A pediatric migraine diagnosis starts with a thorough patient history. I start by having the child or adolescent characterize their headache. What is its location, what does it feel like, how long does it last, and is there associated light or noise sensitivity or nausea? For the young children, this is ascertained by asking if they want to be in a dark or quiet room, or if they complain of stomach upset. I also find out about the onset and temporal course of the headache: When did the headaches start, have they become more frequent over time, and has there been a progression in the intensity of the headaches?

It is also quite important to identify headache triggers. I always ask about sleep schedule, eating habits, and fluid intake, as well as potential stress triggers, as these frequently impact on headaches.

It is appropriate to manage children in the primary care setting when they respond to fairly benign, over-the-counter medications, such as ibuprofen or acetaminophen, or triptan medications in the older kids. Refer to a specialist when your patient is not responding to these types of medications, when the headaches are becoming more frequent or severe, or if you have concerns about your patient’s neurologic status.

Also check family history because migraine is strongly genetically based. A family history of migraine headaches coupled with a typical headache character and normal neurologic exam can support your diagnostic suspicion.

In addition to taking a good history, it is critical to perform a detailed neurological examination to exclude any abnormalities that might suggest a more serious underlying cause for the headaches. It is especially important to look at their optic disks to rule out any evidence of increased intracranial pressure or papilledema. If you are unable to perform this type of exam, it is best to refer your patient to an ophthalmologist for a complete ophthalmologic exam. Any focal neurologic abnormalities should prompt a neuroimaging evaluation such as an MRI.

Evaluate for other headache types. Ask about stress triggers. Kids get stress- or tension-type headaches just like adults. When I see children who report frequent headaches that occur predominantly at school and infrequently on weekends, I’m more suspicious of a stress trigger. If headaches occur shortly before mealtimes, they could be caused by transient hypoglycemia and may be prevented by adding a snack or changing the child’s eating schedule.

Another scenario is headaches that occur after football or soccer practice or other vigorous activities. Here, I consider fatigue, dehydration, or perhaps excessive sun exposure as potential triggers. Ask about fluid intake – particularly how much water, not soft drinks, the child drinks. Sodas do not help with dehydration and are frequently loaded with caffeine. Educate them about hydration and how drinking enough fluids can make a huge difference in their headache frequency and severity.

Headaches that occur infrequently or that do not disrupt the child’s typical activities are less worrisome. For example, I am much less concerned when a child or adolescent reports headaches, but they still go outside to play, or go about their regular routine, and stay engaged in family activities.

A headache calendar filled out by the patient, preferably over weeks or months, is very helpful to your headache specialist. This helps us to better characterize the frequency and severity of episodes, what time of day they occur, and any potential precipitating triggers.

I become concerned when headaches get progressively more severe over time, or become more frequent over a short period. Headaches that awaken kids in the middle of the night, or those associated with nausea and vomiting on awakening, may point to a more serious condition, such as a tumor or other expanding mass inside the head causing increased intracranial pressure.

Probably the most over-ordered tests in the children I see with headaches are neuroimaging studies. The majority of young kids with headaches do not require an expensive MRI scan. Most require only a good history and neurologic exam for appropriate diagnosis.

However, a CT or MRI scan is indicated if you suspect a more serious etiology and/or the patient is younger. For example, I am much more likely to get an imaging study when a 3- or 4-year-old child complains of frequent or severe headaches. Historical information will be more limited in the preschoolers because they frequently can’t tell you as much about their headaches, and your examination might be less reliable as well – as the younger kids may be less cooperative and more difficult to examine. I also perform blood tests on some headache patients, looking for infectious, inflammatory, or metabolic derangements as a cause for headaches, but those are infrequently helpful.

 

Also keep in mind that some headache complaints may be functional in nature. For example, if a particular child gets significant attention with their headaches, there may be some associated secondary gain. A child also might be mimicking adult behavior. If the parents complain frequently about headaches, you might find the kid also complains about headaches.

Although pediatric and adult migraines share many of the same features, the good news is pediatric migraines are frequently not as severe or as protracted in children as they are for adults, and are often highly responsive to treatment. It can be very rewarding managing children with headaches because so many do well.

Dr. Berenson is a pediatric neurologist and section chief of neurology at Children’s Healthcare of Atlanta at Scottish Rite. He is also in private practice at Atlanta Headache Specialists and Pediatric and Adolescent NeuroDevelopmental Associates (PANDA) Neurology. He said he had no relevant financial disclosures.

A pediatric migraine diagnosis starts with a thorough patient history. I start by having the child or adolescent characterize their headache. What is its location, what does it feel like, how long does it last, and is there associated light or noise sensitivity or nausea? For the young children, this is ascertained by asking if they want to be in a dark or quiet room, or if they complain of stomach upset. I also find out about the onset and temporal course of the headache: When did the headaches start, have they become more frequent over time, and has there been a progression in the intensity of the headaches?

It is also quite important to identify headache triggers. I always ask about sleep schedule, eating habits, and fluid intake, as well as potential stress triggers, as these frequently impact on headaches.

It is appropriate to manage children in the primary care setting when they respond to fairly benign, over-the-counter medications, such as ibuprofen or acetaminophen, or triptan medications in the older kids. Refer to a specialist when your patient is not responding to these types of medications, when the headaches are becoming more frequent or severe, or if you have concerns about your patient’s neurologic status.

Also check family history because migraine is strongly genetically based. A family history of migraine headaches coupled with a typical headache character and normal neurologic exam can support your diagnostic suspicion.

In addition to taking a good history, it is critical to perform a detailed neurological examination to exclude any abnormalities that might suggest a more serious underlying cause for the headaches. It is especially important to look at their optic disks to rule out any evidence of increased intracranial pressure or papilledema. If you are unable to perform this type of exam, it is best to refer your patient to an ophthalmologist for a complete ophthalmologic exam. Any focal neurologic abnormalities should prompt a neuroimaging evaluation such as an MRI.

Evaluate for other headache types. Ask about stress triggers. Kids get stress- or tension-type headaches just like adults. When I see children who report frequent headaches that occur predominantly at school and infrequently on weekends, I’m more suspicious of a stress trigger. If headaches occur shortly before mealtimes, they could be caused by transient hypoglycemia and may be prevented by adding a snack or changing the child’s eating schedule.

Another scenario is headaches that occur after football or soccer practice or other vigorous activities. Here, I consider fatigue, dehydration, or perhaps excessive sun exposure as potential triggers. Ask about fluid intake – particularly how much water, not soft drinks, the child drinks. Sodas do not help with dehydration and are frequently loaded with caffeine. Educate them about hydration and how drinking enough fluids can make a huge difference in their headache frequency and severity.

Headaches that occur infrequently or that do not disrupt the child’s typical activities are less worrisome. For example, I am much less concerned when a child or adolescent reports headaches, but they still go outside to play, or go about their regular routine, and stay engaged in family activities.

A headache calendar filled out by the patient, preferably over weeks or months, is very helpful to your headache specialist. This helps us to better characterize the frequency and severity of episodes, what time of day they occur, and any potential precipitating triggers.

I become concerned when headaches get progressively more severe over time, or become more frequent over a short period. Headaches that awaken kids in the middle of the night, or those associated with nausea and vomiting on awakening, may point to a more serious condition, such as a tumor or other expanding mass inside the head causing increased intracranial pressure.

Probably the most over-ordered tests in the children I see with headaches are neuroimaging studies. The majority of young kids with headaches do not require an expensive MRI scan. Most require only a good history and neurologic exam for appropriate diagnosis.

However, a CT or MRI scan is indicated if you suspect a more serious etiology and/or the patient is younger. For example, I am much more likely to get an imaging study when a 3- or 4-year-old child complains of frequent or severe headaches. Historical information will be more limited in the preschoolers because they frequently can’t tell you as much about their headaches, and your examination might be less reliable as well – as the younger kids may be less cooperative and more difficult to examine. I also perform blood tests on some headache patients, looking for infectious, inflammatory, or metabolic derangements as a cause for headaches, but those are infrequently helpful.

 

Also keep in mind that some headache complaints may be functional in nature. For example, if a particular child gets significant attention with their headaches, there may be some associated secondary gain. A child also might be mimicking adult behavior. If the parents complain frequently about headaches, you might find the kid also complains about headaches.

Although pediatric and adult migraines share many of the same features, the good news is pediatric migraines are frequently not as severe or as protracted in children as they are for adults, and are often highly responsive to treatment. It can be very rewarding managing children with headaches because so many do well.

Dr. Berenson is a pediatric neurologist and section chief of neurology at Children’s Healthcare of Atlanta at Scottish Rite. He is also in private practice at Atlanta Headache Specialists and Pediatric and Adolescent NeuroDevelopmental Associates (PANDA) Neurology. He said he had no relevant financial disclosures.

A pediatric migraine diagnosis starts with a thorough patient history. I start by having the child or adolescent characterize their headache. What is its location, what does it feel like, how long does it last, and is there associated light or noise sensitivity or nausea? For the young children, this is ascertained by asking if they want to be in a dark or quiet room, or if they complain of stomach upset. I also find out about the onset and temporal course of the headache: When did the headaches start, have they become more frequent over time, and has there been a progression in the intensity of the headaches?

It is also quite important to identify headache triggers. I always ask about sleep schedule, eating habits, and fluid intake, as well as potential stress triggers, as these frequently impact on headaches.

It is appropriate to manage children in the primary care setting when they respond to fairly benign, over-the-counter medications, such as ibuprofen or acetaminophen, or triptan medications in the older kids. Refer to a specialist when your patient is not responding to these types of medications, when the headaches are becoming more frequent or severe, or if you have concerns about your patient’s neurologic status.

Also check family history because migraine is strongly genetically based. A family history of migraine headaches coupled with a typical headache character and normal neurologic exam can support your diagnostic suspicion.

In addition to taking a good history, it is critical to perform a detailed neurological examination to exclude any abnormalities that might suggest a more serious underlying cause for the headaches. It is especially important to look at their optic disks to rule out any evidence of increased intracranial pressure or papilledema. If you are unable to perform this type of exam, it is best to refer your patient to an ophthalmologist for a complete ophthalmologic exam. Any focal neurologic abnormalities should prompt a neuroimaging evaluation such as an MRI.

Evaluate for other headache types. Ask about stress triggers. Kids get stress- or tension-type headaches just like adults. When I see children who report frequent headaches that occur predominantly at school and infrequently on weekends, I’m more suspicious of a stress trigger. If headaches occur shortly before mealtimes, they could be caused by transient hypoglycemia and may be prevented by adding a snack or changing the child’s eating schedule.

Another scenario is headaches that occur after football or soccer practice or other vigorous activities. Here, I consider fatigue, dehydration, or perhaps excessive sun exposure as potential triggers. Ask about fluid intake – particularly how much water, not soft drinks, the child drinks. Sodas do not help with dehydration and are frequently loaded with caffeine. Educate them about hydration and how drinking enough fluids can make a huge difference in their headache frequency and severity.

Headaches that occur infrequently or that do not disrupt the child’s typical activities are less worrisome. For example, I am much less concerned when a child or adolescent reports headaches, but they still go outside to play, or go about their regular routine, and stay engaged in family activities.

A headache calendar filled out by the patient, preferably over weeks or months, is very helpful to your headache specialist. This helps us to better characterize the frequency and severity of episodes, what time of day they occur, and any potential precipitating triggers.

I become concerned when headaches get progressively more severe over time, or become more frequent over a short period. Headaches that awaken kids in the middle of the night, or those associated with nausea and vomiting on awakening, may point to a more serious condition, such as a tumor or other expanding mass inside the head causing increased intracranial pressure.

Probably the most over-ordered tests in the children I see with headaches are neuroimaging studies. The majority of young kids with headaches do not require an expensive MRI scan. Most require only a good history and neurologic exam for appropriate diagnosis.

However, a CT or MRI scan is indicated if you suspect a more serious etiology and/or the patient is younger. For example, I am much more likely to get an imaging study when a 3- or 4-year-old child complains of frequent or severe headaches. Historical information will be more limited in the preschoolers because they frequently can’t tell you as much about their headaches, and your examination might be less reliable as well – as the younger kids may be less cooperative and more difficult to examine. I also perform blood tests on some headache patients, looking for infectious, inflammatory, or metabolic derangements as a cause for headaches, but those are infrequently helpful.

 

Also keep in mind that some headache complaints may be functional in nature. For example, if a particular child gets significant attention with their headaches, there may be some associated secondary gain. A child also might be mimicking adult behavior. If the parents complain frequently about headaches, you might find the kid also complains about headaches.

Although pediatric and adult migraines share many of the same features, the good news is pediatric migraines are frequently not as severe or as protracted in children as they are for adults, and are often highly responsive to treatment. It can be very rewarding managing children with headaches because so many do well.

Dr. Berenson is a pediatric neurologist and section chief of neurology at Children’s Healthcare of Atlanta at Scottish Rite. He is also in private practice at Atlanta Headache Specialists and Pediatric and Adolescent NeuroDevelopmental Associates (PANDA) Neurology. He said he had no relevant financial disclosures.

CHICAGO—A new monoclonal antibody, blinatumomab, achieves an “exceptionally high complete remission rate” as a single agent in acute lymphoblastic leukemia (ALL), according to investigators.

They reported that about 70% of adult patients with relapsed/refractory B-precursor ALL achieved a hematologic complete remission (CR).

Max Topp, MD, of the Wuerzburg University Medical Center in Germany, presented the findings as abstract 6500 at the 2012 ASCO Annual Meeting held here recently.

Outcomes are poor for adult patients with relapsed/refractory ALL following frontline therapy. Several clinical trials have shown that most patients fail to achieve CR. Response rates are typically 20% to 30%.

“Treatment-related mortality is high, CR is not durable, and overall survival is dismal at a median of 4-6 months after relapse,” Dr Topp said. “[A]llogeneic stem cell transplant (alloSCT) is only really available to patients who reach a CR, and few patients make it to SCT.”

After alloSCT, the overall survival rate at 1 year is about 20%, regardless of CR status. “There is a need for something completely different,” Dr Topp said.

Enter blinatumomab. Blinatumomab is a bispecific T-cell engaging antibody that directs cytotoxic T cells to CD19-expressing target cells.

Dr Topp and colleagues designed an open-label, multicenter, exploratory phase 2 study and enrolled 36 relapsed/refractory ALL patients. The patients were a median age of 31 years and had a high blast count. Some 40% had relapsed after alloSCT.

Patients received blinatumomab by continuous intravenous infusion for 4 weeks, with 2 weeks off, for up to 5 cycles. The investigators determined the safest dose to be 5 µg/m²/day in week 1, followed by 15 µg/m²/day for the remaining treatment. Twenty-three patients entered the extension phase at this dose.

Of the 36 patients enrolled, 26 (72%) achieved a hematologic CR, as did 17 of 23 patients (74%) in the extension phase.

The duration of hematologic CR was 8.9 months after a median observation time of 4.5 months.

Median overall survival was 9 months after a median follow-up of 10.7 months. This compares favorably with historical data, Dr Topp pointed out.

“Most importantly,” he added, “almost every patient who achieved CR had a molecular remission. Only 2 out of 26 patients didn’t reach this endpoint.”

He noted that 13 patients who reached CR had an alloSCT.

Early on, several patients developed cytokine release syndrome. So the researchers developed a prevention strategy of giving corticosteroids upfront. As a result, there were no cases of cytokine release syndrome in the extension phase.

The most common adverse events in the safest dosing schedule were pyrexia and headache. There were few grade 3 events, and all adverse events were reversible.

Dr Topp said the data support further investigation of blinatumomab in adult patients with relapsed/refractory ALL.

He noted that a global phase 2 study in this setting has already been initiated in the United States and Europe.

CHICAGO—A new monoclonal antibody, blinatumomab, achieves an “exceptionally high complete remission rate” as a single agent in acute lymphoblastic leukemia (ALL), according to investigators.

They reported that about 70% of adult patients with relapsed/refractory B-precursor ALL achieved a hematologic complete remission (CR).

Max Topp, MD, of the Wuerzburg University Medical Center in Germany, presented the findings as abstract 6500 at the 2012 ASCO Annual Meeting held here recently.

Outcomes are poor for adult patients with relapsed/refractory ALL following frontline therapy. Several clinical trials have shown that most patients fail to achieve CR. Response rates are typically 20% to 30%.

“Treatment-related mortality is high, CR is not durable, and overall survival is dismal at a median of 4-6 months after relapse,” Dr Topp said. “[A]llogeneic stem cell transplant (alloSCT) is only really available to patients who reach a CR, and few patients make it to SCT.”

After alloSCT, the overall survival rate at 1 year is about 20%, regardless of CR status. “There is a need for something completely different,” Dr Topp said.

Enter blinatumomab. Blinatumomab is a bispecific T-cell engaging antibody that directs cytotoxic T cells to CD19-expressing target cells.

Dr Topp and colleagues designed an open-label, multicenter, exploratory phase 2 study and enrolled 36 relapsed/refractory ALL patients. The patients were a median age of 31 years and had a high blast count. Some 40% had relapsed after alloSCT.

Patients received blinatumomab by continuous intravenous infusion for 4 weeks, with 2 weeks off, for up to 5 cycles. The investigators determined the safest dose to be 5 µg/m²/day in week 1, followed by 15 µg/m²/day for the remaining treatment. Twenty-three patients entered the extension phase at this dose.

Of the 36 patients enrolled, 26 (72%) achieved a hematologic CR, as did 17 of 23 patients (74%) in the extension phase.

The duration of hematologic CR was 8.9 months after a median observation time of 4.5 months.

Median overall survival was 9 months after a median follow-up of 10.7 months. This compares favorably with historical data, Dr Topp pointed out.

“Most importantly,” he added, “almost every patient who achieved CR had a molecular remission. Only 2 out of 26 patients didn’t reach this endpoint.”

He noted that 13 patients who reached CR had an alloSCT.

Early on, several patients developed cytokine release syndrome. So the researchers developed a prevention strategy of giving corticosteroids upfront. As a result, there were no cases of cytokine release syndrome in the extension phase.

The most common adverse events in the safest dosing schedule were pyrexia and headache. There were few grade 3 events, and all adverse events were reversible.

Dr Topp said the data support further investigation of blinatumomab in adult patients with relapsed/refractory ALL.

He noted that a global phase 2 study in this setting has already been initiated in the United States and Europe.

CHICAGO—A new monoclonal antibody, blinatumomab, achieves an “exceptionally high complete remission rate” as a single agent in acute lymphoblastic leukemia (ALL), according to investigators.

They reported that about 70% of adult patients with relapsed/refractory B-precursor ALL achieved a hematologic complete remission (CR).

Max Topp, MD, of the Wuerzburg University Medical Center in Germany, presented the findings as abstract 6500 at the 2012 ASCO Annual Meeting held here recently.

Outcomes are poor for adult patients with relapsed/refractory ALL following frontline therapy. Several clinical trials have shown that most patients fail to achieve CR. Response rates are typically 20% to 30%.

“Treatment-related mortality is high, CR is not durable, and overall survival is dismal at a median of 4-6 months after relapse,” Dr Topp said. “[A]llogeneic stem cell transplant (alloSCT) is only really available to patients who reach a CR, and few patients make it to SCT.”

After alloSCT, the overall survival rate at 1 year is about 20%, regardless of CR status. “There is a need for something completely different,” Dr Topp said.

Enter blinatumomab. Blinatumomab is a bispecific T-cell engaging antibody that directs cytotoxic T cells to CD19-expressing target cells.

Dr Topp and colleagues designed an open-label, multicenter, exploratory phase 2 study and enrolled 36 relapsed/refractory ALL patients. The patients were a median age of 31 years and had a high blast count. Some 40% had relapsed after alloSCT.

Patients received blinatumomab by continuous intravenous infusion for 4 weeks, with 2 weeks off, for up to 5 cycles. The investigators determined the safest dose to be 5 µg/m²/day in week 1, followed by 15 µg/m²/day for the remaining treatment. Twenty-three patients entered the extension phase at this dose.

Of the 36 patients enrolled, 26 (72%) achieved a hematologic CR, as did 17 of 23 patients (74%) in the extension phase.

The duration of hematologic CR was 8.9 months after a median observation time of 4.5 months.

Median overall survival was 9 months after a median follow-up of 10.7 months. This compares favorably with historical data, Dr Topp pointed out.

“Most importantly,” he added, “almost every patient who achieved CR had a molecular remission. Only 2 out of 26 patients didn’t reach this endpoint.”

He noted that 13 patients who reached CR had an alloSCT.

Early on, several patients developed cytokine release syndrome. So the researchers developed a prevention strategy of giving corticosteroids upfront. As a result, there were no cases of cytokine release syndrome in the extension phase.

The most common adverse events in the safest dosing schedule were pyrexia and headache. There were few grade 3 events, and all adverse events were reversible.

Dr Topp said the data support further investigation of blinatumomab in adult patients with relapsed/refractory ALL.

He noted that a global phase 2 study in this setting has already been initiated in the United States and Europe.

Robert Gould, MD, a hospitalist in suburban Seattle, knows that his HM colleagues don't immediately think of pertussis as a diagnosis. But as an epidemic of whooping cough rolls through Washington state, he urges they keep the disease in mind.

"I'm thinking about it more," says Dr. Gould, a hospitalist at Swedish/Edmonds Hospital in Edmonds, Wash., who has treated one patient who tested positive for the illness. "One thing I think about is if someone comes in with a primary respiratory issue and they have underlying COPD and they're having a cough. Do you test for it? Do you consider it? It's just so hard, because do you test everyone who comes in with one week of cough?"

The topic is timely. The Washington State Department of Health reports that through May 26, the state reported 1,947 cases of whooping cough, up from just 154 cases for the same time period last year.

Dr. Gould says the outbreak of pertussis brings up an interesting question for hospitalists. HM physicians don't want to order unnecessary tests—particularly in light of recent initiatives to combat the practice—but not testing can leave a person vulnerable to the disease's progression. When suspicions are high that whooping cough is the diagnosis, one solution is simply to order one of the most common therapies: azithromycin. That eliminates the testing cost, which can run up to several hundred dollars, while giving the patient a medication not greatly associated with Clostridium difficile or other negative outcomes, Dr. Gould says.

"Thinking about it is the biggest thing," he adds.

Robert Gould, MD, a hospitalist in suburban Seattle, knows that his HM colleagues don't immediately think of pertussis as a diagnosis. But as an epidemic of whooping cough rolls through Washington state, he urges they keep the disease in mind.

"I'm thinking about it more," says Dr. Gould, a hospitalist at Swedish/Edmonds Hospital in Edmonds, Wash., who has treated one patient who tested positive for the illness. "One thing I think about is if someone comes in with a primary respiratory issue and they have underlying COPD and they're having a cough. Do you test for it? Do you consider it? It's just so hard, because do you test everyone who comes in with one week of cough?"

The topic is timely. The Washington State Department of Health reports that through May 26, the state reported 1,947 cases of whooping cough, up from just 154 cases for the same time period last year.

Dr. Gould says the outbreak of pertussis brings up an interesting question for hospitalists. HM physicians don't want to order unnecessary tests—particularly in light of recent initiatives to combat the practice—but not testing can leave a person vulnerable to the disease's progression. When suspicions are high that whooping cough is the diagnosis, one solution is simply to order one of the most common therapies: azithromycin. That eliminates the testing cost, which can run up to several hundred dollars, while giving the patient a medication not greatly associated with Clostridium difficile or other negative outcomes, Dr. Gould says.

"Thinking about it is the biggest thing," he adds.

Robert Gould, MD, a hospitalist in suburban Seattle, knows that his HM colleagues don't immediately think of pertussis as a diagnosis. But as an epidemic of whooping cough rolls through Washington state, he urges they keep the disease in mind.

"I'm thinking about it more," says Dr. Gould, a hospitalist at Swedish/Edmonds Hospital in Edmonds, Wash., who has treated one patient who tested positive for the illness. "One thing I think about is if someone comes in with a primary respiratory issue and they have underlying COPD and they're having a cough. Do you test for it? Do you consider it? It's just so hard, because do you test everyone who comes in with one week of cough?"

The topic is timely. The Washington State Department of Health reports that through May 26, the state reported 1,947 cases of whooping cough, up from just 154 cases for the same time period last year.

Dr. Gould says the outbreak of pertussis brings up an interesting question for hospitalists. HM physicians don't want to order unnecessary tests—particularly in light of recent initiatives to combat the practice—but not testing can leave a person vulnerable to the disease's progression. When suspicions are high that whooping cough is the diagnosis, one solution is simply to order one of the most common therapies: azithromycin. That eliminates the testing cost, which can run up to several hundred dollars, while giving the patient a medication not greatly associated with Clostridium difficile or other negative outcomes, Dr. Gould says.

"Thinking about it is the biggest thing," he adds.

Clinical question: With the current use of warfarin for stroke prophylaxis in patients with nonvalvular atrial fibrillation, what do the most recent data show with regard to time spent in the therapeutic window, stroke risk, and bleeding risk?

Background: Historically, warfarin has been shown to decrease stroke risk in nonvalvular atrial fibrillation by 62% compared with placebo, balanced by a significant risk of bleeding. Despite the availability of multiple new antithrombotic agents, warfarin will likely continue to be widely used given its lower cost. As a result, physicians need an accurate estimate of warfarin’s efficacy and safety as currently used in practice.

Study design: Meta-analysis of randomized controlled trials (RCTs).

Setting: RCTs comparing warfarin to an alternative antithrombotic agent from 2001 to 2011.

Synopsis: Eight RCTs of nonvalvular atrial fibrillation were included, yielding data on 32,053 patients with a mean age range of 70 to 82 years and widely variable CHADS2 scores. The time spent at a therapeutic INR was found to be improved when compared to historical rates, ranging from 55% to 68%. The rate of stroke or non-central-nervous-system embolism ranged from 1.2% to 2.3% per year, with a pooled event rate of 1.66% per year, compared with 2.09% per year in earlier trials.

Major bleeding was defined differently across studies, with a reported incidence of 1.4% to 3.4% per year, a pooled event rate of intracranial hemorrhage of 0.61%, and a cumulative adverse event rate of 3.0% to 7.64%. Stroke rates were highest in patients older than 75 years, women, those with a history of transient ischemic attack or stroke, those new to warfarin, and those with higher CHADS2 scores.

Bottom line: Warfarin as currently used is associated with an annual rate of stroke or systemic embolism of 1.66% and an annual rate of major bleeding ranging from 1.4% to 3.4%.

Citation: Agarwal S, Hachamovitch R, Menon V. Current trial-associated outcomes with warfarin in prevention of stroke in patients with nonvalvular atrial fibrillation: a meta-analysis. Arch Intern Med. 2012;172:623-631.

Clinical question: With the current use of warfarin for stroke prophylaxis in patients with nonvalvular atrial fibrillation, what do the most recent data show with regard to time spent in the therapeutic window, stroke risk, and bleeding risk?

Background: Historically, warfarin has been shown to decrease stroke risk in nonvalvular atrial fibrillation by 62% compared with placebo, balanced by a significant risk of bleeding. Despite the availability of multiple new antithrombotic agents, warfarin will likely continue to be widely used given its lower cost. As a result, physicians need an accurate estimate of warfarin’s efficacy and safety as currently used in practice.

Study design: Meta-analysis of randomized controlled trials (RCTs).

Setting: RCTs comparing warfarin to an alternative antithrombotic agent from 2001 to 2011.

Synopsis: Eight RCTs of nonvalvular atrial fibrillation were included, yielding data on 32,053 patients with a mean age range of 70 to 82 years and widely variable CHADS2 scores. The time spent at a therapeutic INR was found to be improved when compared to historical rates, ranging from 55% to 68%. The rate of stroke or non-central-nervous-system embolism ranged from 1.2% to 2.3% per year, with a pooled event rate of 1.66% per year, compared with 2.09% per year in earlier trials.

Major bleeding was defined differently across studies, with a reported incidence of 1.4% to 3.4% per year, a pooled event rate of intracranial hemorrhage of 0.61%, and a cumulative adverse event rate of 3.0% to 7.64%. Stroke rates were highest in patients older than 75 years, women, those with a history of transient ischemic attack or stroke, those new to warfarin, and those with higher CHADS2 scores.

Bottom line: Warfarin as currently used is associated with an annual rate of stroke or systemic embolism of 1.66% and an annual rate of major bleeding ranging from 1.4% to 3.4%.

Citation: Agarwal S, Hachamovitch R, Menon V. Current trial-associated outcomes with warfarin in prevention of stroke in patients with nonvalvular atrial fibrillation: a meta-analysis. Arch Intern Med. 2012;172:623-631.

Clinical question: With the current use of warfarin for stroke prophylaxis in patients with nonvalvular atrial fibrillation, what do the most recent data show with regard to time spent in the therapeutic window, stroke risk, and bleeding risk?

Background: Historically, warfarin has been shown to decrease stroke risk in nonvalvular atrial fibrillation by 62% compared with placebo, balanced by a significant risk of bleeding. Despite the availability of multiple new antithrombotic agents, warfarin will likely continue to be widely used given its lower cost. As a result, physicians need an accurate estimate of warfarin’s efficacy and safety as currently used in practice.

Study design: Meta-analysis of randomized controlled trials (RCTs).

Setting: RCTs comparing warfarin to an alternative antithrombotic agent from 2001 to 2011.

Synopsis: Eight RCTs of nonvalvular atrial fibrillation were included, yielding data on 32,053 patients with a mean age range of 70 to 82 years and widely variable CHADS2 scores. The time spent at a therapeutic INR was found to be improved when compared to historical rates, ranging from 55% to 68%. The rate of stroke or non-central-nervous-system embolism ranged from 1.2% to 2.3% per year, with a pooled event rate of 1.66% per year, compared with 2.09% per year in earlier trials.

Major bleeding was defined differently across studies, with a reported incidence of 1.4% to 3.4% per year, a pooled event rate of intracranial hemorrhage of 0.61%, and a cumulative adverse event rate of 3.0% to 7.64%. Stroke rates were highest in patients older than 75 years, women, those with a history of transient ischemic attack or stroke, those new to warfarin, and those with higher CHADS2 scores.

Bottom line: Warfarin as currently used is associated with an annual rate of stroke or systemic embolism of 1.66% and an annual rate of major bleeding ranging from 1.4% to 3.4%.

Citation: Agarwal S, Hachamovitch R, Menon V. Current trial-associated outcomes with warfarin in prevention of stroke in patients with nonvalvular atrial fibrillation: a meta-analysis. Arch Intern Med. 2012;172:623-631.

SHM has joined the growing number of professional medical societies calling for the repeal of the sustainable growth rate (SGR) formula, and they want you to join the fight.

In the past few weeks, SHM, the Medical Group Management Association (MGMA), and the American Medical Association (AMA) have decried the Medicare payment system and called for its end. All were responding to a U.S. House of Representatives request for comments on how to rebuild Medicare reimbursement for physicians.

Unless Congress repeals the formula or approves the latest in a series of extensions, Medicare physician payments will be reduced by 30.9% on Jan. 1, 2013. And while most observers doubt the deep cuts will ever be implemented, the specter of them is cause for concern.

"It's hugely disruptive to the planning process for any business, no matter what size," says Ron Greeno, MD, MHM, Cogent HMG's chief medical officer and the chair of SHM's Public Policy Committee.

SHM has thrown its support behind one potential solution, a bipartisan bill drafted by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck (R-Nev.). If passed, it would eliminate the SGR formula and push for new payment models.

Dr. Greeno, who is "hopeful but not optimistic" that the bill can pass, says hospitalists need to step up and support those who are supporting hospitalists. To that end, the society is urging members to contact their local representatives to support the legislation.

"You have to be vocal, you have to be consistently vocal," he says. "We have to be diligent, continue to advance this as an issue, continue to support the people that are seeking reasonable solutions. Despite everything that gets put in our way, we have to continue to be vocal and continue to support this. One of these times, it’s going to work."

For more information, check out SHM's Advocacy portal. Use this directory to find and email your elected officials.

SHM has joined the growing number of professional medical societies calling for the repeal of the sustainable growth rate (SGR) formula, and they want you to join the fight.

In the past few weeks, SHM, the Medical Group Management Association (MGMA), and the American Medical Association (AMA) have decried the Medicare payment system and called for its end. All were responding to a U.S. House of Representatives request for comments on how to rebuild Medicare reimbursement for physicians.

Unless Congress repeals the formula or approves the latest in a series of extensions, Medicare physician payments will be reduced by 30.9% on Jan. 1, 2013. And while most observers doubt the deep cuts will ever be implemented, the specter of them is cause for concern.

"It's hugely disruptive to the planning process for any business, no matter what size," says Ron Greeno, MD, MHM, Cogent HMG's chief medical officer and the chair of SHM's Public Policy Committee.

SHM has thrown its support behind one potential solution, a bipartisan bill drafted by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck (R-Nev.). If passed, it would eliminate the SGR formula and push for new payment models.

Dr. Greeno, who is "hopeful but not optimistic" that the bill can pass, says hospitalists need to step up and support those who are supporting hospitalists. To that end, the society is urging members to contact their local representatives to support the legislation.

"You have to be vocal, you have to be consistently vocal," he says. "We have to be diligent, continue to advance this as an issue, continue to support the people that are seeking reasonable solutions. Despite everything that gets put in our way, we have to continue to be vocal and continue to support this. One of these times, it’s going to work."

For more information, check out SHM's Advocacy portal. Use this directory to find and email your elected officials.

SHM has joined the growing number of professional medical societies calling for the repeal of the sustainable growth rate (SGR) formula, and they want you to join the fight.

In the past few weeks, SHM, the Medical Group Management Association (MGMA), and the American Medical Association (AMA) have decried the Medicare payment system and called for its end. All were responding to a U.S. House of Representatives request for comments on how to rebuild Medicare reimbursement for physicians.

Unless Congress repeals the formula or approves the latest in a series of extensions, Medicare physician payments will be reduced by 30.9% on Jan. 1, 2013. And while most observers doubt the deep cuts will ever be implemented, the specter of them is cause for concern.

"It's hugely disruptive to the planning process for any business, no matter what size," says Ron Greeno, MD, MHM, Cogent HMG's chief medical officer and the chair of SHM's Public Policy Committee.

SHM has thrown its support behind one potential solution, a bipartisan bill drafted by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck (R-Nev.). If passed, it would eliminate the SGR formula and push for new payment models.

Dr. Greeno, who is "hopeful but not optimistic" that the bill can pass, says hospitalists need to step up and support those who are supporting hospitalists. To that end, the society is urging members to contact their local representatives to support the legislation.

"You have to be vocal, you have to be consistently vocal," he says. "We have to be diligent, continue to advance this as an issue, continue to support the people that are seeking reasonable solutions. Despite everything that gets put in our way, we have to continue to be vocal and continue to support this. One of these times, it’s going to work."

For more information, check out SHM's Advocacy portal. Use this directory to find and email your elected officials.

In less than four months CMS' Hospital Readmissions Reduction Program will start penalizing hospitals with higher-than-projected readmissions rates. But as the Oct. 1 program launch looms for many hospitals, one readmission initiative is making significant progress to reduce unnecessary hospitalizations.

The Minnesota Reducing Avoidable Readmissions Effectively (RARE) campaign set a goal of preventing 4,000 avoidable readmissions among commercial health plan patients by the end of 2012, a 20% reduction from 2009 baseline data. The campaign was launched last September by three operating partners: the Minnesota Hospital Association (MHA); the Institute for Clinical Systems Improvement (ICSI), a nonprofit collaborative of 55 medical groups and hospitals; and Stratis Health, the state's QI organization. RARE's partners include more than 80 hospitals, which according to the MHA already have prevented 1,011 avoidable readmissions in 2011 and expect to surpass the target goal by the end of 2012.

"We had a specific process for each partner to follow, including a commitment by leadership to support and provide needed resources and development of a guidance team and a working team at each site," says Kathy Cummings, RN, MA, project manager at ICSI.

Each participating hospital was invited to join one of three quality collaboratives: one based on Project RED; one based on Dr. Eric Coleman's Care Transitions model; and one focused on safe transitions-of-care communication developed by the MHA.

"Everyone is rallying around the goals. They are all talking at the table, and starting to break down the silos between hospital, nursing home, clinic, and the chasms in between," says hospitalist Howard Epstein, MD, FHM, ICSI's chief health systems officer. "One of the key attributes of hospitalists is collaboration and systems improvement within their hospitals. Working with RARE is broadening their perspectives on the workings of the healthcare system as a whole."

In less than four months CMS' Hospital Readmissions Reduction Program will start penalizing hospitals with higher-than-projected readmissions rates. But as the Oct. 1 program launch looms for many hospitals, one readmission initiative is making significant progress to reduce unnecessary hospitalizations.

The Minnesota Reducing Avoidable Readmissions Effectively (RARE) campaign set a goal of preventing 4,000 avoidable readmissions among commercial health plan patients by the end of 2012, a 20% reduction from 2009 baseline data. The campaign was launched last September by three operating partners: the Minnesota Hospital Association (MHA); the Institute for Clinical Systems Improvement (ICSI), a nonprofit collaborative of 55 medical groups and hospitals; and Stratis Health, the state's QI organization. RARE's partners include more than 80 hospitals, which according to the MHA already have prevented 1,011 avoidable readmissions in 2011 and expect to surpass the target goal by the end of 2012.

"We had a specific process for each partner to follow, including a commitment by leadership to support and provide needed resources and development of a guidance team and a working team at each site," says Kathy Cummings, RN, MA, project manager at ICSI.

Each participating hospital was invited to join one of three quality collaboratives: one based on Project RED; one based on Dr. Eric Coleman's Care Transitions model; and one focused on safe transitions-of-care communication developed by the MHA.

"Everyone is rallying around the goals. They are all talking at the table, and starting to break down the silos between hospital, nursing home, clinic, and the chasms in between," says hospitalist Howard Epstein, MD, FHM, ICSI's chief health systems officer. "One of the key attributes of hospitalists is collaboration and systems improvement within their hospitals. Working with RARE is broadening their perspectives on the workings of the healthcare system as a whole."

In less than four months CMS' Hospital Readmissions Reduction Program will start penalizing hospitals with higher-than-projected readmissions rates. But as the Oct. 1 program launch looms for many hospitals, one readmission initiative is making significant progress to reduce unnecessary hospitalizations.

The Minnesota Reducing Avoidable Readmissions Effectively (RARE) campaign set a goal of preventing 4,000 avoidable readmissions among commercial health plan patients by the end of 2012, a 20% reduction from 2009 baseline data. The campaign was launched last September by three operating partners: the Minnesota Hospital Association (MHA); the Institute for Clinical Systems Improvement (ICSI), a nonprofit collaborative of 55 medical groups and hospitals; and Stratis Health, the state's QI organization. RARE's partners include more than 80 hospitals, which according to the MHA already have prevented 1,011 avoidable readmissions in 2011 and expect to surpass the target goal by the end of 2012.

"We had a specific process for each partner to follow, including a commitment by leadership to support and provide needed resources and development of a guidance team and a working team at each site," says Kathy Cummings, RN, MA, project manager at ICSI.

Each participating hospital was invited to join one of three quality collaboratives: one based on Project RED; one based on Dr. Eric Coleman's Care Transitions model; and one focused on safe transitions-of-care communication developed by the MHA.

"Everyone is rallying around the goals. They are all talking at the table, and starting to break down the silos between hospital, nursing home, clinic, and the chasms in between," says hospitalist Howard Epstein, MD, FHM, ICSI's chief health systems officer. "One of the key attributes of hospitalists is collaboration and systems improvement within their hospitals. Working with RARE is broadening their perspectives on the workings of the healthcare system as a whole."

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

Quality of care for ascites, the most common complication of cirrhosis, was found to be suboptimal at several Veterans Affairs medical centers, reported Dr. Fasiha Kanwal and colleagues in the July issue of Gastroenterology.

"In general, care targeted at diagnosis and treatment was more likely to meet standards than preventive care," wrote Dr. Kanwal, of the Michael E. DeBakey Veterans Affairs Medical Center, Houston.

"We also found a trend towards improved outcomes in patients who met recommended quality indicators," added the investigators, although these findings "can only be regarded as preliminary."

The authors studied records from 774 patients (mean age 54.7 years, 99% male) in a database comprising 3 VA medical centers and 15 affiliated clinics in the Midwest (Gastroenterology 2012 [doi: 10.1053/j.gastro.2012.03.038]).

All patients had at least two ICD-9 codes for cirrhosis or at least one code for cirrhosis with either a code for complications of cirrhosis or an aspartate aminotransferase to platelet ratio greater than 2. The patients were seen between January 2000 and December 2007.

The authors compared data on these patients to a set of class 1 ascites care quality indicators (QIs). These indicators were derived by using the RAND/University of California, Los Angeles (UCLA), Appropriateness Method, which had been previously published elsewhere (Clin. Gastroenterol. Hepatol. 2010;8:709-17).

If a patient had been hospitalized more than once, only the first hospitalization was assessed. The rate of adherence to each QI was expressed as a percentage of subjects who received the recommended care, among those who were eligible for the QI.

The first QI assessed the percentage of new-onset ascites patients who underwent abdominal paracentesis within 30 days of diagnosis. On this measure, the VA scored 50.6%. The second indicator was whether known ascites patients admitted with either ascites or hepatic encephalopathy underwent abdominal paracentesis during the index hospitalization. Just over half (57.6%) of patients met this criterion.

The next QI was more likely to be met: 89.3% of patients who underwent abdominal paracentesis received ascitic fluid cell count and differential. Another indicator that was met for a high percentage of patients addressed whether ascites patients with normal renal function received diuretics within 30 days of diagnosis – 82.8% met this criterion.

Similarly, among hospitalized patients with spontaneous bacterial peritonitis (SBP), 72.0% received antibiotics within 24 hours before or after ascitic fluid analysis.

However, just 30% of patients with SBP who survived and were discharged from the facility received long-term outpatient antibiotics (for secondary prophylaxis) within 30 days. And just under half (49.2%) of patients admitted with a GI bleed received antibiotics during the index hospitalization.

The final QI was associated with the worst compliance rate: just 22.2% of patients with ascitic fluid total protein levels less than 1 g/dL and serum bilirubin of greater than 2.5 mg/dL received long-term outpatient antibiotics (for primary prophylaxis) within –3 to 30 days of that test result.

Next, the authors assessed which demographic or other independent factors were associated with higher QI compliance. In general, they reported that better care was inversely related to a worsening liver disease. More specifically, they found that patients who saw a gastroenterologist received higher-quality care than those who did not (odds ratio, 1.33), as did patients who were seen at a VA facility with academic affiliation, versus unaffiliated centers (OR, 1.73).

Finally, in two exploratory analyses, the authors examined how adherence to the ascites QIs affected patient outcomes.

Not surprisingly, "we found that after adjusting for age, liver disease severity, and comorbidity, patients receiving suboptimum care had 37% higher odds of death and 35% higher odds of readmission during the 12-month follow-up compared to patients who received optimum ascites care," although these figures did not reach statistical significance.

This study was supported by the 2008 American Society of Gastrointestinal Endoscopy Quality of Care Award and by the 2009 American College of Gastroenterology Clinical Research Award. The authors stated that they had no personal conflicts of interest.

Quality of care for ascites, the most common complication of cirrhosis, was found to be suboptimal at several Veterans Affairs medical centers, reported Dr. Fasiha Kanwal and colleagues in the July issue of Gastroenterology.

"In general, care targeted at diagnosis and treatment was more likely to meet standards than preventive care," wrote Dr. Kanwal, of the Michael E. DeBakey Veterans Affairs Medical Center, Houston.

"We also found a trend towards improved outcomes in patients who met recommended quality indicators," added the investigators, although these findings "can only be regarded as preliminary."

The authors studied records from 774 patients (mean age 54.7 years, 99% male) in a database comprising 3 VA medical centers and 15 affiliated clinics in the Midwest (Gastroenterology 2012 [doi: 10.1053/j.gastro.2012.03.038]).

All patients had at least two ICD-9 codes for cirrhosis or at least one code for cirrhosis with either a code for complications of cirrhosis or an aspartate aminotransferase to platelet ratio greater than 2. The patients were seen between January 2000 and December 2007.

The authors compared data on these patients to a set of class 1 ascites care quality indicators (QIs). These indicators were derived by using the RAND/University of California, Los Angeles (UCLA), Appropriateness Method, which had been previously published elsewhere (Clin. Gastroenterol. Hepatol. 2010;8:709-17).

If a patient had been hospitalized more than once, only the first hospitalization was assessed. The rate of adherence to each QI was expressed as a percentage of subjects who received the recommended care, among those who were eligible for the QI.

The first QI assessed the percentage of new-onset ascites patients who underwent abdominal paracentesis within 30 days of diagnosis. On this measure, the VA scored 50.6%. The second indicator was whether known ascites patients admitted with either ascites or hepatic encephalopathy underwent abdominal paracentesis during the index hospitalization. Just over half (57.6%) of patients met this criterion.

The next QI was more likely to be met: 89.3% of patients who underwent abdominal paracentesis received ascitic fluid cell count and differential. Another indicator that was met for a high percentage of patients addressed whether ascites patients with normal renal function received diuretics within 30 days of diagnosis – 82.8% met this criterion.

Similarly, among hospitalized patients with spontaneous bacterial peritonitis (SBP), 72.0% received antibiotics within 24 hours before or after ascitic fluid analysis.

However, just 30% of patients with SBP who survived and were discharged from the facility received long-term outpatient antibiotics (for secondary prophylaxis) within 30 days. And just under half (49.2%) of patients admitted with a GI bleed received antibiotics during the index hospitalization.

The final QI was associated with the worst compliance rate: just 22.2% of patients with ascitic fluid total protein levels less than 1 g/dL and serum bilirubin of greater than 2.5 mg/dL received long-term outpatient antibiotics (for primary prophylaxis) within –3 to 30 days of that test result.

Next, the authors assessed which demographic or other independent factors were associated with higher QI compliance. In general, they reported that better care was inversely related to a worsening liver disease. More specifically, they found that patients who saw a gastroenterologist received higher-quality care than those who did not (odds ratio, 1.33), as did patients who were seen at a VA facility with academic affiliation, versus unaffiliated centers (OR, 1.73).

Finally, in two exploratory analyses, the authors examined how adherence to the ascites QIs affected patient outcomes.

Not surprisingly, "we found that after adjusting for age, liver disease severity, and comorbidity, patients receiving suboptimum care had 37% higher odds of death and 35% higher odds of readmission during the 12-month follow-up compared to patients who received optimum ascites care," although these figures did not reach statistical significance.

This study was supported by the 2008 American Society of Gastrointestinal Endoscopy Quality of Care Award and by the 2009 American College of Gastroenterology Clinical Research Award. The authors stated that they had no personal conflicts of interest.

Quality of care for ascites, the most common complication of cirrhosis, was found to be suboptimal at several Veterans Affairs medical centers, reported Dr. Fasiha Kanwal and colleagues in the July issue of Gastroenterology.

"In general, care targeted at diagnosis and treatment was more likely to meet standards than preventive care," wrote Dr. Kanwal, of the Michael E. DeBakey Veterans Affairs Medical Center, Houston.

"We also found a trend towards improved outcomes in patients who met recommended quality indicators," added the investigators, although these findings "can only be regarded as preliminary."

The authors studied records from 774 patients (mean age 54.7 years, 99% male) in a database comprising 3 VA medical centers and 15 affiliated clinics in the Midwest (Gastroenterology 2012 [doi: 10.1053/j.gastro.2012.03.038]).

All patients had at least two ICD-9 codes for cirrhosis or at least one code for cirrhosis with either a code for complications of cirrhosis or an aspartate aminotransferase to platelet ratio greater than 2. The patients were seen between January 2000 and December 2007.

The authors compared data on these patients to a set of class 1 ascites care quality indicators (QIs). These indicators were derived by using the RAND/University of California, Los Angeles (UCLA), Appropriateness Method, which had been previously published elsewhere (Clin. Gastroenterol. Hepatol. 2010;8:709-17).

If a patient had been hospitalized more than once, only the first hospitalization was assessed. The rate of adherence to each QI was expressed as a percentage of subjects who received the recommended care, among those who were eligible for the QI.

The first QI assessed the percentage of new-onset ascites patients who underwent abdominal paracentesis within 30 days of diagnosis. On this measure, the VA scored 50.6%. The second indicator was whether known ascites patients admitted with either ascites or hepatic encephalopathy underwent abdominal paracentesis during the index hospitalization. Just over half (57.6%) of patients met this criterion.

The next QI was more likely to be met: 89.3% of patients who underwent abdominal paracentesis received ascitic fluid cell count and differential. Another indicator that was met for a high percentage of patients addressed whether ascites patients with normal renal function received diuretics within 30 days of diagnosis – 82.8% met this criterion.

Similarly, among hospitalized patients with spontaneous bacterial peritonitis (SBP), 72.0% received antibiotics within 24 hours before or after ascitic fluid analysis.

However, just 30% of patients with SBP who survived and were discharged from the facility received long-term outpatient antibiotics (for secondary prophylaxis) within 30 days. And just under half (49.2%) of patients admitted with a GI bleed received antibiotics during the index hospitalization.

The final QI was associated with the worst compliance rate: just 22.2% of patients with ascitic fluid total protein levels less than 1 g/dL and serum bilirubin of greater than 2.5 mg/dL received long-term outpatient antibiotics (for primary prophylaxis) within –3 to 30 days of that test result.

Next, the authors assessed which demographic or other independent factors were associated with higher QI compliance. In general, they reported that better care was inversely related to a worsening liver disease. More specifically, they found that patients who saw a gastroenterologist received higher-quality care than those who did not (odds ratio, 1.33), as did patients who were seen at a VA facility with academic affiliation, versus unaffiliated centers (OR, 1.73).

Finally, in two exploratory analyses, the authors examined how adherence to the ascites QIs affected patient outcomes.

Not surprisingly, "we found that after adjusting for age, liver disease severity, and comorbidity, patients receiving suboptimum care had 37% higher odds of death and 35% higher odds of readmission during the 12-month follow-up compared to patients who received optimum ascites care," although these figures did not reach statistical significance.

This study was supported by the 2008 American Society of Gastrointestinal Endoscopy Quality of Care Award and by the 2009 American College of Gastroenterology Clinical Research Award. The authors stated that they had no personal conflicts of interest.

As I write this, the government’s "new jobs" figures are at last turning a bit optimistic. This is consistent with the growing number of questions I’m receiving on a subject that hasn’t come up for awhile: hiring new employees. So although we probably haven’t seen the end of the Great Recession just yet, now might be a good time to review the basic rules in preparation for getting your office back to full speed.

Many of the personnel questions I receive concern the dreaded "marginal employee": the person who has done neither anything heinous enough to merit firing, nor anything special to merit continued employment. I always advise getting rid of such people, and then changing the hiring criteria that all too often result in poor hires.

Most bad hires come about because the employer does not have a clear vision of the kind of employee he or she wants. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate, from your initial screening of applicants through your assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate checking of references.

So now – before a job vacancy occurs – is the time to reevaluate your entire hiring process. Take a hard look at your job descriptions, or start compiling them if you don’t have any. A good description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes (accurately and in detail) exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match. This is not a place to cut corners. Screen your candidates carefully, and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It is also sometimes tempting to hire the candidate that you have the "best feeling" about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.

Be alert for red flags in resumes: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their resumes; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of calling references; many applicants know that. Some old bosses will be reluctant to tell you anything substantive; I always ask, "Would you hire this person again?" You can interpret a lot from the answer – or lack of.

Interviews often get short shrift as well. Many doctors tend to do all the talking; as I’ve observed numerous times, listening is not our strong suit, as a general rule. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, gender, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

But there are acceptable alternatives to some of those questions: You can ask if an applicant has ever gone by another name (for your background check), for example. You can ask if he or she is legally authorized to work in this country, and whether he or she will be physically able to perform the duties specified in the job description. Although past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. "The best executive," wrote Theodore Roosevelt, "is the one who has sense enough to pick good people to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it."

 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

As I write this, the government’s "new jobs" figures are at last turning a bit optimistic. This is consistent with the growing number of questions I’m receiving on a subject that hasn’t come up for awhile: hiring new employees. So although we probably haven’t seen the end of the Great Recession just yet, now might be a good time to review the basic rules in preparation for getting your office back to full speed.

Many of the personnel questions I receive concern the dreaded "marginal employee": the person who has done neither anything heinous enough to merit firing, nor anything special to merit continued employment. I always advise getting rid of such people, and then changing the hiring criteria that all too often result in poor hires.

Most bad hires come about because the employer does not have a clear vision of the kind of employee he or she wants. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate, from your initial screening of applicants through your assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate checking of references.

So now – before a job vacancy occurs – is the time to reevaluate your entire hiring process. Take a hard look at your job descriptions, or start compiling them if you don’t have any. A good description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes (accurately and in detail) exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match. This is not a place to cut corners. Screen your candidates carefully, and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It is also sometimes tempting to hire the candidate that you have the "best feeling" about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.

Be alert for red flags in resumes: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their resumes; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of calling references; many applicants know that. Some old bosses will be reluctant to tell you anything substantive; I always ask, "Would you hire this person again?" You can interpret a lot from the answer – or lack of.

Interviews often get short shrift as well. Many doctors tend to do all the talking; as I’ve observed numerous times, listening is not our strong suit, as a general rule. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, gender, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

But there are acceptable alternatives to some of those questions: You can ask if an applicant has ever gone by another name (for your background check), for example. You can ask if he or she is legally authorized to work in this country, and whether he or she will be physically able to perform the duties specified in the job description. Although past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. "The best executive," wrote Theodore Roosevelt, "is the one who has sense enough to pick good people to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it."

 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.

As I write this, the government’s "new jobs" figures are at last turning a bit optimistic. This is consistent with the growing number of questions I’m receiving on a subject that hasn’t come up for awhile: hiring new employees. So although we probably haven’t seen the end of the Great Recession just yet, now might be a good time to review the basic rules in preparation for getting your office back to full speed.

Many of the personnel questions I receive concern the dreaded "marginal employee": the person who has done neither anything heinous enough to merit firing, nor anything special to merit continued employment. I always advise getting rid of such people, and then changing the hiring criteria that all too often result in poor hires.

Most bad hires come about because the employer does not have a clear vision of the kind of employee he or she wants. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate, from your initial screening of applicants through your assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate checking of references.

So now – before a job vacancy occurs – is the time to reevaluate your entire hiring process. Take a hard look at your job descriptions, or start compiling them if you don’t have any. A good description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes (accurately and in detail) exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match. This is not a place to cut corners. Screen your candidates carefully, and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It is also sometimes tempting to hire the candidate that you have the "best feeling" about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.

Be alert for red flags in resumes: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their resumes; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of calling references; many applicants know that. Some old bosses will be reluctant to tell you anything substantive; I always ask, "Would you hire this person again?" You can interpret a lot from the answer – or lack of.

Interviews often get short shrift as well. Many doctors tend to do all the talking; as I’ve observed numerous times, listening is not our strong suit, as a general rule. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, gender, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

But there are acceptable alternatives to some of those questions: You can ask if an applicant has ever gone by another name (for your background check), for example. You can ask if he or she is legally authorized to work in this country, and whether he or she will be physically able to perform the duties specified in the job description. Although past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. "The best executive," wrote Theodore Roosevelt, "is the one who has sense enough to pick good people to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it."

 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J.