Annals for Educators - 18 December 2018
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2018)

Web Exclusives18 December 2018Annals for Educators - 18 December 2018FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201812180 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsIncreasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism. A Controlled Pragmatic TrialDespite the well-established safety of outpatient treatment for pulmonary embolism in appropriately selected, low-risk patients, most of these patients continue to be hospitalized to start treatment. This multicenter clinical trial tested whether delivery of a focused clinical decision support system could safely increase the number of patients with acute pulmonary embolism who are discharged to home from the emergency department.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners which patients with venous thromboembolism (VTE) require hospitalization. Which patients may be safely treated at home?How do your learners arrange for outpatient management of a patient with newly diagnosed VTE? What needs to be in place? What teaching is required? How is this accomplished, and who checks on whether everything is safely arranged? How should follow-up be arranged?Review the histories of several patients recently admitted with pulmonary embolism. Could any have been treated completely as an outpatient? What are the potential barriers to outpatient management at your institution, even among patients for whom it would be medically appropriate?Invite someone from your institution's emergency department to discuss the intervention used in this study with your team. Is there an algorithm for deciding on outpatient management in your emergency department?Intermediate Diabetes Outcomes in Patients Managed by Physicians, Nurse Practitioners, or Physician Assistants. A Cohort StudyIn this study, more than 368,000 patients with diabetes mellitus received most of their care from a physician assistant (PA), a nurse practitioner (NP), or a physician. The researchers investigated whether hemoglobin A1c, systolic blood pressure, and serum lipoprotein cholesterol values differed among patients depending on the type of clinician providing their care.Use this paper to:Ask your learners what may be concluded from this study with regard to diabetic care provided by physicians, NPs, and PAs. What are the limitations?Why did the authors limit their analysis to patients who had a primary care provider (PCP) consistently for 2 years? The authors explain in the paper's discussion.What is an intermediate outcome? Why might diabetes be a good disease in which to study intermediate outcomes?The editorialist comments that it is time to stop referring to NPs and PAs as “mid-level” providers. Why? Is this term used at your institution? Why might it be appropriate or inappropriate? Do NPs and PAs prefer that this term be used? What roles do NPs and PAs serve at your institution? Do they serve as patients' PCPs? How does the care they provide differ from and/or complement that of other members of the health care team? Are there limitations? How is it coordinated with the care provided by physicians?What might be the advantages and disadvantages of care provided by physicians, NPs, and PAs?Are there tensions between these groups of PCPs? If so, why?Smoking, Vaping, and Use of Edibles and Other Forms of Marijuana Among U.S. AdultsThis concise report of a nationally representative survey of U.S. adults found that 1 in 7 reported using marijuana in 2017.Use this study to:Ask your learners whether they ask their patients about marijuana use. Why or why not? Might it be important?What do we know about the potential benefits and harms of marijuana? Use the findings of recent systematic reviews ( here and here) to help inform your discussion. What do patients believe are the benefits and harms? Use data from this same survey to prompt discussion. Why is it important to know what patients view as the harms and benefits? Teach at the bedside! Ask patients on your service about marijuana use. Why do they use it? In what forms? Do they believe it is beneficial? Do they worry about potential harm?High-Deductible Insurance and Delay in Care for the Macrovascular Complications of DiabetesIn this observational, longitudinal, before–after study using 10 years of data from a large national health insurer, the authors sought to determine whether a transition from low-deductible to high-deductible insurance is associated with delayed medical care for macrovascular complications of diabetes.Use this study to:Ask your learners if they know what high-deductible insurance plans are. How might such plans reduce health care costs? Who benefits? What might be the harms?How does this study attempt to mimic an interventional study? What did this study find? What may be concluded from the data?What are the limitations to interpreting the findings of administrative data such as those used in this study? Use the accompanying editorial to help frame your discussion. Teach at the bedside! Ask patients on your service if copays affect whether and when they seek care.Humanism and ProfessionalismOn Being a Doctor: Healing the WoundsDr. Bartecchi describes the work of physicians during wartime, noting that although many would describe them as heroes, they would say they were just doing their jobs.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they have ever been inspired by the commitment of mentors and colleagues who go “above and beyond the call of duty.”Is there a limit to our responsibilities as physicians to ensure the best possible care to our patients, regardless of the circumstances?Do your learners allow themselves to feel proud of how hard they work in the service of their patients? Should they? Are they “just” doing their jobs?MKSAP 18 QuestionA 59-year-old woman arrives at the emergency department with left lower leg swelling of 2 weeks' duration and shortness of breath of 1 week's duration that has worsened during the past 6 hours. She reports no chest pain or hemoptysis. She has no history of recent travel, surgery, malignancy, or immobilization. She takes no medications.On physical examination, temperature is 37.7 °C (99.9 °F), blood pressure is 140/85 mm Hg, pulse rate is 102/min, and respiration rate is 19/min. Oxygen saturation is 95% breathing ambient air. Edema of the left lower extremity is noted.Laboratory studies show an elevated D-dimer level.CT angiography shows a right subsegmental pulmonary embolism.The patient's Pulmonary Embolism Severity Index score is 59.It is determined the patient can be safely treated as an outpatient.Which of the following is the most appropriate treatment?A. ApixabanB. DabigatranC. EdoxabanD. Low-molecular-weight heparinCorrect AnswerA. ApixabanEducational ObjectiveTreat pulmonary embolism with non–vitamin K antagonist oral anticoagulant monotherapy.CritiqueThis patient should be treated with apixaban. Patients with pulmonary embolism (PE) were previously hospitalized for anticoagulant therapy. However, admission rates are decreasing because of the recognition that appropriate patients can be safely managed in the outpatient setting. The Outpatient Treatment for Pulmonary Embolism (OTPE) trial was an open-label, randomized, noninferiority trial. A total of 344 patients with acute, symptomatic, objectively confirmed PE were randomly assigned to inpatient or outpatient management. Patients were classified as low risk or high risk of death using the Pulmonary Embolism Severity Index (PESI). Among patients with low-risk PESI scores who were randomly assigned to outpatient or inpatient care, recurrent venous thromboembolism (VTE) occurred within 90 days in 1 of 171 (0.6%) outpatients and zero inpatients, a finding that met the criteria for noninferiority. The PESI stratifies patients into five risk categories for all-cause 30-day mortality based on 11 clinical parameters.Pulmonary Embolism Severity IndexClinical ParameterScoreAge (in years)(enter age)Male sex10Current cancer30Chronic heart failure10Chronic lung disease10Pulse rate >110/min20Systolic BP <100 mm Hg30Respiration rate >30/min20Temperature <36 °C (96.8 °F)20Disorientation, lethargy, stupor, or coma60Oxygen saturation <90%20In the appropriate clinical setting, patients with a PESI score less than 65 are very low risk for 30-day mortality (0%), and those with a score less than 85 are low risk for 30-day mortality (1%); patients in these categories can be considered for outpatient management. This patient's PESI score is 59. Therefore, outpatient management can be considered, but the appropriate agent must be selected. The 2016 American College of Chest Physicians guidelines recommend non–vitamin K antagonist oral anticoagulants as first line for patients without cancer with VTE. Dabigatran and edoxaban require bridging with parenteral anticoagulation, whereas apixaban and rivaroxaban can be used as monotherapy in the treatment of VTE.Long-term low-molecular-weight heparin is only considered first-line treatment in patients with malignancy. This patient does not have cancer; therefore, apixaban is a more appropriate choice.Key PointPatients with a Pulmonary Embolism Severity Index score of less than 65 are at low risk of death and may be managed in the outpatient setting with a non–vitamin K antagonist oral anticoagulant, such as apixaban or rivaroxaban.BibliographyAujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011;378:41-8. doi:10.1016/S0140-6736(11)60824-6Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 18 December 2018Volume 169, Issue 12Page: ED12KeywordsAnticoagulantsApixabanEmergency departmentInpatientsLow molecular weight heparinMarijuanaMortalityOutpatientsPulmonary embolismVenous thromboembolism ePublished: 18 December 2018 Issue Published: 18 December 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...