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HospitalistWeekly 5-21-08

Special Internal Medicine 2008 issue

ACP Regents and Governors

• Governors discuss impact of drug and imaging preapprovals
• Regents approve clinical guidelines on preventing fractures, consider hospital-acquired infections

Scientific sessions of note

• Less can be more for hospitalized elderly
• Managing inpatient glucose levels
• Racial, ethnic disparities: Use patient-centered care, not stereotypes

Cartoon caption contest

• And the winner is. . .

Editorial notice: ACP HospitalistWeekly will not be published on May 28 in observance of the Memorial Day holiday.

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ACP Regents and Governors

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Governors discuss impact of drug and imaging preapprovals

The Board of Governors voted last Wednesday to recommend that the Regents evaluate the impact of drug and medical imaging preauthorization requirements; endorse electronic prescribing of controlled substances; establish benchmarks for reasonable health insurance administrative costs; and publicize misleading and/or fraudulent representations by health insurers.

Though the resolution was ultimately referred for further study, the governors also vigorously debated whether to advocate for certain standards in relationships with drug companies and other medically related industries. Those standards might include banning gifts at medical meetings, banning industry-sponsored meals, disallowing drug trade names in medical promotional materials, and discouraging physicians from ghostwriting articles for academic journals.

College members have, on occasion, been offered money to sign on to articles slated for publication in peer-reviewed journals, even though they were not involved in writing or researching the paper, Governor Jay Butler, FACP, of Alaska noted in discussing the provision on ghostwriting.

Also referred for further study was the possibility of offering a reduced ACP membership rate to members who elect to receive all communications electronically and of making Key Contact enrollment an automatic benefit to which members could opt out if they desired.

In addition, the Governors voted to ask that the Regents:

• Monitor the national news for negative articles and broadcasts about primary and general internal medicine care, and launch a prompt media response that explains the limitations posed by the current system of primary care, as well as the patient-centered medical home concept.
• Support legislation specifically funding National Institutes of Health or Agency for Healthcare Research and Quality research that serves to further characterize primary care practice patterns in regions that provide high-quality health care at lower cost.
• Advocate for an amendment to the Controlled Substance Act to allow electronic prescribing of controlled substances with the same security standards as non-narcotics, and incorporate this into the existing system for electronic prescribing rather than in a separate mechanism.
• Work to ensure that a patient's provider has access to all his/her health care records from the Veterans' Health Administration.
• Advocate for an evaluation of the impact of pharmaceutical and advanced medical imaging preauthorization programs on cost savings, patient satisfaction and the work of the physician office, and for compensating providers for the cost of the preauthorizations.
• Study how to promote further expansion of the number of Federally Qualified Health Centers in order to decrease health care disparities.
• Publicize to College members the potential dangers of signing ambiguous forms from health insurers, and explicitly identify companies that implement misleading or fraudulent policies, as well as work with other medical societies to ensure that such actions are brought to the attention of regulators.
• Establish benchmarks for reasonable health insurance administrative costs and explore means for reducing and controlling these costs, as well as for setting guidelines on the appropriate percentage of premium that needs to be spent on patient care delivery.
• Call upon the American Board of Internal Medicine to develop further pathways for recertification that allow more options for achieving board certification—in particular, the substitution of additional non-ABIM-developed, high-quality continuing medical education in place of ABIM-developed modules.
• Explore hiring and supervising individuals to serve as "virtual" executive directors for several chapters at a time—or as regional executive directors shared among chapters. Chapters who elect this service would pay the national office for the associated costs.

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Regents approve clinical guidelines on preventing fractures, consider hospital-acquired infections

The Board of Regents on Tuesday approved clinical practice guidelines aimed at preventing fractures, as well as a measure that could lead to ACP's first guideline on reducing hospital-acquired infections.

The Regents also agreed to form a group of physicians and other health professionals to advise College members on practice management issues; to set policies on the employment of international medical graduates (IMGs) in the U.S.; and to work with the American Medical Association to establish business practice benchmarks for health insurance companies that will be given to providers, purchasers, patients and policymakers.

The following items also were approved at the meeting:

• A practice guideline, "Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women," which is expected to be published in the Annals of Internal Medicine by September.
• A measure recommending that the Agency for Healthcare Research and Quality (AHRQ) commission an evidence-based review on making hospital-acquired infection a quality improvement measure—an effort that could potentially lead to development of a clinical guideline by the Clinical Efficacy Assessment Subcommittee. In the meantime, the Regents will inform ACP members of strategies to reduce hospital-acquired infection rates via education at annual meetings and possibly other venues.
• Establish a Practice Support Advisory Group, staffed by member physicians as well as nurses, laboratory technicians and other staff, which would advise College members by phone and e-mail on practice management issues.
• Provide an ongoing assessment of the projected costs—such as completing coursework and paperwork—to large and small practices of meeting the requirements for being a patient-centered medical home (PCMH). A research team is currently working with various practices to determine the costs of complying with each element of the PCMH, with the goal of advocating to Medicare and other payers that they provide adequate payment.
• Work with the Society of General Internal Medicine, the Society of Hospital Medicine and the Association of Program Directors in Internal Medicine on developing recommendations on the impact of resident duty hours on clinical and teaching responsibilities of faculty.
• A policy on the role of IMGs in the U.S. physician workforce. Under the policy, ACP supports:
• streamlining the process for obtaining J-1 and H-1B visas for IMGs who want postgraduate medical training or to practice in the U.S.;
• expanding J-1 visa waiver programs to help alleviate physician shortages in underserved urban and rural areas;
• exempting from the H-1B visa cap those physicians trained in specialties that are facing shortages;
• collaborating with medical schools and teaching hospitals in less developed countries to improve their medical education and training; and
• developing a Global Health Corps or other entity that could facilitate opportunities for U.S. physicians to serve in less developed countries.

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Scientific sessions of note

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Less can be more for hospitalized elderly

When caring for hospitalized elderly patients, sometimes the best thing to do is nothing, according to Jeffrey Wallace, ACP Member. Dr. Wallace offered the following tips for dealing with delirium, nutritional problems and pain management, among other topics, at last week's sessions on "Top Ten Rules for Rounding on Hospitalized Elders."

Keep variable illness presentation in mind. Physicians should be aware that some illnesses present differently in the elderly, Dr. Wallace said. For example, in patients older than 85, the most common symptom of acute myocardial infarction is dyspnea, not chest pain.

Try nondrug methods for delirium-related behavioral problems. Dr. Wallace recommended using "social" restraints in patients with delirium instead, such as having a sitter or a family member in the room. If drugs are absolutely necessary, use haloperidol, he advised.

Beware of drug-drug interactions. In patients taking at least eight drugs, the chance of an interaction is 100%, and nearly 50% of community-dwelling geriatric patients have had at least one drug-drug interaction, Dr. Wallace noted. "We have to be careful with medications in the elderly," he said.

Explain new drugs to patients. A 2006 Archives of Internal Medicine study found that 25% of doctors never told patients the name of the drug they were prescribing, and explicit directions and information on duration of use were provided only 50% of time. If you tell patients what they'll be taking and why, compliance will improve, Dr. Wallace predicted.

Be alert for depression. Even minor depression can have major sequelae, Dr. Wallace said. Treatment with antidepressants or nondrug approaches, such as psychotherapy and exercise, can improve outcomes. Also, remember to arrange for appropriate postdischarge follow-up, he noted.

Avoid specialized diets. To make sure patients stay nourished, let them eat what they want, other than restricting sodium when warranted, and try to minimize iatrogenic starvation such as NPO orders for tests, Dr. Wallace advised.

Assess function before discharge. "I don't let my older patients out of the door without road-testing them," Dr. Wallace said. He recommended using the "Get Up and Go" test to see if patients can rise from a chair without using their arms for support and walk 10 feet without difficulty.

Don't discount opioids. "I think we are frankly too reluctant to use opioids in older adults," Dr. Wallace said. In most cases, the list of potential consequences is longer, and more serious, than the list of potential side effects, he noted.

Take advantage of the transfer sheet. "What you write on that is Gospel" for patients being transferred to other facilities, Dr. Wallace said.

Don't just do something, stand there. That's Dr. Wallace's rule for patients over age 75 or age 85. "Let the dust settle and see what's going on before you jump in," Dr. Wallace recommended. But watch out for ageism, he cautioned, and keep the patients' functional age rather than their chronological age in mind. "The best guides to assessment and management are the clinical circumstances and the patients' preferences," he concluded.

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Managing inpatient glucose levels

Hyperglycemia in the hospital is common, and insulin therapy needs to be managed very carefully because of the associated risk for medication error-related injuries, said Stephen Clement, MD, at last week's session "Diabetes and Hospitalization: The Evidence for New Inpatient Glucose Targets."

Two trials by Van den Berghe and colleagues, published in the New England Journal of Medicine in 2001 and 2005, found that meticulous blood glucose control reduced risk of poor outcomes in the ICU. But no randomized, controlled trials have been performed outside the ICU, Dr. Clement said. In addition, a study by Brunkhorst and colleagues published in the New England Journal of Medicine this year found that intensive insulin therapy increased hypoglycemia-related adverse events in critically ill patients with severe sepsis.

So what should clinicians do while they're waiting for new data? The best they can, Dr. Clement said. One of the points he stressed most strongly was the danger of relying on sliding-scale insulin, which he said should be considered just a small piece of the overall puzzle. "The reason [sliding scale] doesn't work by itself is because it treats things after the event," Dr. Clement said. "I consider sliding-scale alone as very sloppy management."

When an increase in the daily insulin requirement is attributed to illness, stress or treatment, patients' needs will vary widely by individual, Dr. Clement noted. "You just have to look at the sugars every day and make daily adjustments either upwards or downwards," he said. Physicians should also remember that patients' insulin needs will decrease as their clinical condition improves, Dr. Clement said.

With enteral nutrition, physicians can use short-acting insulin as a dose-finding regimen, Dr. Clement said. In patients on continuous enteral regimens, he advised giving half the insulin as basal insulin and half as regular insulin every four to six hours during the feeding period; with bolus enteral regimens, he advised giving half as basal and half as regular insulin. "This gives the nurse at the bedside the flexibility that they can hold a dose," he said.

For patients receiving total parenteral nutrition, Dr. Clement recommended using a separate IV insulin infusion for 24 hours to determine the daily insulin requirement, then adding approximately that amount to subsequent bags daily.

In cases where physicians are transitioning a patient from IV to subcutaneous insulin, Dr. Clement offered the following do's and don'ts:

• Do overlap subcutaneous and IV insulin by at least two to three hours to minimize "hyperglycemia escape."
• Don't switch to oral agents alone from IV insulin.
• Arrange for follow-up of patients who have never been on insulin before.
• Ensure adequate food intake when switching patients to subcutaneous insulin.

Dr. Clement stressed that inpatient glucose control is a team effort that requires education of physicians, nurses and patients. "Keep in mind how big this whole operation is," he said. "Everyone needs to be involved, you as the hospitalist, your surgery colleagues, the pharmacist, dietitian, the nurse. But keep in mind that the patient is always at the center of the whole team."

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Racial, ethnic disparities: Use patient-centered care, not stereotypes

Based on existing research, how should you treat an older hypertensive woman if she happens to be Hispanic?

The same as any other hypertensive patient, said Michael J. Bloch, ACP Member, during last week's session "Racial and Ethnic Disparities in Cardiometabolic Risk: Lessons for Clinical Practice."

While research has shown that the prevalence of certain cardiovascular risk factors varies based on race and ethnicity—and this should affect one's approach to screening—it doesn't affect the therapies one should recommend.

"These differences…don't affect the management or care of individual patients," Dr. Bloch said. "What may change, however, is how you deliver that care."

Studies have shown that race and ethnicity affect health care outcomes, even when researchers control for income, education, occupation and insurance coverage. The root causes of this are complex, and may include inequities in the health care delivery system, differences in patient behaviors and preferences, and problems with the provider-patient relationship, Dr. Bloch said.

Indeed, a 2004 observational study published in the American Journal of Public Health found that physicians were 23% more verbally dominant and engaged in 33% less patient-centered communication with African-American patients than with white patients, regardless of the provider's own race, Dr. Bloch said.

Some cultural competency programs have used this kind of data as a basis for educating physicians on specific values, customs and beliefs that are thought to be unique to different racial and ethnic groups. But focusing on stereotypes is not the best solution to altering provider behavior, Dr. Bloch said.

"These programs are well-meaning but run the risk of over-simplifying," Dr. Bloch said. "So we use a patient-centered approach to improve communication between the practitioner and patient."

Dr. Bloch noted that Joseph Betancourt, MD, and colleagues have developed a patient-centered approach, called the ESFT (Explanatory, Social, Fears, Treatment) Model, that works well for cross-cultural communication with patients, he said. The model's components involve the patient's:

• Explanation and conceptualization of his/her illness. The provider may ask the patient:
• What do you call your problem?
• What do you think is causing it?
• How does it affect your life? How does your family feel about it?
• What kind of treatment do you think will work?
• Social and financial barriers to adherence
• Does your insurance cover your medications?
• Do you have access to a pharmacy?
• Is it difficult to afford your medications or copayments?
• How are your medications organized at home? Do you have a pill box?
• Fears and concerns about the treatment or its potential side effects
• How do you feel about taking the medication?
• What have you heard about this medication?
• What worries do you have about side effects?
• Do you think the medication will interfere with your life?
• Understanding of his/her treatment regimen
• How do you plan to take the medications?
• How do you feel about your treatment plan?
• Can you repeat the (treatment) instructions back to me in your own words?

"You may not ask every single question, but you can use it as a guide in deciding which questions are the most meaningful in a given situation," Dr. Bloch said. "Best of all, this model works for majority and minority populations."

Read more about cultural competency in ACP Hospitalist.

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Cartoon caption contest

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And the winner is…

We've compiled the results from our latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Dave Johnston, a student at the Brody School of Medicine at East Carolina University in Greenville, N.C., who receives a $50 gift certificate good toward any ACP product, program or service.

ACP readers cast 240 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

"No doc, this time I fell down a spiral staircase!"

The winning caption received 44.2% of the votes cast. The two runners up were:
"I know it looks bad, so just give it to me straight." (35.8%)
"Another one falls victim to the Hokey Pokey." (20%)

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated