In the News

IV alteplase in stroke patients; hospitalist practice models and job satisfaction.

Score predicts outcomes of using IV alteplase with stroke patients

A new score can help predict how ischemic stroke patients will respond to intravenous (IV) alteplase, a study reports.

Finnish researchers tested their acronymic “DRAGON” score on 1,319 ischemic stroke patients treated with IV alteplase at an academic hospital in Helsinki, Finland. They examined outcomes at three months post-stroke, with a good outcome defined as independence in daily activities as measured by the modified Rankin Scale (mRS). A bad outcome was defined as being bedridden, incontinent and in need of constant nursing care, or dead. Patients were assigned a score of 0 to 10 based on factors that were known at admission or shortly thereafter, and before alteplase was given. These factors include age, pre-stroke mRS, glucose level on admission, onset to treatment time, stroke severity (via National Institutes of Health Stroke Scale), and presence of hyperdense cerebral artery sign and early infarct signs on a CT head scan at admission. Results were published in the Feb. 7 Neurology.

Proportions of patients with good outcomes, defined as mRS scores of 0-2, were 96% of those who scored 0-1 on the DRAGON, 88% of those who scored a 2, 74% of those who scored a 3, and 0% of those who scored an 8-10. Proportions of patients with a poor outcome, i.e. an mRS score of 5-6, were 0% for 0-1 points on the DRAGON, 2% for 2 points, 5% for 3 points, 70% for 8 points and 100% for 9-10 points. External validation with a cohort of 330 patients at an academic hospital in Basel, Switzerland showed similar results. The area under the receiver-operating characteristic curve (AUC-ROC) was 0.84 in the derivation cohort and 0.80 in the validation cohort.

The DRAGON score is simple, free and fast—it took less than a minute to calculate the score at the researchers' institution, the authors wrote. Patients with a low score can be told their likelihood of a good recovery after IV alteplase is high, while those with a high score can be told the opposite. This information empowers patients to decide on alteplase use, as well as the use of add-on therapies in cases when alteplase alone doesn't seem to offer good outcomes, they wrote. The score wasn't studied in patients with basilar artery occlusion, the authors noted.

Hospitalist practice models have little effect on job satisfaction, burnout, survey finds

Job satisfaction and burnout rates are similar across different hospitalist practice models, a recent survey found.

Researchers administered the survey to a randomized, stratified sample of 3,767 potential hospitalists, 662 of whom were members of three multistate hospitalist companies. The survey used a five-point Likert scale to address hospitalist group characteristics, work patterns, demographic information, global job satisfaction and 11 satisfaction domains including compensation, autonomy, personal time, care quality and organizational fairness. They examined relationships between global satisfaction and satisfaction domains, and burnout symptoms and career longevity. Results were published online Jan. 23 in the Journal of Hospital Medicine and in the January Journal of General Internal Medicine.

A total of 794 responses were included in the analysis. Among respondents, 44% were directly employed by a hospital, 15% by a multispecialty physician group, 14% by a multistate hospitalist group, 14% by a university or medical school, 12% by a local hospitalist group and 2% by “other.” Reported findings included the following:

  • Hospitalists with local groups had more clinical shifts per month (19 shifts for local groups vs. 17 for multistate groups, 15 for multispecialty groups and academics, 16 for hospital-employed);
  • Hospitalists with local and multistate groups had more billable encounters per shift (17 encounters for each vs. 15 for hospital-employed, 14 for multispecialty groups, 13 for academics);
  • Job burnout symptoms were reported by 30% of respondents, who were more likely to leave their jobs or reduce work effort;
  • Academic hospitalists had fewer night shifts (14% of shifts vs. 23% each for multistate and multispecialty groups), more nonclinical work hours per month (71 hours vs. 19 for multistate groups) and lower earnings ($166,478 on average vs. $226,065 for local groups);
  • Academic hospitalists were least likely to participate in comanagement (71% vs. 100% with local groups), intensive care unit (ICU) care (27% vs. 94% with multistate groups) and nursing home care (8% vs. 30% with local groups);
  • 11% to 19% of time was spent on administrative and committee work, with the least amount spent by hospitalists in multistate groups and the most by academic hospitalists;
  • A majority of respondents (62%) had high satisfaction ratings (≥4 on a 5-point scale);
  • The greatest satisfaction was with the quality of care provided and relationships with staff and colleagues; and
  • The least satisfaction was with organizational climate, autonomy, compensation, and availability of personal time.

While there were differences among the practice models in clinical and nonclinical responsibilities, and in factors most important to job satisfaction, the levels of job satisfaction and burnout were similar, the researchers noted in the JHM article. The finding suggests “individuals find settings that allow them to address their individual professional goals,” they wrote. They also noted a growth in the number of hospitalists who participate in ICU care and co-management as proof that “collaborative care (is) one of the dominant drivers of the hospitalist movement.” Finally, they noted that compensation and workload are not the only factors that contribute to job satisfaction, and advised administrators to adopt “more nuanced approaches” to recruiting and retaining hospitalists than simply focusing on salary and workload.

Sexual activity safe for most cardiovascular disease patients

It is reasonable for most patients with cardiovascular disease (CVD) to engage in sexual activity, according to a scientific statement from the American Heart Association.

A multidisciplinary group of experts developed the evidence-based statement to synthesize and summarize existing data into recommendations and foster communication between clinicians and patients about sexual activity. The statement specifically addresses several different conditions, including coronary artery disease, heart failure, valvular heart disease and arrhythmias.

In general, the experts concluded that sexual activity is reasonable for patients who, on clinical evaluation, are at low risk of cardiovascular complications (Class IIa, Level of Evidence B recommendation). Any patients with unstable or severe symptoms should be stabilized before sexual activity (III, C). To determine which category a patient falls into, a comprehensive history and physical is reasonable before a physician provides a recommendation (IIa, C). If a patient's risk is uncertain after examination, exercise testing can be useful (IIa, C).

Cardiovascular drugs that can improve symptoms and survival should not be withheld because of concerns about sexual function, the statement said (III, C). Recent data do not show clear relationships between most of these drugs and erectile dysfunction. For patients who do have sexual dysfunction and stable CVD, PDE5 inhibitors can be useful (I, A). However, PDE5 inhibitors are absolutely contraindicated in patients taking nitrates (III, B).

Physicians should assess anxiety and depression regarding sexual activity in their CVD patients, the statement recommended (I, B). They should also counsel both the patient and spouse or partner about sexual activity following an acute cardiac event, new CVD diagnosis or ICD implantation (I, B). Suggestions to the patient for making activity safer could include “being well rested at the time of sexual activity, avoiding unfamiliar surroundings and partners to minimize stress during sexual activity, avoiding heavy meals or alcohol before sexual activity, and using a position that does not restrict respiration.”

The statement was also endorsed by the American Urological Association, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association of Cardiovascular and Pulmonary Rehabilitation, International Society of Sexual Medicine, American College of Cardiology Foundation, Heart Rhythm Society, and Heart Failure Society of America. It was published online by Circulation on Jan. 19.

Most Medicare demonstration projects fail to reduce costs

The Congressional Budget Office (CBO) has analyzed recent Medicare demonstration projects and concluded that most have not reduced costs, but those that did had certain specific characteristics.

The CBO issue brief reviewed 10 projects, six that focused on disease management and care coordination and four that were value-based payment demonstrations. All of the care coordination projects used nurses as care managers and sought to reduce hospital admissions. On average, the programs achieved little or no reduction in admissions, but the effects of the programs varied considerably. Some programs reduced admissions by 15% or more, while in others admissions rose by at least 15%.

In most of the care coordination programs, the care manager was not integrated into the physician's office and had only telephone contact with patients. The CBO analysis found that these two design elements were associated with the results of the programs; care coordinators who interacted more closely with physicians and patients were more likely to reduce admissions. However, even these more successful programs did not, for the most part, achieve enough savings to offset the fees they were paid for the demonstration. Whether the practice's fees were at risk in the demonstration did not appear to affect the success or failure of a program.

The four value-based demonstration programs in the analysis were the Physician Group Practice Demonstration, the Premier Hospital Quality Incentive Demonstration, the Medicare Participating Heart Bypass Center Demonstration and the Home Health Pay-for-Performance Demonstration. Only the bypass demonstration yielded significant savings for Medicare, reducing expenditures for bypass surgery by about 10%. The bypass demonstration was the only one of the four that used a bundled payment system to reduce costs. Participating hospitals and physicians were motivated to accept a discounted, bundled payment for their services due to competitive pressures in their markets, the CBO brief noted.

These findings suggest that substantial changes to payment and delivery systems will probably be required before demonstrations like these can significantly reduce spending or improve care, the brief concluded. The author also cited several other lessons to be taken from these demonstrations, including the need to gather timely data, focus on transitions of care, use team-based care, target high-risk patients, and limit the fees paid to participating organizations. The brief was published Jan. 18.