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

ACP HospitalistWeekly 4-7-10

Highlights

• States' medical boards increased disciplinary actions in 2009
• Nearly one-third of older adults need end-of-life decisions made but lack ability

Pulmonary embolism

• Age-adjusted D-dimer value helps exclude PE in older patients

Transitions of care

• Diabetes drugs not restarted at discharge post-MI

From ACP Internist

• The next issue of ACP Internist is online

Internal Medicine 2010

• ACP Job Placement Center calls for physician profiles

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

Highlights

.

States' medical boards increased disciplinary actions in 2009

The Federation of State Medical Boards reported a 6% increase in disciplinary actions in 2009 overall among state medical boards. The annual report summarizing disciplinary actions against physicians by 70 medical and osteopathic boards across the country and U.S. territories recorded 5,721 actions taken against doctors in 2009, an increase of 342 from 2008. The year 2008 saw an increase of 60 over 2007.

Because of the wide variations between state medical boards in terms of composition, funding, size and levels of proof required, the report is most useful in comparing variations within each state over time, instead of comparisons among the states.

However, each year the federation issues a Composite Action Index, an average of disciplinary actions that weights the severity of actions taken, such as license revocations and suspensions.

While most states were fairly consistent, some states saw wider variations in the numbers of disciplinary actions taken between 2009 and 2008. New Hampshire's more than doubled from 7 (against 7 doctors) to 16 (against 16 doctors). South Dakota's also rose from 7 (against 7 doctors) to 16 (against 15 doctors). Nebraska increased to 69 (against 65 doctors) from 32 (against 29 doctors). Florida's Board of Osteopathic Medicine handed out 16 actions (against 16 doctors) in 2009, compared to 54 (against 46 doctors) in 2008.

Other state boards issued fewer actions. Idaho handed out 19 actions (against 16 doctors) in 2009, compared to 29 actions (against 28 doctors) in 2008. South Carolina handed out 20 actions (against 20 doctors) in 2009, compared to 56 actions (against 54 doctors) in 2008.

Top

.

Nearly one-third of older adults need end-of-life decisions made but lack ability

About 30% of older adults near the end of life needed decisions made about medical treatment but lacked such decision-making capacity, a new study found, and most of those with advance directives got the care they had specified.

Using data from the Health and Retirement Study, researchers studied 3,746 adults age 60 years or older who had died between 2000 and 2006 and for whom a proxy answered study questions after the patient died. Outcomes included whether the patient had completed a living will or durable power of attorney, maintained decision-making capacity, and needed decision making at the end of his or her life. Data were also collected on care preferences of subjects who completed a living will, and researchers compared these preferences with the outcomes of surrogate decision making. Results were published in the April 1 New England Journal of Medicine.

Forty-two-and-a-half percent of study patients needed decision making, and of these, 70.3% lacked the capacity to make decisions for themselves. Within this subgroup, 67.6% of patients had advance directives; 6.8% had only a living will; 21.3% had only appointed a durable power of attorney; and 39.4% had both prepared a living will and appointed a durable power of attorney. Among those patients who had completed living wills and stated preferences for or against all care possible, there was strong agreement between their preference and the care received (P<0.001). Eighty-three percent of those who requested limited care, and 97.1% of those who requested comfort care, got care consistent with these preferences. Those who requested all care possible were more likely to get it than those who didn't request it (adjusted odds ratio, 22.62; 95% CI, 4.45 to 115), but 7.1% (n=30) of those who didn't indicate an all-care preference got it anyway, and 50% (n=5) of those who wanted all care didn't receive it.

While the results suggest more than a quarter of older adults may need surrogate decision making before death, the data also indicate it's difficult to predict who will need this decision making, the authors noted. The fact that so many older adults have advance directives suggests they find them acceptable, familiar, available and valuable, they added. A causal relationship can't be inferred, but the findings suggest advance directives influence end-of-life decisions, they said. Of those patients who wanted aggressive care but didn't receive it, the decisions may have been overridden by their surrogates, or such care may not have been an option. Overall, the study suggests the health care system should ensure clinicians receive the time and reimbursement needed to help patients plan for the end of life, the authors concluded.

Top

Pulmonary embolism

.

Age-adjusted D-dimer value helps exclude PE in older patients

Using an age-adjusted D-dimer cutoff value increased the proportion of older patients in whom pulmonary embolism could be excluded as a diagnosis, a new study found.

In a retrospective, multicenter cohort study in Europe, researchers analyzed data from four studies comprising 5,132 patients with clinically suspected pulmonary embolism (PE). To derive a new D-dimer cutoff value, they used data from two studies to divide patients older than 50 years (the derivation set) into 10-year age groups. They constructed receiver-operating characteristic (ROC) curves of the D-dimer test for each age group to find the best cutoff value, with a sensitivity of 100% and the highest corresponding specificity. Then, the cutoff value was validated with two additional independent data sets. Outcome measures were the proportion of patients in the validation cohorts with a negative D-dimer test, the proportion in whom PE could be excluded, and false-negative rates. The study was published online March 30 in BMJ.

For patients older than 50 years, the D-dimer cutoff value was (patient’s age × 10) µg/L. The old cutoff value was less than 500 µg/L. When the new value was used, 42% of the patients in the data set with an "unlikely" clinical probability assessment score had PE excluded, compared to 36% with the old value. In the two validation sets, the increase in the proportion of patients with a D-dimer below the new value versus the old value was 5% and 6%. For patients older than 70 years in the three data sets, the absolute increase was 13% to 16%. The failure rates for all ages in the three sets ranged from 0.2% to 0.6%.

The clinical usefulness of the new cutoff value increased significantly with age, the authors noted. Safety wasn't compromised with the new value, as there was no difference in the false-negative rate in the derivation and validation sets, and the 95% upper confidence levels were below 3% for all patients older than 50 years, they said. In addition, the cost-effectiveness of the test in patients older than 80 years probably increases with the new value, as the number needed to test was lower in this group (3.5 vs. 6.6 with the old). This means that for every 35 patients older than 80 years with a low/intermediate or "unlikely" clinical probability of PE, imaging tests can be avoided in 10 patients with the new value, compared to five with the old, the authors said. The new D-dimer cutoff still needs to be validated prospectively before being implemented in practice, they added.

Top

Transitions of care

.

Diabetes drugs not restarted at discharge post-MI

Diabetic patients who are hospitalized for acute myocardial infarction (AMI) are not always restarted on their antihyperglycemic therapy upon discharge, and those not getting the drugs have a higher risk of death, a new study found.

The retrospective study included about 9,000 Medicare beneficiaries who had diabetes, were discharged after hospitalization for AMI, and were taking at least one antihyperglycemic agent when admitted. The primary outcome of the study was death within a year, with a secondary outcome of rehospitalization within one year. The study was published online March 30 in Circulation: Cardiovascular Quality and Outcomes.

At discharge, 86.6% of the patients were prescribed an antihyperglycemic therapy, but the other 13.4% of the studied patients were off diabetes drugs. Over the next year, the patients who didn’t get the drugs had a significantly higher mortality rate (hazard ratio, 1.29; 95% CI, 1.15 to 1.45). The two groups did not show a significant difference, however, in readmission rates.

According to the study authors, the results show that abandonment of antihyperglycemic therapy in older patients with recent AMI can be problematic, despite doubts raised about the benefits of intensive glycemic control by recent studies. The authors cautioned that they weren’t able to evaluate the relationship between glycemic control and mortality directly because the study used discharge medications as a surrogate marker. The study was also limited by lack of information about the reasons for discontinuation of the medications.

Future research should evaluate these reasons and look at the specific effects of glycemic treatment after AMI, the authors suggested. In the meantime, it appears that maintaining patients on some regimen for their diabetes after AMI may be important in preventing adverse clinical outcomes.

Top

From ACP Internist

.

The next issue of ACP Internist is online

The April issue of ACP Internist features the following articles:

Array of symptoms can point to celiac. Celiac disease incidence has risen since the 1950s, so alert internists listen to the symptoms, get to the basis, and make accurate attributions to make the right diagnosis. A constellation of symptoms can point to a common underlying condition.

EHR era ushers in stricter privacy, security. Offices feeling confident about HIPAA compliance now face HITECH, which involves increased demands meant to secure confidential information in a digital age. As the demands have increased, so have the penalties.

Mindful Medicine: Seeing the whole diagnostic picture. For a year, one patient saw specialist after specialist and received a different diagnosis each time. Like the story of the blind men and the elephant, specialists often see the patient through only one component of training, as anchoring and availability sneak into their thinking.

Top

Internal Medicine 2010

.

ACP Job Placement Center calls for physician profiles

Physicians looking for a new job may submit a Job Seeker's Profile to the ACP Job Placement Center, a service available at Internal Medicine 2010 in Toronto, Canada. The Center, located in the Metro Toronto Convention Centre’s Exhibit Hall, Booth 222, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Profiles are distributed to numerous employers participating in Internal Medicine 2010, which will be held April 22-24. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the Convention Centre. Profiles can be submitted online.

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 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