Jacob Imber, MD

Clinical question: Do higher rates of patient satisfaction lead to lower rates of hospital readmission?

Background: Readmissions account for 32.1% of total health care expenditures in the United States, of which 15%-20% are considered potentially preventable. Multiple studies have examined a variety of possible indicators of readmission, but rarely has patient perspective prior to discharge been examined.

Study design: Thematic interview and questionnaire.

Setting: Two inpatient medical units at Massachusetts General Hospital, Boston.

Synopsis: 846 patients were enrolled during their index admission with 201 of these patients being readmitted within 30 days of discharge. During the index admission, the patients completed a questionnaire developed by the authors and underwent a formal, thematic interview with identification of core domains performed by trained research coordinators. The primary outcome was 30-day readmission. Readmitted patients were less likely to have reported being “very satisfied” with their overall care (67.7% vs. 76.4%; P = .045) and were less likely to have reported that physicians “always listened” to them (65.7% vs. 73.2%; P = .048). Interestingly, if health care providers discussed the possible need for help after hospital stay, the patient had an increased risk of readmission (adjusted odds ratio, 1.56; 95% confidence interval, 1.02-2.39; P = .04) and patients who predicted they were “very likely” to require readmission were not more likely to be readmitted (aOR, 1.35; 95% CI, 0.83-2.19; P = .22). The major limitations of this study are that researchers interviewed only English-speaking patients who were able to participate in an in-depth interview and survey, perhaps resulting in a healthier-patient bias, as well as an inability to capture hospital admission at other institutions. Additionally, these patients are drawn from a tertiary-care service designed to care for medically complex cases and may not be generalizable to larger populations.

Bottom line: Lower rates of 30-day hospital readmission were associated with higher rates of patient satisfaction and a higher level of patient perception that providers were listening to them.

Citation: Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 2018 Sep;27:683-90.

Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.

Clinical question: Do higher rates of patient satisfaction lead to lower rates of hospital readmission?

Background: Readmissions account for 32.1% of total health care expenditures in the United States, of which 15%-20% are considered potentially preventable. Multiple studies have examined a variety of possible indicators of readmission, but rarely has patient perspective prior to discharge been examined.

Study design: Thematic interview and questionnaire.

Setting: Two inpatient medical units at Massachusetts General Hospital, Boston.

Synopsis: 846 patients were enrolled during their index admission with 201 of these patients being readmitted within 30 days of discharge. During the index admission, the patients completed a questionnaire developed by the authors and underwent a formal, thematic interview with identification of core domains performed by trained research coordinators. The primary outcome was 30-day readmission. Readmitted patients were less likely to have reported being “very satisfied” with their overall care (67.7% vs. 76.4%; P = .045) and were less likely to have reported that physicians “always listened” to them (65.7% vs. 73.2%; P = .048). Interestingly, if health care providers discussed the possible need for help after hospital stay, the patient had an increased risk of readmission (adjusted odds ratio, 1.56; 95% confidence interval, 1.02-2.39; P = .04) and patients who predicted they were “very likely” to require readmission were not more likely to be readmitted (aOR, 1.35; 95% CI, 0.83-2.19; P = .22). The major limitations of this study are that researchers interviewed only English-speaking patients who were able to participate in an in-depth interview and survey, perhaps resulting in a healthier-patient bias, as well as an inability to capture hospital admission at other institutions. Additionally, these patients are drawn from a tertiary-care service designed to care for medically complex cases and may not be generalizable to larger populations.

Bottom line: Lower rates of 30-day hospital readmission were associated with higher rates of patient satisfaction and a higher level of patient perception that providers were listening to them.

Citation: Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 2018 Sep;27:683-90.

Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.

Clinical question: Do higher rates of patient satisfaction lead to lower rates of hospital readmission?

Background: Readmissions account for 32.1% of total health care expenditures in the United States, of which 15%-20% are considered potentially preventable. Multiple studies have examined a variety of possible indicators of readmission, but rarely has patient perspective prior to discharge been examined.

Study design: Thematic interview and questionnaire.

Setting: Two inpatient medical units at Massachusetts General Hospital, Boston.

Synopsis: 846 patients were enrolled during their index admission with 201 of these patients being readmitted within 30 days of discharge. During the index admission, the patients completed a questionnaire developed by the authors and underwent a formal, thematic interview with identification of core domains performed by trained research coordinators. The primary outcome was 30-day readmission. Readmitted patients were less likely to have reported being “very satisfied” with their overall care (67.7% vs. 76.4%; P = .045) and were less likely to have reported that physicians “always listened” to them (65.7% vs. 73.2%; P = .048). Interestingly, if health care providers discussed the possible need for help after hospital stay, the patient had an increased risk of readmission (adjusted odds ratio, 1.56; 95% confidence interval, 1.02-2.39; P = .04) and patients who predicted they were “very likely” to require readmission were not more likely to be readmitted (aOR, 1.35; 95% CI, 0.83-2.19; P = .22). The major limitations of this study are that researchers interviewed only English-speaking patients who were able to participate in an in-depth interview and survey, perhaps resulting in a healthier-patient bias, as well as an inability to capture hospital admission at other institutions. Additionally, these patients are drawn from a tertiary-care service designed to care for medically complex cases and may not be generalizable to larger populations.

Bottom line: Lower rates of 30-day hospital readmission were associated with higher rates of patient satisfaction and a higher level of patient perception that providers were listening to them.

Citation: Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 2018 Sep;27:683-90.

Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.

 

Background: Acute variceal bleeding remains the most severe and life-threatening complication of portal hypertension in cirrhotic patients. Several small studies have shown improved outcomes with p-TIPS without worsening of hepatic encephalopathy or other adverse events.

Study design: Multicenter, international, observational study.

Setting: One Canadian and 33 European referral centers.

Synopsis: 2,138 patients were registered for analysis, of which 671 were identified as high risk based on Child-Pugh score (either Child class C of less than 14 or Child class B with active bleeding seen on endoscopy). Multiple exclusion criteria were used including Child-Pugh score of 14 or more, renal failure, occlusive portal vein thrombosis, sepsis, heart failure, or hepatocellular carcinoma outside Milan criteria. Each patient underwent initial management with vasoactive medications, antibiotics, and endoscopy with subsequent intervention (p-TIPS vs. standard care) based on provider decision. p-TIPS was defined as TIPS within 72 hours of initial bleed. 31.4% of the cohort was lost to follow-up at 1 year. p-TIPS improved 1-year mortality significantly (78% vs. 62%; P = .014) and did not confer an increased risk of hepatic encephalopathy or other complication. Additionally, the authors found that the effect was significantly greater in the Child-Pugh Class C group (1-year mortality rate of 78% vs. 53%; P = .002). The authors then compared observed mortality with MELD-predicted mortality and found that with standard care, MELD scores matched with predicted mortality, but with p-TIPS, MELD scores predicted a greater mortality than the observed mortality. The authors calculated that the number needed to treat to save one life for 1 year with p-TIPS is 4.2. The major limitation of this study is the observational design and the inherent risk of selection bias. Additionally, almost one-third of patients were lost to follow-up.

Bottom line: Significant improvements in mortality are observed when high-risk patients undergo p-TIPS procedures as opposed to usual care with medications and endoscopy.

Citation: Hernández Gea V et al. Preemptive TIPS improves outcome in high risk variceal bleeding: An observational study. Hepatology. 2018 Jul 16. doi: 10.1002/hep.30182.

Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
 

 

Background: Acute variceal bleeding remains the most severe and life-threatening complication of portal hypertension in cirrhotic patients. Several small studies have shown improved outcomes with p-TIPS without worsening of hepatic encephalopathy or other adverse events.

Study design: Multicenter, international, observational study.

Setting: One Canadian and 33 European referral centers.

Synopsis: 2,138 patients were registered for analysis, of which 671 were identified as high risk based on Child-Pugh score (either Child class C of less than 14 or Child class B with active bleeding seen on endoscopy). Multiple exclusion criteria were used including Child-Pugh score of 14 or more, renal failure, occlusive portal vein thrombosis, sepsis, heart failure, or hepatocellular carcinoma outside Milan criteria. Each patient underwent initial management with vasoactive medications, antibiotics, and endoscopy with subsequent intervention (p-TIPS vs. standard care) based on provider decision. p-TIPS was defined as TIPS within 72 hours of initial bleed. 31.4% of the cohort was lost to follow-up at 1 year. p-TIPS improved 1-year mortality significantly (78% vs. 62%; P = .014) and did not confer an increased risk of hepatic encephalopathy or other complication. Additionally, the authors found that the effect was significantly greater in the Child-Pugh Class C group (1-year mortality rate of 78% vs. 53%; P = .002). The authors then compared observed mortality with MELD-predicted mortality and found that with standard care, MELD scores matched with predicted mortality, but with p-TIPS, MELD scores predicted a greater mortality than the observed mortality. The authors calculated that the number needed to treat to save one life for 1 year with p-TIPS is 4.2. The major limitation of this study is the observational design and the inherent risk of selection bias. Additionally, almost one-third of patients were lost to follow-up.

Bottom line: Significant improvements in mortality are observed when high-risk patients undergo p-TIPS procedures as opposed to usual care with medications and endoscopy.

Citation: Hernández Gea V et al. Preemptive TIPS improves outcome in high risk variceal bleeding: An observational study. Hepatology. 2018 Jul 16. doi: 10.1002/hep.30182.

Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
 

 

Background: Acute variceal bleeding remains the most severe and life-threatening complication of portal hypertension in cirrhotic patients. Several small studies have shown improved outcomes with p-TIPS without worsening of hepatic encephalopathy or other adverse events.

Study design: Multicenter, international, observational study.

Setting: One Canadian and 33 European referral centers.

Synopsis: 2,138 patients were registered for analysis, of which 671 were identified as high risk based on Child-Pugh score (either Child class C of less than 14 or Child class B with active bleeding seen on endoscopy). Multiple exclusion criteria were used including Child-Pugh score of 14 or more, renal failure, occlusive portal vein thrombosis, sepsis, heart failure, or hepatocellular carcinoma outside Milan criteria. Each patient underwent initial management with vasoactive medications, antibiotics, and endoscopy with subsequent intervention (p-TIPS vs. standard care) based on provider decision. p-TIPS was defined as TIPS within 72 hours of initial bleed. 31.4% of the cohort was lost to follow-up at 1 year. p-TIPS improved 1-year mortality significantly (78% vs. 62%; P = .014) and did not confer an increased risk of hepatic encephalopathy or other complication. Additionally, the authors found that the effect was significantly greater in the Child-Pugh Class C group (1-year mortality rate of 78% vs. 53%; P = .002). The authors then compared observed mortality with MELD-predicted mortality and found that with standard care, MELD scores matched with predicted mortality, but with p-TIPS, MELD scores predicted a greater mortality than the observed mortality. The authors calculated that the number needed to treat to save one life for 1 year with p-TIPS is 4.2. The major limitation of this study is the observational design and the inherent risk of selection bias. Additionally, almost one-third of patients were lost to follow-up.

Bottom line: Significant improvements in mortality are observed when high-risk patients undergo p-TIPS procedures as opposed to usual care with medications and endoscopy.

Citation: Hernández Gea V et al. Preemptive TIPS improves outcome in high risk variceal bleeding: An observational study. Hepatology. 2018 Jul 16. doi: 10.1002/hep.30182.

Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
 

Background: Anticoagulation for at-risk medical populations for posthospitalization thromboprophylaxis has been investigated in previous studies demonstrating a benefit in reducing risk of asymptomatic deep-vein thrombosis (DVT) development, but no studies have examined symptomatic DVTs.

Study design: Randomized, double-­blind, placebo-controlled, multinational clinical trial.

Setting: 671 multinational hospitals.

Synopsis: 11,962 patients were identified as at-risk patients based on length of hospitalization (3-10 days), diagnosis, and additional risk factors identified by an IMPROVE risk score of greater than 4 or 2-3 with a D-dimer level more than twice the upper limit of normal. Patients were randomly assigned to receive rivaroxaban or placebo for 45 days. Primary outcome was composite of any symptomatic DVT or death related to VTE. Safety outcomes were principally related to bleeding. Symptomatic VTE or death from VTE occurred in 0.83% in the anticoagulation group and 1.1% in the placebo group (95% confidence interval, 0.52-1.09; P = .14). No significant difference was found in safety outcomes. The major limitation of the study was the low incidence of VTE and the need to include lower-­risk patients (IMPROVE score 2/3 with elevated D-dimer), which may have decreased the effect of anticoagulation in the high-risk group (IMPROVE score 4 or greater).

Bottom line: No significant improvement in symptomatic VTE complications was found with posthospitalization thromboprophylaxis using rivaroxaban for an at-risk medical population.

Citation: Spyropoulos AC et al. Rivaroxaban for thromboprophylaxis after hospitalization for medical illness. N Eng J Med. 2018 Sep 20;379:1118-27.

Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.

Background: Anticoagulation for at-risk medical populations for posthospitalization thromboprophylaxis has been investigated in previous studies demonstrating a benefit in reducing risk of asymptomatic deep-vein thrombosis (DVT) development, but no studies have examined symptomatic DVTs.

Study design: Randomized, double-­blind, placebo-controlled, multinational clinical trial.

Setting: 671 multinational hospitals.

Synopsis: 11,962 patients were identified as at-risk patients based on length of hospitalization (3-10 days), diagnosis, and additional risk factors identified by an IMPROVE risk score of greater than 4 or 2-3 with a D-dimer level more than twice the upper limit of normal. Patients were randomly assigned to receive rivaroxaban or placebo for 45 days. Primary outcome was composite of any symptomatic DVT or death related to VTE. Safety outcomes were principally related to bleeding. Symptomatic VTE or death from VTE occurred in 0.83% in the anticoagulation group and 1.1% in the placebo group (95% confidence interval, 0.52-1.09; P = .14). No significant difference was found in safety outcomes. The major limitation of the study was the low incidence of VTE and the need to include lower-­risk patients (IMPROVE score 2/3 with elevated D-dimer), which may have decreased the effect of anticoagulation in the high-risk group (IMPROVE score 4 or greater).

Bottom line: No significant improvement in symptomatic VTE complications was found with posthospitalization thromboprophylaxis using rivaroxaban for an at-risk medical population.

Citation: Spyropoulos AC et al. Rivaroxaban for thromboprophylaxis after hospitalization for medical illness. N Eng J Med. 2018 Sep 20;379:1118-27.

Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.

Background: Anticoagulation for at-risk medical populations for posthospitalization thromboprophylaxis has been investigated in previous studies demonstrating a benefit in reducing risk of asymptomatic deep-vein thrombosis (DVT) development, but no studies have examined symptomatic DVTs.

Study design: Randomized, double-­blind, placebo-controlled, multinational clinical trial.

Setting: 671 multinational hospitals.

Synopsis: 11,962 patients were identified as at-risk patients based on length of hospitalization (3-10 days), diagnosis, and additional risk factors identified by an IMPROVE risk score of greater than 4 or 2-3 with a D-dimer level more than twice the upper limit of normal. Patients were randomly assigned to receive rivaroxaban or placebo for 45 days. Primary outcome was composite of any symptomatic DVT or death related to VTE. Safety outcomes were principally related to bleeding. Symptomatic VTE or death from VTE occurred in 0.83% in the anticoagulation group and 1.1% in the placebo group (95% confidence interval, 0.52-1.09; P = .14). No significant difference was found in safety outcomes. The major limitation of the study was the low incidence of VTE and the need to include lower-­risk patients (IMPROVE score 2/3 with elevated D-dimer), which may have decreased the effect of anticoagulation in the high-risk group (IMPROVE score 4 or greater).

Bottom line: No significant improvement in symptomatic VTE complications was found with posthospitalization thromboprophylaxis using rivaroxaban for an at-risk medical population.

Citation: Spyropoulos AC et al. Rivaroxaban for thromboprophylaxis after hospitalization for medical illness. N Eng J Med. 2018 Sep 20;379:1118-27.

Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.

 

Condition Help: A patient- and family-initiated rapid response system

Implementation of a patient/family-initiated rapid response system at an academic, urban medical center resulted in 367 calls over 3½ years with 83.4% of them being for “nonsafety” issues and 11.4% being for “safety” issues.

Citation: Elizabeth L. Eden, MD, Laurie L. Rack, DNP, RN, Ling-Wan Chen, MS, Bump GM, Condition Help: A patient- and family-initiated rapid response system. J Hosp Med. 2017;3;157-161. doi: 10.12788/jhm.2697.

Association between U.S. norepinephrine shortage and mortality among patients with septic shock

A retrospective cohort study of 26 U.S. hospitals affected by the 2011 norepinephrine shortage demonstrated that phenylephrine was the most frequently used alternative and in-hospital mortality for patients admitted with septic shock rose from 35.9% to 39.6%.

Citation: Vail E, Gershengorn HB, Hua M, Walkey AJ, Rubenfeld G, Wunsch H. Association Between US Norepinephrine Shortage and Mortality Among Patients With Septic Shock. JAMA. 2017;317(14):1433-1442. doi: 10.1001/jama.2017.2841

Patient mortality during unannounced accreditation surveys at U.S. hospitals

An evaluation of quasi-randomized Medicare admissions at 1,984 hospitals demonstrated that 30-day mortality decreased by 0.18% in all hospitals and 0.48% at major teaching hospitals during The Joint Commission survey periods; both changes were greater than could be attributed to chance alone when compared to other, similar time periods.

Citation: Barnett ML, Olenski AR, Jena AB. Patient Mortality During Unannounced Accreditation Surveys at US Hospitals. JAMA Intern Med. 2017;177(5):693-700. doi: 10.1001/jamainternmed.2016.9685

Association between a virtual glucose management service and glycemic control in hospitalized adult patients

Institution of a virtual glucose management system resulted in a 39% decrease in hyperglycemic patients and a 36% decrease in hypoglycemic patients per 100 patient-days at three major teaching hospitals.

Citation: Rushakoff RJ, Sullivan MM, MacMaster HW, Shah AD, Rajkomar A, Glidden DV, et al. Association Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients: An Observational Study. Ann Intern Med. 2017;166:621-627. doi: 10.7326/M16-1413

Dr. Imber is assistant professor in the division of hospital medicine at the University of New Mexico.

 

Condition Help: A patient- and family-initiated rapid response system

Implementation of a patient/family-initiated rapid response system at an academic, urban medical center resulted in 367 calls over 3½ years with 83.4% of them being for “nonsafety” issues and 11.4% being for “safety” issues.

Citation: Elizabeth L. Eden, MD, Laurie L. Rack, DNP, RN, Ling-Wan Chen, MS, Bump GM, Condition Help: A patient- and family-initiated rapid response system. J Hosp Med. 2017;3;157-161. doi: 10.12788/jhm.2697.

Association between U.S. norepinephrine shortage and mortality among patients with septic shock

A retrospective cohort study of 26 U.S. hospitals affected by the 2011 norepinephrine shortage demonstrated that phenylephrine was the most frequently used alternative and in-hospital mortality for patients admitted with septic shock rose from 35.9% to 39.6%.

Citation: Vail E, Gershengorn HB, Hua M, Walkey AJ, Rubenfeld G, Wunsch H. Association Between US Norepinephrine Shortage and Mortality Among Patients With Septic Shock. JAMA. 2017;317(14):1433-1442. doi: 10.1001/jama.2017.2841

Patient mortality during unannounced accreditation surveys at U.S. hospitals

An evaluation of quasi-randomized Medicare admissions at 1,984 hospitals demonstrated that 30-day mortality decreased by 0.18% in all hospitals and 0.48% at major teaching hospitals during The Joint Commission survey periods; both changes were greater than could be attributed to chance alone when compared to other, similar time periods.

Citation: Barnett ML, Olenski AR, Jena AB. Patient Mortality During Unannounced Accreditation Surveys at US Hospitals. JAMA Intern Med. 2017;177(5):693-700. doi: 10.1001/jamainternmed.2016.9685

Association between a virtual glucose management service and glycemic control in hospitalized adult patients

Institution of a virtual glucose management system resulted in a 39% decrease in hyperglycemic patients and a 36% decrease in hypoglycemic patients per 100 patient-days at three major teaching hospitals.

Citation: Rushakoff RJ, Sullivan MM, MacMaster HW, Shah AD, Rajkomar A, Glidden DV, et al. Association Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients: An Observational Study. Ann Intern Med. 2017;166:621-627. doi: 10.7326/M16-1413

Dr. Imber is assistant professor in the division of hospital medicine at the University of New Mexico.

 

Condition Help: A patient- and family-initiated rapid response system

Implementation of a patient/family-initiated rapid response system at an academic, urban medical center resulted in 367 calls over 3½ years with 83.4% of them being for “nonsafety” issues and 11.4% being for “safety” issues.

Citation: Elizabeth L. Eden, MD, Laurie L. Rack, DNP, RN, Ling-Wan Chen, MS, Bump GM, Condition Help: A patient- and family-initiated rapid response system. J Hosp Med. 2017;3;157-161. doi: 10.12788/jhm.2697.

Association between U.S. norepinephrine shortage and mortality among patients with septic shock

A retrospective cohort study of 26 U.S. hospitals affected by the 2011 norepinephrine shortage demonstrated that phenylephrine was the most frequently used alternative and in-hospital mortality for patients admitted with septic shock rose from 35.9% to 39.6%.

Citation: Vail E, Gershengorn HB, Hua M, Walkey AJ, Rubenfeld G, Wunsch H. Association Between US Norepinephrine Shortage and Mortality Among Patients With Septic Shock. JAMA. 2017;317(14):1433-1442. doi: 10.1001/jama.2017.2841

Patient mortality during unannounced accreditation surveys at U.S. hospitals

An evaluation of quasi-randomized Medicare admissions at 1,984 hospitals demonstrated that 30-day mortality decreased by 0.18% in all hospitals and 0.48% at major teaching hospitals during The Joint Commission survey periods; both changes were greater than could be attributed to chance alone when compared to other, similar time periods.

Citation: Barnett ML, Olenski AR, Jena AB. Patient Mortality During Unannounced Accreditation Surveys at US Hospitals. JAMA Intern Med. 2017;177(5):693-700. doi: 10.1001/jamainternmed.2016.9685

Association between a virtual glucose management service and glycemic control in hospitalized adult patients

Institution of a virtual glucose management system resulted in a 39% decrease in hyperglycemic patients and a 36% decrease in hypoglycemic patients per 100 patient-days at three major teaching hospitals.

Citation: Rushakoff RJ, Sullivan MM, MacMaster HW, Shah AD, Rajkomar A, Glidden DV, et al. Association Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients: An Observational Study. Ann Intern Med. 2017;166:621-627. doi: 10.7326/M16-1413

Dr. Imber is assistant professor in the division of hospital medicine at the University of New Mexico.

Clinical question: Are patients with obstructive sleep apnea (OSA) and preoperative hypercapnia more likely to experience postoperative complications than those without?

Background: Obesity hypoventilation syndrome (OHS) is known to increase medical morbidity in patients with OSA, but its impact on postoperative outcome is unknown.

Study design: Retrospective cohort study.

Setting: Single tertiary-care center.

Synopsis: The study examined 1,800 patients with body mass index (BMI) ≥30 who underwent polysomnography, elective non-cardiac surgery (NCS), and had a blood gas performed. Of those, 194 patients were identified as having OSA with hypercapnia, and 325 were identified as having only OSA. Investigators found that the presence of hypercapnia in patients with OSA, whether from OHS, COPD, or another cause, was associated with worse postoperative outcomes. They found a statistically significant increase in postoperative respiratory failure (21% versus 2%), heart failure (8% versus 0%), tracheostomy (2% versus 1%), and ICU transfer (21% versus 6%). Mortality data did not reach significance.

The major limitation to the study is that hypercapnia is underrecognized in this patient population, and as a result, only patients who had a blood gas were included; many hypercapnic patients may have had elective NCS without receiving a blood gas and were thus excluded.

Bottom line: Consider performing a preoperative blood gas in patients with OSA undergoing elective NCS to help with postoperative complication risk assessment.

Citation: Kaw R, Bhateja P, Paz y Mar H, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest. 2016;149(1):84-91 doi:10.1378/chest.14-3216.

Clinical question: Are patients with obstructive sleep apnea (OSA) and preoperative hypercapnia more likely to experience postoperative complications than those without?

Background: Obesity hypoventilation syndrome (OHS) is known to increase medical morbidity in patients with OSA, but its impact on postoperative outcome is unknown.

Study design: Retrospective cohort study.

Setting: Single tertiary-care center.

Synopsis: The study examined 1,800 patients with body mass index (BMI) ≥30 who underwent polysomnography, elective non-cardiac surgery (NCS), and had a blood gas performed. Of those, 194 patients were identified as having OSA with hypercapnia, and 325 were identified as having only OSA. Investigators found that the presence of hypercapnia in patients with OSA, whether from OHS, COPD, or another cause, was associated with worse postoperative outcomes. They found a statistically significant increase in postoperative respiratory failure (21% versus 2%), heart failure (8% versus 0%), tracheostomy (2% versus 1%), and ICU transfer (21% versus 6%). Mortality data did not reach significance.

The major limitation to the study is that hypercapnia is underrecognized in this patient population, and as a result, only patients who had a blood gas were included; many hypercapnic patients may have had elective NCS without receiving a blood gas and were thus excluded.

Bottom line: Consider performing a preoperative blood gas in patients with OSA undergoing elective NCS to help with postoperative complication risk assessment.

Citation: Kaw R, Bhateja P, Paz y Mar H, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest. 2016;149(1):84-91 doi:10.1378/chest.14-3216.

Clinical question: Are patients with obstructive sleep apnea (OSA) and preoperative hypercapnia more likely to experience postoperative complications than those without?

Background: Obesity hypoventilation syndrome (OHS) is known to increase medical morbidity in patients with OSA, but its impact on postoperative outcome is unknown.

Study design: Retrospective cohort study.

Setting: Single tertiary-care center.

Synopsis: The study examined 1,800 patients with body mass index (BMI) ≥30 who underwent polysomnography, elective non-cardiac surgery (NCS), and had a blood gas performed. Of those, 194 patients were identified as having OSA with hypercapnia, and 325 were identified as having only OSA. Investigators found that the presence of hypercapnia in patients with OSA, whether from OHS, COPD, or another cause, was associated with worse postoperative outcomes. They found a statistically significant increase in postoperative respiratory failure (21% versus 2%), heart failure (8% versus 0%), tracheostomy (2% versus 1%), and ICU transfer (21% versus 6%). Mortality data did not reach significance.

The major limitation to the study is that hypercapnia is underrecognized in this patient population, and as a result, only patients who had a blood gas were included; many hypercapnic patients may have had elective NCS without receiving a blood gas and were thus excluded.

Bottom line: Consider performing a preoperative blood gas in patients with OSA undergoing elective NCS to help with postoperative complication risk assessment.

Citation: Kaw R, Bhateja P, Paz y Mar H, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest. 2016;149(1):84-91 doi:10.1378/chest.14-3216.

Clinical question: How useful are rapid immunoassays (RIs) compared to other tests for heparin-induced thrombocytopenia (HIT)?

Background: HIT is a clinicopathologic diagnosis, which traditionally requires clinical criteria and laboratory confirmation through initial testing with enzyme-linked immunosorbent assay (ELISA) and “gold standard” testing with washed platelet functional assays when available. There are an increasing number of RIs available, which have lab turnaround times of less than one hour. Their clinical utility is not well understood.

Study design: Meta-analysis.

Setting: Twenty-three studies.

Synopsis: The authors found 23 articles to include for review. These studies included 5,637 unique patients and included heterogeneous (medical, surgical, non-ICU) populations. These articles examined six different rapid immunoassays, which have been developed in recent years. All RIs examined had excellent negative predictive values (NPVs) ranging from 0.99 to 1.00, though positive predictive values (PPVs) had much wider variation (0.42–0.71). The greatest limitation in this meta-analysis is that 17 of the studies were marked as “high risk of bias” because they did not compare the RIs to the “gold standard” assay.

Bottom line: RIs for the diagnosis of HIT have very high NPVs and may be usefully incorporated into the diagnostic algorithm for HIT, but they cannot take the place of “gold standard” washed platelet functional assays.

Citation: Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis [published online ahead of print January 14, 2016]. Thromb Haemost. doi:10.1160/TH15-06-0523.

Clinical question: How useful are rapid immunoassays (RIs) compared to other tests for heparin-induced thrombocytopenia (HIT)?

Background: HIT is a clinicopathologic diagnosis, which traditionally requires clinical criteria and laboratory confirmation through initial testing with enzyme-linked immunosorbent assay (ELISA) and “gold standard” testing with washed platelet functional assays when available. There are an increasing number of RIs available, which have lab turnaround times of less than one hour. Their clinical utility is not well understood.

Study design: Meta-analysis.

Setting: Twenty-three studies.

Synopsis: The authors found 23 articles to include for review. These studies included 5,637 unique patients and included heterogeneous (medical, surgical, non-ICU) populations. These articles examined six different rapid immunoassays, which have been developed in recent years. All RIs examined had excellent negative predictive values (NPVs) ranging from 0.99 to 1.00, though positive predictive values (PPVs) had much wider variation (0.42–0.71). The greatest limitation in this meta-analysis is that 17 of the studies were marked as “high risk of bias” because they did not compare the RIs to the “gold standard” assay.

Bottom line: RIs for the diagnosis of HIT have very high NPVs and may be usefully incorporated into the diagnostic algorithm for HIT, but they cannot take the place of “gold standard” washed platelet functional assays.

Citation: Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis [published online ahead of print January 14, 2016]. Thromb Haemost. doi:10.1160/TH15-06-0523.

Clinical question: How useful are rapid immunoassays (RIs) compared to other tests for heparin-induced thrombocytopenia (HIT)?

Background: HIT is a clinicopathologic diagnosis, which traditionally requires clinical criteria and laboratory confirmation through initial testing with enzyme-linked immunosorbent assay (ELISA) and “gold standard” testing with washed platelet functional assays when available. There are an increasing number of RIs available, which have lab turnaround times of less than one hour. Their clinical utility is not well understood.

Study design: Meta-analysis.

Setting: Twenty-three studies.

Synopsis: The authors found 23 articles to include for review. These studies included 5,637 unique patients and included heterogeneous (medical, surgical, non-ICU) populations. These articles examined six different rapid immunoassays, which have been developed in recent years. All RIs examined had excellent negative predictive values (NPVs) ranging from 0.99 to 1.00, though positive predictive values (PPVs) had much wider variation (0.42–0.71). The greatest limitation in this meta-analysis is that 17 of the studies were marked as “high risk of bias” because they did not compare the RIs to the “gold standard” assay.

Bottom line: RIs for the diagnosis of HIT have very high NPVs and may be usefully incorporated into the diagnostic algorithm for HIT, but they cannot take the place of “gold standard” washed platelet functional assays.

Citation: Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis [published online ahead of print January 14, 2016]. Thromb Haemost. doi:10.1160/TH15-06-0523.

Clinical question: Is a delay in completion of hospital discharge summary associated with hospital readmissions?

Background: Inpatient discharge summaries serve as a communication tool to future care providers. Previous studies have shown mixed impact on the timeliness of discharge summaries on hospital readmissions.

Study design: Retrospective cohort study.

Setting: Adult medical patients at Johns Hopkins University Hospital, Baltimore.

Synopsis: Study authors examined the time between hospital discharge and discharge summary completion on 87,994 hospitalizations to assess whether a delay increased the odds of hospital readmission. In those hospitalizations, 14,248 patients (16.2%) were readmitted within 30 days of discharge. There was a statistically significant adjusted odds ratio of 1.09 (P=0.001) for readmission associated with discharge summaries completed more than three days after discharge.

The main advantage of the study is that the investigators reviewed a large number of hospitalizations. The major limitation is that deaths or admissions to other hospitals within 30 days of discharge were not measured.

Bottom line: Completing a discharge summary within three days of discharge may decrease the risk of 30-day readmission.

Citation: Hoyer EH, Odonkor CA, Bhatia SN, Leung C, Deutschendorf A, Brotman DJ. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland [published online ahead of print February 23, 2016]. J Hosp Med. doi:10.1002/jhm.2556

Short Take

Effectiveness of Rapid Response Teams

A meta-analysis of 30 eligible studies evaluating the impact of rapid response teams (RRTs) from 2000 to 2016 found that RRTs are effective at reducing both in-hospital cardiac arrest and hospital mortality.

Citation: Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis [published online ahead of print Febraury 1, 2016]. J Hosp Med. doi:10.1002/jhm.2554.

Clinical question: Is a delay in completion of hospital discharge summary associated with hospital readmissions?

Background: Inpatient discharge summaries serve as a communication tool to future care providers. Previous studies have shown mixed impact on the timeliness of discharge summaries on hospital readmissions.

Study design: Retrospective cohort study.

Setting: Adult medical patients at Johns Hopkins University Hospital, Baltimore.

Synopsis: Study authors examined the time between hospital discharge and discharge summary completion on 87,994 hospitalizations to assess whether a delay increased the odds of hospital readmission. In those hospitalizations, 14,248 patients (16.2%) were readmitted within 30 days of discharge. There was a statistically significant adjusted odds ratio of 1.09 (P=0.001) for readmission associated with discharge summaries completed more than three days after discharge.

The main advantage of the study is that the investigators reviewed a large number of hospitalizations. The major limitation is that deaths or admissions to other hospitals within 30 days of discharge were not measured.

Bottom line: Completing a discharge summary within three days of discharge may decrease the risk of 30-day readmission.

Citation: Hoyer EH, Odonkor CA, Bhatia SN, Leung C, Deutschendorf A, Brotman DJ. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland [published online ahead of print February 23, 2016]. J Hosp Med. doi:10.1002/jhm.2556

Short Take

Effectiveness of Rapid Response Teams

A meta-analysis of 30 eligible studies evaluating the impact of rapid response teams (RRTs) from 2000 to 2016 found that RRTs are effective at reducing both in-hospital cardiac arrest and hospital mortality.

Citation: Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis [published online ahead of print Febraury 1, 2016]. J Hosp Med. doi:10.1002/jhm.2554.

Clinical question: Is a delay in completion of hospital discharge summary associated with hospital readmissions?

Background: Inpatient discharge summaries serve as a communication tool to future care providers. Previous studies have shown mixed impact on the timeliness of discharge summaries on hospital readmissions.

Study design: Retrospective cohort study.

Setting: Adult medical patients at Johns Hopkins University Hospital, Baltimore.

Synopsis: Study authors examined the time between hospital discharge and discharge summary completion on 87,994 hospitalizations to assess whether a delay increased the odds of hospital readmission. In those hospitalizations, 14,248 patients (16.2%) were readmitted within 30 days of discharge. There was a statistically significant adjusted odds ratio of 1.09 (P=0.001) for readmission associated with discharge summaries completed more than three days after discharge.

The main advantage of the study is that the investigators reviewed a large number of hospitalizations. The major limitation is that deaths or admissions to other hospitals within 30 days of discharge were not measured.

Bottom line: Completing a discharge summary within three days of discharge may decrease the risk of 30-day readmission.

Citation: Hoyer EH, Odonkor CA, Bhatia SN, Leung C, Deutschendorf A, Brotman DJ. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland [published online ahead of print February 23, 2016]. J Hosp Med. doi:10.1002/jhm.2556

Short Take

Effectiveness of Rapid Response Teams

A meta-analysis of 30 eligible studies evaluating the impact of rapid response teams (RRTs) from 2000 to 2016 found that RRTs are effective at reducing both in-hospital cardiac arrest and hospital mortality.

Citation: Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis [published online ahead of print Febraury 1, 2016]. J Hosp Med. doi:10.1002/jhm.2554.

Clinical question: Does assigning a single medical team to a nursing unit (regionalizing) improve communication and prevent adverse events?

Background: Many factors impact communication in healthcare delivery. Failures in communication are a known source of adverse events in hospital care. Previous studies of the impact of regionalized care (assigning medical physician teams to nursing units) on communication and outcomes have had mixed results.

Study design: Pre-post intervention cohort analysis.

Setting: Brigham and Women’s Hospital, Boston.

Synopsis: Three medical teams were assigned to 15-bed nursing units with structured multidisciplinary meeting times for one year. Assessments of concordance of care plan and adverse event detection (with a focus on adverse drug events and poor glycemic control) were performed before and after this assignment. Regionalization of care in the study site improved recognition of care team members (0.56 versus 0.86; P<0.001), discussion of care plan (0.73 versus 0.88; P<0.001), and agreement on estimated discharge date (0.56 versus 0.68; P<0.003). However, it did not significantly improve nurse and physician concordance of the plan or reduce the odds of preventable adverse events.

This study may not have captured an impact on more subtle adverse events or other aspects of interprofessional relationships that enhance patient care.

Bottom line: Regionalization effectively promotes communication but may not lead to patient safety improvements.

Citation: Mueller SK, Schnipper JL, Giannelli K, Roy CL, Boxer R. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services [published online ahead of print February 24, 2016]. J Hosp Med. doi:10.1002/jhm.2566.

Clinical question: Does assigning a single medical team to a nursing unit (regionalizing) improve communication and prevent adverse events?

Background: Many factors impact communication in healthcare delivery. Failures in communication are a known source of adverse events in hospital care. Previous studies of the impact of regionalized care (assigning medical physician teams to nursing units) on communication and outcomes have had mixed results.

Study design: Pre-post intervention cohort analysis.

Setting: Brigham and Women’s Hospital, Boston.

Synopsis: Three medical teams were assigned to 15-bed nursing units with structured multidisciplinary meeting times for one year. Assessments of concordance of care plan and adverse event detection (with a focus on adverse drug events and poor glycemic control) were performed before and after this assignment. Regionalization of care in the study site improved recognition of care team members (0.56 versus 0.86; P<0.001), discussion of care plan (0.73 versus 0.88; P<0.001), and agreement on estimated discharge date (0.56 versus 0.68; P<0.003). However, it did not significantly improve nurse and physician concordance of the plan or reduce the odds of preventable adverse events.

This study may not have captured an impact on more subtle adverse events or other aspects of interprofessional relationships that enhance patient care.

Bottom line: Regionalization effectively promotes communication but may not lead to patient safety improvements.

Citation: Mueller SK, Schnipper JL, Giannelli K, Roy CL, Boxer R. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services [published online ahead of print February 24, 2016]. J Hosp Med. doi:10.1002/jhm.2566.

Clinical question: Does assigning a single medical team to a nursing unit (regionalizing) improve communication and prevent adverse events?

Background: Many factors impact communication in healthcare delivery. Failures in communication are a known source of adverse events in hospital care. Previous studies of the impact of regionalized care (assigning medical physician teams to nursing units) on communication and outcomes have had mixed results.

Study design: Pre-post intervention cohort analysis.

Setting: Brigham and Women’s Hospital, Boston.

Synopsis: Three medical teams were assigned to 15-bed nursing units with structured multidisciplinary meeting times for one year. Assessments of concordance of care plan and adverse event detection (with a focus on adverse drug events and poor glycemic control) were performed before and after this assignment. Regionalization of care in the study site improved recognition of care team members (0.56 versus 0.86; P<0.001), discussion of care plan (0.73 versus 0.88; P<0.001), and agreement on estimated discharge date (0.56 versus 0.68; P<0.003). However, it did not significantly improve nurse and physician concordance of the plan or reduce the odds of preventable adverse events.

This study may not have captured an impact on more subtle adverse events or other aspects of interprofessional relationships that enhance patient care.

Bottom line: Regionalization effectively promotes communication but may not lead to patient safety improvements.

Citation: Mueller SK, Schnipper JL, Giannelli K, Roy CL, Boxer R. Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services [published online ahead of print February 24, 2016]. J Hosp Med. doi:10.1002/jhm.2566.

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.