to overcome in order to get that information, when I’m in the middle of seeing a whole bunch of patients during my day, involves getting on the phone, punching some numbers, waiting for a call back, as opposed to having the information available on my screen automatically through some information technology solution.”

He has provided his staff with a list of contacts, including hospitalists, for whom he is to be interrupted in order to take calls.

Jeffrey Simmons, MD, MSc, of Cincinnati Children’s, says that in their effort to boost the reliability of placing calls to PCPs, his hospitalists found that confusion within primary care offices is a stumbling block.

“About half the time when we get complaints about this process, when we investigate, we learn that the major problem has been within the practice,” he says. “We may have made a call to Partner X and had a good conversation … [but] between then and when the patient sees Dr. Y, there’s been very little communication between Partner X and Partner Y.”

Setting up the right system is the key—on both ends, Dr. Ejnes says.

“It’s all about workflow,” he says. “If you can integrate these communications into the regular workflow of the physician, either community-based or hospitalist, it’s more likely to happen. Having the will to do it is the first step. But I think it’s got to be facilitated as much as possible.”

— Thomas R. Collins

NEW YORK (Reuters Health) - An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction

(NSTEMI) or unstable angina, according to the After Eighty clinical trial.

"Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group dueto comorbidities," Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. "These factors may reduce the benefits and increase the risk of complications from invasive treatment."

Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.

Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a

conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.

The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.

In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet, online January 12.

During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41% vs. 61%, p=0.0001).

Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48% less likely to experience MI and 81% less likely to require urgent revascularization. They were also 40% less likely to have a stroke and 11% less likely to die, but these latter differences were not significant.

Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10%) than in the conservative strategy group (7%).

"The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina," Dr.Bendz and Dr. Tegn said. "However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference."

Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, "The After-80 study now provides the direct

evidence we needed to support this 'early invasive' approach. Given how difficult it is to recruit very elderly patients to clinical studies - and this was reflected by the fact that almost 80% of screened patients were not actually enrolled into After-80 - the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many 'very old' patients admitted to our cardiology and general medicine wards with ACS."

"In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70-80% of patients who were screened for this study were ultimately not

enrolled," he reiterated. "There would have been many reasons why so many patients were excluded, but it does emphasize that the study's findings won't apply to everyone over the age of 80 who presents with ACS."

"As always, the decision making process needs to be individually tailored," Dr. Psaltis said. "The patient's pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account."

"Moreover, we should not just consider its potential benefits in terms of whether it will reduce mortality or risk of recurrent infarcts," Dr. Psaltis added. "In certain individuals >90, an invasive approach may be taken to improve quality of life and symptom burden, help to keep patients in independent living at home, or reduce readmission rates to hospital or even

the use of anti-anginal medications that can be associated with debilitating side-effects."

Dr. Paul Erne from the University of Zurich in Switzerland, who heads the steering committee of the Acute Myocardial Infarction in Sweden (AMIS), stressed, "Conservative treatment

does not result in a poor outcome in every patient and we need to know much more about differential approach."

"However, active treatment remains a great option for part of the elderly patients," regardless of age, he told Reuters Health by email. "Please note the increasing number of patients

treated at age above 100 years which proves to be a good option if the patients want to live actively."

Dr. Rahul Potluri, founder of the ACALM (Algorithm for Comorbidities, Associations, Length of Stay and Mortality) Study Unit, Birmingham, U.K., recently reviewed the role of

angioplasty in octogenarian ACS patients.

He told Reuters Health by email, "This study is the most conclusive evidence to date, showing the benefits of an invasive approach in patients above the age of 80 with the most common types of ACS (namely NSTEMI and unstable angina). The findings are most surprising given that both the groups were very similar in terms of patient characteristics and medications taken, thus delineating the true benefit of the invasive strategy in the most controlled fashion and in a short follow-up period."

The study did not have commercial funding and the researchers declared no competing interests.

NEW YORK (Reuters Health) - An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction

(NSTEMI) or unstable angina, according to the After Eighty clinical trial.

"Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group dueto comorbidities," Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. "These factors may reduce the benefits and increase the risk of complications from invasive treatment."

Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.

Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a

conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.

The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.

In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet, online January 12.

During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41% vs. 61%, p=0.0001).

Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48% less likely to experience MI and 81% less likely to require urgent revascularization. They were also 40% less likely to have a stroke and 11% less likely to die, but these latter differences were not significant.

Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10%) than in the conservative strategy group (7%).

"The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina," Dr.Bendz and Dr. Tegn said. "However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference."

Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, "The After-80 study now provides the direct

evidence we needed to support this 'early invasive' approach. Given how difficult it is to recruit very elderly patients to clinical studies - and this was reflected by the fact that almost 80% of screened patients were not actually enrolled into After-80 - the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many 'very old' patients admitted to our cardiology and general medicine wards with ACS."

"In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70-80% of patients who were screened for this study were ultimately not

enrolled," he reiterated. "There would have been many reasons why so many patients were excluded, but it does emphasize that the study's findings won't apply to everyone over the age of 80 who presents with ACS."

"As always, the decision making process needs to be individually tailored," Dr. Psaltis said. "The patient's pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account."

"Moreover, we should not just consider its potential benefits in terms of whether it will reduce mortality or risk of recurrent infarcts," Dr. Psaltis added. "In certain individuals >90, an invasive approach may be taken to improve quality of life and symptom burden, help to keep patients in independent living at home, or reduce readmission rates to hospital or even

the use of anti-anginal medications that can be associated with debilitating side-effects."

Dr. Paul Erne from the University of Zurich in Switzerland, who heads the steering committee of the Acute Myocardial Infarction in Sweden (AMIS), stressed, "Conservative treatment

does not result in a poor outcome in every patient and we need to know much more about differential approach."

"However, active treatment remains a great option for part of the elderly patients," regardless of age, he told Reuters Health by email. "Please note the increasing number of patients

treated at age above 100 years which proves to be a good option if the patients want to live actively."

Dr. Rahul Potluri, founder of the ACALM (Algorithm for Comorbidities, Associations, Length of Stay and Mortality) Study Unit, Birmingham, U.K., recently reviewed the role of

angioplasty in octogenarian ACS patients.

He told Reuters Health by email, "This study is the most conclusive evidence to date, showing the benefits of an invasive approach in patients above the age of 80 with the most common types of ACS (namely NSTEMI and unstable angina). The findings are most surprising given that both the groups were very similar in terms of patient characteristics and medications taken, thus delineating the true benefit of the invasive strategy in the most controlled fashion and in a short follow-up period."

The study did not have commercial funding and the researchers declared no competing interests.

NEW YORK (Reuters Health) - An early invasive strategy provides better outcomes than a conservative strategy in octogenarians with non-ST-elevation myocardial infarction

(NSTEMI) or unstable angina, according to the After Eighty clinical trial.

"Management of the very elderly with myocardial infarction (NSTE-ACS) is challenging, because they often present later, have atypical symptoms, and are a more heterogeneous group dueto comorbidities," Dr. Bjorn Bendz and Dr. Nicolai Tegn from Oslo University Hospital in Norway told Reuters Health in a joint email. "These factors may reduce the benefits and increase the risk of complications from invasive treatment."

Large randomized trials have demonstrated the superiority of an invasive strategy in this setting, but patients aged 80 years and over are underrepresented in these studies.

Dr. Bendz and Dr. Tegn and colleagues from 16 hospitals in Norway investigated whether patients aged 80 years or older would benefit from an early invasive strategy versus a

conservative strategy in terms of a composite primary endpoint of MI, need for urgent revascularization, and death.

The invasive strategy (n=229) included early coronary angiography with immediate assessment for ad hoc percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or optimal medical treatment, whereas the conservative strategy (n=228) included optimal medical treatment alone.

In the invasive group, 107 underwent PCI and six had CABG, the researchers report in The Lancet, online January 12.

During follow-up, patients in the invasive group were significantly less likely to experience the primary endpoint (41% vs. 61%, p=0.0001).

Compared with patients in the conservative-strategy group, those in the invasive-strategy group were 48% less likely to experience MI and 81% less likely to require urgent revascularization. They were also 40% less likely to have a stroke and 11% less likely to die, but these latter differences were not significant.

Minor bleeding complications (but not major bleeding complications) were somewhat more common in the invasive strategy group (10%) than in the conservative strategy group (7%).

"The present results support an invasive strategy in patients over 80 years with NSTEMI and unstable angina," Dr.Bendz and Dr. Tegn said. "However, the efficacy was less with increasing age, and for patients older than 90 years we cannot conclude if an invasive strategy is beneficial. Thus, management of acute coronary syndrome (ACS) patients over 90 must be individually tailored, considering life expectancy, comorbid illnesses, bleeding risk, cognitive and functional status, and patient preference."

Dr. Peter Psaltis from the University of Adelaide in South Australia, who co-wrote an accompanying editorial, told Reuters Health by email, "The After-80 study now provides the direct

evidence we needed to support this 'early invasive' approach. Given how difficult it is to recruit very elderly patients to clinical studies - and this was reflected by the fact that almost 80% of screened patients were not actually enrolled into After-80 - the investigators deserve credit for taking this study on. Their study is especially important because in developed countries, we see so many 'very old' patients admitted to our cardiology and general medicine wards with ACS."

"In extrapolating the results of After-80 to real-world clinical practice, we firstly have to remember that 70-80% of patients who were screened for this study were ultimately not

enrolled," he reiterated. "There would have been many reasons why so many patients were excluded, but it does emphasize that the study's findings won't apply to everyone over the age of 80 who presents with ACS."

"As always, the decision making process needs to be individually tailored," Dr. Psaltis said. "The patient's pre-existing comorbid status, quality of life, cognitive function and personal wishes are all important factors that need to be taken into account."

"Moreover, we should not just consider its potential benefits in terms of whether it will reduce mortality or risk of recurrent infarcts," Dr. Psaltis added. "In certain individuals >90, an invasive approach may be taken to improve quality of life and symptom burden, help to keep patients in independent living at home, or reduce readmission rates to hospital or even

the use of anti-anginal medications that can be associated with debilitating side-effects."

Dr. Paul Erne from the University of Zurich in Switzerland, who heads the steering committee of the Acute Myocardial Infarction in Sweden (AMIS), stressed, "Conservative treatment

does not result in a poor outcome in every patient and we need to know much more about differential approach."

"However, active treatment remains a great option for part of the elderly patients," regardless of age, he told Reuters Health by email. "Please note the increasing number of patients

treated at age above 100 years which proves to be a good option if the patients want to live actively."

Dr. Rahul Potluri, founder of the ACALM (Algorithm for Comorbidities, Associations, Length of Stay and Mortality) Study Unit, Birmingham, U.K., recently reviewed the role of

angioplasty in octogenarian ACS patients.

He told Reuters Health by email, "This study is the most conclusive evidence to date, showing the benefits of an invasive approach in patients above the age of 80 with the most common types of ACS (namely NSTEMI and unstable angina). The findings are most surprising given that both the groups were very similar in terms of patient characteristics and medications taken, thus delineating the true benefit of the invasive strategy in the most controlled fashion and in a short follow-up period."

The study did not have commercial funding and the researchers declared no competing interests.

NEW YORK (Reuters Health) - Rates of kidney stones have increased substantially over the past 20 years, particularly among children, adolescents, females, and blacks, according to a population-based study in South Carolina.

Historically, the highest rates of kidney stone disease have been in middle-aged white men, but the new findings underscore emerging changes in this pattern. Prior studies have found that prevalent kidney stone disease has nearly doubled in the United States over the past two decades. The extent to which specific groups of patients have been affected has been less clear, although there have been reports of increasing frequency of kidney stones among youth.

"My colleagues and I wondered if kidney stones were increasing preferentially among adolescents more than in other age groups," lead researcher Dr. Gregory Tasian, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told Reuters Health by email.

To estimate the annual kidney stone incidence in South Carolina in their repeated cross-sectional study, the researchers used U.S. Census data and data from the South Carolina Medical Encounter Data and Financial Reports, which includes information on all surgeries, emergency department visits, and inpatient hospitalizations in the state from 1997 to 2012. Using linear mixed models, they also sought to identify the patient groups in whom the rate of stones has increased the most.

Nearly 153,000 adult and pediatric patients among a state population of about 4.6 million received care for kidney stones from 1997 to 2012, the researchers reported online January 14 in the Clinical Journal of the American Society of Nephrology.

The annual incidence increased 16% during that time, with the largest increases occurring in teens, blacks, and women.  Teens 15 to 19 years comprised the age group with the largest increase in incidence of kidney stones from 1997 (an age-specific rate of nearly 80 per 100,000) to 2012 (about 155 per 100,000).

Overall, teens 15 to 19 experienced a 26% increase per five years (incidence rate ratio, 1.26), after adjusting for sex and race. The increase was substantially greater among teen girls,

with an annual incidence 52% higher than for teen boys.

Increases in cumulative risk of kidney stones during childhood were similar for girls (87%) and boys (90%), although the risks in 2012 were "modest," at 0.9% (for girls) and 0.6% (for boys), the researchers say. They note that the "emergence of nephrolithiasis as a disease that begins in childhood is worrisome because there is limited evidence about how to best treat children" with the condition.

After adjusting for age and race, incidence of kidney stones  increased an estimated 15% per five years (IRR, 1.15) among females of all ages during the study period, but was stable among males (IRR, 0.99). The estimated lifetime risk for women increased from 10.5% in 1997 to 15.2% in 2012, but remained unchanged for men at about 23%. Incidence of kidney stones among blacks rose an estimated 15% per five years (IRR, 1.15) during the study period, compared with an estimated 3% among whites (IRR, 1.03).

"We were not surprised by the high occurrence of kidney  stones among adolescents and females (5% and 3% per year), which is consistent with other studies reported to date," Dr. Tasian

said. "We were, however, surprised by how much kidney stones were increasing in African-Americans, as previous studies have not really studied differences in kidney stone occurrence among different racial groups."

Although the study focused on kidney stone disease in South Carolina, it's likely that similar patterns exist across the nation, he said.

"Kidney stones have increased 70% over the last 30 years in adults in the U.S., and we are also seeing higher rates of kidney stones in children across the U.S.," Dr. Tasian said.

However, even though kidney stones are also increasing in many areas in the world, for many reasons, the results should not be generalized beyond the United States, he noted.

"This study is an important step forward in understanding the changing epidemiology of kidney stone disease," Dr. Charles D. Scales, of Duke University Medical Center in Durham, North Carolina, told Reuters Health by email. The underlying causes of the increase are unclear. "In adults, it may be related to the tidal wave of obesity and diabetes in the United States," said Dr. Scales, an expert in kidney stones who was not involved with the study.

These epidemiologic trends provide more support for the concept that "chronic and poorly understood metabolic derangements are likely causing all of these new stones in previously low-risk individuals," he said.

Increased consumption of high-sodium processed food and dehydration also may be contributing factors, he added. "Emerging evidence suggests that a kidney stone may foreshadow future medical problems, such as heart disease, bone density loss, and chronic kidney disease," Dr. Scales said. "So from the public-health perspective, the worst may be yet to come as these teenagers with stones become adults."

The study had no commercial funding and the authors reported no disclosures.

NEW YORK (Reuters Health) - Rates of kidney stones have increased substantially over the past 20 years, particularly among children, adolescents, females, and blacks, according to a population-based study in South Carolina.

Historically, the highest rates of kidney stone disease have been in middle-aged white men, but the new findings underscore emerging changes in this pattern. Prior studies have found that prevalent kidney stone disease has nearly doubled in the United States over the past two decades. The extent to which specific groups of patients have been affected has been less clear, although there have been reports of increasing frequency of kidney stones among youth.

"My colleagues and I wondered if kidney stones were increasing preferentially among adolescents more than in other age groups," lead researcher Dr. Gregory Tasian, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told Reuters Health by email.

To estimate the annual kidney stone incidence in South Carolina in their repeated cross-sectional study, the researchers used U.S. Census data and data from the South Carolina Medical Encounter Data and Financial Reports, which includes information on all surgeries, emergency department visits, and inpatient hospitalizations in the state from 1997 to 2012. Using linear mixed models, they also sought to identify the patient groups in whom the rate of stones has increased the most.

Nearly 153,000 adult and pediatric patients among a state population of about 4.6 million received care for kidney stones from 1997 to 2012, the researchers reported online January 14 in the Clinical Journal of the American Society of Nephrology.

The annual incidence increased 16% during that time, with the largest increases occurring in teens, blacks, and women.  Teens 15 to 19 years comprised the age group with the largest increase in incidence of kidney stones from 1997 (an age-specific rate of nearly 80 per 100,000) to 2012 (about 155 per 100,000).

Overall, teens 15 to 19 experienced a 26% increase per five years (incidence rate ratio, 1.26), after adjusting for sex and race. The increase was substantially greater among teen girls,

with an annual incidence 52% higher than for teen boys.

Increases in cumulative risk of kidney stones during childhood were similar for girls (87%) and boys (90%), although the risks in 2012 were "modest," at 0.9% (for girls) and 0.6% (for boys), the researchers say. They note that the "emergence of nephrolithiasis as a disease that begins in childhood is worrisome because there is limited evidence about how to best treat children" with the condition.

After adjusting for age and race, incidence of kidney stones  increased an estimated 15% per five years (IRR, 1.15) among females of all ages during the study period, but was stable among males (IRR, 0.99). The estimated lifetime risk for women increased from 10.5% in 1997 to 15.2% in 2012, but remained unchanged for men at about 23%. Incidence of kidney stones among blacks rose an estimated 15% per five years (IRR, 1.15) during the study period, compared with an estimated 3% among whites (IRR, 1.03).

"We were not surprised by the high occurrence of kidney  stones among adolescents and females (5% and 3% per year), which is consistent with other studies reported to date," Dr. Tasian

said. "We were, however, surprised by how much kidney stones were increasing in African-Americans, as previous studies have not really studied differences in kidney stone occurrence among different racial groups."

Although the study focused on kidney stone disease in South Carolina, it's likely that similar patterns exist across the nation, he said.

"Kidney stones have increased 70% over the last 30 years in adults in the U.S., and we are also seeing higher rates of kidney stones in children across the U.S.," Dr. Tasian said.

However, even though kidney stones are also increasing in many areas in the world, for many reasons, the results should not be generalized beyond the United States, he noted.

"This study is an important step forward in understanding the changing epidemiology of kidney stone disease," Dr. Charles D. Scales, of Duke University Medical Center in Durham, North Carolina, told Reuters Health by email. The underlying causes of the increase are unclear. "In adults, it may be related to the tidal wave of obesity and diabetes in the United States," said Dr. Scales, an expert in kidney stones who was not involved with the study.

These epidemiologic trends provide more support for the concept that "chronic and poorly understood metabolic derangements are likely causing all of these new stones in previously low-risk individuals," he said.

Increased consumption of high-sodium processed food and dehydration also may be contributing factors, he added. "Emerging evidence suggests that a kidney stone may foreshadow future medical problems, such as heart disease, bone density loss, and chronic kidney disease," Dr. Scales said. "So from the public-health perspective, the worst may be yet to come as these teenagers with stones become adults."

The study had no commercial funding and the authors reported no disclosures.

NEW YORK (Reuters Health) - Rates of kidney stones have increased substantially over the past 20 years, particularly among children, adolescents, females, and blacks, according to a population-based study in South Carolina.

Historically, the highest rates of kidney stone disease have been in middle-aged white men, but the new findings underscore emerging changes in this pattern. Prior studies have found that prevalent kidney stone disease has nearly doubled in the United States over the past two decades. The extent to which specific groups of patients have been affected has been less clear, although there have been reports of increasing frequency of kidney stones among youth.

"My colleagues and I wondered if kidney stones were increasing preferentially among adolescents more than in other age groups," lead researcher Dr. Gregory Tasian, of the University of Pennsylvania Perelman School of Medicine in Philadelphia, told Reuters Health by email.

To estimate the annual kidney stone incidence in South Carolina in their repeated cross-sectional study, the researchers used U.S. Census data and data from the South Carolina Medical Encounter Data and Financial Reports, which includes information on all surgeries, emergency department visits, and inpatient hospitalizations in the state from 1997 to 2012. Using linear mixed models, they also sought to identify the patient groups in whom the rate of stones has increased the most.

Nearly 153,000 adult and pediatric patients among a state population of about 4.6 million received care for kidney stones from 1997 to 2012, the researchers reported online January 14 in the Clinical Journal of the American Society of Nephrology.

The annual incidence increased 16% during that time, with the largest increases occurring in teens, blacks, and women.  Teens 15 to 19 years comprised the age group with the largest increase in incidence of kidney stones from 1997 (an age-specific rate of nearly 80 per 100,000) to 2012 (about 155 per 100,000).

Overall, teens 15 to 19 experienced a 26% increase per five years (incidence rate ratio, 1.26), after adjusting for sex and race. The increase was substantially greater among teen girls,

with an annual incidence 52% higher than for teen boys.

Increases in cumulative risk of kidney stones during childhood were similar for girls (87%) and boys (90%), although the risks in 2012 were "modest," at 0.9% (for girls) and 0.6% (for boys), the researchers say. They note that the "emergence of nephrolithiasis as a disease that begins in childhood is worrisome because there is limited evidence about how to best treat children" with the condition.

After adjusting for age and race, incidence of kidney stones  increased an estimated 15% per five years (IRR, 1.15) among females of all ages during the study period, but was stable among males (IRR, 0.99). The estimated lifetime risk for women increased from 10.5% in 1997 to 15.2% in 2012, but remained unchanged for men at about 23%. Incidence of kidney stones among blacks rose an estimated 15% per five years (IRR, 1.15) during the study period, compared with an estimated 3% among whites (IRR, 1.03).

"We were not surprised by the high occurrence of kidney  stones among adolescents and females (5% and 3% per year), which is consistent with other studies reported to date," Dr. Tasian

said. "We were, however, surprised by how much kidney stones were increasing in African-Americans, as previous studies have not really studied differences in kidney stone occurrence among different racial groups."

Although the study focused on kidney stone disease in South Carolina, it's likely that similar patterns exist across the nation, he said.

"Kidney stones have increased 70% over the last 30 years in adults in the U.S., and we are also seeing higher rates of kidney stones in children across the U.S.," Dr. Tasian said.

However, even though kidney stones are also increasing in many areas in the world, for many reasons, the results should not be generalized beyond the United States, he noted.

"This study is an important step forward in understanding the changing epidemiology of kidney stone disease," Dr. Charles D. Scales, of Duke University Medical Center in Durham, North Carolina, told Reuters Health by email. The underlying causes of the increase are unclear. "In adults, it may be related to the tidal wave of obesity and diabetes in the United States," said Dr. Scales, an expert in kidney stones who was not involved with the study.

These epidemiologic trends provide more support for the concept that "chronic and poorly understood metabolic derangements are likely causing all of these new stones in previously low-risk individuals," he said.

Increased consumption of high-sodium processed food and dehydration also may be contributing factors, he added. "Emerging evidence suggests that a kidney stone may foreshadow future medical problems, such as heart disease, bone density loss, and chronic kidney disease," Dr. Scales said. "So from the public-health perspective, the worst may be yet to come as these teenagers with stones become adults."

The study had no commercial funding and the authors reported no disclosures.

Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?

Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.

Study design: Retrospective review.

Setting: Anthem insurance members.

Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.

Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.

The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.

Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.

Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.

Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?

Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.

Study design: Retrospective review.

Setting: Anthem insurance members.

Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.

Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.

The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.

Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.

Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.

Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?

Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.

Study design: Retrospective review.

Setting: Anthem insurance members.

Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.

Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.

The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.

Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.

Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.