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HospitalistWeekly 12-10-08
Highlights
- IOM favors more limits on resident hours
- Rapid response teams fail to lower code, mortality rates
- Cleveland Clinic lists physician-industry ties
Drug news
- Generic cardiovascular drugs are as effective as brand-name
- Tinzaparin may heighten death risk for older patients with renal insufficiency
Annals of Internal Medicine
- New HIV-testing guidelines from ACP
From ACP Hospitalist
- December's issue is online
From ACP Internist's blog
- Sermo's new flu tracking tool
Cartoon caption contest
- Pick the year's best
Highlights
.IOM favors more limits on resident hours
The Institute of Medicine recommended last week that the workloads and schedules of medical residents be reduced in the interests of patient safety.
The new IOM report suggests that residents be allowed to work no more than 16 hours in a row without sleep and that their number of mandatory days off be increased. Medical moonlighting by residents should also be restricted, the report said. Under the proposed changes, residents could either work a shift of 16 continuous hours or they could work 30 hours if they received a 5-hour sleep break after working 16 hours. The sleep break would count toward the current 80-hour limit, which the group did not suggest changing.
The report also called for greater supervision by attendings, and recommended that first-year residents not be left on duty without immediate access to an on-site supervisor. Residency review committees for all medical specialties should set specific limits on how many patients residents can treat per shift, the IOM said. Currently, only internal medicine has such rules. To reduce the chance of hand-off errors, residents should be scheduled on overlapping shifts.
The committee which wrote the report noted that the proposed changes would require increases in the number of residents and other providers, including midlevels and trained physicians, caring for patients in the hospital. They estimated the additional personnel costs at $1.7 billion annually, but noted that a reduction in errors would also reduce the cost of the changes.
.Rapid response teams fail to lower code, mortality rates
Rapid response teams do not appear to reduce the incidence of hospital-wide cardiopulmonary arrests or deaths, according to the results of a study published last week in the Journal of the American Medical Association.
The study, which tests the Institute for Healthcare Improvement’s (IHI) recommendation that hospitals implement rapid response teams as one of six strategies to reduce preventable in-hospital deaths, was performed over several years at a single mid-western hospital. Hospitals nationwide fell in line with IHI’s recommendation, the authors noted, despite limited published data in support of its efficacy.
Over a three-year period, the study evaluated 24,193 adult patient admissions prior to the rapid response team intervention (Jan. 1, 2004 - Aug. 31, 2005) and 24,978 admissions after the intervention (Jan. 1, 2006 - Aug. 31, 2007). Of the 376 rapid response team activations during 20-months following the intervention, most were triggered by altered neurological status, tachycardia exceeding 130 beats per minute, tachypnea exceeding 30 breaths per minute, and hypotension assessed as blood pressure lower than 90 mmHg.
Mean hospital-wide code rates per 1,000 admissions were 11.2 before and 7.5 after rapid response team intervention. A decrease in non-ICU code rates accounted for the majority of the difference. Fatality rates after cardiopulmonary arrest and hospital-wide mortality were similar prior to and after the rapid response team intervention.
The authors noted that, given the study's findings, more research is needed to establish the effectiveness of rapid response teams and that hospitals may benefit by investing their resources in more evidence-based improvement initiatives.
.Cleveland Clinic lists physician-industry ties
Physicians who work for the Cleveland Clinic will now have to publicly release their business relationships with pharmaceutical and device manufacturers, the health system announced last week.
All of the clinic's 1,800 staff physicians and researchers will now be included in an online directory. With each name will be posted a list of any device or drug companies with which the physician collaborates. Disclosure will be required for any consulting relationship that pays $5,000 or more per year, as well as any equity, royalty or fiduciary interests.
The clinic began internally monitoring such relationships more than a year ago, according to the Dec. 3 New York Times. All Cleveland Clinic staff physicians report their industry relationships at least yearly and the hospital's Innovation Management and Conflict of Interest Committee reviews the collaborations to identify any potential conflicts. Less than one-quarter of the clinic's physicians have such relationships to report, a clinic representative told the New York Times.
The Cleveland Clinic is apparently the first academic medical center to publicly disclose individual physician-industry ties, said the hospital's chief of staff. Currently, the directory only lists company names and the type of relationship but there are plans to expand it next year to include specific dollar amounts.
Drug news
.Generic cardiovascular drugs are as effective as brand-name
Generic and brand-name cardiovascular drugs are no different in terms of clinical outcomes, a new meta-analysis in the Dec. 3 Journal of the American Medical Association found.
Researchers searched peer-reviewed publications for articles from January 1984 to August 2008, and found 47 articles comparing the safety and efficacy of generic and brand-name drugs. Thirty-eight of the articles were randomized controlled trials (RCT). The generic and brand-name drugs were found to be clinically equal in all seven beta-blockers RCTs; 10 of 11 diuretics RCTs; five of seven calcium channel blockers RCTs; all three antiplatelet agents RCTS; both statins RCTs; one angiotensin-converting enzyme inhibitors RCT; one alpha-blockers RCT; one class 1 anti-arrhythmic agents RCT; and five of five warfarin RCTs.
The clinical outcomes that were measured included vital signs, lab values like international normalized ratio (INR), adverse effects, and use of the health care system. The aggregate effect size was -0.03, showing brand name drugs weren't superior to generics. Despite this, about half of the editorials with the studies revealed negative viewpoints about switching to generics. Still, this article's authors concluded that switching from brand-name to generic drugs is safe, though they advised physicians to monitor the INR of high-risk patients during the transition period.
.Tinzaparin may heighten death risk for older patients with renal insufficiency
Tinzaparin (Innohep) may increase the mortality risk of patients with renal insufficiency who are age 70 or older, the FDA said in an alert.
A clinical study comparing unfractionated heparin to tinzaparin found a 13% all-cause mortality rate for older patients with renal insufficiency who took tinzaparin, compared to 5% rate for patients who took unfractionated heparin. The study was stopped in February 2008. In July 2008, the maker of tinzaparin revised prescribing information to restrict use of the drug in patients 90 years of age or older, but FDA has requested another revision to restrict use in patients age 70 and older with renal insufficiency.
Physicians should consider using alternative treatments when treating elderly patients age 70 years and older with renal insufficiency and deep vein thrombosis, pulmonary embolism, or both, FDA said.
Annals of Internal Medicine
.New HIV-testing guidelines from ACP
ACP urges physicians to offer routine HIV screening to all patients beginning at age 13, regardless of risk factors, in a new guidance statement published in the Dec. 2 Annals of Internal Medicine. The guidance statement differs slightly from those of the CDC, which recommend routine screening of patients until age 64 unless the prevalence of HIV is known to be less than 0.1% in the patient population. The recommendations also differ from those put forth by the U.S. Preventive Services Task Force, which urge routine screening only of patients at increased risk for infection.
It is very difficult for physicians to determine the HIV prevalence rate for their patient population, said Amir Qaseem, MD, senior medical associate in ACP's department of Clinical Programs and Quality of Care. “It is estimated that 1 million to 1.2 million Americans have HIV, but 24% to 27% of that number are undiagnosed or unaware of their infection,” he explained. “ACP recommends that clinicians adopt routine screening of all their patients.” Each year in the U.S. 20,000 new HIV infections are caused by individuals who are unaware that they are infected. An ACP video news release about the guidance statement is online.
Other articles in the latest issue of Annals assess the impact of hospitalists on emergency room crowding and whether apology laws improve patient-physician relations.
A new free patient education DVD, Living with HIV is now available.
From ACP Hospitalist
.December's issue is online
The latest issue of ACP Hospitalist is online and headed for your mailbox. Topics include:
Nocturnists. Disparities between day and night care, as well as new guidelines and public pressure, are pushing hospital administrators and hospitalist practices to offer 24/7 care.
Errors. Hospitals should always work to prevent serious or fatal medical errors, but they also need to have a plan in place for what to do if an error occurs.
Careers. Clinical research at community hospitals in collaboration with academic medical facilities is gaining traction around the U.S.
The latest issue is online.
From ACP Internist's blog
.Sermo's new flu tracking tool
This week on ACP Internist's blog, we assess the good and bad of medicine on the web: Sermo is using its members to track the spread of flu, but doctor rating services show little value. There's also talk of an insurer's new plan to charge people for the option to buy insurance. And, we're not counting it as Medical News of the Obvious, but did you know that students and residents are sleepy and sad?
Cartoon caption contest
.Pick the year's best
December's Grand Prize cartoon contest will pit the three top vote getters from 2008 head-to-head, with one lucky voter winning a $100 gift certificate. Voting continues through Dec. 22, with the winner announced in the Dec. 23 issue of ACP InternistWeekly.
Voting is online.
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