Katie Lappe, MD

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin scale.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups. The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. New Engl J Med. 2015;372(24):2296–2306.

Visit our website for more hospitalist reviews of HM-focused research.

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin scale.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups. The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. New Engl J Med. 2015;372(24):2296–2306.

Visit our website for more hospitalist reviews of HM-focused research.

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin scale.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups. The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. New Engl J Med. 2015;372(24):2296–2306.

Visit our website for more hospitalist reviews of HM-focused research.

Clinical question: In post-operative cardiothoracic surgery patients, is high-flow nasal oxygen therapy inferior to BiPAP for resolution of acute respiratory failure?

Background: Acute respiratory failure is common following cardiothoracic surgery, and noninvasive ventilation often is used to avoid intubation. Noninvasive ventilation is resource-intensive and might be uncomfortable to patients. High-flow nasal oxygen therapy is an alternative modality, which provides large amounts of oxygen with more ease and patient comfort.

Study design: Multi-center, randomized, noninferiority trial.

Setting: Six ICUs in France.

Synopsis: Investigators randomized 830 patients who met criteria (obesity, heart failure, or failure of spontaneous breathing trial) after cardiothoracic surgery. These patients were prophylactically treated with high-flow nasal oxygen or BiPAP. Patients with sleep apnea, nausea/vomiting, agitation/confusion, or hemodynamic instability were excluded. Data collected included arterial blood gas, respiratory rate, and patient-rated dyspnea. The primary outcome was treatment failure as defined by reintubation and mechanical ventilation, a switch to the other study treatment, or study treatment discontinuation.

Complications included pneumothorax, colonic pseudoobstruction, and nosocomial pneumonia. The expected rate of failure for BiPAP was 20%. High-flow nasal oxygen therapy was not inferior to BiPAP, with similar treatment failure rates occurring in both groups (21.9% in BiPAP patients vs. 21% of high-flow nasal oxygen patients); 20% of patients experienced persistent discomfort with either treatment method.

There were no significant differences in complications between the two study groups. Limitations included lack of blinding and potential for bias, leading to treatment failure and crossover.

Bottom line: High-flow nasal oxygen was noninferior to BiPAP in patients with respiratory failure after cardiothoracic surgery.

Citation: Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313(23):2331-2339.

Clinical question: In post-operative cardiothoracic surgery patients, is high-flow nasal oxygen therapy inferior to BiPAP for resolution of acute respiratory failure?

Background: Acute respiratory failure is common following cardiothoracic surgery, and noninvasive ventilation often is used to avoid intubation. Noninvasive ventilation is resource-intensive and might be uncomfortable to patients. High-flow nasal oxygen therapy is an alternative modality, which provides large amounts of oxygen with more ease and patient comfort.

Study design: Multi-center, randomized, noninferiority trial.

Setting: Six ICUs in France.

Synopsis: Investigators randomized 830 patients who met criteria (obesity, heart failure, or failure of spontaneous breathing trial) after cardiothoracic surgery. These patients were prophylactically treated with high-flow nasal oxygen or BiPAP. Patients with sleep apnea, nausea/vomiting, agitation/confusion, or hemodynamic instability were excluded. Data collected included arterial blood gas, respiratory rate, and patient-rated dyspnea. The primary outcome was treatment failure as defined by reintubation and mechanical ventilation, a switch to the other study treatment, or study treatment discontinuation.

Complications included pneumothorax, colonic pseudoobstruction, and nosocomial pneumonia. The expected rate of failure for BiPAP was 20%. High-flow nasal oxygen therapy was not inferior to BiPAP, with similar treatment failure rates occurring in both groups (21.9% in BiPAP patients vs. 21% of high-flow nasal oxygen patients); 20% of patients experienced persistent discomfort with either treatment method.

There were no significant differences in complications between the two study groups. Limitations included lack of blinding and potential for bias, leading to treatment failure and crossover.

Bottom line: High-flow nasal oxygen was noninferior to BiPAP in patients with respiratory failure after cardiothoracic surgery.

Citation: Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313(23):2331-2339.

Clinical question: In post-operative cardiothoracic surgery patients, is high-flow nasal oxygen therapy inferior to BiPAP for resolution of acute respiratory failure?

Background: Acute respiratory failure is common following cardiothoracic surgery, and noninvasive ventilation often is used to avoid intubation. Noninvasive ventilation is resource-intensive and might be uncomfortable to patients. High-flow nasal oxygen therapy is an alternative modality, which provides large amounts of oxygen with more ease and patient comfort.

Study design: Multi-center, randomized, noninferiority trial.

Setting: Six ICUs in France.

Synopsis: Investigators randomized 830 patients who met criteria (obesity, heart failure, or failure of spontaneous breathing trial) after cardiothoracic surgery. These patients were prophylactically treated with high-flow nasal oxygen or BiPAP. Patients with sleep apnea, nausea/vomiting, agitation/confusion, or hemodynamic instability were excluded. Data collected included arterial blood gas, respiratory rate, and patient-rated dyspnea. The primary outcome was treatment failure as defined by reintubation and mechanical ventilation, a switch to the other study treatment, or study treatment discontinuation.

Complications included pneumothorax, colonic pseudoobstruction, and nosocomial pneumonia. The expected rate of failure for BiPAP was 20%. High-flow nasal oxygen therapy was not inferior to BiPAP, with similar treatment failure rates occurring in both groups (21.9% in BiPAP patients vs. 21% of high-flow nasal oxygen patients); 20% of patients experienced persistent discomfort with either treatment method.

There were no significant differences in complications between the two study groups. Limitations included lack of blinding and potential for bias, leading to treatment failure and crossover.

Bottom line: High-flow nasal oxygen was noninferior to BiPAP in patients with respiratory failure after cardiothoracic surgery.

Citation: Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313(23):2331-2339.

Clinical question: Does routine oxygen supplementation in patients with STEMI increase myocardial injury?

Background: Because of physiologic and clinical studies conducted before the era of acute coronary intervention, supplemental oxygen routinely is administered to patients with STEMI, regardless of oxygen saturation; however, recent studies have shown possible adverse effects of oxygen, including increased reperfusion injury and increased adverse outcomes in small clinical trials.

Study design: Multicenter, prospective, randomized, controlled trial (RCT).

Setting: Nine metropolitan hospitals.

Synopsis: This multicenter study included 441 patients with STEMI who were 18 years or older and were randomized by paramedics to receive either 8 L/min of oxygen or no supplemental oxygen. All patients then received protocolized care. The primary endpoint of myocardial infarct size, determined by mean peak of creatine kinase, was significantly increased in the oxygen group compared to the no oxygen group (1948 vs. 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There were nonsignificant increases of secondary endpoints in the oxygen group, including rate of recurrent myocardial infarction (5.5% vs. 0.9%; P=0.006), frequency of arrhythmia (40.4% vs. 31.4%; P=0.05), and size of infarct on six-month cardiac MRI (n=139; 20.3 vs. 13.1 g; P=0.04).

This study has several limitations: It was powered to detect differences in biomarkers (not clinical endpoints) and the treatment was not blinded to paramedics, patients, or cardiology teams.

Bottom line: Supplemental oxygen administration in patients with STEMI might increase infarct size and lead to poorer clinical outcomes; however, larger clinical trials are warranted.

Citation: Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150.

Clinical question: Does routine oxygen supplementation in patients with STEMI increase myocardial injury?

Background: Because of physiologic and clinical studies conducted before the era of acute coronary intervention, supplemental oxygen routinely is administered to patients with STEMI, regardless of oxygen saturation; however, recent studies have shown possible adverse effects of oxygen, including increased reperfusion injury and increased adverse outcomes in small clinical trials.

Study design: Multicenter, prospective, randomized, controlled trial (RCT).

Setting: Nine metropolitan hospitals.

Synopsis: This multicenter study included 441 patients with STEMI who were 18 years or older and were randomized by paramedics to receive either 8 L/min of oxygen or no supplemental oxygen. All patients then received protocolized care. The primary endpoint of myocardial infarct size, determined by mean peak of creatine kinase, was significantly increased in the oxygen group compared to the no oxygen group (1948 vs. 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There were nonsignificant increases of secondary endpoints in the oxygen group, including rate of recurrent myocardial infarction (5.5% vs. 0.9%; P=0.006), frequency of arrhythmia (40.4% vs. 31.4%; P=0.05), and size of infarct on six-month cardiac MRI (n=139; 20.3 vs. 13.1 g; P=0.04).

This study has several limitations: It was powered to detect differences in biomarkers (not clinical endpoints) and the treatment was not blinded to paramedics, patients, or cardiology teams.

Bottom line: Supplemental oxygen administration in patients with STEMI might increase infarct size and lead to poorer clinical outcomes; however, larger clinical trials are warranted.

Citation: Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150.

Clinical question: Does routine oxygen supplementation in patients with STEMI increase myocardial injury?

Background: Because of physiologic and clinical studies conducted before the era of acute coronary intervention, supplemental oxygen routinely is administered to patients with STEMI, regardless of oxygen saturation; however, recent studies have shown possible adverse effects of oxygen, including increased reperfusion injury and increased adverse outcomes in small clinical trials.

Study design: Multicenter, prospective, randomized, controlled trial (RCT).

Setting: Nine metropolitan hospitals.

Synopsis: This multicenter study included 441 patients with STEMI who were 18 years or older and were randomized by paramedics to receive either 8 L/min of oxygen or no supplemental oxygen. All patients then received protocolized care. The primary endpoint of myocardial infarct size, determined by mean peak of creatine kinase, was significantly increased in the oxygen group compared to the no oxygen group (1948 vs. 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There were nonsignificant increases of secondary endpoints in the oxygen group, including rate of recurrent myocardial infarction (5.5% vs. 0.9%; P=0.006), frequency of arrhythmia (40.4% vs. 31.4%; P=0.05), and size of infarct on six-month cardiac MRI (n=139; 20.3 vs. 13.1 g; P=0.04).

This study has several limitations: It was powered to detect differences in biomarkers (not clinical endpoints) and the treatment was not blinded to paramedics, patients, or cardiology teams.

Bottom line: Supplemental oxygen administration in patients with STEMI might increase infarct size and lead to poorer clinical outcomes; however, larger clinical trials are warranted.

Citation: Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143-2150.

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin score.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups.

The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptoms onset in ischemic stroke. New Engl J Med. 2015;372(24):2296-2306.

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin score.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups.

The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptoms onset in ischemic stroke. New Engl J Med. 2015;372(24):2296-2306.

Clinical question: Does thrombectomy, in conjunction with medical therapy, improve functional independence in patients with an acute proximal anterior stroke?

Background: Revascularization of proximal anterior strokes with alteplase alone occurs less than 50% of the time. First-generation thrombectomy devices (i.e., Merci and Penumbra) have not shown improvement in revascularization or functional outcomes; however, the development of thrombectomy stent retriever devices has led to more promising results, with several recent studies demonstrating functional improvement using endovascular retrieval in addition to medical therapy in proximal anterior circulation strokes.

Study design: Prospective, multicenter, randomized, sequential, open-label, phase 3 study with blinded evaluation.

Setting: Four hospitals in Spain.

Synopsis: Approximately 200 patients who were diagnosed within eight hours of onset of a large vessel anterior stroke were randomly assigned to medical therapy (alteplase) plus endovascular treatment versus medical therapy alone. In order to reduce selection bias, the study was conducted within a population-based registry of acute stroke patients from the same area. The major exclusion criterion was evidence of a large infarct on imaging. The primary outcome was severity of disability at 90 days based on the modified Rankin score.

Study results showed a significant improvement in functional status in the thrombectomy group, with 66% of patients demonstrating revascularization. The rate of death and intracranial hemorrhage was similar between both groups.

The trial stopped recruitment after the first interim analysis given lack of equipoise, with emerging literature supporting endovascular therapy.

Bottom line: Thrombectomy performed in proximal, large vessel anterior circulation strokes within eight hours of onset of symptoms improves functional status at 90 days.

Citation: Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptoms onset in ischemic stroke. New Engl J Med. 2015;372(24):2296-2306.

Clinical question: Does interdisciplinary care on general medical wards improve patient outcomes?

Background: Patients on general medical wards might experience errors and/or preventable deaths. One mechanism that could reduce the risk of errors or preventable death is the utilization of interdisciplinary team care.

Study design: Systematic review.

Setting: Studies published in English from 1998 through 2013 in Embase, MEDLINE, and PsycINFO.

Synopsis: Reports of interdisciplinary team care interventions on general medical wards in which the care was evaluated against an objective patient outcome were reviewed. Outcomes were grouped into early (less than 30 days) or late (30 days to 12 months). Thirty studies of more than 66,000 total patients were included; these were composed of RCTs, nonrandomized cluster trials, and controlled before-after studies.

Interventions either altered the composition of the care team or addressed the logistics of team practice. Studies evaluated complications of care, length of stay, readmissions, and mortality. Although some evidence showed interdisciplinary care reduces complications, the majority of studies did not show significant improvements in any other outcomes.

Bottom line: In a systematic review, interdisciplinary team care in general medical wards is not associated with reduced complications, length of stay, readmissions, or mortality.

Citation: Pannick S, Davis R, Ashrafian H, et al. Effects of interdisciplinary team care interventions on general medical wards: a systematic review. JAMA Intern Med. 2015;175(8):1288-1298.

Clinical question: Does interdisciplinary care on general medical wards improve patient outcomes?

Background: Patients on general medical wards might experience errors and/or preventable deaths. One mechanism that could reduce the risk of errors or preventable death is the utilization of interdisciplinary team care.

Study design: Systematic review.

Setting: Studies published in English from 1998 through 2013 in Embase, MEDLINE, and PsycINFO.

Synopsis: Reports of interdisciplinary team care interventions on general medical wards in which the care was evaluated against an objective patient outcome were reviewed. Outcomes were grouped into early (less than 30 days) or late (30 days to 12 months). Thirty studies of more than 66,000 total patients were included; these were composed of RCTs, nonrandomized cluster trials, and controlled before-after studies.

Interventions either altered the composition of the care team or addressed the logistics of team practice. Studies evaluated complications of care, length of stay, readmissions, and mortality. Although some evidence showed interdisciplinary care reduces complications, the majority of studies did not show significant improvements in any other outcomes.

Bottom line: In a systematic review, interdisciplinary team care in general medical wards is not associated with reduced complications, length of stay, readmissions, or mortality.

Citation: Pannick S, Davis R, Ashrafian H, et al. Effects of interdisciplinary team care interventions on general medical wards: a systematic review. JAMA Intern Med. 2015;175(8):1288-1298.

Clinical question: Does interdisciplinary care on general medical wards improve patient outcomes?

Background: Patients on general medical wards might experience errors and/or preventable deaths. One mechanism that could reduce the risk of errors or preventable death is the utilization of interdisciplinary team care.

Study design: Systematic review.

Setting: Studies published in English from 1998 through 2013 in Embase, MEDLINE, and PsycINFO.

Synopsis: Reports of interdisciplinary team care interventions on general medical wards in which the care was evaluated against an objective patient outcome were reviewed. Outcomes were grouped into early (less than 30 days) or late (30 days to 12 months). Thirty studies of more than 66,000 total patients were included; these were composed of RCTs, nonrandomized cluster trials, and controlled before-after studies.

Interventions either altered the composition of the care team or addressed the logistics of team practice. Studies evaluated complications of care, length of stay, readmissions, and mortality. Although some evidence showed interdisciplinary care reduces complications, the majority of studies did not show significant improvements in any other outcomes.

Bottom line: In a systematic review, interdisciplinary team care in general medical wards is not associated with reduced complications, length of stay, readmissions, or mortality.

Citation: Pannick S, Davis R, Ashrafian H, et al. Effects of interdisciplinary team care interventions on general medical wards: a systematic review. JAMA Intern Med. 2015;175(8):1288-1298.

Clinical question: Is there an association between objective measures of surgical quality and patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?

Background: The Centers for Medicare and Medicaid Services (CMS) has tied financial reimbursement to patient satisfaction scores. It is unknown whether high-quality surgery correlates with higher patient satisfaction scores.

Study design: Retrospective, observational study.

Setting: One hundred eighty hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

Synopsis: The study included 103,866 Medicare patients 65 and older who had surgery at a participating ACS NSQIP hospital between 2004-2008. Data regarding these patients were collected from a linked database (including Medicare inpatient claims, ACS NSQIP, the American Hospital Association annual survey, and Hospital Compare). Analysis of five 30-day outcomes was performed in order to assess surgical quality:

• Post-operative mortality;
• Major complication;
• Minor complication;
• Death following a complication; and
• Readmission.

Participating hospitals were grouped into quartiles based upon their performance on the HCAHPS survey.

Hospitals that performed in the highest quartile on the HCAHPS survey had significantly lower 30-day mortality, death following complications, and minor complications. No differences were detected in hospital readmissions or major complications based on patient satisfaction.

The results of this study may not be generalizable to all hospitals given the fact that the dataset is from Medicare patients only and participation in the ACS NSQIP is voluntary.

Bottom line: Using data from a national database, researchers found a positive association between patient satisfaction scores and objective measures of surgical quality.

Citation: Sacks GD, Lawson EH, Dawes AJ, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality [published online ahead of print June 24, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.1108.

Clinical question: Is there an association between objective measures of surgical quality and patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?

Background: The Centers for Medicare and Medicaid Services (CMS) has tied financial reimbursement to patient satisfaction scores. It is unknown whether high-quality surgery correlates with higher patient satisfaction scores.

Study design: Retrospective, observational study.

Setting: One hundred eighty hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

Synopsis: The study included 103,866 Medicare patients 65 and older who had surgery at a participating ACS NSQIP hospital between 2004-2008. Data regarding these patients were collected from a linked database (including Medicare inpatient claims, ACS NSQIP, the American Hospital Association annual survey, and Hospital Compare). Analysis of five 30-day outcomes was performed in order to assess surgical quality:

• Post-operative mortality;
• Major complication;
• Minor complication;
• Death following a complication; and
• Readmission.

Participating hospitals were grouped into quartiles based upon their performance on the HCAHPS survey.

Hospitals that performed in the highest quartile on the HCAHPS survey had significantly lower 30-day mortality, death following complications, and minor complications. No differences were detected in hospital readmissions or major complications based on patient satisfaction.

The results of this study may not be generalizable to all hospitals given the fact that the dataset is from Medicare patients only and participation in the ACS NSQIP is voluntary.

Bottom line: Using data from a national database, researchers found a positive association between patient satisfaction scores and objective measures of surgical quality.

Citation: Sacks GD, Lawson EH, Dawes AJ, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality [published online ahead of print June 24, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.1108.

Clinical question: Is there an association between objective measures of surgical quality and patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?

Background: The Centers for Medicare and Medicaid Services (CMS) has tied financial reimbursement to patient satisfaction scores. It is unknown whether high-quality surgery correlates with higher patient satisfaction scores.

Study design: Retrospective, observational study.

Setting: One hundred eighty hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

Synopsis: The study included 103,866 Medicare patients 65 and older who had surgery at a participating ACS NSQIP hospital between 2004-2008. Data regarding these patients were collected from a linked database (including Medicare inpatient claims, ACS NSQIP, the American Hospital Association annual survey, and Hospital Compare). Analysis of five 30-day outcomes was performed in order to assess surgical quality:

• Post-operative mortality;
• Major complication;
• Minor complication;
• Death following a complication; and
• Readmission.

Participating hospitals were grouped into quartiles based upon their performance on the HCAHPS survey.

Hospitals that performed in the highest quartile on the HCAHPS survey had significantly lower 30-day mortality, death following complications, and minor complications. No differences were detected in hospital readmissions or major complications based on patient satisfaction.

The results of this study may not be generalizable to all hospitals given the fact that the dataset is from Medicare patients only and participation in the ACS NSQIP is voluntary.

Bottom line: Using data from a national database, researchers found a positive association between patient satisfaction scores and objective measures of surgical quality.

Citation: Sacks GD, Lawson EH, Dawes AJ, et al. Relationship between hospital performance on a patient satisfaction survey and surgical quality [published online ahead of print June 24, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.1108.

Clinical question: Among patients with a first episode of unprovoked pulmonary embolism (PE), what are the benefits and harms of extending the duration of anticoagulation for secondary prophylaxis against recurrent VTE?

Background: Optimal duration of anticoagulation after initial unprovoked PE is not known. Prior studies demonstrated risk reduction of recurrent VTE while on therapy but have had inadequate long-term monitoring of patients or enrollment of patients with PE, who are known to have a higher case-fatality rate of recurrent VTE than patients with DVT.

Study design: Multicenter, randomized, double-blinded, parallel-grouped, placebo-controlled trial.

Setting: Fourteen French hospitals from 2007 to 2012.

Synopsis: Investigators randomized 371 patients with a first episode of symptomatic unprovoked PE who had completed six months of warfarin to 18 additional months of warfarin or placebo. Patients were followed for 24 months after discontinuation of therapy.

During the treatment period, the primary outcome (composite of recurrent VTE and major bleeding) occurred in 3.3% of the warfarin group vs. 13.5% of the placebo group (HR 0.22). This difference was primarily due to reduction in risk of recurrent VTE (1.7% vs. 13.5%, HR 0.15), with only minimal increased bleeding risk (2.2% vs. 0.5%, NS).

There was no significant difference in the composite outcome (20.8% in warfarin group vs. 24% in placebo) on analysis of the entire study period (treatment and follow-up), however, suggesting the benefit of extended warfarin therapy upon recurrent VTE risk diminished upon cessation.

Bottom line: Patients treated with extended-therapy warfarin after a first unprovoked PE have a decreased risk of recurrent VTE compared to standard therapy only while on treatment; the risk of recurrent VTE returns upon cessation of therapy.

Citation: Couturand F, Sanchez O, Pernod G, et al. Six months vs extended oral anticoagulation after a first episode of pulmonary embolism: The PADIS-PE randomized clinical trial. JAMA. 2015;314(1):31-40.

Clinical question: Among patients with a first episode of unprovoked pulmonary embolism (PE), what are the benefits and harms of extending the duration of anticoagulation for secondary prophylaxis against recurrent VTE?

Background: Optimal duration of anticoagulation after initial unprovoked PE is not known. Prior studies demonstrated risk reduction of recurrent VTE while on therapy but have had inadequate long-term monitoring of patients or enrollment of patients with PE, who are known to have a higher case-fatality rate of recurrent VTE than patients with DVT.

Study design: Multicenter, randomized, double-blinded, parallel-grouped, placebo-controlled trial.

Setting: Fourteen French hospitals from 2007 to 2012.

Synopsis: Investigators randomized 371 patients with a first episode of symptomatic unprovoked PE who had completed six months of warfarin to 18 additional months of warfarin or placebo. Patients were followed for 24 months after discontinuation of therapy.

During the treatment period, the primary outcome (composite of recurrent VTE and major bleeding) occurred in 3.3% of the warfarin group vs. 13.5% of the placebo group (HR 0.22). This difference was primarily due to reduction in risk of recurrent VTE (1.7% vs. 13.5%, HR 0.15), with only minimal increased bleeding risk (2.2% vs. 0.5%, NS).

There was no significant difference in the composite outcome (20.8% in warfarin group vs. 24% in placebo) on analysis of the entire study period (treatment and follow-up), however, suggesting the benefit of extended warfarin therapy upon recurrent VTE risk diminished upon cessation.

Bottom line: Patients treated with extended-therapy warfarin after a first unprovoked PE have a decreased risk of recurrent VTE compared to standard therapy only while on treatment; the risk of recurrent VTE returns upon cessation of therapy.

Citation: Couturand F, Sanchez O, Pernod G, et al. Six months vs extended oral anticoagulation after a first episode of pulmonary embolism: The PADIS-PE randomized clinical trial. JAMA. 2015;314(1):31-40.

Clinical question: Among patients with a first episode of unprovoked pulmonary embolism (PE), what are the benefits and harms of extending the duration of anticoagulation for secondary prophylaxis against recurrent VTE?

Background: Optimal duration of anticoagulation after initial unprovoked PE is not known. Prior studies demonstrated risk reduction of recurrent VTE while on therapy but have had inadequate long-term monitoring of patients or enrollment of patients with PE, who are known to have a higher case-fatality rate of recurrent VTE than patients with DVT.

Study design: Multicenter, randomized, double-blinded, parallel-grouped, placebo-controlled trial.

Setting: Fourteen French hospitals from 2007 to 2012.

Synopsis: Investigators randomized 371 patients with a first episode of symptomatic unprovoked PE who had completed six months of warfarin to 18 additional months of warfarin or placebo. Patients were followed for 24 months after discontinuation of therapy.

During the treatment period, the primary outcome (composite of recurrent VTE and major bleeding) occurred in 3.3% of the warfarin group vs. 13.5% of the placebo group (HR 0.22). This difference was primarily due to reduction in risk of recurrent VTE (1.7% vs. 13.5%, HR 0.15), with only minimal increased bleeding risk (2.2% vs. 0.5%, NS).

There was no significant difference in the composite outcome (20.8% in warfarin group vs. 24% in placebo) on analysis of the entire study period (treatment and follow-up), however, suggesting the benefit of extended warfarin therapy upon recurrent VTE risk diminished upon cessation.

Bottom line: Patients treated with extended-therapy warfarin after a first unprovoked PE have a decreased risk of recurrent VTE compared to standard therapy only while on treatment; the risk of recurrent VTE returns upon cessation of therapy.

Citation: Couturand F, Sanchez O, Pernod G, et al. Six months vs extended oral anticoagulation after a first episode of pulmonary embolism: The PADIS-PE randomized clinical trial. JAMA. 2015;314(1):31-40.

Clinical question: Should the Wells score be used for DVT risk stratification in the hospital?

Background: The Wells score was derived to reduce lower extremity ultrasounds (LEUS) in the outpatient evaluation of DVTs. There has never been a large prospective trial to validate its use in hospitalized patients.

Study design: Single-center, prospective cohort study.

Setting: Quaternary care, academic hospital.

Synopsis: Between November 2012 and December 2013, all inpatients at a single medical center who underwent a LEUS for suspected DVT, including 1,135 inpatients 16 years or older, had Wells risk factors recorded. The incidence of proximal DVTs noted for low, moderate, and high pretest probability groups were 5.9%, 9.5%, and 16.4%, respectively. Compared to the outpatient incidence of 3.0%, 16.6%, and 74.6% reported by Wells and colleagues, there were nonsignificant differences among inpatient groups. The difference between low and moderate pretest probability groups was not significant.

Discrimination of risk for DVT in hospitalized patients performed only slightly better than chance (AUC, 0.60) and the failure rate was double that of the original outpatient study (5.9% vs. 3.0%).

A possible explanation for these findings is the increased prevalence of immobilization (6x), cancer (3x), and risk factors not included in the Wells score (COPD, heart failure, and infection) in hospitalized patients.

Bottom line: The Wells score may not be sufficient to rule out DVT or influence management in the inpatient setting.

Citation: Silveira PC, Ip IK, Goldhaber SZ, Piazza G, Benson CB, Khorasani R. Performance of Wells score for deep vein thrombosis in the inpatient setting. JAMA Intern Med. 2015;175(7):1112-1117.

Clinical question: Should the Wells score be used for DVT risk stratification in the hospital?

Background: The Wells score was derived to reduce lower extremity ultrasounds (LEUS) in the outpatient evaluation of DVTs. There has never been a large prospective trial to validate its use in hospitalized patients.

Study design: Single-center, prospective cohort study.

Setting: Quaternary care, academic hospital.

Synopsis: Between November 2012 and December 2013, all inpatients at a single medical center who underwent a LEUS for suspected DVT, including 1,135 inpatients 16 years or older, had Wells risk factors recorded. The incidence of proximal DVTs noted for low, moderate, and high pretest probability groups were 5.9%, 9.5%, and 16.4%, respectively. Compared to the outpatient incidence of 3.0%, 16.6%, and 74.6% reported by Wells and colleagues, there were nonsignificant differences among inpatient groups. The difference between low and moderate pretest probability groups was not significant.

Discrimination of risk for DVT in hospitalized patients performed only slightly better than chance (AUC, 0.60) and the failure rate was double that of the original outpatient study (5.9% vs. 3.0%).

A possible explanation for these findings is the increased prevalence of immobilization (6x), cancer (3x), and risk factors not included in the Wells score (COPD, heart failure, and infection) in hospitalized patients.

Bottom line: The Wells score may not be sufficient to rule out DVT or influence management in the inpatient setting.

Citation: Silveira PC, Ip IK, Goldhaber SZ, Piazza G, Benson CB, Khorasani R. Performance of Wells score for deep vein thrombosis in the inpatient setting. JAMA Intern Med. 2015;175(7):1112-1117.

Clinical question: Should the Wells score be used for DVT risk stratification in the hospital?

Background: The Wells score was derived to reduce lower extremity ultrasounds (LEUS) in the outpatient evaluation of DVTs. There has never been a large prospective trial to validate its use in hospitalized patients.

Study design: Single-center, prospective cohort study.

Setting: Quaternary care, academic hospital.

Synopsis: Between November 2012 and December 2013, all inpatients at a single medical center who underwent a LEUS for suspected DVT, including 1,135 inpatients 16 years or older, had Wells risk factors recorded. The incidence of proximal DVTs noted for low, moderate, and high pretest probability groups were 5.9%, 9.5%, and 16.4%, respectively. Compared to the outpatient incidence of 3.0%, 16.6%, and 74.6% reported by Wells and colleagues, there were nonsignificant differences among inpatient groups. The difference between low and moderate pretest probability groups was not significant.

Discrimination of risk for DVT in hospitalized patients performed only slightly better than chance (AUC, 0.60) and the failure rate was double that of the original outpatient study (5.9% vs. 3.0%).

A possible explanation for these findings is the increased prevalence of immobilization (6x), cancer (3x), and risk factors not included in the Wells score (COPD, heart failure, and infection) in hospitalized patients.

Bottom line: The Wells score may not be sufficient to rule out DVT or influence management in the inpatient setting.

Citation: Silveira PC, Ip IK, Goldhaber SZ, Piazza G, Benson CB, Khorasani R. Performance of Wells score for deep vein thrombosis in the inpatient setting. JAMA Intern Med. 2015;175(7):1112-1117.

Clinical question: Is antibiotic therapy noninferior to appendectomy for treatment of uncomplicated acute appendicitis?

Background: Previous randomized clinical trials have compared antibiotic therapy versus appendectomy for the treatment of uncomplicated, acute appendicitis. Each of these studies had significant limitations, and appendectomy has remained the standard of care.

Study design: Noninferiority, randomized clinical trial.

Setting: Six hospitals in Finland.

Synopsis: Investigators randomized 530 patients with uncomplicated appendicitis confirmed on CT to appendectomy or antibiotic therapy, with a noninferiority margin of 24%. Of the 256 patients randomized to antibiotics who were available for follow-up, 70 received surgical intervention within one year. This resulted in a difference between treatment groups of -27%. Further analysis revealed that five of those patients had normal appendices and did not actually require appendectomy. Secondary outcome analysis demonstrated a significantly lower complication rate among patients in the antibiotic group (2.8%) compared with the surgical group (20.5%); however, the open operative approach used on most patients may have resulted in increased wound complications.

Although noninferiority of antibiotic treatment was not demonstrated, the majority of patients in the antibiotic group (73%) were found to have successful treatment with antibiotics alone. None of these patients, including those eventually undergoing appendectomy, suffered major complications. Although the overall approach to uncomplicated appendicitis may not change, physicians and patients should utilize this data to make an informed decision between antibiotic treatment and appendectomy.

Bottom line: In patients with CT-proven, uncomplicated acute appendicitis, antibiotic treatment did not meet the pre-specified threshold for noninferiority compared with appendectomy, yet a significant majority of patients in the antibiotic arm had successful recovery.

Citation: Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: The APPAC randomized clinical trial. JAMA. 2015;313(23):2340-2348

Clinical question: Is antibiotic therapy noninferior to appendectomy for treatment of uncomplicated acute appendicitis?

Background: Previous randomized clinical trials have compared antibiotic therapy versus appendectomy for the treatment of uncomplicated, acute appendicitis. Each of these studies had significant limitations, and appendectomy has remained the standard of care.

Study design: Noninferiority, randomized clinical trial.

Setting: Six hospitals in Finland.

Synopsis: Investigators randomized 530 patients with uncomplicated appendicitis confirmed on CT to appendectomy or antibiotic therapy, with a noninferiority margin of 24%. Of the 256 patients randomized to antibiotics who were available for follow-up, 70 received surgical intervention within one year. This resulted in a difference between treatment groups of -27%. Further analysis revealed that five of those patients had normal appendices and did not actually require appendectomy. Secondary outcome analysis demonstrated a significantly lower complication rate among patients in the antibiotic group (2.8%) compared with the surgical group (20.5%); however, the open operative approach used on most patients may have resulted in increased wound complications.

Although noninferiority of antibiotic treatment was not demonstrated, the majority of patients in the antibiotic group (73%) were found to have successful treatment with antibiotics alone. None of these patients, including those eventually undergoing appendectomy, suffered major complications. Although the overall approach to uncomplicated appendicitis may not change, physicians and patients should utilize this data to make an informed decision between antibiotic treatment and appendectomy.

Bottom line: In patients with CT-proven, uncomplicated acute appendicitis, antibiotic treatment did not meet the pre-specified threshold for noninferiority compared with appendectomy, yet a significant majority of patients in the antibiotic arm had successful recovery.

Citation: Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: The APPAC randomized clinical trial. JAMA. 2015;313(23):2340-2348

Clinical question: Is antibiotic therapy noninferior to appendectomy for treatment of uncomplicated acute appendicitis?

Background: Previous randomized clinical trials have compared antibiotic therapy versus appendectomy for the treatment of uncomplicated, acute appendicitis. Each of these studies had significant limitations, and appendectomy has remained the standard of care.

Study design: Noninferiority, randomized clinical trial.

Setting: Six hospitals in Finland.

Synopsis: Investigators randomized 530 patients with uncomplicated appendicitis confirmed on CT to appendectomy or antibiotic therapy, with a noninferiority margin of 24%. Of the 256 patients randomized to antibiotics who were available for follow-up, 70 received surgical intervention within one year. This resulted in a difference between treatment groups of -27%. Further analysis revealed that five of those patients had normal appendices and did not actually require appendectomy. Secondary outcome analysis demonstrated a significantly lower complication rate among patients in the antibiotic group (2.8%) compared with the surgical group (20.5%); however, the open operative approach used on most patients may have resulted in increased wound complications.

Although noninferiority of antibiotic treatment was not demonstrated, the majority of patients in the antibiotic group (73%) were found to have successful treatment with antibiotics alone. None of these patients, including those eventually undergoing appendectomy, suffered major complications. Although the overall approach to uncomplicated appendicitis may not change, physicians and patients should utilize this data to make an informed decision between antibiotic treatment and appendectomy.

Bottom line: In patients with CT-proven, uncomplicated acute appendicitis, antibiotic treatment did not meet the pre-specified threshold for noninferiority compared with appendectomy, yet a significant majority of patients in the antibiotic arm had successful recovery.

Citation: Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: The APPAC randomized clinical trial. JAMA. 2015;313(23):2340-2348

Clinical question: Why do healthcare providers work while sick?

Background: Healthcare providers generally are aware of the risks of infection to hospitalized patients; however, despite this knowledge, several studies have revealed providers continue to work while ill.

Study design: Mixed-method analysis of a cross-sectional survey.

Setting: Large academic children’s hospital.

Synopsis: Investigators completed 538 of 929 surveys of attending physicians and advanced practice clinicians (APCs), a response rate of 58%. Of the respondents, 95% agreed that sick providers continuing patient care increased their patients’ risk for infection; however, 83% admitted to caring for patients while sick, with physicians being more likely to do so.

Several factors contributed to this behavior, including fear of letting colleagues or patients down, fear of ostracism by colleagues, and concerns for understaffing or discontinuity of care. Qualitative analysis of free-text responses revealed additional factors, including the difficulty of finding sick coverage, the strong cultural norms to continue working unless severely ill, and the ambiguity of defining “too sick to work.”

Limitations of this study included possible response bias, lack of a validated survey, and inclusion of only a single center; however, results confirm prior studies and reveal additional systems factors that hospital leadership could address, supporting providers and improving patient care.

Bottom line: Sick healthcare providers face several challenges that drive them to put their patients at risk by continuing patient care, and these factors could be addressed by healthcare systems as a means of improving overall quality of care.

Citation: Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: a mixed-methods analysis. JAMA Pediatr. 2015;169(9):815-821. doi:10.1001/jamapediatrics.2015.0684.

Clinical question: Why do healthcare providers work while sick?

Background: Healthcare providers generally are aware of the risks of infection to hospitalized patients; however, despite this knowledge, several studies have revealed providers continue to work while ill.

Study design: Mixed-method analysis of a cross-sectional survey.

Setting: Large academic children’s hospital.

Synopsis: Investigators completed 538 of 929 surveys of attending physicians and advanced practice clinicians (APCs), a response rate of 58%. Of the respondents, 95% agreed that sick providers continuing patient care increased their patients’ risk for infection; however, 83% admitted to caring for patients while sick, with physicians being more likely to do so.

Several factors contributed to this behavior, including fear of letting colleagues or patients down, fear of ostracism by colleagues, and concerns for understaffing or discontinuity of care. Qualitative analysis of free-text responses revealed additional factors, including the difficulty of finding sick coverage, the strong cultural norms to continue working unless severely ill, and the ambiguity of defining “too sick to work.”

Limitations of this study included possible response bias, lack of a validated survey, and inclusion of only a single center; however, results confirm prior studies and reveal additional systems factors that hospital leadership could address, supporting providers and improving patient care.

Bottom line: Sick healthcare providers face several challenges that drive them to put their patients at risk by continuing patient care, and these factors could be addressed by healthcare systems as a means of improving overall quality of care.

Citation: Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: a mixed-methods analysis. JAMA Pediatr. 2015;169(9):815-821. doi:10.1001/jamapediatrics.2015.0684.

Clinical question: Why do healthcare providers work while sick?

Background: Healthcare providers generally are aware of the risks of infection to hospitalized patients; however, despite this knowledge, several studies have revealed providers continue to work while ill.

Study design: Mixed-method analysis of a cross-sectional survey.

Setting: Large academic children’s hospital.

Synopsis: Investigators completed 538 of 929 surveys of attending physicians and advanced practice clinicians (APCs), a response rate of 58%. Of the respondents, 95% agreed that sick providers continuing patient care increased their patients’ risk for infection; however, 83% admitted to caring for patients while sick, with physicians being more likely to do so.

Several factors contributed to this behavior, including fear of letting colleagues or patients down, fear of ostracism by colleagues, and concerns for understaffing or discontinuity of care. Qualitative analysis of free-text responses revealed additional factors, including the difficulty of finding sick coverage, the strong cultural norms to continue working unless severely ill, and the ambiguity of defining “too sick to work.”

Limitations of this study included possible response bias, lack of a validated survey, and inclusion of only a single center; however, results confirm prior studies and reveal additional systems factors that hospital leadership could address, supporting providers and improving patient care.

Bottom line: Sick healthcare providers face several challenges that drive them to put their patients at risk by continuing patient care, and these factors could be addressed by healthcare systems as a means of improving overall quality of care.

Citation: Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: a mixed-methods analysis. JAMA Pediatr. 2015;169(9):815-821. doi:10.1001/jamapediatrics.2015.0684.