Clinical

4/8/15

HM15 Presenter: Tammie Quest, MD

Summation: Heroics- a set of medical actions that attempt to prolong life with a low likelihood of success.

Palliative care- an approach of care provided to patients and families suffering from serious and/or life limiting illness; focus on physical, spiritual, psychological and social aspects of distress.

Hospice care- intense palliative care provided when the patient has terminal illness with a prognosis of 6 months or less if the disease runs its usual course.

We underutilize Palliative and Hospice care in the US. Here in the US fewer than 50% of all persons receive hospice care at EOL, of those who receive hospice care more than half receive care for less than 20 days, and 1 in 5 patients die in an ICU. Palliative Care can/should co-exist with life prolonging care following the diagnosis of serious illness.

Common therapies/interventions to be contemplated and discussed with patient at end of life: cpr, mechanical ventilation, central venous/arterial access, renal replacement therapy, surgical procedures, valve therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental oxygen, artificial nutrition, antimicrobials, blood products, cancer directed therapy, antithrombotics, anticoagulation.

Practical Elements of Palliative Care: pain and symptom management, advance care planning, communication/goals of care, truth-telling, social support, spiritual support, psychological support, risk/burden assessment of treatments.

Key Points/HM Takeaways:

1-Palliative Care Bedside Talking Points-

• Cardiac arrest is the moment of death, very few people survive an attempt at reversing death
• If you are one of the few who survive to discharge, you may do well but few will survive to discharge
• Antibiotics DO improve survival, antibiotics DO NOT improve comfort
• No evidence to show that dying from pneumonia, or other infection, is painful
• Allowing natural death includes permitting the body to shut itself down through natural mechanisms, including infection
• Dialysis may extend life, but there will be progressive functional decline

2-Goals of Care define what therapies are indicated. Balance prolongation of life with illness experience.

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

4/8/15

HM15 Presenter: Tammie Quest, MD

Summation: Heroics- a set of medical actions that attempt to prolong life with a low likelihood of success.

Palliative care- an approach of care provided to patients and families suffering from serious and/or life limiting illness; focus on physical, spiritual, psychological and social aspects of distress.

Hospice care- intense palliative care provided when the patient has terminal illness with a prognosis of 6 months or less if the disease runs its usual course.

We underutilize Palliative and Hospice care in the US. Here in the US fewer than 50% of all persons receive hospice care at EOL, of those who receive hospice care more than half receive care for less than 20 days, and 1 in 5 patients die in an ICU. Palliative Care can/should co-exist with life prolonging care following the diagnosis of serious illness.

Common therapies/interventions to be contemplated and discussed with patient at end of life: cpr, mechanical ventilation, central venous/arterial access, renal replacement therapy, surgical procedures, valve therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental oxygen, artificial nutrition, antimicrobials, blood products, cancer directed therapy, antithrombotics, anticoagulation.

Practical Elements of Palliative Care: pain and symptom management, advance care planning, communication/goals of care, truth-telling, social support, spiritual support, psychological support, risk/burden assessment of treatments.

Key Points/HM Takeaways:

1-Palliative Care Bedside Talking Points-

• Cardiac arrest is the moment of death, very few people survive an attempt at reversing death
• If you are one of the few who survive to discharge, you may do well but few will survive to discharge
• Antibiotics DO improve survival, antibiotics DO NOT improve comfort
• No evidence to show that dying from pneumonia, or other infection, is painful
• Allowing natural death includes permitting the body to shut itself down through natural mechanisms, including infection
• Dialysis may extend life, but there will be progressive functional decline

2-Goals of Care define what therapies are indicated. Balance prolongation of life with illness experience.

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

4/8/15

HM15 Presenter: Tammie Quest, MD

Summation: Heroics- a set of medical actions that attempt to prolong life with a low likelihood of success.

Palliative care- an approach of care provided to patients and families suffering from serious and/or life limiting illness; focus on physical, spiritual, psychological and social aspects of distress.

Hospice care- intense palliative care provided when the patient has terminal illness with a prognosis of 6 months or less if the disease runs its usual course.

We underutilize Palliative and Hospice care in the US. Here in the US fewer than 50% of all persons receive hospice care at EOL, of those who receive hospice care more than half receive care for less than 20 days, and 1 in 5 patients die in an ICU. Palliative Care can/should co-exist with life prolonging care following the diagnosis of serious illness.

Common therapies/interventions to be contemplated and discussed with patient at end of life: cpr, mechanical ventilation, central venous/arterial access, renal replacement therapy, surgical procedures, valve therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental oxygen, artificial nutrition, antimicrobials, blood products, cancer directed therapy, antithrombotics, anticoagulation.

Practical Elements of Palliative Care: pain and symptom management, advance care planning, communication/goals of care, truth-telling, social support, spiritual support, psychological support, risk/burden assessment of treatments.

Key Points/HM Takeaways:

1-Palliative Care Bedside Talking Points-

• Cardiac arrest is the moment of death, very few people survive an attempt at reversing death
• If you are one of the few who survive to discharge, you may do well but few will survive to discharge
• Antibiotics DO improve survival, antibiotics DO NOT improve comfort
• No evidence to show that dying from pneumonia, or other infection, is painful
• Allowing natural death includes permitting the body to shut itself down through natural mechanisms, including infection
• Dialysis may extend life, but there will be progressive functional decline

2-Goals of Care define what therapies are indicated. Balance prolongation of life with illness experience.

Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

HM15 Presenters: Roy Sittig MD SFHM, Jeffrey Frank MD MBA, Jodi Braun

Summation: Speakers covered timely topics regarding the Accountable Care Act, namely Medicaid Expansion and Bundled Payment arrangements; and reviewed the seminal paper on “Key Principals and Characteristics of an Effective Hospitalist Medicine Group” and lessons learned in implementing those 10 Key Principles.

Medicaid Expansion: EDs serving the 29 Medicaid expansion states are reporting higher volumes, likely due to 11.4million new lives now insured under the ACA. While the ACA does provide for higher Medicaid payment rates thus far, only 34% of providers accept Medicaid, a 21% drop since the ACA went into effect.

Bundled Payment Arrangements:

• Bundled Payment Care Initiative (BPCI) lexicon:

  • Model 2-Episode Anchor (anchor admission) AND 90days post d/c; Medicare pays 98% of usual cost
  • Model 3-90days post d/c AFTER anchor admission; Medicare pays 97% of usual cost
  • Convener-entity that brings providers together and enters into CMS agreement to bear risk for bundles
  • Awardee (entity having agreement with Medicare to assume risk and receive payment via BPCI) and Convener own the Bundle
  • Episode initiator (EI) triggers “bundle period”
  • Bundles based on DRG

10-Key Principles of an Effective Hospitalist Medicine Group:

1. Effective Leadership
2. Engaged Hospitalists
3. Adequate Resources
4. Planning and Management Infrastructure
5. Alignment with Hospital/Health System
6. Care Coordination Across Settings
7. Leadership in Key Clinical Issues in the Hospital/Health System
8. Thoughtful Approach to Scope of Activity
9. Patient/Family-Centered, Team-Based Care; Effective Communication
10. Recruiting/Retaining Qualified Clinicians

Key Points/HM Takeaways:

Medicaid Expansion- many of the 11.4M newly insured lives under the ACA have moved into Medicaid. Only about 1/3 of providers now accept Medicaid- 1 in 5 covered persons now have Medicaid, nearly 20% increase since 2013.

Bundled Payments- Majority of savings opportunity lies in Post-Acute Care. Awardee and Convener make profit is total cost is less than 98% of Target Price. In gainsharing agreements individuals can be reimbursed up to 150% usual Medicare rate. Pay occurs in usual Medicare fashion but is reconciled 60-90 days after end of bundle. For more information: http://innovation.cms.gov/initiatives/bundled-payments/

Effective HM Groups- Three important areas for focus when beginning to address group performance are: engaged hospitalists, planning and management infrastructure, care coordination across settings. These three topics have broad reaching implications into the hospitalist practice and patient care. [Cawley P, et al. Journal of Hospital Medicine 2014; 9(2):123-128]

In a presentation on guidelines for ALTE, Jack Percelay, SHM representative to the AAP Subcommittee, provided further insight to the work that has been done for the clinical entity known as apparent life-threatening events (ALTE) since a consensus statement was put forward by the NIH in 1986. The original statement emphasized 4 possible features to constitute ALTE: apnea, color change, change in tone or gagging. The imprecise nature of the definition, along with both provider and caretaker anxiety related to the diagnosis, have lead to a cascade of diagnostic testing and treatments for what is a symptom complex, not a disease.

Subsequent work in the field has clarified that an ALTE is not a risk factor for SIDS. Of the myriad of etiologies that can cause an ALTE, many will have a readily identifiable etiology that a good history and physical exam will diagnose. Most other diseases, if not diagnosed at initial presentation, will become apparent subsequently without any significant consequences (for example epilepsy). Two diagnoses, which if missed, may have significant consequences include child abuse and a cardiac arrhythmia.

In an effort to synthesize new data along with expert opinion, the American Academy of Pediatrics has convened a Subcommittee on the Guideline for ALTE, lead by Joel Tieder, to develop a new practice guideline. This guideline is still in development with certain areas not ready for broad dissemination. The highlight of the new guideline will be a proposal for a name change for ALTEs. Dr Percelay reports the proposed new name would be BRUE (pronounced “brew”), Brief Resolved Unexplained Event. He anticipates further information to be published that will offer a framework to specify which infants to consider at low risk of recurrence versus higher risk for significant pathology. For those infants identified as low risk, the guideline will offer specific evaluation and treatment recommendations. An anticipated key point of the new guideline will be that a careful history and physical is the cornerstone of the initial evaluation and that in the absence of specific historical or exam findings, diagnostic testing of well-appearing infants is of low value.

In a presentation on guidelines for ALTE, Jack Percelay, SHM representative to the AAP Subcommittee, provided further insight to the work that has been done for the clinical entity known as apparent life-threatening events (ALTE) since a consensus statement was put forward by the NIH in 1986. The original statement emphasized 4 possible features to constitute ALTE: apnea, color change, change in tone or gagging. The imprecise nature of the definition, along with both provider and caretaker anxiety related to the diagnosis, have lead to a cascade of diagnostic testing and treatments for what is a symptom complex, not a disease.

Subsequent work in the field has clarified that an ALTE is not a risk factor for SIDS. Of the myriad of etiologies that can cause an ALTE, many will have a readily identifiable etiology that a good history and physical exam will diagnose. Most other diseases, if not diagnosed at initial presentation, will become apparent subsequently without any significant consequences (for example epilepsy). Two diagnoses, which if missed, may have significant consequences include child abuse and a cardiac arrhythmia.

In an effort to synthesize new data along with expert opinion, the American Academy of Pediatrics has convened a Subcommittee on the Guideline for ALTE, lead by Joel Tieder, to develop a new practice guideline. This guideline is still in development with certain areas not ready for broad dissemination. The highlight of the new guideline will be a proposal for a name change for ALTEs. Dr Percelay reports the proposed new name would be BRUE (pronounced “brew”), Brief Resolved Unexplained Event. He anticipates further information to be published that will offer a framework to specify which infants to consider at low risk of recurrence versus higher risk for significant pathology. For those infants identified as low risk, the guideline will offer specific evaluation and treatment recommendations. An anticipated key point of the new guideline will be that a careful history and physical is the cornerstone of the initial evaluation and that in the absence of specific historical or exam findings, diagnostic testing of well-appearing infants is of low value.

In a presentation on guidelines for ALTE, Jack Percelay, SHM representative to the AAP Subcommittee, provided further insight to the work that has been done for the clinical entity known as apparent life-threatening events (ALTE) since a consensus statement was put forward by the NIH in 1986. The original statement emphasized 4 possible features to constitute ALTE: apnea, color change, change in tone or gagging. The imprecise nature of the definition, along with both provider and caretaker anxiety related to the diagnosis, have lead to a cascade of diagnostic testing and treatments for what is a symptom complex, not a disease.

Subsequent work in the field has clarified that an ALTE is not a risk factor for SIDS. Of the myriad of etiologies that can cause an ALTE, many will have a readily identifiable etiology that a good history and physical exam will diagnose. Most other diseases, if not diagnosed at initial presentation, will become apparent subsequently without any significant consequences (for example epilepsy). Two diagnoses, which if missed, may have significant consequences include child abuse and a cardiac arrhythmia.

In an effort to synthesize new data along with expert opinion, the American Academy of Pediatrics has convened a Subcommittee on the Guideline for ALTE, lead by Joel Tieder, to develop a new practice guideline. This guideline is still in development with certain areas not ready for broad dissemination. The highlight of the new guideline will be a proposal for a name change for ALTEs. Dr Percelay reports the proposed new name would be BRUE (pronounced “brew”), Brief Resolved Unexplained Event. He anticipates further information to be published that will offer a framework to specify which infants to consider at low risk of recurrence versus higher risk for significant pathology. For those infants identified as low risk, the guideline will offer specific evaluation and treatment recommendations. An anticipated key point of the new guideline will be that a careful history and physical is the cornerstone of the initial evaluation and that in the absence of specific historical or exam findings, diagnostic testing of well-appearing infants is of low value.

Listen to Daniel Hunt, MD, chief of the hospital medicine unit at Massachusetts General Hospital, Boston, discuss his recent article titled “Perspectives” in the New England Journal of Medicine on consultation visits by primary care providers.

Listen to Daniel Hunt, MD, chief of the hospital medicine unit at Massachusetts General Hospital, Boston, discuss his recent article titled “Perspectives” in the New England Journal of Medicine on consultation visits by primary care providers.

Listen to Daniel Hunt, MD, chief of the hospital medicine unit at Massachusetts General Hospital, Boston, discuss his recent article titled “Perspectives” in the New England Journal of Medicine on consultation visits by primary care providers.

Jeffrey Greenwald, MD, a hospitalist at Massacusetts General Hospital with 15 years of experience in hospital medicine, discusses his view of the spectrum of endocrine disorders and how hospitalists should approach the question of when to call in an endocrine specialist.

Jeffrey Greenwald, MD, a hospitalist at Massacusetts General Hospital with 15 years of experience in hospital medicine, discusses his view of the spectrum of endocrine disorders and how hospitalists should approach the question of when to call in an endocrine specialist.

Jeffrey Greenwald, MD, a hospitalist at Massacusetts General Hospital with 15 years of experience in hospital medicine, discusses his view of the spectrum of endocrine disorders and how hospitalists should approach the question of when to call in an endocrine specialist.

Amy Boutwell, MD, MPP, a hospitalist and founder of Collaborative Healthcare Strategies, talks about what clinicians can do to help improve care transitions based on her experience directing IHI’s STAAR Initiative (State-Action on Avoidable Re-hospitalizations).

Amy Boutwell, MD, MPP, a hospitalist and founder of Collaborative Healthcare Strategies, talks about what clinicians can do to help improve care transitions based on her experience directing IHI’s STAAR Initiative (State-Action on Avoidable Re-hospitalizations).

Amy Boutwell, MD, MPP, a hospitalist and founder of Collaborative Healthcare Strategies, talks about what clinicians can do to help improve care transitions based on her experience directing IHI’s STAAR Initiative (State-Action on Avoidable Re-hospitalizations).

Johns Hopkins hospitalist Eric Howell, MD, SFHM, discusses connections between SHM, hospitalist practices, handoffs, and successful care transitions.

Johns Hopkins hospitalist Eric Howell, MD, SFHM, discusses connections between SHM, hospitalist practices, handoffs, and successful care transitions.

Johns Hopkins hospitalist Eric Howell, MD, SFHM, discusses connections between SHM, hospitalist practices, handoffs, and successful care transitions.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.