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HospitalistWeekly 8-13-08

News highlight

  • Aging population fuels jump in hospital visits, CDC reports

Neurology

  • GI bleeding linked to poor outcomes after ischemic stroke

CMS update

  • New conditions added to "do not pay" list

FDA update

  • Dozens of generic drugs recalled from hospitals, pharmacies
  • IV clevidipine butyrate approved to control blood pressure
  • Class 1 recall of Levitronix CentriMag Extracorporeal Blood Pumping System

From ACP Internist

  • From the blog: Patients rank bedside manner No. 1; FDA tightens expert panelist guidelines; nurses step up for HIV
  • Mindful Medicine case studies wanted

Cartoon caption contest

  • Put words in our mouth …

News highlight

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Aging population fuels jump in hospital visits, CDC reports

Visits to physician offices and hospital outpatient and emergency departments jumped by 26% to 1.1 billion between 1996 and 2006, driven by the increasing health care needs of a large aging population, according to statistics released last week by the CDC.

The aging population had a dramatic effect on hospital inpatient departments, according to the National Health Statistics reports[PDF] compiled by the CDC's National Center for Health Statistics. The percent of hospital inpatients 65 years and older grew from 20% in 1970 to 38% in 2006, while the percentage 75 years and over grew from 9% to 24%.

The report also revealed persisting racial and socioeconomic disparities, with the proportion of visits to hospital OPDs and EDs increasing as poverty levels increased. In addition, black patients had higher visit rates than whites to OPDs and EDs and lower visit rates to office-based surgical and medical specialists.

Other findings from the report included:

  • The overall number of ED visits increased by 32% during the study period while OPD visits rose by 52%.
  • About half of all non-obstetric hospital patients were admitted through the ED for impatient services, up from 36% in 1996.
  • Overall, patients waited an average of nearly 56 minutes to see a physician in the ED.
  • At least one medication was provided, prescribed or continued in seven out of 10 visits in 2006. Analgesics, the most common pain medication used in primary care and EDs, accounted for 13.6% of all prescriptions.
  • The percentage of visits to OPDs by adults with chronic diabetes increased by 43% while visits by adults with chronic hypertension increased by 51% between 1996 and 2006.

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Neurology

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GI bleeding linked to poor outcomes after ischemic stroke

Patients who develop gastrointestinal (GI) bleeding are more likely than patients who do not develop bleeding to die after an ischemic stroke, according to a new study.

Canadian researchers examined 6,853 patients treated for ischemic stroke at 11 hospitals between July 2003 and June 2006. Forty-nine percent of patients were women, and the mean age was 72 (SD 13.9) years. The goal of the study was to determine the relationship between poststroke bleeding and clinical outcomes. The results were published online Aug. 6 by Neurology.

Overall, 100 patients (1.5%) developed a poststroke GI hemorrhage during hospitalization, 36 (0.5%) requiring blood transfusion. Multivariable analysis found that history of peptic ulcer disease, cancer and severity of stroke independently predicted GI bleeding. Among patients who developed GI bleeding, an independent association was seen for death or severe dependence at hospital discharge (odds ratio, 3.3 [95% CI, 1.9 to 5.8]) and death at six months (hazard ratio, 1.5 [95% CI, 1.1 to 2.0]). Most patients with GI bleeding and most patients without were receiving antithrombotic therapy at hospital discharge (87.5% vs. 93.9%, respectively).

Although their study had limitations, including its retrospective design, the authors concluded that GI bleeding is strongly associated with poor outcomes in patients with ischemic stroke, even six months after hospital discharge. They called for further studies to examine the effect of bleeding episodes on rates of recurrent vascular events and mortality.

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CMS update

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New conditions added to "do not pay" list

CMS has added three new conditions to its so-called "do not pay" list, the agency announced.

In 2007, CMS announced that as of Oct. 1, 2008, it would no longer reimburse for eight conditions: objects inadvertently left in a patient after surgery, air embolisms, blood incompatibility, catheter-associated urinary tract infections, pressure ulcers, vascular catheter-associated infection, surgical site infection or mediastinitis after coronary artery bypass graft surgery, and certain types of falls and trauma if these events or conditions occurred during a hospital visit. In April 2008, CMS proposed adding nine additional conditions to the existing list. After reviewing public comments, it has decided to add the following three:

  • Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity;
  • Certain manifestations of poor control of blood sugar levels; and
  • Deep venous thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures.

The rule applies to discharges on or after Oct. 1, 2008, CMS said in a press release. Beginning on that date, Medicare will no longer reimburse hospitals for these 11 conditions if they are acquired in the hospital. The rule also expands the hospital quality measure reporting program to 42 quality measures by adding 13 new measures and retiring one, oxygenation assessment, as of Jan. 1, 2009.

The final rule will appear in the Aug. 19, 2008 Federal Register.

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FDA update

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Dozens of generic drugs recalled from hospitals, pharmacies

Generic drug maker Actavis is voluntarily recalling more than 60 products at the retail level due to an FDA inspection that showed its operations didn’t meet standards for good manufacturing practices.

The precautionary recall affects all products made at Actavis’ Little Falls, N.J. facility, including oxycodone, glyburide, guanfacine and mirtazapine. A full list of recalled drugs is online.

Patients should keep taking these medications, since stopping suddenly could put them at risk, Actavis said in a release posted on the FDA Web site. Recall letters have been issued to wholesalers and retailers, including hospitals and pharmacies, it said. More information is available online.

In late April, Actavis issued a Class 1 recall of digoxin tablets (Digitek), saying tablets might contain double the intended amount of the active ingredient.

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IV clevidipine butyrate approved to control blood pressure

The FDA last week approved intravenous clevidipine butyrate (Cleviprex) to reduce blood pressure.

A dihydropyridine calcium-channel blocker, the IV drug has a quick onset and offset of action that can be titrated for exact control in a critical care setting. It is metabolized in the blood and tissues and does not accumulate in the body, a company release said.

IV clevidipine butyrate may produce systemic hypotension and reflex tachycardia, the company noted. The most common adverse reactions are headache, nausea and vomiting. Full prescribing information is online.

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Class 1 recall of Levitronix CentriMag Extracorporeal Blood Pumping System

The FDA issued a Class 1 recall of the Levitronix CentriMag Extracorporeal Blood Pumping System and Primary & Backup Consoles because it may result in injury or death.

The system temporarily replaces the function of the heart and lungs in order to maintain correct blood and oxygen levels during surgery. Levitronix recently issued a letter[PDF] warning doctors not to use Valleylab Force FX-C or SSE2L electrosurgery devices with the CentriMag Blood Pumping System because such use may result in stoppage of the pump and cause serious injury or death. The recall of the entire system “is an interim fix while the firm further investigates the source of the problem,” an FDA safety alert said.

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From ACP Internist

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From the blog: Patients rank bedside manner No. 1; FDA updates conflict-of-interest rules; nurses step up for HIV

A new survey finds patients rank bedside manner as the No. 1 reason for liking their doctor, plus new FDA guidelines for experts who advise during committee meetings, and Africa enlists specially trained nurses to care for HIV—and gets better patient satisfaction over physician care. Find these stories and Medical News of the Obvious every Monday at ACP Internist's blog.

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Mindful Medicine case studies wanted

'Mindful Medicine' columnists Jerome Groopman, FACP, and Pamela Hartzband, FACP, will soon be featured in ACP Hospitalist and would like to hear about your stories of difficult or missed diagnoses for possible use in future columns.

Dr. Groopman, a hematologist/oncologist and author of the bestselling "How Doctors Think," and Dr. Hartzband, an endocrinologist, are on the Harvard Medical School faculty and serve as staff physicians at Boston's Beth Israel Deaconess Medical Center. Every other issue, they present a case study from a reader describing a difficult or missed diagnosis, and provide commentary on how a mistake was, or might have been, avoided.

Please e-mail your suggestions to Drs. Groopman and Hartzband. The authors will contact you to discuss the case if your submission is selected for the column.

Previous Mindful Medicine columns are online.

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Cartoon caption contest

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Put words in our mouth …

ACP HospitalistWeekly and ACP InternistWeekly want readers to create captions for this cartoon and help choose the winner.

Put words in our mouth …

E-mail all entries this week to acphospitalist@acponline.org by August 15. ACP staff will choose three finalists and post them in the Aug. 20 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Aug. 27 issue.

Pen the winning caption and win a copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history.

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