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In the News
for the Week of 2-16-11
Highlights
ACP releases guideline on inpatient glucose control
Intensive insulin therapy should not be used to normalize blood glucose in ICU patients or to strictly control glucose in patients hospitalized outside of the ICU, according to a new clinical guideline from ACP. More...
Conference coverage: potential benefits, limitations of ACO model discussed
Accountable care organizations (ACOs) were the topic of much speculation and debate at two recent conferences. More...
Stroke
AHA issues statement on cerebral venous thrombosis diagnosis, management
The American Heart Association/American Stroke Association last week issued a scientific statement on the diagnosis, treatment and management of cerebral venous thrombosis. More...
Transitions of care
Failure to follow up on inpatient test results is common
A significant percentage of tests performed in the hospital are not followed up, according to a new systematic review. More...
Heart failure
Wireless pulmonary monitoring associated with less hospitalization
A wireless implantable hemodynamic monitoring system was associated with a significant reduction in hospitalizations for heart failure patients, researchers found. More...
Internal Medicine 2011
ACP Job Placement Center calls for job seekers' profiles
Physicians looking for a new job may submit a profile to the ACP Job Placement Center, a service available at Internal Medicine 2011, to be held April 7-9 in San Diego. More...
Cartoon Caption Contest
Vote for your favorite entry
ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner. More...
Physician editor: A. Scott Keller, FACP
Highlights
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ACP releases guideline on inpatient glucose control
Intensive insulin therapy should not be used to normalize blood glucose in ICU patients or to strictly control glucose in patients hospitalized outside of the ICU, according to a new clinical guideline from ACP.
The guideline was published in the Feb. 15 Annals of Internal Medicine, along with a systematic evidence review of studies relating to inpatient glucose control, and it contains three main recommendations.
The first, which is a strong recommendation based on moderate-quality evidence, advises clinicians not to use intensive insulin therapy to strictly control glucose in non-ICU patients with or without diabetes. The recommendations define intensive insulin therapy as use of intravenous insulin to achieve a targeted blood glucose level with frequent testing and adjustment of insulin doses. The evidence shows that a target of 80 to 180 mg/dL has not been associated with reduced mortality in inpatients with a variety of medical conditions. The guidelines did not specify an optimal target for glucose levels in non-ICU patients as intensive insulin therapy was associated with an increased risk of hypoglycemia in almost all trials and there were no clear differences in mortality, but they did say that avoiding targets under 140 mg/dL should be a priority.
The second recommendation, which is also graded strong and based on high-quality evidence, called for not using intensive therapy to normalize glucose in patients in surgical or medical ICUs. Normalization was defined as a target of 80 to 110 mg/dL, and the evidence review found an increase in mortality and hypoglycemia associated with aiming for these targets.
In a third, weak recommendation based on moderate-quality evidence, the ACP guideline recommended that if clinicians choose to use insulin therapy in ICU patients, the target glucose should be 140 to 200 mg/dL. The evidence did not indicate a precise optimal range for blood glucose in these patients, but that target is a reasonable option because it is associated with similar mortality and less hypoglycemia compared to a target of 80 to 110 mg/dL, according to the guideline. If hospitals do choose to use intensive insulin therapy in the ICU, efforts should be made to minimize the risk of hypoglycemia through quality improvement and training initiatives, the guidelines concluded.
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Conference coverage: potential benefits, limitations of ACO model discussed
WASHINGTON—Accountable care organizations (ACOs) were the topic of much speculation and debate at two recent conferences.
The specifics of ACOs will remain uncertain until the Centers for Medicare and Medicaid Services (CMS) releases rules on the new provider organizations (which were created under health care reform to bring together inpatient and outpatient clinicians to improve quality while reducing cost), but experts offered preliminary perspectives at the annual National Health Policy Conference on Feb. 7 and a seminar at the Brookings Institute on Feb. 1.
Given the uncertainty about what ACOs will be, several speakers focused on what they will not be—a new name for the current silo system, or an HMO, or an incentive to withhold care. "The focus is not withholding care but reducing waste," said CMS administrator Donald Berwick, MD. "We now invest in volume and throughput. The ACO will invest in value and outcome."
How value and outcomes will be measured is still uncertain, speakers said. The health care law requires ACOs to be measured in a number of areas, including processes of care, clinical outcomes, patient experience, care coordination, and transitions, said John Pilotte, acting director of CMS's performance-based payment policy staff. The cost of care provided by ACOs will also be measured, and compared to benchmarks based on each organization's past performance. If costs are lower than benchmarks, Medicare will share the savings with the ACO. The ACO will be responsible for distributing the shared savings and collecting and reporting on the quality measures.
Shared savings will provide an incentive for physicians and hospitals to provide the most cost-effective care, possibly reducing demand for expensive technologies, and give more power to primary care physicians to refer patients to the most cooperative specialists, said Hal Luft, PhD, of the Palo Alto Medical Foundation Research Institute. However, some speakers argued that the shared saving system does not go far enough, and the clinicians should also share the risk of losing money if the cost of care exceeds benchmarks.
The ACO model may conflict with anti-trust regulations by establishing financial relationships between clinicians, especially if the clinicians' financial cooperation spread to negotiations with private payers. A cooperative workgroup of the Department of Justice, the Office of the Inspector General and the Federal Trade Commission is currently working on these issues, Dr. Berwick said.
Other issues about ACO implementation still to be resolved include allocation of patients to ACOs (prospective or retrospective), preventing cherry-picking of patients (or the reverse, "dumping" of costly patients), communicating with patients about ACOs, measurement methods of ACO quality, and privacy and data-sharing, the speakers said. Dr. Berwick expressed pleasure with the level of public interest in these issues, and gave a hint that the forthcoming ACO regulations would offer some flexibility. "An ACO won't be one thing. It will be a collection of models," he said.
ACP issued a policy statement on ACOs in April 2010 and joined the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association in releasing joint principles on ACOs in November 2010.
—Stacey Butterfield, associate editor
Stroke
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AHA issues statement on cerebral venous thrombosis diagnosis, management
The American Heart Association (AHA)/American Stroke Association last week issued a scientific statement on the diagnosis, treatment and management of cerebral venous thrombosis (CVT).
CVT is uncommon, representing 0.5% to 1% of all strokes, and usually affects individuals younger than age 50. Diagnosis and management can be difficult because of the diverse underlying risk factors, and the lack of uniformity in treatment, the statement said. Recommendations for diagnosis and treatment include the following:
In patients with suspected CVT, perform routine blood studies comprising complete blood count, chemistry panel, prothrombin time and activated partial thromboplastin time (Class I, Level C evidence).
Patients should be screened for potential prothrombotic conditions (including use of contraceptives, underlying inflammatory disease, or infectious process) that may predispose to CVT (Class I, Level C evidence).
In patients with headache associated with atypical features, imaging of the cerebral venous system is reasonable to exclude CVT (Class IIa, Level C evidence).
Although a plain computed tomography (CT) scan or magnetic resonance imaging (MRI) scan is useful in the initial evaluation of patients with suspected CVT, a negative plain CT or MRI doesn't rule out CVT. If CVT is suspected and either scan is negative, perform a venographic study. The study should also be performed to define the extent of CVT, when CT or MRI suggests the condition (Class I, Level C evidence).
Patients with CVT and a suspected bacterial infection should receive appropriate antibiotics and surgical drainage of purulent collections of infectious sources associated with CVT, when appropriate (Class I, Level C evidence).
It's reasonable to admit patients with CVT to a stroke unit for treatment and to prevent clinical complications (Class IIa, Level C evidence).
For patients with CVT, use initial anticoagulation with adjusted-dose unfractionated heparin or weight-based low molecular-weight heparin in full anticoagulant doses, followed by vitamin K antagonists, whether or not intracerebral hemorrhage is present (Class IIa, Level C evidence).
Patients with CVT and increased intracranial pressure should be monitored for progressive visual loss. If visual loss is observed, they should be treated urgently for increased intracranial pressure (Class I, Level C). In patients with CVT and increased intracranial pressure, it is reasonable to start treatment with acetazolamide. Therapies including lumbar puncture, optic nerve decompression or shunts can be effective if there is progressive visual loss (Class IIa, Level C evidence).
Steroids aren't recommended for CVT patients, even in the presence of parenchymal brain lesions on CT/MRI, unless needed for another underlying disease (Class III, Level B evidence). Routine use of antiepileptics also isn't recommended, in the absence of seizures (Class III, Level C evidence).
The recommendations also include evaluation and management of CVT during pregnancy. The statement was published online Feb. 3 by Stroke. Its educational value has been affirmed by the American Academy of Neurology, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. The Ibero-American Stroke Society and the Society of NeuroInterventional Surgery have endorsed the statement, as well.
Transitions of care
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Failure to follow up on inpatient test results is common
A significant percentage of tests performed in the hospital are not followed up, according to a new systematic review.
The review included 12 studies, eight of which were conducted in the U.S, all of which quantified the proportion of diagnostic tests not followed up for inpatients. The review found wide variation. For admitted patients, estimates of missed follow up ranged from 1% to 22.9%. (as a proportion of inpatients) and from 20.04% to 61.9% when reported per test type.
There was even greater variation in follow-up on tests performed in the emergency department, with estimates ranging from 1% to 75% of tests not followed up, or 0% to 16.5% as a proportion of patients. Several studies observed serious negative outcomes resulting from the failure to follow up, including missed cancer diagnoses. The review was published online by BMJ Quality and Safety on Feb. 7.
The review authors noted particular problems with critical test results, which were apparently lost to follow-up due to communication breakdowns, including noncompliance with guidelines calling for results to be phoned to practitioners. Patients who moved across health care settings, for example from inpatient to outpatient or from the emergency department to another setting, also posed challenges for follow-up. This finding highlights the "need for systems, policies and practices which facilitate communication of information across different settings," the study authors said.
The review also looked at the role of various medical records systems, but found no evidence of any association between the type of record system used and follow-up of test results. Electronic, paper, and mixed electronic/paper systems all had high rates of missed results. Electronic systems that can be accessed by clinicians in and out of the hospital and those that include a function for clinicians to endorse results may be helpful, but they would require further study, and should be combined with other strategies. Test result management systems should be flexible and integrated into clinical work practices, the review authors concluded.
Heart failure
.
Wireless pulmonary monitoring associated with less hospitalization
A wireless implantable hemodynamic monitoring system was associated with a significant reduction in hospitalizations for heart failure patients, researchers found.
Patients (n =550) from 64 American centers in a single-blind trial were randomly assigned to receive a wireless implantable hemodynamic monitoring system or to a control group receiving standard care for at least six months. Patients had New York Heart Association class III heart failure, irrespective of the left ventricular ejection fraction, and a previous hospital admission for heart failure. Only patients were masked to their assignment group. Results were released online Feb. 10 in The Lancet.
The primary efficacy endpoint was the rate of heart-failure-related hospitalizations at six months. In six months, 83 heart-failure-related hospitalizations were reported in the treatment group (n=270), compared with 120 in the control group (n=280; rate, 0.31 vs. 0.44; hazard ratio [HR], 0.70; 95% CI, 0.60 to 0.84; P<0.0001). During a mean follow-up of 15 months, the treatment group had a 39% reduction in heart-failure-related hospitalization compared with the control group (153 vs. 253; HR, 0.64; 95% CI, 0.55 to 0.75; P<0.0001). Non-heart-failure related hospitalizations were not different between the groups.
The treatment group had a greater reduction in pulmonary artery mean pressure, more days alive outside the hospital, and better quality of life than the control group during six months of follow-up. Survival rates in the treatment and control groups at six months were similar (255 [94%] vs. 260 [93%]; HR, 0.77; 95% CI, 0.40 to 1.51; P=0.45).
Length of stay for heart-failure-related hospitalizations was 2.2 days (SD, 6.8) in the treatment group versus 3.8 days (SD, 11.1) in the control group (P=0.02). The treatment group had a significantly greater number of changes to drugs for heart failure (2,468; mean, 9.1 per patient; SD, 7.4) than did the control group (1,061; 3.8 per patient; SD, 4.5; P<0.0001).
The first primary safety endpoint of the study was device-related or system-related complications (DSRCs). This was defined as adverse events related to the wireless pressure sensor or external electronics that required invasive treatment other than an intramuscular drug administration or a right-heart catheterization. Patients had 98.6% (95% CI, 97.3 to 99.4) freedom from DSRC.
The second primary safety endpoint was pressure-sensor failure, defined as an inability to obtain readings. No pressure-sensor failures occurred. There were 15 serious adverse events, eight related to DSRC and seven related to the implantation procedure.
Internal Medicine 2011
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ACP Job Placement Center calls for job seekers' profiles
Physicians looking for a new job may submit a profile to the ACP Job Placement Center, a service available at Internal Medicine 2011, to be held April 7-9 in San Diego. The center, located in the San Diego Convention Center's Exhibit Hall, Booth #1601, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.
Profiles will be included in one of two booklets distributed only to Job Placement Center sponsors and exhibitors who have submitted a job posting based on your criteria. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the center. Profiles can be submitted online.
Editorial note:ACP HospitalistWeekly will not be published next week due to the Presidents' Day holiday.
Cartoon Caption Contest
.
Vote for your favorite entry
ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner.
"You've got a virus. Let me write you a script for Norton."
"That wasn't a seizure. That was a power surge."
"Congratulations! You're my first mouse call."
Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Feb. 28, with the winner announced in the March 1 issue.
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