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ACP HospitalistWeekly
In the News for the Week of 10-5-11
Highlights
Median hospitalist pay rose slightly between 2009 and 2010, survey finds
Median compensation for internal medicine hospitalists rose 2.4% between 2009 and 2010, from $215,000 to $220,144, according to a new survey report by the Medical Group Management Association (MGMA) and Society of Hospital Medicine (SHM). More...
For excluding PE, D-dimer plus decision rule or gestalt is usually safe
Combining D-dimer testing with either a decision rule or a physician's unstructured estimate (gestalt) is usually safe when evaluating adults for suspected pulmonary embolism (PE), a meta-analysis found. More...
Guidelines
Updated guideline released on PAD diagnosis and management
An updated guideline on diagnosis and management of peripheral artery disease (PAD) was released last week by the American College of Cardiology Foundation and the American Heart Association, in conjunction with several other medical organizations. More...
Drug therapy
SSRI increases bleeding risk after MI
Patients who received a selective serotonin reuptake inhibitor (SSRI) after acute myocardial infarction were at higher risk of bleeding, a new study found. More...
Statins worked even for MI patients with low LDL
Statin therapy was beneficial for post-myocardial infarction (MI) patients who had low-density lipoprotein (LDL) cholesterol levels under 70, a new study found. More...
Imaging
MRIs safe for ICDs and pacemakers, if proper protocol followed
Magnetic resonance imaging (MRI) can be performed safely in patients with certain pacemakers and implantable cardioverter-defibrillators (ICD) as long as experts are on hand to monitor and intervene if needed, a new study found. More...
From ACP Internist
The next issue of ACP Internist is online
The October issue of ACP internist is now online. Featured stories are about sports internists who treat players as patients, and management of elderly patients with cardiovascular disease. More...
Cartoon caption contest
Put words in our mouth
ACP HospitalistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...
Editorial note: ACP HospitalistWeekly will not be published next week due to the Explorers' Day holiday.
Physician editor: James S. Newman, MD, FACP
Highlights
.
Median hospitalist pay rose slightly between 2009 and 2010, survey finds
Median compensation for internal medicine hospitalists rose 2.4% between 2009 and 2010, from $215,000 to $220,144, according to a new survey report by the Medical Group Management Association (MGMA) and Society of Hospital Medicine (SHM).
The State of Hospital Medicine: 2011 Report Based on 2010 Data comprises fiscal year 2010 data from 4,633 clinicians from 412 medical groups, including 36 hospitalist nurse practitioners and 24 physician assistants. The data revealed that, for internal medicine hospitalists, productivity also was up slightly; the annual median work relative value unit (wRVU) rate was 4,174 in 2010, compared to 4,100 in 2009. (A wRVU refers to the relative level of time, skill, training and intensity of a particular service.) Compensation per wRVU for internal medicine hospitalists rose to $54.24 from $51.90 the previous year, while pediatric hospitalists were paid $83.15/wRVU, down from $87.26/wRVU in 2009.
In a combined group of family practice and internal medicine hospitalist survey respondents, compensation was highest for those working in local hospitalist-only groups at $248,000 and lowest for those in multistate hospitalist groups and management companies at $209,082. Those working within call-based staffing models made more than those in shift-based staffing models ($263,000 vs. $221,640). As well, the lower the proportion of total compensation paid as base salary, the higher the overall compensation. For example, those with 50% or less of their compensation as base salary made $288,154 on average, compared to $205,003 for those with 100% of compensation as base salary. On the whole, hospitalists received 80% of their compensation as base compensation, 16% as production incentives and 4% as performance incentives.
"The compensation methodology is still evolving, which provides increased potential for hospitalists to negotiate from a straight base salary to a base salary-plus–incentive program based on production and quality metrics," said Jeffrey B. Milburn, of the MGMA Health Care Consulting Group, in a press release.
Seventy-eight percent of respondent practices used a shift-based staffing model, compared to 70% in 2009. Forty-nine percent reported having nurse practitioners and/or physician assistants working in their practice in 2010, and 41% reported using nocturnists. The proportion of clinical support staff, such as nurses and social workers, declined from 0.21 per full time equivalent (FTE) in 2009 to 0.17 FTE per FTE physician in 2010.
A full copy of the survey can be purchased online.
ACP Hospitalist published an article about preliminary findings from the survey in July.
.
For excluding PE, D-dimer plus decision rule or gestalt is usually safe
Combining D-dimer testing with either a decision rule or a physician's unstructured estimate (gestalt) is usually safe when evaluating adults for suspected pulmonary embolism (PE), a meta-analysis found.
Researchers sought to compare the test characteristics of gestalt and clinical decision rules for evaluating adults with suspected PE, and assess the failure rate of gestalt and rules when combined with D-dimer testing. They searched articles in MEDLINE and EMBASE between 1966 and June 2011, and found 52 prospective studies of 55,268 inpatients, emergency department patients and referred patients who were thought to have PE. The studies estimated the probability of PE using gestalt or a decision rule, and verified the diagnosis using a reference standard. ("Gestalt" was defined as a physician's unstructured clinical probability estimate after collecting routine data from patient history, physical examination, electrocardiography or chest radiography.) They identified five sets of clinical decision rules in the studies: the Wells rules (with cutoff values of <2 or ≤4) and simplified Wells rules, the Geneva rules (original, revised and simplified revised), the Pisa rules (original and revised), the Charlotte rule and the PERC rule. Most rules use only clinical data, except the original Geneva rule and Pisa rules, which use electrocardiography and chest radiography.
Meta-analysis was performed on those studies that used gestalt (15 studies; sensitivity, 0.85; specificity, 0.51); the Wells rule with a cutoff value <2 (19 studies; sensitivity, 0.84; specificity, 0.58) or ≤4 (11 studies; sensitivity, 0.60; specificity, 0.80); the Geneva rule (5 studies; sensitivity, 0.84; specificity, 0.50); and the revised Geneva rule (4 studies; sensitivity, 0.91; specificity, 0.37). The other decision rules weren't included in the meta-analysis because they had been used in fewer than four studies. The analysis found that increased prevalence of PE was associated with higher sensitivity and lower specificity. Neither the clinical decision rules nor gestalt were sensitive enough to safely exclude PE on their own, but all could do so when combined with sensitive D-dimer testing. The article was published in the October 4 Annals of Internal Medicine.
The authors recommended using a decision rule instead of gestalt, since "physicians who use gestalt tend to assign a higher probability to PE to avoid missing it, thus causing more false-positive results and exposing more patients to unnecessary pulmonary imaging." It's important to remember that the sensitivity of a decision rule increases, and specificity decreases, as PE prevalence increases, they noted. Physicians should use the strategy that fits their situation best, they concluded: in a high-prevalence setting, as with referred patients, a rule with higher specificity is desirable; in a lower-prevalence setting, rules with higher sensitivity are more desirable.
Guidelines
.
Updated guideline released on PAD diagnosis and management
An updated guideline on diagnosis and management of peripheral artery disease (PAD) was released last week by the American College of Cardiology Foundation and the American Heart Association, in conjunction with several other medical organizations.
The guideline, which updates 2005 recommendations on the subject, expands criteria for using the ankle-brachial index (ABI), recommends increased efforts to ensure access to smoking cessation services, encourages improved antiplatelet and antithrombotic therapy, and more precisely defines interventions to avoid limb amputation and treat aortic aneurysms. Specific recommendations include the following:
- The ABI should first be performed in patients age 65 years or older, compared with patients age 70 years or older in the 2005 guideline.
- Current and former smokers should be asked about tobacco use at each visit and should be proactively offered support to help them quit, such as counseling, pharmacologic therapies and/or formal smoking cessation programs.
- Aspirin plus clopidogrel may be considered in patients with symptomatic atherosclerotic lower-extremity PAD to reduce risk for cardiovascular events.
- Balloon angioplasty is a reasonable first-line treatment for patients with severe PAD who may need amputation and are expected to live for two years or less; for those expected to live more than two years, bypass surgery is a reasonable option.
- Open repair for abdominal aortic aneurysms is reasonable in patients who are good candidates for surgery but can't comply with periodic long-term surveillance after endovascular repair.
The guideline was published online Sept. 29 by the Journal of the American College of Cardiology and Circulation. It was developed in collaboration with the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery.
Drug therapy
.
SSRI increases bleeding risk after MI
Patients who received a selective serotonin reuptake inhibitor (SSRI) after acute myocardial infarction were at higher risk of bleeding, a new study found.
The retrospective cohort study included 27,000 patients discharged from a Canadian hospital following an acute myocardial infarction (MI). All of the patients were taking some form of antiplatelet therapy: 14,426 were on aspirin (ASA), 2,467 received clopidogrel and 9,475 took both. Some of the patients also received an SSRI in combination with aspirin (406 patients), with clopidogrel (45) or both (239). The study followed the patients until death, readmission due to bleeding or repeat MI, or the end of the study period.
The addition of the SSRI to the antiplatelet regimens was associated with an increased risk of bleeding, researchers found. Compared to patients taking only aspirin, patients in the ASA plus SSRI group had a 42% increased risk of bleeding (95% confidence interval [CI] for hazard ratio, 1.08 to 1.87). The use of an SSRI, aspirin and clopidogrel all together increased risk by 57% compared to just dual antiplatelet therapy (95% CI for hazard ratio, 1.07 to 2.32). The study also found a higher bleeding risk in patients taking clopidogrel with an SSRI than those on clopidogrel alone, but the patient population was too small to prove significance.
The study authors noted that previous studies have reported increased bleeding with SSRIs that have a higher affinity to serotonin, a finding that was not replicated by this research. This study was limited by its observational nature, reliance on billing information, and lack of data on compliance with medication regimens. Still, the authors concluded that physicians should cautiously weigh the benefits of SSRI therapy against the risk of bleeding in post-MI patients with major depression. The study was published online by the Canadian Medical Association Journal on Sept. 26.
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Statins worked even for MI patients with low LDL
Statin therapy was beneficial for post-myocardial infarction (MI) patients who had low-density lipoprotein (LDL) cholesterol levels under 70, a new study found.
The observational study included about 1,000 Korean patients who had an acute myocardial infarction and an LDL below 70 (measured within 24 hours of MI). About 600 of them received a statin and about 450 did not. They were followed for a year for a primary composite endpoint of major adverse cardiac events, including death, recurrent MI, target vessel revascularization and coronary artery bypass grafting.
Patients in the statin group had a significantly lower risk of the primary endpoint (adjusted hazard ratio [HR], 0.56; P=0.015), a difference driven by their decrease in cardiac death (HR, 0.47; P=0.031) and coronary revascularization (HR, 0.45; P=0.013). The two groups did not show any difference, however, in all-cause death, recurrent MI, and repeated percutaneous coronary intervention. The results were published online by the Journal of the American College of Cardiology on Oct. 3.
Statin treatment of patients with LDL below 70 is a controversial issue, the study authors acknowledged. They noted that such patients are usually older and likely to have other comorbidities. Subgroup analyses showed the most beneficial effects of statins in men, the elderly, smokers or ex-smokers, STEMI patients, and patients without diabetes, hypertension or prior dyslipidemia. High C-reactive protein levels were also associated with more benefit. The study authors concluded that statins are associated with improved outcomes in post-MI patients with LDL below 70, although they called for their findings to be confirmed by randomized trials on the subject.
The non-randomized nature of this study is a major limitation, an accompanying editorial said. In addition, patients' LDLs were not retaken after the initial measurement. However, based on this trial and others suggesting that statins have significant benefit in the year after MI, a placebo-controlled clinical trial of statin therapy in this setting is worth considering, the editorialist concluded.
Imaging
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MRIs safe for ICDs and pacemakers, if proper protocol followed
Magnetic resonance imaging (MRI) can be performed safely in patients with certain pacemakers and implantable cardioverter-defibrillators (ICD) as long as experts are on hand to monitor and intervene if needed, a new study found.
Up to 75% of patients with pacemakers and ICDs develop an indication to undergo MRIs, study authors noted. To define a protocol for scanning such patients, researchers at Johns Hopkins University in Baltimore, and Rambam Medical Center, in Haifa, Israel, enrolled patients from primary and subspecialty physicians between February 2003 and April 2010. Patients with newly implanted leads (less than six weeks) and those with abandoned or epicardial leads were excluded, resulting in 438 patients with devices (54% with pacemakers and 46% with ICDs) who underwent 555 MRI studies. MRIs were done at a magnetic strength of 1.5 T (Tesla). Pacing mode was changed to asynchronous for pacemaker-dependent patients and to demand for others. Tachyarrhythmia functions were disabled. Blood pressure, electrocardiography, oximetry and symptoms were monitored by a nurse with experience in cardiac life support and who had immediate backup from an electrophysiologist. Study results appeared in the Oct. 4 issue of Annals of Internal Medicine.
Researchers looked at whether exposure to electromagnetic interference might cause implantable devices to revert to a back-up programming mode known as "power-on-reset." In this mode, pacing is set to an inhibited mode and tachycardia therapies are enabled. There were three power-on-reset events. One occurred during cardiac MRI in a patient with a single-chamber ICD that had been implanted in 1999. The ICD did not attempt to deliver tachyarrhythmia therapy, but the patient experienced a pulling sensation in his chest and the MRI examination was discontinued. The other two patients had pacemakers implanted in 1997 and 2003 and were undergoing brain and cervical spine examinations, respectively. Both patients had occasional pacing inhibition associated with programming reversion to the inhibited pacing mode, but they were not pacemaker-dependent and completed their MRI examinations. None of the three patients had device dysfunction during long-term follow-up.
When the device was located in the MRI field of view, image distortion, signal voids or bright areas, and poor fat suppression occurred. Selecting imaging planes perpendicular to the plane of the device generator, shortening the echo time, and using spin echo and fast spin echo sequences reduced the effect. Artifacts occurred during thoracic exams, and because thoracic MRIs have a greater effect on the devices, they should be reserved for patients with an absolute clinical need, the study authors said. They noted that they did not test all available cardiac devices, that follow-up was unavailable in 43 patients (10%), and that some data were missing. Defibrillation threshold testing and randomization to a control group were not performed.
An editorialist commented that MRIs are not risk free, but the risks are quantitatively small. "[T]he risks of MRI in the presence of CRMDs [cardiac rhythm management devices], although potentially serious, have probably been overestimated and can be managed effectively in many cases. In our opinion, the presence of a CRMD should no longer be considered an absolute contraindication to MRI. Rather, the risks and benefits of MRI in a patient with a CRMD should be assessed on an individualized basis, as with any important medical decision."
To manage risks, practitioners should conduct MRIs only at 1.5 T, implants should be in place for at least six weeks to reduce movement of leads, and no epicardial or nonfunctioning leads should be present, he added. "Most important, the equipment and experienced personnel necessary to manage any eventuality must be immediately available," the editorial concluded.
From ACP Internist
.
The next issue of ACP Internist is online
The October issue of ACP internist is now online. Featured stories include:
Sports internists treat players as patients. These internists turned their own athletic pursuits into careers with professional sports teams, treating high-caliber athletes as they practice and play. Working the sidelines, it's just another day not at the office.
Managing the elderly with cardiovascular disease. As patients are living longer, they're seeking more care for their cardiovascular diseases, as well as comorbidities such as diabetes. Experts provide insight on effective therapy in the older population.
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.
About ACP HospitalistWeekly
ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. It is automatically sent to all College members who have an e-mail address on file with ACP.
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