Annals for Hospitalists - 17 July 2018
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2018)

Web Exclusives17 July 2018Annals for Hospitalists - 17 July 2018FREEDavid H. Wesorick, MD* and Vineet Chopra, MD, MSc*David H. Wesorick, MD*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this author and Vineet Chopra, MD, MSc*From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFHO201807170 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesBedrest is Toxic—Why Mobility Matters in the Hospital—S. Ryan Greysen, MD, MHS, and Mitesh S. Patel, MD, MBA, MSLying in bed leads to functional decline in hospitalized patients. This month's Inpatient Notes explains how hospitalists can take the lead in combatting this problem.Highlights of Recent Articles From Annals of Internal MedicineClinicians' Perspectives on Providing Emergency-Only Hemodialysis to Undocumented Immigrants: A Qualitative StudyAnn Intern Med. 2018;168:78-86. Published 22 May 2018. doi:10.7326/M18-0400This qualitative study utilized semistructured interviews to evaluate the perceptions of a wide range of clinicians on the provision of emergency-only hemodialysis to undocumented immigrants. The study was done in 2 hospitals that adhered to a policy of providing hemodialysis to these immigrants only when they present with life-threatening emergencies (in contrast to regularly scheduled hemodialysis that would normally be provided to patients with end-stage kidney disease). Thematic analysis of the interviews revealed that the practice of emergency-only hemodialysis led to professional burnout, moral distress from propagating injustice, and dissatisfaction related to the extremely wasteful and futile cycle that it imposed.Key points for hospitalists include:It is already known that policies requiring emergency-only hemodialysis for undocumented immigrants are bad for patients (causing unnecessary suffering and higher mortality) and health systems (driving costs higher and causing inappropriate use of certain resources, such as emergency services).This study shows that these policies are also bad for clinicians, whom they force to allow preventable suffering, provide suboptimal and unjust care, participate in extreme waste, and compromise their integrity.The article effectively shows that clinicians find emergency-only hemodialysis policies to be unacceptable and that they suffer personally and professionally when they are forced to comply with them.An editorialist notes that the ethical problems related to emergency-only hemodialysis would disappear in a system with universal health coverage and encourages physicians to advocate for that type of system while simultaneously leveraging existing resources to abolish perverse health policies.Associations Between American Board of Internal Medicine Maintenance of Certification Status and Performance on a Set of Healthcare Effectiveness Data and Information Set Process MeasuresAnn Intern Med. 2018;168:97-105. Published 12 June 2018. doi:10.7326/M16-2643This observational study compared rates of compliance with several Healthcare Effectiveness Data and Information Set (HEDIS) measures between general internists who maintained their American Board of Internal Medicine certification and those who did not. The results show a statistically significantly higher compliance with some of the HEDIS measures in the maintenance of certification group. The examined measures included semiannual testing of hemoglobin A1c levels (compliance rates of 58.4% vs. 54.4%) and annual testing of low-density lipoprotein cholesterol levels (compliance rates of 83.1% vs. 80.5%) in patients with diabetes.Key points for hospitalists include:The authors conclude that there is a significant association between maintenance of certification and fulfillment of these HEDIS measures.However, an accompanying editorial notes that the presence of even small, unmeasured confounders could easily eliminate the significance of the difference between the groups. More important, the editorialist points out that the HEDIS measures examined in this study simply do not pass the sniff test as robust quality indicators. This study does little to support the notion that the traditional system of maintenance of certification leads to provision of meaningful, higher-quality care.Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause?Ann Intern Med. 2018;169:50-51. Published 8 May 2018. doi:10.7326/M18-0139This opinion piece highlights the widely held belief that the electronic health record (EHR) has contributed to the rise in professional dissatisfaction and burnout in the medical community. However, it also notes that the launch of EHRs in other countries (outside of the United States) has been met with much less dissatisfaction and suggests that the difference may be related to the simpler documentation and billing requirements in those countries.Key points for hospitalists include:The authors hypothesize that it may not be the EHR per se that is contributing to physician dissatisfaction. Rather, it may be the excessive regulations around documentation and billing in the U.S. that are driving physicians to spend more time with the computer and less time with the patient.The authors suggest that regulatory reform may be a key element in the battle against physician burnout in the U.S.The Latest Highlights from ACP Journal ClubWhat are the 2018 guideline recommendations for acute stroke?Guideline: The AHA/ASA made 217 recommendations for early management of acute ischemic stroke in adultsAnn Intern Med. 2018;168:JC63. doi:10.7326/ACPJC-2018-168-12-063This guideline from the American Heart Association and the American Stroke Association offers an extensive list of recommendations for early management of patients with acute ischemic stroke. Notable new or revised recommendations include the use of mechanical thrombectomy in patients with symptom onset within 6 to 16 hours and avoiding treatment of elevated blood pressure (<220/120 mm Hg) for the first 48 to 72 hours in patients who are not treated with intravenous alteplase or endovascular therapy.Do corticosteroids reduce mortality in septic shock?Hydrocortisone plus fludrocortisone reduced mortality at 90 days in patients with septic shockAnn Intern Med. 2018;168:JC68. doi:10.7326/ACPJC-2018-168-12-068Hydrocortisone did not reduce mortality at 90 days in patients with septic shockAnn Intern Med. 2018;168:JC69. doi:10.7326/ACPJC-2018-168-12-069These randomized controlled trials both evaluated the effect of low-dose corticosteroids (200 mg/d intravenous hydrocortisone) in patients with variably defined septic shock and came to different conclusions. The first study (n = 1241), which also included treatment with fludrocortisone, demonstrated decreased mortality at 90 days as well as at discharge from the intensive care unit or the hospital. The second study (n = 3800), in which hydrocortisone was administered as a continuous infusion without fludrocortisone, did not demonstrate a mortality benefit. When these studies are combined with others, the pooled results do not confirm a mortality benefit at 1 month, making it difficult to offer firm recommendations about the use of corticosteroids in this population.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W, V.C.)Disclosures:Drs. Wesorick and Chopra have disclosed no conflicts of interest. The forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.* The authors are co-first authors and contributed equally to the article. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Bedrest Is Toxic—Why Mobility Matters in the Hospital S. Ryan Greysen and Mitesh S. Patel Metrics 17 July 2018Volume 169, Issue 2Page: HO2KeywordsElectronic medical recordsFludrocortisoneHospitalistsIschemic strokeMortalityQualitative studiesQuality indicatorsRenal failureResearch quality assessmentShock ePublished: 17 July 2018 Issue Published: 17 July 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.Loading ...