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ACP HospitalistWeekly 5-20-09
Highlights: Hospital Medicine 2009
- Hospitalists must demonstrate own value in strained economic climate
- Hospitalists key to long-term outcomes in patients with aortic dissection
More conference coverage: SGIM
- Bedside barcode scanning, physician quality measures among research highlights
From Annals of Internal Medicine
- Kyphosis, fractures may link to increased mortality in older women
FDA update
- Class I recall for cardiac marker test
- Testosterone gel recalled for possible pediatric exposure
- Caraco recalled for active ingredient
From ACP Hospitalist
- Suggest a colleague as a 'top hospitalist'
From ACP Internist
- ACP members discuss medical reports in the mainstream media
From the College
- Announcing the 2009 ACP National Abstract winners
Cartoon caption contest
- Vote for your favorite entry
Physician editor: A. Scott Keller, MD
Editorial note: ACP HospitalistWeekly will not be published next week due to the Memorial Day holiday.
Highlights: Hospital Medicine 2009
.Hospitalists must demonstrate own value in strained economic climate
CHICAGO—Hospitalists are under more pressure than ever to demonstrate their value due to the current economic crisis, an increasing need for hospitalist subsidies, and greater competition for hospital budget dollars, experts told a packed audience at the Society of Hospital Medicine annual conference here last week.
As such, hospitalists must ensure that their sponsoring organizations really understand the reasons they may not be covering their costs, said Leslie Flores of Nelson Flores Hospital Medicine Consultants. These reasons often include an unpredictable and highly variable workload, costly night coverage, a high proportion of uninsured and underinsured patients, and an inefficient work flow due to ready access and many interruptions,
Still, such explanations only go so far: Increasingly, hospitalists also need to prove their value to hospital executives with good, solid financial data.
“In the past, we were able to get by with a lot of anecdotal stories and by managing relationships in order to get the money we needed to support our practices,” Ms. Flores said. “Now, we are moving to an evidence-based management decision-making model.”
Helpful sources for the data needed for a hard return-on-investment analysis include hospital information systems, such as admissions-discharge-transfer and clinical information systems; clinical/financial data repositories that member hospitals report into; government databases; and third party payers. These data can be used to analyze the overall net benefit to the hospital of factors like decreasing average length of stay, optimizing capacity, and helping the emergency department avoid diversion through efficient throughput.
“Establish a good relationship with the people in your hospital’s finance department,” Ms. Flores advised. “They can really help you.”
—By Jessica Berthold, senior writer
.Hospitalists key to long-term outcomes in patients with aortic dissection
CHICAGO—Hospitalists are ideally placed to improve long-term outcomes in patients with aortic dissection, according to a Hospital Medicine 2009 session held here last week.
"You are the people who probably have the biggest chance to impact long-term risk from dissection of anybody in the country, because you're the ones caring for them in hospital and then helping them to transition to whatever care they will get," Kim A. Eagle, MD, director of the University of Michigan Cardiovascular Center, told attendees.
Hospitalists need to stress to patients that aortic dissection is a disease for life, Dr. Eagle said. Survival rates after treatment for aortic dissection are poor in the first year because many patients are lost to good follow-up. "[Patients] don't know that they have to get their medicines when they run out, [that] they've got to get follow-up imaging," he said.
Beta-blockers are the mainstay of therapy, despite a lack of randomized, controlled trials, Dr. Eagle said. He also recommended angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in addition to beta-blockers, based in part on the results of the Jikei Heart Study, and said that statins are indicated in patients with atherosclerosis.
Over the long term, patients who've had aortic dissection should aim for a heart rate less than 60 beats per minute. Blood pressure should be controlled to less than 120/80 mm Hg, or "as low as you can get it and not have hypoperfusion symptoms," Dr. Eagle said. Clinicians should order imaging studies to watch for aneurysm formation one, three, six, and 12 months after the initial event.
Patients should be told to avoid lifting more than 30 or 40 pounds and should not play contact sports, such as soccer or football. They should know to seek urgent medical help if they have any sudden onset of pain in their chest, back or belly, Dr. Eagle noted. Also, they need to understand that their medications are vital to their survival.
"When they run out of medicines, they are threatening their lives," he said. "So they can't run out of their medicines."
—By Jennifer Kearney-Strouse, editor
More conference coverage: SGIM
.Bedside barcode scanning, physician quality measures among research highlights
MIAMI—Bedside barcode scanning and factors affecting physician quality measurement were among the research abstracts selected for presentation at the Society of General Internal Medicine's annual meeting last week.
One study analyzed the impact of different patient populations on physician quality measures. Researchers in the Massachusetts General Hospital system rated 159 physicians' performance on several cancer screening and chronic care quality measures. They then looked at differences in the characteristics of the physicians and in 87,000 of their patients. The study found that physicians who rated in the bottom quartile for performance treated significantly more non-English speakers, minorities and nonpaying patients, leading them to conclude that physician quality measures may represent the composition of a doctor's patient population, rather than just the quality of his or her care. The study also found that female physicians met more measures in the treatment of female patients, while male physicians scored better treating men.
During the same session, researchers from Brigham and Women's Hospital in Boston showed how implementation of bedside barcode scanning affected medication errors at their hospital. The study had clinical nurses record administration of medications given to patients on the medical, surgical and intensive care wards and then compare the drugs actually administered to the orders given to check for errors. Before the barcodes to match patients to medications were implemented, 11.6% of administrations resulted in errors. With barcodes, the error rate declined to 7%. Pre-barcode, potential adverse drug events occurred in 3.2% of cases, compared to 1.6% after implementation. The study authors noted that although their results are not necessarily generalizable to other hospitals, the study does indicate that barcode systems have the potential to dramatically reduce adverse drug events.
—By Stacey Butterfield, staff writer
Annals of Internal Medicine
.Kyphosis, fractures may link to increased mortality in older women
Studies have long linked vertebral fractures to an increased risk for death in older persons. Some studies have suggested that kyphosis may also be associated with poor health and death. To assess whether increased kyphosis or undetected vertebral fractures were the underlying reason for earlier death, researchers conducted a prospective cohort study of 610 white women between the ages of 67 and 93. The authors measured the degree of kyphosis, bone mineral density, and vertebral fractures. The researchers then assessed the women’s mortality rates over an average follow-up of 13.5 years. Women with vertebral fractures and hyperkyphosis had greater risk for mortality than women with only one of these conditions. Among women without vertebral fracture, kyphosis and death were not associated.
Quality more important than volume in predicting coronary bypass outcomes
When choosing a surgeon or surgery center, quality of care is the most important factor. Patients and payers often associate high procedure volume with better outcomes. Researchers collected data on 81,289 patients cared for by 1,451 surgeons at 164 hospitals and found that hospital and surgeon procedure volume had few consistent associations with outcomes. However, overall adherence to quality measures was strongly associated with differences in mortality rates, regardless of volume. According to researchers, this finding is important because improving quality of care at hospitals is potentially more feasible and desirable than increasing case volume. They suggest that efforts to increase quality of care so patients can “shop for the best” is a wise approach that hospitals should undertake wherever coronary artery bypass surgery is done.
Splinting reduces pain, disability in base-of-thumb OA
Researchers studied 112 patients with base-of-thumb osteoarthritis (BTOA) to determine whether wearing a hand splint could improve pain and hand function. Fifty-seven patients were randomly assigned to wear a custom-made nighttime splint, and 55 patients were randomly assigned to usual care. Nighttime splinting had no effect after one month, but it significantly reduced patients’ pain and disability after 12 months. The study authors conclude that splinting could be an inexpensive and effective alternative to drug treatment for patients with BTOA.
USPSTF recommends syphilis screening for pregnant women
The U.S. Preventive Services Task Force recommends that all pregnant women be screened for syphilis at their first prenatal visit, because it can cause severe problems or death and it’s not always symptomatic. If the blood and follow-up tests are positive, the woman should be treated with antibiotics. Antibiotic treatment protects the woman and her baby from the effects of syphilis. Researchers conclude that the benefits of screening for syphilis outweigh the potential harms that include unnecessary worry and unnecessary antibiotic treatment.
FDA update
.Class I recall for cardiac marker test
The FDA last week issued a Class 1 recall of lot #W44467B of Biosite brand Triage Cardiac Panel because it may yield false-negative results in some patients, the agency said in an alert.
The test, used to help diagnose myocardial infarction, may lead to false-negative results with patient samples containing troponin I at very low levels, with CK-MB, and with myoglobin. A false negative would indicate a person has not had a heart attack or heart muscle injury when in fact he or she has. There have been no reports of patient misdiagnosis to date.
The affected lot, Catalog No. 97000HS, was shipped as 25 individually pouched devices per kit box, and was distributed from Jan. 24 through Feb. 17, 2009.
.Testosterone gel recalled for possible pediatric exposure
FDA will require two prescription topical testosterone gel products, AndroGel 1% and Testim 1%, to include a boxed warning on the products’ labels after receiving reports of eight cases of secondary exposure to testosterone in children ages nine months to five years.
Adverse events reported in these children included inappropriate enlargement of the genitalia, premature development of pubic hair, advanced bone age, increased libido and aggressive behavior. Recommendations and precautions to minimize the potential for secondary exposure are online.
.Caraco recalled for active ingredient
All tablets of Caraco brand Digoxin, USP, 0.25 mg, distributed prior to March 31, 2009, which are not expired and are within the expiration date of August 2011, are being voluntarily recalled to the consumer level. The tablets are being recalled because they may differ in size and therefore could have more or less of the active ingredient, digoxin.
The existence of higher-than-labeled dose may pose a risk of digoxin toxicity in patients with renal failure. Digoxin toxicity can cause nausea, vomiting, dizziness, low blood pressure, cardiac instability, and slow heart rate. Death can also result from excessive digoxin intake. A lower-than-labeled dose may pose a risk of heart failure and abnormal heart rhythms.
Consumers with the products that are within expiration date and labeled Caraco Digoxin (A-S Medication Solutions; Digoxin 0.25 mg is a scored round biconvex white tablet imprinted with “441”) with the NDC numbers 54569-5758-0 (30-count) should return these products to the place of purchase.
From ACP Hospitalist
.Suggest a colleague as a 'top hospitalist'
ACP Hospitalist is seeking candidates for our second annual Top Hospitalists issue. We're looking for the hospitalists who made notable contributions to the field in 2009, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.
Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 13, 2009, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2009 issue.
From ACP Internist
.ACP members discuss medical reports in the mainstream media
ACP Internist's current poll relates to an Annals of Internal Medicine study which concluded that press releases from academic medical centers often exaggerate the importance of new medical research. How is this finding reflected in mainstream media coverage of medical news? Tell us in our current poll, "Your Thoughts Exactly: Media reporting of medical research."
From the College
.Announcing the 2009 ACP National Abstract Winners
More than 2,200 abstracts were submitted to the 2009 National Associates and Medical Students Abstract Competitions. This year's competition concluded at the Internal Medicine meeting with an impressive poster showcase from Associate and Medical Student Members. Over 300 Associates and 80 medical students presented their displays to a team of judges for review. Also featured at the meeting were oral presentations of the highest scoring abstracts from the national competition. A complete list of poster winners and oral presenters is posted online.
Cartoon caption contest
.Vote for your favorite entry
Our cartoon caption contest continues. ACP staff has selected three finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.
Go online to view the cartoon and pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting will be extended through the Memorial Day weekend until June 1, with the winner announced in the June 3 issue.
About ACP HospitalistWeekly
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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