Annals for Hospitalists - 21 March 2017
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2017)

Web Exclusives21 March 2017Annals for Hospitalists - 21 March 2017FREEDavid 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/AFHO201703210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - What Do French Wine and Hospital Infections Have in Common?by Payal K. Patel, MD, MPH, and Sanjay Saint, MD, MPHThis commentary begins as a salute to the infection control heroes from the past and ends with some innovative, new ideas for reducing hospital-acquired infections.Highlights of Recent Articles From Annals of Internal MedicineIssues Surrounding Age-Adjusted D-Dimer Cutoffs That Practicing Physicians Need to Know When Evaluating Patients With Suspected Pulmonary EmbolismAnn Intern Med. 2017;166:361-363. Published 27 December 2016. doi:10.7326/M16-2030This Ideas and Opinions piece discusses the lack of standardization of D-dimer testing, especially as it pertains to interpretation of age-adjusted D-dimer (AADD) test results. Although many commercial D-dimer assays are available, their units of measure vary, and only a few have been studied in the context of age adjustment. According to current regulations, assays that have not been studied using age adjustment must undergo a validation process before they can be used with age-adjusted interpretation, and this limits the immediate, universal adoption of AADD levels in clinical practice.Key points for hospitalists include:Hospitalists should know whether their laboratory uses one of the D-dimer assays that have been studied in the context of AADD interpretation (these assays are listed in a table in the article).The authors recommend that all D-dimer vendors perform the necessary validation for their individual assays to support wider use of age adjustment in clinical practice.The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic ReviewAnn Intern Med. 2017;166:341-353. Published 10 January 2017. doi:10.7326/M16-1881This systematic review examined 69 studies (58 ambulatory settings and 11 inpatient) to document the effects of pay-for-performance programs. The strength of evidence was generally considered to be low, and the analysis is limited by heterogeneity in the study populations and program characteristics. In the ambulatory setting, pay-for-performance programs may have some effect on process-of-care outcomes, but not patient health outcomes. Fewer studies demonstrated no clear effects on patient health outcomes in the hospital, although 1 study did detect an associated reduction in readmissions.Key points for hospitalists include:Although pay-for-performance programs are becoming increasingly common, there is still little evidence that they improve patient health outcomes.An editorial notes that 2017 will see the roll-out of the largest pay-for-performance initiative in history, affecting more than 500 000 clinicians. Because hospital medicine currently has only a few established Centers for Medicare & Medicaid Services–approved quality measures, the details of pay-for-performance programs for these practitioners will continue to evolve over time. Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older: A Systematic Review and Meta-analysisAnn Intern Med. 2017;166:419-429. Published 17 January 2017. doi:10.7326/M16-1754This article reviews 21 randomized, controlled trials (RCTs) and 3 observational trials to evaluate optimal blood pressure (BP) targets in patients aged 60 years or older. The authors conclude that high-strength evidence indicates that reducing BP to less than 150/90 mm Hg reduces death, cardiovascular events, and stroke. The evidence for targets of 140/85 mm Hg and lower is weaker and heavily influenced by a single study that enrolled patients at high risk for cardiovascular events. Lower targets are associated with marginally significant decreases in cardiac events (relative risk [RR], 0.82 [95% CI, 0.64 to 1.00]) and stroke (RR, 0.79 [CI, 0.59 to 0.99]) and a statistically insignificant reduction in deaths (RR, 0.86 [CI, 0.69 to 1.06]).Key points for hospitalists include:Although there is strong evidence that reducing BP to less than 150/90 mm Hg is beneficial, tighter control may benefit only selected patients.The new American College of Physicians/American Academy of Family Physicians guideline, which is based on these findings, suggests that a BP target of 140/85 mm Hg and higher be reserved for patients with a history of stroke or transient ischemic attack and those at high risk for cardiovascular events. The Latest Highlights From ACP Journal ClubWhat is the transfusion threshold for hospital patients?Guideline: A hemoglobin threshold of 7 to 8 g/dL is recommended for hemodynamically stable hospitalized patientsAnn Intern Med. 2017;166:JC15. doi:10.7326/ACPJC-2017-166-4-015This clinical practice guideline recommends a hemoglobin threshold for transfusion of packed red blood cells less than 7 g/dL for most hospital patients and greater than 8 g/dL for patients having cardiac or orthopedic surgery, or those with underlying cardiovascular disease. No recommendation is given for patients with acute coronary syndromes because of lack of data.Should patients with moderate hypoxemia at rest, or moderate desaturations with activity, be treated with long-term oxygen therapy?In stable COPD with moderate desaturation, long-term supplemental oxygen did not reduce deaths or hospitalizationsAnn Intern Med. 2017;166:JC17. doi:10.7326/ACPJC-2017-166-4-017This randomized, unblinded trial found that long-term oxygen therapy did not benefit patients with moderate resting hypoxemia (SpO2 89% to 93%) or who have moderate desaturation with activity (reduced to 80% to 89% during a 6-minute hall walk). Home oxygen did not alter the outcomes (death, first hospitalization, exacerbations of chronic obstructive pulmonary disease, and quality of life) in this population.In patients with sepsis, is continuous infusion of antibiotics more effective than intermittent infusion?Pooled RCTs: In sepsis, continuous (vs intermittent) antibiotic infusion reduced hospital mortalityAnn Intern Med. 2017;166:JC19. doi:10.7326/ACPJC-2017-166-4-019This meta-analysis of 3 RCTs, including 632 patients admitted to the intensive care unit (ICU) with sepsis, found that continuous compared with traditional intermittent infusion of antibiotics was associated with a lower 30-day mortality rate (number needed to treat, 14 [95% CI, 9 to 189]). However, there was no difference in ICU mortality or clinical cure.After percutaneous coronary intervention, is long-term dual-antiplatelet therapy better than short term?Review: Long-term dual-antiplatelet therapy (DAPT) after PCI is no better than short-term DAPT, even in patients with diabetesAnn Intern Med. 2017;166:JC22. doi:10.7326/ACPJC-2017-166-4-022This meta-analysis of 6 studies (n = 11 473) compared patients using dual-antiplatelet therapy (DAPT) for 3 to 6 months with those using it for 12 or more months after percutaneous coronary intervention. It found that the rates of major adverse cardiac events at 1 year were not statistically different between the groups (even in the subgroup of diabetes patients), but bleeding rates were higher in the long-term DAPT patients.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 - What Do French Wine and Hospital Infections Have in Common? Payal K. Patel and Sanjay Saint Metrics 21 March 2017Volume 166, Issue 6Page: HO6KeywordsD-dimerHospitalistsIntensive care unitsMyocardial infarctionOxygenPercutaneous coronary interventionPopulation statisticsRelative riskSepsisTreatment guidelines ePublished: 21 March 2017 Issue Published: 21 March 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...