• Current Issue
• ACP Hospitalist Weekly
  • Archives
• Supplements
• Blog
• Archives
• Career Connection
• Subscribe
• RSS Feeds

ACP HospitalistWeekly 3-17-10

Highlights

• Many hospitalists don't perform individual 'core competencies' in a given year
• Shock patients have more arrhythmias with dopamine vs. norepinephrine

Perioperative care

• Beta-blockers underused before and after cardiac rhythm device procedures

Hospital-acquired pneumonia

• 1996 guidelines better than 2005 set for ICU patients with potentially resistant microorganisms

FDA update

• Boxed warning added for hematology drug

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

Highlights

.

Many hospitalists don't perform individual 'core competencies' in a given year

Though hospitalists perform more of the nine inpatient procedures designated as "core competencies" by the Society of Hospital Medicine (SHM) than non-hospitalists, only 11% perform all these procedures in a given year, a survey found.

Researchers analyzed data from a national survey mailed to internal medicine members of the American College of Physicians in 2004; there were 1,059 eligible respondents. The survey asked whether respondents had performed any of 40 different bedside procedures in the last year, and the individual volume of those they had performed. Of the 40 procedures, researchers evaluated nine that have been designated as core competencies by SHM: electrocardiogram interpretation, chest X-ray interpretation, arthrocentesis, thoracocentesis, abdominal paracentesis, lumbar puncture, central line placement, endotracheal intubation and ventilator management. They defined hospitalists as respondents who spent more than 10 hours per week in clinical activity, and more than 40% of clinical time in hospital-based activity. The study was published online March 2 in the Journal of General Internal Medicine.

Nearly 17% of eligible respondents were classified as hospitalists (n=175). Eleven percent of hospitalists performed all nine SHM core procedures, compared with 3% of non-hospitalists (P<0.001). Hospitalists performed significantly more of the individual core procedures than non-hospitalists, except for electrocardiogram interpretation, arthrocentesis and chest X-ray interpretation. The hospitalists performed a median of four of the nine SHM core procedures in the previous year (interquartile range [IQR], two to six). They performed less than a median of six central line placements, thoracenteses, paracenteses, or lumbar punctures in the previous year.

Hospitalists who worked more than 45 hours per week performed more core procedures than those who worked fewer hours (P<0.001). Hospitalists spent a median of 40 hours per week in hospital-based patient care versus five hours per week for non-hospitalists (P<0.001); both types of physicians worked a median of 50 hours per week (IQR, 36 to 60 hours per week; P=0.32). There was no significant difference between hospitalists and non-hospitalists in terms of year of medical school graduation, hospital size or population of practice location.

There are several possible reasons why hospitalists don't perform more of the SHM core procedures, the authors said. Invasive diagnostic procedures may be less necessary than other procedures, given advances in diagnostic imaging techniques and clinical decision-making tools. Hospitalists also may opt to focus on cognitive and relational tasks, and refer certain patients to subspecialists, surgeons or radiologists, they said.

In addition, reimbursement for some procedures may not match up with the time needed to perform them—a hypothesis partially supported by a non-significant trend showing that hospitalists whose incomes were less tied to productivity (for example, salaried hospitalists) performed a wider variety of core procedures than those whose incomes were more contingent on productivity, the authors said. Study limitations include that data were self-reported and that respondents were ACP members, which may limit generalizability of results. The survey was also undertaken in 2004; practice patterns may have changed since then, the authors noted.

Top

.

Shock patients have more arrhythmias with dopamine vs. norepinephrine

Dopamine and norepinephrine carry the same overall mortality risk when used to treat shock patients, but dopamine is associated with more arrhythmias, a new study found.

In a multicenter, randomized, blinded trial, researchers assigned 1,679 European patients with shock to either dopamine or norepinephrine in order to restore and maintain blood pressure. A patient was considered to be in shock if the mean arterial pressure was less than 70 mm Hg or the systolic blood pressure was less than 100 mm Hg despite having been administered an adequate amount of fluids, and if there were signs of tissue hypoperfusion. Dosing was administered according to body weight, with doses of dopamine increased or decreased by 2 µg per kilogram per minute and doses of norepinephrine increased or decreased by 0.02 µg per kilogram per minute. If patients were still hypotensive at maximum doses (20 µg per kilogram per minute for dopamine or 0.19 µg per kilogram per minute for norepinephrine), then open-label norepinephrine, epinephrine or vasopressin was added.

Mortality rate at 28 days—the primary outcome—didn't differ significantly between the dopamine (52.5%) and norepinephrine (48.5%) groups (odds ratio [OR] with dopamine, 1.17; 95% CI, 0.97 to 1.42; P=0.10). There was also no difference in mortality at six months, at twelve months, during the hospital stay or during the ICU stay. There were more arrhythmic events among dopamine patients than norepinephrine patients (207 events [24.1%] vs. 102 events [12.4%], P<0.001), including more arrhythmic events that required withdrawal from the study. In predefined subgroup analysis, the 280 patients with cardiogenic shock had a greater mortality risk if they received dopamine versus norepinephrine (P=0.03); this risk difference wasn't present for septic shock and hypovolemic shock subgroups. The study was published in the March 4 New England Journal of Medicine.

Previous, smaller observational studies have suggested dopamine may be harmful to patients with septic shock, yet for the 1,044 septic shock patients in this study, there was no outcome difference based on administration of dopamine versus norepinephrine, the authors noted. The differences in mortality for cardiogenic shock patients and in arrhythmic events for all patients "strongly challenge the current American College of Cardiology–American Heart Association guidelines, which recommend dopamine as the first-choice agent to increase arterial pressure among patients who have hypotension as a result of an acute myocardial infarction," the authors concluded.

Top

Perioperative care

.

Beta-blockers underused before and after cardiac rhythm device procedures

Heart failure patients often don’t receive optimal beta-blocker therapy before and after undergoing cardiac rhythm device procedures, according to a new study.

According to current guidelines, patients considered for cardiac rhythm devices should first receive optimal medical therapy. Researchers speculated that such therapy, particularly beta-blockers, is underused, perhaps because physicians tend to rely on technological rather than medical management of heart failure or are not aware of the impact of beta-blockers in this population. To test their hypothesis, they used a multistate managed care database to examine use of beta-blockers before and after cardiac device procedures in patients with heart failure. The study’s primary outcome measures were beta-blocker use before the procedure and changes in beta-blocker use after hospital discharge.

Data from 2,766 managed care beneficiaries were included. Most (approximately 79%) were male; median age was 61 years. Sixty-five percent had hypertension, approximately 36% had diabetes, and approximately 20% had lung disease. Overall, 1,846 patients had implantable cardioverter-defibrillators implanted, revised or replaced; 814 received combined defibrillator-resynchronization devices and 106 received cardiac resynchronization devices. The study results were published online March 2 by Circulation: Cardiovascular Quality and Outcomes.

In the 90 days before a device procedure was performed, patients spent a median of 46 days on beta-blockers, and 925 patients (33.4%) spent no days on beta-blocker therapy. Patients who did not take beta-blockers before receiving a cardiac device were more likely to be elderly and to have fewer outpatient cardiologist visits; they were less likely to have been previously hospitalized for heart failure or acute myocardial infarction. Beta-blocker use was more common in the 180 days after device procedures; the median number of days on beta-blockers was 155, and 83.4% of patients had at least one day prescribed for a beta-blocker.

The authors acknowledged several limitations of their study. For example, they noted, patients could have filled beta-blocker prescriptions without going through their managed care plans, and physicians could have written beta-blocker prescriptions that then went unfilled. However, the authors concluded that beta-blocker use in patients undergoing cardiac device procedures is not optimal, particularly before such procedures are performed. They called for additional studies “to delineate the extent of the problem in the non-managed-care setting, to link underuse with poorer outcomes, and to devise strategies to ensure that optimal medical therapy is provided to patients before device implantation.”

Top

Hospital-acquired pneumonia

.

1996 guidelines better than 2005 set for ICU patients with potentially resistant microorganisms

Older guidelines more accurately predicted whether cases of hospital-acquired pneumonia were drug resistant than updated guidelines, according to a new study of intensive care patients.

The Spanish study prospectively observed 276 patients who acquired pneumonia while in the intensive care unit. The patients were divided into two groups based on the 2005 guidelines from the American Thoracic Society–Infectious Diseases Society of America, which determined the risk for drug resistance based on time of onset and certain risk factors. The 38 patients in group 1 had early onset of pneumonia and no risk factors. However, 26% of the patients in the group were found to have potentially drug-resistant microorganisms, resulting in an overall predictive accuracy of 50%.

The 2005 guidelines were better at prediction in the group 2 patients, who had late-onset pneumonia or risk factors, scoring 92%. Overall, the 2005 guidelines successfully predicted causative pathogens in 86% of the patients. When the researchers reclassified patients according to the 1996 American Thoracic Society guidelines, the accuracy was improved, with the etiology accurately predicted in an additional nine patients. The patients were identified based on risk factors that had been eliminated from the 2005 guidelines, including previous prolonged and complicated surgery, chronic alcohol abuse, COPD and solid cancer.

The study also assessed physicians’ adherence to guidelines, and found adherence was more common for group 2 patients, possibly indicating that physicians (at least in this hospital) were reluctant to discount previously recommended risk factors, the authors speculated. Adherence to guidelines was associated with better clinical response in the group 2 patients but not in group 1. There was no difference in mortality or length of stay in either group 1 or 2 based on adherence to the guidelines.

The authors also noted that the most common pathogens were the same in patients with early- and late-onset pneumonia. Therefore, rather than the time of onset, identification of risk factors for specific pathogens is crucial in choosing an appropriate empirical treatment. The authors recommended that future guidelines for the treatment of hospital-acquired pneumonia, at least for patients in the ICU, use the risk factors from the 1996 guidelines. Further assessment would be needed to determine whether the findings could be extrapolated to non-ICU patients or ICUs in the rest of the world, they concluded.

Top

FDA update

.

Boxed warning added for hematology drug

A boxed warning has been added to WinRho SDF (Rho(D) Immune Globulin Intravenous), according to a letter the FDA sent to health care professionals last week.

The warning was motivated by cases of intravascular hemolysis (IVH), including fatalities, which have been reported in patients treated for immune thrombocytopenic purpura (ITP) with WinRho SDF. The warning does not apply to patients receiving therapy for the suppression of Rh isoimmunization.

According to the new prescribing information, clinicians should closely monitor patients treated with WinRho SDF for ITP in a health care setting for at least eight hours after administration; perform a dipstick urinalysis at baseline, 2 hours, and 4 hours after administration and prior to the end of the monitoring period; and alert patients to the signs and symptoms of IVH, which include back pain, shaking chills, fever, and discolored urine or hematuria.

The administration section of the label has also been modified to recommend alternative treatments in patients with hemoglobin levels that are less than 8 g/dL due to the risk of increasing the severity of the anemia.

Top

Cartoon caption contest

.

Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries to acphospitalist@acponline.org. ACP staff will choose three finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

Top

---

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.

To change your e-mail address or other contact information in our records, please click here.

Copyright 2010 by the American College of Physicians.

Prepare with the Experts: Live Recert Prep Courses from ACP

ACP Launches Depression Care Guide

© ACP Hospitalist and American College of Physicians

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