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In the News

for the Week of 3-16-11

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Highlights

U.S. and U.K. doctors differ on reporting conflicts, errors, impaired colleagues

Physicians in both the U.S. and the United Kingdom report differences between their professional values and their actual behavior, according to new survey results. More...

Transient cognitive impairment at discharge may impede elderly patients' self-care

It may be worthwhile to screen patients for low cognition at hospital discharge and to offer care instructions after—rather than at the time of—discharge for those who score poorly, a new study suggests. More...

Mental illness

Depression management program helps cardiac inpatients

A depression management program begun during hospitalization helped improve mental and physical health outcomes months later, a new study found. More...

Critical care

Secondary benefit seen for early tracheotomy in cardiac patients with prolonged mechanical ventilation

Mechanically ventilated patients who had early tracheotomy or prolonged intubation after cardiac surgery didn't differ in number of ventilator-free days or infection rates, but the former required less sedation, a study found. 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...

Physician editor: A. Scott Keller, FACP

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Highlights

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U.S. and U.K. doctors differ on reporting conflicts, errors, impaired colleagues

Physicians in both the U.S. and the United Kingdom report differences between their professional values and their actual behavior, according to new survey results.

Researchers collected responses from about 1,900 American physicians in various specialties from 2003 to 2004 and about 1,100 physicians in the U.K. in 2009 to a series of questions about their professional values. The results, published online March 7 in BMJ Quality and Safety, revealed differences in beliefs and practices between the two countries, as well as gaps between physicians' values and actions.

For example, nearly a fifth of doctors in both countries reported direct personal experience with an impaired or incompetent colleague in the past three years, but one-third of those respondents had not reported the colleague to authorities. U.K. physicians were far more likely (34% vs. 12%) to list fear of retribution as a reason for their failure to report—an issue that has been previously noted in British medicine, the study authors said. The U.S. physicians were more likely to respond to incompetence by not referring patients to the colleague, an option which is often less available to U.K. physicians.

The doctors also differed on their acceptance of conflicts of interest: 83% of U.S. doctors reported receiving samples or gifts from industry (compared to 73% of British doctors), 47% thought business ventures with patients were never appropriate (60% in the U.K.), and 9% had actually provided care for a person with whom they had a direct financial relationship (1% in the U.K.). A majority, but far from all, physicians in both countries felt that physicians should put patients' welfare above their own financial interests (79% in the U.S., 82% in the U.K.).

U.S. physicians were more strongly in favor of disclosing their own financial relationships with industry and benefits and risks of treatment to patients than their British peers (65% vs. 59% and 88% vs. 74%, respectively). However, they were less likely to believe in disclosing all significant medical errors to affected patients (64% vs. 70%) due to the fear of being sued (21% vs. 13%).

The results indicate that physicians in both countries share a core of professional values, but that they have some differences that may be a result of the contexts in which they practice, study authors said. Given that both countries are currently working on major health care reform, physicians should advocate for creation of health care systems that encourage behavior congruent with physicians' values, they concluded.

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Transient cognitive impairment at discharge may impede elderly patients' self-care

It may be worthwhile to screen patients for low cognition at hospital discharge and to offer care instructions after—rather than at the time of—discharge for those who score poorly, a new study suggests.

To determine the frequency of low cognition at hospital discharge, researchers conducted face-to-face surveys at the time of discharge and one month later in the homes of 200 community-dwelling seniors. The subjects had been admitted for more than 24 hours to the acute medicine service of Northwestern Memorial Hospital in Chicago. Their mean age was 79.6 years (range, 70 to 100 years) and 58% were women. Patients were excluded if they were unable to consent to their own procedures (which implies known cognitive dysfunction), had previously documented cognitive loss, or were admitted for cognitive changes. Results appeared online March 4 in the Journal of General Internal Medicine.

Researchers applied the Folstein Mini-Mental Status Examination (MMSE), Backward Digit Span, and 15 Word Immediate and Delayed Recall Tests to evaluate cognition. Upon hospital discharge, 31.5% of subjects (n=60) had previously unrecognized low cognition. One month later, only 13.5% (n=27) had low cognition (P<0.001). Patients with low cognition had a mean score on the MMSE of 20.56 (range, 14 to 24) at discharge, which improved to a mean of 24.57 (range, 18 to 29) by one month (P<0.001). Orientation, task completion, registration, repetition, naming, reading, writing and calculation improved significantly. At discharge, only 54% of low-cognition subjects were able to correctly complete a three-step task of folding paper, placing it in their left hands, and handing the pieces to an interviewer. One month later, 98.4% were able to perform the task correctly.

According to assessment by the Backward Digit Span test, low cognition in working memory was present at discharge in 35.5% of the subjects, and declined to 31.5% one month later (P=0.014). With the 15 Word Immediate and Delayed Recall Tests, 50% of subjects had low cognition and were not able to remember more than one word from the 15-word list after eight minutes. One month post-discharge, significant improvements were seen, but 34.5% of subjects still had trouble (P<0.001).

Transient cognitive impairment threatens the comprehension and fulfillment of discharge instructions for seniors, over half of whom lived alone and almost 85% of whom managed their own medications in this study, the authors said. Screening for low cognition at discharge and educating caregivers to provide more attention to those who score poorly would help seniors transition back into their home environments, the authors wrote. "This tailoring of discharge interventions would decrease the costs to the hospital of initiating sweeping interventions to all discharged seniors," they wrote. "These seniors may also benefit from closer follow-up with their primary care physician to ensure that the discharge plan is being followed and to monitor the cognitive impairment."

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Mental illness

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Depression management program helps cardiac inpatients

A depression management program begun during hospitalization helped improve mental and physical health outcomes months later, a new study found.

In a randomized, prospective trial, researchers assigned 175 depressed inpatients with acute coronary syndrome, arrhythmia or heart failure to usual care or a collaborative depression care management program. The patients—who were admitted to one of three cardiac units at an urban academic hospital—were defined as depressed if they had a score of 10 or higher on the Patient Health Questionnaire-9 (PHQ-9), with five or more symptoms present more than half the days for the preceding two weeks. For the usual care patients, a care manager informed the inpatient treatment team of the patient's depression and recommended treatment. For the collaborative care patients, the care manager provided patient education about depression and its impact on cardiac disease; helped the patient schedule enjoyable activities after discharge; and described treatment options (drugs or therapy). For the latter patients, the manager also consulted with the study psychiatrist, who developed individualized treatment recommendations that the care manager then worked to implement with in- and outpatient health professionals. The study was published online March 8 in Circulation: Cardiovascular Quality and Outcomes.

Post-discharge interventions lasted 12 weeks, during which subjects received three separate phone assessments of depression symptoms. If a usual-care subject still scored as depressed, his or her primary care physician was informed. If a collaborative care subject was depressed, a multi-component intervention similar to the one in the hospital was enacted. Study outcomes were measured at six and 12 weeks and six months. Collaborative care subjects had significantly greater improvement of depression symptoms at six weeks (between-group difference in PHQ-9 improvement of −3.03 points; 95% CI, −4.97 to −1.10; P=0.002) and 12 weeks (−3.43-point difference; 95% CI, −5.41 to −1.45; P<0.001) after discharge. There was a nonsignificant trend toward improvement at six months (P=0.081).

Depression response on the PHQ-9 was also greater at six weeks for intervention subjects (59.7% vs. 33.7% for usual care; odds ratio [OR], 2.91; P=0.003) and 12 weeks (51.5% vs. 34.4%; OR, 2.02; P=0.04), but not significantly different at six months. Intervention subjects had greater improvement in number of cardiac symptoms (improvement greater by 0.80 symptom; P=0.047) and intensity of symptoms (2.15 points; P=0.011) at six months, but there was no difference at six or 12 weeks. Self-reported adherence to medical recommendations was also greater in the collaborative care arm at six months (15.9 mean adherence score vs. 14.6 for usual care; P=0.027), but not at six and 12 weeks.

The waning of psychiatric benefit from the intervention by six months is not surprising, the authors wrote, given that subjects received only three telephone contacts in a 12-week discharge period, and no contact after. This is a "much less intense follow-up intervention than most successful collaborative care programs," they noted. The improvement in adherence and cardiac symptoms at six months suggests patients may first need improvement in mental health before they can improve cardiac health behaviors, the authors wrote. This study extended prior work in that it addressed patients with several cardiac conditions for which collaborative depression care hadn't been used before. It also used phone rather than in-person interventions, and social workers instead of nurses as care workers; both of these allowed the intervention to be more feasible, the authors wrote. Limitations include that it was performed at a single center, most patients were white, and unit staff members were aware a depression study was ongoing.

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Critical care

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Secondary benefit seen for early tracheotomy in cardiac patients with prolonged mechanical ventilation

Mechanically ventilated patients who had early tracheotomy or prolonged intubation after cardiac surgery didn't differ in number of ventilator-free days or infection rates, but the former required less sedation, a study found.

In a prospective, randomized controlled trial, 216 mechanically ventilated patients were assigned to early percutaneous tracheotomy or prolonged intubation. Patients, who came from a single academic center in France, were eligible if they had undergone cardiac surgery and were still on mechanical ventilation four days afterwards; hadn't passed a weaning screening test or spontaneous breathing trial; and were expected to require mechanical ventilation for a week or more. The primary end point was number of days alive and breathing without assistance (i.e., ventilator-free days) during the first 60 days after randomization. Secondary end points included number of ventilator-free days at 28 and 90 days; mortality rates at 28, 60 and 90 days; duration of mechanical ventilation; length of ICU and hospital stays; ventilator-associated pneumonia rate; unscheduled extubations; sedative, analgesic and neuroleptic use; patient comfort and ease of care; and long-term quality of life and psychosocial status. Results were published in the March 15 Annals of Internal Medicine.

There was no difference in ventilator-free days in the first 60 days after randomization between the tracheotomy and prolonged intubation groups (mean, 30.4 days vs. 28.3 days, respectively; P=0.50), nor in 28-, 60-, or 90-day mortality rates (16% vs. 21%, 26% vs. 28%, 30% vs. 30%, respectively). Frequency of ventilator-associated pneumonia was similar in the tracheotomy and intubation groups (50% vs. 47%, respectively; P=0.77), as were duration of mechanical ventilation (17.9 days vs. 19.3 days; P=0.55) and hospitalization (39 days vs. 37.5 days; P=0.56). Early tracheotomy patients had significantly shorter duration of intravenous sedation (6.4 days vs. 9.6 days; P=0.007) and more sedation-free days in the first 28 days (19 days vs. 15.5 days; P=0.005); lower cumulative haloperidol dose for agitation and/or delirium during days 1 to 15 (0.26 mg/kg vs. 0.57 mg/kg; P=0.002); fewer unscheduled extubations (3 vs. 17; P<0.001); more days nurse-assessed as comfortable (11.8 vs. 10.4; P=0.01); and earlier resumption of oral nutrition (91% resumed at 15 days vs. 57%; P<0.001).

Although previous studies have linked decreased sedation with shorter duration on mechanical ventilation, there was no such indication in this study, the authors noted. This may be because polyneuropathy acquired in the ICU prolonged ventilation for both groups, or because the strict weaning protocol that was applied to the intubation group compensated for higher sedative use, they said. Only 29% of patients required tracheotomy at day 15 or later—far fewer than was found in a previous study, editorialists noted. It's possible this is because the cardiac population only requires mechanical ventilation for one or two weeks after surgery, or that clinicians don't predict clinical course well for these patients, they wrote. The finding that sedation and other medication needs are lower in patients with early tracheotomy raises the question of whether the procedure can facilitate an earlier return to independence (eating, mobility), when paired with an aggressive mobilization protocol, the editorialists wrote.

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Cartoon Caption Contest

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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.

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