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ACP HospitalistWeekly 6-30-10

Highlights

• ACGME recommends restricting first-years to 16 duty hours per day
• Hypoglycemia increases mortality risk in pneumonia

Postoperative care

• Post-op infection rates decline with adherence to two or more prevention measures

Critical care

• Duration of ICU delirium associated with long-term cognitive performance

Industry interactions

• Most physicians think free lunches, small gifts OK

Cardiology

• Specialist groups issue clinical alert to guide clopidogrel prescribers

FDA update

• Mylotarg withdrawn from market

From ACP Hospitalist

• Suggest a colleague as a Top Hospitalist

From ACP Internist

• The next issue of ACP Internist is online

Cartoon caption contest

• And the winner is…

Physician editor: A. Scott Keller, FACP

Editorial note: ACP HospitalistWeekly will not be published next week due to the Independence Day holiday.

Highlights

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ACGME recommends restricting first-years to 16 duty hours per day

The Accreditation Council for Graduate Medical Education (ACGME) is recommending that first-year residents' duty hours be capped at 16 per day. Citing differences in capabilities and the need for more supervision, the Council said in a draft of standards that first-years work longer and that fatigue among them leads to more errors.

The draft standards propose other significant changes to first-year resident training, including more detailed directives for supervision and stricter requirements for duty hour exceptions. The group published its statement online June 23 in the New England Journal of Medicine.

The group received position statements from more than 100 medical organizations, heard personal testimony, and discussed the issue with the Institute of Medicine, patient advocates, sleep physiologists, patient safety experts and educators. While the same standards are applied to different specialties and levels of training, educators wanted more flexibility.

ACGME wrote, "As residents mature in knowledge, experience and clinical judgment, the standards permit them to gradually move from a structured, directly supervised, time-limited setting to more advanced training, then to the independent practice of medicine, in which the structure of work and the allotment of time are dictated by patients' needs and physician professionalism. This progression logically begins with a more highly controlled first year of residency."

The standards will be available for comment until August 9 on the ACGME website. The new proposed restrictions follow ACGME's original limitations placed in 2003. The organization had said at that time it would revisit the issue in five years. If adopted by ACGME, the restrictions would take effect July 2011.

The American Medical Student Association said it supports the move and called for 16-hour shifts for second- and third-year residents.

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Hypoglycemia increases mortality risk in pneumonia

Pneumonia patients who are hypoglycemic at hospital admission have a higher mortality risk, creating a red flag that physicians should make sure these patients receive more intensive follow-up and surveillance during hospitalization and after discharge, a new study found.

The prospective, population-based Canadian study included almost 3,000 patients who were admitted to six hospitals with community-acquired pneumonia between 2000 and 2002. Patients with a glucose level above 6.1 mmol/L (approximately 110 mg/dL) at admission were excluded and the remaining patients were categorized as normoglycemic (4.0 to 6.1 mmol/L [70 to 110 mg/dL]) or hypoglycemic (less than 4.0 mmol/L). The study appears in the June American Journal of Medicine.

In the total study population, 2% of patients were hypoglycemic at admission. Once the hyperglycemic patients were excluded from the study, the percentage increased to 6%. Patients with hypoglycemia were more likely than normoglycemic ones to have severe pneumonia (72% vs 55%) and to be admitted to the intensive care unit (30% vs 8%). A higher percentage of them were also diabetic.

The hypoglycemic patients were also more likely to die, in the hospital, after 30 days, and after a year, even when factors such as pneumonia severity, ICU admission and having diabetes were controlled for. Their unadjusted risk of mortality was double that of the normoglycemic group both in-hospital (20% vs 9%, P=0.03) and during the next 30 days (20% vs 10%, P<0.01). The increase in risk diminished over time, but remained borderline statistically significant (P=0.05) at one year.

The results show that hypoglycemia is an important and underrecognized prognostic factor in pneumonia, the study authors concluded. The study’s findings could also provide new information about the risks of hyperglycemia. Most other research has compared outcomes in hyperglycemic patients to a combined group of normo- and hypoglycemic patients. If hypoglycemic patients have a higher-than-average mortality risk, then the gap between normo- and hyperglycemic patients is likely larger than previously thought.

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Postoperative care

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Post-op infection rates decline with adherence to two or more prevention measures

Adherence to at least two of six postoperative infection-prevention measures appears to lower infection rates, but adherence to individual measures doesn't seem to make a difference, a new study found.

In a retrospective cohort study, researchers examined data from an inpatient administrative database to determine the outcome of self-reported adherence to national quality measures. The measures studied were the six publicly reported measures from the Surgical Care Improvement Project (SCIP) that focus on postoperative infection prevention. The data represent 405,720 discharges from 398 hospitals with at least one reported SCIP quality measure between July 1, 2006 and March 31, 2008. In addition to item-level analysis, the measures were aggregated into two all-or-none measures of adherence. The S-INF-Core represents patients who were eligible for the original three SCIP measures, which deal with the use of antibiotics. The S-INF represents patients with any two (or more) recorded SCIP measures of the six. Results were reported in the June 23/30 Journal of the American Medical Association.

Adherence to the S-INF composite measure significantly decreased postoperative infection rates from 14.2 to 6.8 per 1,000 discharges (adjusted odds ratio [AOR], 0.85; 95% CI, 0.76 to 0.95), while the decrease with adherence to the S-INF-Core composite wasn't significant (11.5 to 5.3 per 1,000 discharges; AOR, 0.86; 95% CI, 0.74 to 1.01). No individual SCIP measure significantly lowered the probability of infection. Adherence to these individual measures is reported to the public via the Hospital Compare website.

Given that individual measures don't appear to lower infection rates, reporting adherence to them doesn't "fulfill their stated purpose of pointing consumers toward high-quality hospitals," the authors noted. Further, reporting individual measures is a component of the Centers for Medicare and Medicaid Services' value-based purchasing initiatives, yet this study's data suggest that implementing incentive-based reimbursement schemes on these individual items would do little to further improve hospital quality," the authors noted.

Still, the success of using aggregate measures in lowering infection rates suggests there is some association between SCIP adherence and quality. "Improved individual process-of-care measures and use of aggregation techniques in addition to improved data collection methods may be necessary to truly drive improvements in patient outcomes," the researchers concluded.

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Critical care

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Duration of ICU delirium associated with long-term cognitive performance

The longer a mechanically ventilated patient has delirium, the worse his or her long-term cognitive performance, a study found.

Researchers studied 126 mechanically ventilated patients in the medical intensive care unit of a large community hospital in Nashville. Trained study personnel assessed patients for delirium every day until discharge, or for a maximum of 28 days, using the Confusion Assessment Method for the ICU (CAM-ICU). Duration of mechanical ventilation was measured from the time of endotracheal intubation to the start of successful unassisted breathing. Cognitive outcomes were assessed at three and 12 months after enrollment by a neuropsychologist who was blinded to the details of each patient's critical illness. Patients were tested using a battery of nine neuropsychological tests designed to measure seven core domains of cognitive functioning, with performance determined by averaging age-adjusted and education-adjusted T-scores from the tests. Results were published in the July Critical Care Medicine.

Ninety-nine of the 126 patients survived three months or more after their critical illness, and long-term cognitive outcomes were obtained for 78% of patients (n=77). The median duration of delirium was two days. At three-month follow-up, 79% of survivors were cognitively impaired; 62% had severe impairment. At 12 months, 71% of survivors were cognitively impaired; 36% had severe impairment. After adjustment for age, illness severity, severe sepsis, education, preexisting cognitive function, and exposure to sedatives in the ICU, a longer duration of delirium independently predicted worse cognitive performance at three months (P=0.02) and 12 months (P=0.03). Duration of mechanical ventilation wasn't associated with long-term cognitive impairment.

Study limitations include its single-center design and small sample size. The study didn't adjust for depression and post-traumatic stress disorder, which can contribute to cognitive impairment and may confound the relationship between delirium and impairment, the authors noted. Overall, the results highlight the importance of continuing to investigate ways to reduce acute brain dysfunction in the ICU, such as creating protocols for care and certain pharmacologic strategies, the researchers concluded.

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Industry interactions

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Most physicians think free lunches, small gifts OK

Physicians of all specialties, but especially surgeons, continue to see gifts from the pharmaceutical and device industries in a positive light, according to a recent survey.

Almost 600 physicians and medical students in the Mount Sinai School of Medicine consortium were asked about their attitudes toward industry interaction. A majority of the respondents favored the use of samples as well as industry sponsorship of lunches, educational materials and medical school and residency programs. More than half also thought it was acceptable to receive dinner at a modest restaurant if an educational component was included, and to have industry pay for travel expenses to a conference.

Just less than half of the survey participants found it appropriate to accept a small gift (less than $50) from a company, and only a quarter thought it was OK to take a larger gift. The surveyed physicians also thought that they personally were less likely to be affected by free food or gifts than their colleagues: Only about 35% said it would affect their prescribing, while 52% said their colleagues would be influenced. The study was published in the June Archives of Surgery.

Surgeons, trainees and respondents who weren’t familiar with their own institution’s guidelines on the subject were more likely to have a positive attitude toward pharma interactions and gifts. This may be because less attention has been paid to this issue by surgical journals and societies, according to the study authors.

A critique that accompanied the article also noted the importance of distinguishing between types of interactions with industry; development of new surgical techniques requires collaboration between clinicians and device makers, but the benefit of a free pen or sandwich does not outweigh the risk of influence, the critique said.

Based on the survey’s results, one can conclude that physicians generally may be out of synch with public thinking about industry interactions, the study authors said. Despite changes in medical school policies and governmental concern about the issue, physician attitudes are similar to those found in studies going back to 2001. Physician attitudes are not likely to change until the entire culture of medicine rejects industry influences more thoroughly, the authors concluded.

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Cardiology

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Specialist groups issue clinical alert to guide clopidogrel prescribers

Two cardiology groups released a clinical alert to guide doctors prescribing clopidogrel after the FDA added a boxed warning to the label about genetic variations that affect the drug's efficacy.

The FDA estimates that 2% to 14% of patients poorly metabolize clopidogrel (Plavix). Although there is increasing information about specific genetic variations that might affect metabolism, the agency says there is not sufficient evidence to develop specific recommendations related to genetic testing in patients.

In light of the FDA warning, the American College of Cardiology (ACC) Foundation and the American Heart Association (AHA) issued a statement outlining key issues to consider and recommendations for practice. The statement says that:

• Evidence-based guidelines from the ACC, AHA or other professional societies for using antiplatelet therapies should remain the foundation of care. If clopidogrel is prescribed, health care providers should ensure that patients take it as prescribed.
• Clinicians must be aware that in certain patients with either acute or chronic coronary artery disease, genetic variability in response to clopidogrel can affect its inhibition of platelet function.
• Careful clinical judgment, including weighing the risks and benefits, is needed in considering all therapies. The new boxed warning points out that for clopidogrel, if there is a lack of efficacy, the outcome could be fatal.
• Results from ongoing clinical trials in large groups of patients will provide more information about the predictive value of genetic testing and better inform the role genotyping might play in personalizing medicine and optimizing outcomes.
• Genetic testing to determine if a patient is a “poor metabolizer” may be considered before starting clopidogrel therapy in patients believed to be at moderate or high risk for poor outcomes, such as patients undergoing elective high-risk percutaneous coronary intervention procedures.
• Using alternative antiplatelet therapies or altering the dosing of clopidogrel may be reasonable options in patients who experience an adverse event while taking clopidogrel and have been taking the drug as prescribed.

The statement authors cautioned that patients currently taking clopidogrel should not stop the drug unless advised by their clinician.

The American Academy of Family Physicians, the Society for Cardiovascular Angiography and Interventions and the Society for Thoracic Surgeons have also endorsed the recommendations, which will appear July 20 in the Journal of the American College of Cardiology and Circulation: Journal of the American Heart Association. The document will also be available on the ACC and AHA websites.

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FDA update

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Mylotarg withdrawn from market

Leukemia drug gemtuzumab ozogamicin (Mylotarg) was voluntarily withdrawn from the U.S. market last week by manufacturer Pfizer, according to an announcement from the FDA.

The withdrawal was requested by the FDA after results from a recent clinical trial raised safety concerns, including an association with liver veno-occlusive disease, and the drug failed to demonstrate clinical benefit to patients.

The drug had been approved in May 2000 under the accelerated approval program for patients with acute myeloid leukemia. Under accelerated approval, manufacturers are required to conduct additional clinical trials after approval to confirm the drug’s benefit. Since it’s been withdrawn, the drug will no longer be commercially available to new patients. Those who are currently receiving it may complete their therapy following consultation with their health care professional.

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From ACP Hospitalist

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Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our third annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2010, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, 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 16, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2010 issue

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From ACP Internist

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The next issue of ACP Internist is online

The July/August issue of ACP Internist features the following articles:

Rheumatoid arthritis hurts the whole body. Taking care of a patient with rheumatoid arthritis involves a partnership between internists and subspecialists, and management of cardiovascular risks, cancer or infections.

Doctors debate the ethics of assisted suicide. The medical community and the world at large are looking at how physician-assisted suicide is playing out in Washington, Oregon and Montana. Are these states a bellwether or a death knell for legalizing the issue elsewhere? And how should physicians respond when presented with such requests from their patients?

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Cartoon caption contest

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And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

 

 

 

 

 

 

 

 

".sessalg deen yam uoY"

This issue's winning cartoon caption was submitted by Matthew C. Bowen, a student member from Des Moines University in Iowa. Readers cast 95 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry captured 45.3% of the votes.

The runners-up were:
"No, you don't have situs inversus; you have 'sighted inversus.'
"In a world of no drug reps, no standardized eye charts."

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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