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ACP HospitalistWeekly 4-15-09

Highlights

  • ACP, others release statement on transitions of care
  • Hospitalist service works for low-severity trauma patients

Infection control

  • Asymptomatic catheter-associated bacteriuria treated inappropriately, study suggests

Nephrology

  • Combining GFR, albuminuria predicts progression to end-stage renal disease

FDA update

  • Efalizumab to be off U.S. market by June 8 due to PML risk

From ACP Internist

  • Your thoughts exactly: unemployed patients
  • Planning to tweet from Internal Medicine 2009?

Cartoon caption contest

Physician editor: A. Scott Keller, MD


Highlights

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ACP, others release consensus standards on transitions of care

Six professional medical societies, including ACP, have developed a set of consensus standards for improving transitions of care.

The American College of Physicians, the Society of Hospital Medicine, the Society of General Internal Medicine, the American Geriatric Society, the American College of Emergency Physicians and the Society for Academic Emergency Medicine established 10 principles to address the quality gaps in transitions between inpatient and outpatient care:

  • Accountability;
  • Communication;
  • Timely interchange of information;
  • Involvement of the patient and family member;
  • Respect the hub of coordination of care;
  • All patients and their family/caregivers should have a medical home or coordinating clinician;
  • At every point of transitions the patient and/or their family/caregivers need to know who is responsible for their care at that point;
  • National standards; and
  • Standardized metrics related to these standards in order to lead to quality improvement and accountability.

The group then developed standards to help implement these principles, including coordinating clinicians, care plans/transition record, communication infrastructure, standard communication formats, transition responsibility, timeliness, community standards and measurement. The group also identified challenges that will need to be addressed in the future, such as use of electronic health records and the need for patient-centered approaches.

The consensus statement was published online April 3 by the Journal of General Internal Medicine.

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Hospitalist service works for low-severity trauma patients

Trauma patients who are cared for by hospitalists have similar outcomes to those who are treated by surgical teams, a new study found.

In 2004, the Swedish Medical Center in Englewood, Colo., established a Trauma MEDical service (TMED) in which hospitalists cared for trauma patients with low-energy mechanism, single-system injuries. Study authors created an algorithm to identify patients who could be treated by the TMED service. Applying the algorithm to trauma patients admitted in 2003 (before TMED) and 2006 (when TMED was in place), researchers calculated the impact of the service on various patient outcomes. The study was published in the April issue of Surgery.

Adjusted outcomes data found no differences between the groups in mortality, complications, length of stay (LOS) in the emergency department, or placement to rehabilitation facilities. The overall LOS was slightly longer in the 2006 group (3.7 days vs. 4.1 days). Study authors speculated the longer LOS might be due in part to the extra emphasis that hospitalists place on discharge and recovery planning.

The use of hospitalists to treat trauma patients could help alleviate surgeon shortages and improve hospital efficiency, the study authors said. Surgeons have time to devote to more severely injured patients; the study found an increase in the percent of patients with a severe injury seen by a surgical service. Also, patients on a TMED service benefit from the broad knowledge of hospitalists, including experience with comorbidities and community referrals, the study concluded. The authors hypothesized that the TMED model could improve efficiency if it were applied in other trauma centers. The primary potential limitation of the study is that a proxy population was used for the 2006 TMED population due to over- and underadmission to TMED. Another potential limitation is that the population comparison occurred across time.

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Infection control

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Asymptomatic catheter-associated bacteriuria treated inappropriately, study suggests

Patients with catheter-associated asymptomatic bacteriuria (CAABU) often receive inappropriate antibiotic treatment, according to a new study.

Evidence-based guidelines call for no antibiotic treatment in patients with asymptomatic bacteriuria. The authors hypothesized that patients with indwelling and condom catheters who receive a diagnosis of catheter-associated urinary tract infection (CAUTI) may actually have CAABU and therefore should not receive antibiotic treatment. They performed a retrospective study of urine cultures obtained at Veterans Affairs Medical Center over a three-month period to see how many patients with CAABU were treated with antibiotics. Infections associated with indwelling catheters or condom collection systems were classified as CAABUs or CAUTIs; antibiotic therapy was considered appropriate for the latter but not for the former. The results were published in the May Clinical Infectious Diseases.

Of 164 episodes of CAABU, 111 (68%) were not treated with antibiotics but 53 (32%) were. Patients who were older, had predominantly gram-negative bacteriuria and had more white blood cells in their urine were significantly more likely to receive inappropriate treatment for CAABU. Although the study was retrospective and looked at only one medical center, the authors concluded that better recognition of CAABU can help reduce inappropriate antibiotic use in hospitals. They suggested the first strategy for decreasing the number of reported cases of CAUTI may be to simply not screen for CAABU.

An accompanying editorial called attention to the study's flaws, noting that "there is no reason to assume that the long-term outcomes of patients with CAABU and those with CAUTI would be different or that treatment would alter the natural history of catheter-associated infections—so long as the instrument remains in place." The editorialist also noted that the authors extrapolated results from earlier studies of patients with uncomplicated UTIs to patients with catheter-associated UTIs, and that the study design did not allow the researchers to adjust for antibiotics given for reasons besides a positive urine culture. Nevertheless, the editorialist wrote that the study, "despite its defects, is helpful because it reminds us that antibiotics continue to be used inappropriately for patients with urinary collection devices" and "compels us to reconsider how best to evaluate and manage urosepsis in patients with indwelling catheters."

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Nephrology

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Combining GFR, albuminuria predicts progression to end-stage renal disease

Estimated glomerular filtration rate (eGFR) and urinary albumin may predict who will develop end-stage renal disease (ESRD) and allow physicians to intervene earlier, according to Norwegian researchers. In the U.S., ESRD is expected to affect 785,000 people by 2020, or more than double the number in 2007. The disease currently costs $32 billion a year to treat.

Norwegian researchers analyzed data from 65,589 adults in a population-based study and found 124 people who developed ESRD after 10 years of follow-up. Hazard ratios for eGFR of 45 to 59 mL/min per 1.73 m2, 30 to 44 mL/min per 1.73 m2, and 15 to 29 mL/min per 1.73 m2 were 6.7, 18.8, and 65.7, respectively (P<0.001 for all). Hazard ratios for micro- and macroalbuminuria were 13.0 and 47.2 (P<0.001 for both).

Referrals to specialists based only on current chronic kidney disease stage 3 to 4 would include 4.7% of the general population and identify 69.4% of all individuals progressing to ESRD. Referrals using both eGFR and albuminuria would include 1.4% of the general population without losing predictive power, detecting 65.6% of those expected to progress to ESRD. Using these combined measurements might help reduce the number of patients referred to specialists without eliminating the ability to detect future ESRD cases, as well as improve efficient handling of this large group of patients, authors said in the Journal of the American Society of Nephrology. Generalizability of the study may be limited by its homogeneous population.

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FDA update

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Efalizumab to be off U.S. market by June 8 due to PML risk

Psoriasis drug efalizumab (Raptiva) will be phased out of the U.S. market by June 8 because of a potential risk to patients of developing progressive multifocal leukoencephalopathy (PML), the FDA said last week in a statement.

Physicians shouldn't start patients on new treatment with the drug, and should immediately talk with patients currently using efalizumab about transitioning to alternate therapies. PML, for which there is no known treatment, generally occurs in people whose immune systems have been severely weakened, and often leads to irreversible decline in neurologic function and death.

The FDA issued an advisory in February about the risk of PML after reports that four patients taking efalizumab developed the disease. The drug's label has warned of the risk since October 2008.

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From ACP Internist

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Your thoughts exactly: unemployed patients

Walgreens' in-store clinics are offering free care to established patients who lose their health insurance. How do you handle patients who have lost their jobs or are otherwise uninsured? Take our latest poll online.

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Planning to tweet from Internal Medicine 2009?

Join Vineet Arora, FACP, in Tweeting from ACP's annual meeting. We'll post the best meeting Tweets on our blog. For a new ACP Internist article about the pros and cons of twittering in medicine, click here.

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Cartoon caption contest

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Put words in our mouth

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

E-mail all entries by April 17. ACP staff will choose three finalists and post them in the April 22 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in Internal Medicine 2009 News, a special e-newsletter that will be generated live from Internal Medicine 2009. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service

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ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. Please forward any comments or suggestions to acphospitalist@acponline.org.

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Copyright 2009 by the American College of Physicians.

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