Annals for Hospitalists - 21 January 2020
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2020)

Web Exclusives21 January 2020Annals for Hospitalists - 21 January 2020FREEDavid H. Wesorick, MD*, 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, 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/AWHO202001210 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesThe Role of Hospitalists in the Creation of Learning Healthcare Systems—Heather M. Gilmartin, PhD, NP; Vincent X. Liu, MD, MSc; and Robert E. Burke, MD, MSIs it possible to create health systems with the inherent ability to learn and improve continuously? This month's commentary discusses the concept of Learning Healthcare Systems, and how hospitalists may be involved in their advancement.Highlights of Recent Articles from Annals of Internal MedicinePreoperative N-Terminal Pro-B-Type Natriuretic Peptide and Cardiovascular Events After Noncardiac Surgery: A Cohort StudyAnn Intern Med. 2020;172:96-104. Published 24 December 2019. doi:10.7326/M19-2501This cohort study examined the association between preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and the occurrence of the primary outcome (a composite of vascular death or myocardial injury after noncardiac surgery). More than 10 000 patients were tested, and the treating physicians were blinded to the NT-proBNP levels. The level of NT-proBNP was directly related to risk for the primary outcome, and the authors derived risk thresholds for the NT-proBNP levels. The addition of NT-proBNP to the revised cardiac risk index (RCRI) criteria more accurately predicted the primary outcome than the RCRI score alone.Key points for hospitalists include:This study shows that the preoperative NT-proBNP level is helpful in assigning risk for vascular death and MINS in noncardiac surgical patients, and that the information derived from measuring NT-proBNP levels improves preoperative risk stratification when added to the RCRI. Editorialists conclude that NT-proBNP improves the accuracy of preoperative risk stratification but also suggest that more research is needed to determine whether an NT-proBNP–driven perioperative management strategy will actually improve outcomes for patients. Predicting 6-Month Mortality for Older Adults Hospitalized With Acute Myocardial Infarction: A Cohort StudyAnn Intern Med. Published 10 December 2019. doi:10.7326/M19-0974This prospective cohort study derived and validated a risk model for 6-month post–myocardial infarction (MI) mortality in older adults. The study enrolled 3006 participants from 94 U.S. hospitals, aged 75 years or older, who were hospitalized for acute MI. Fifteen factors associated with 6-month mortality were identified, including comorbid diseases, laboratory values, in-hospital procedures, and functional impairments (including impairment in hearing and mobility). The model was well calibrated and showed good discrimination (validation cohort area under the curve = 0.84), which was significantly better than the commonly used GRACE mortality risk score. These data were used to create the SILVER-AMI score ( www.silverscore.org), which differs from the GRACE score in that it's designed for patients aged 75 years or older and incorporates functional impairment. The model has not been externally validated.Key points for hospitalists include:This new risk model may more accurately predict 6-month post-MI mortality for patients aged 75 years or older.Use of the model might allow for more accurate identification of high-risk, older patients who may benefit from more aggressive secondary prevention measures, closer follow-up, and even palliative approaches to care. Editorialists note that additional research is needed to externally validate the model and to develop and deploy interventions to improve outcomes for the highest-risk patients. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled TrialAnn Intern Med. Published 17 December 2019. doi:10.7326/M19-0600In this trial, 91 low-risk adults who presented to the emergency department and were found to require hospital-level care were randomized to either receive acute hospital-level care at home or to be admitted to the hospital. Acute hospital-level care at home included 1 physician visit and 2 nurse visits per day, in addition to remote monitoring and video communication. The primary outcome was cost (excluding physician costs), and the secondary outcome was health care use and physical activity during the acute episode of care and at 30 days. The cost of care was 38% lower in the home patients, who had fewer lab test, fewer imaging studies, and fewer consultations. Home patients were also more active and were readmitted less frequently (7% vs. 23%). Of note, including physician labor costs in the calculation attenuated the cost savings.Key points for hospitalists include:In this study of highly selected patients, hospital-level care at home (vs. traditional hospital admission) resulted in lower costs, less health care use, and lower hospital readmission rates while preserving quality, safety, and patient satisfaction.The home care provided in this study employed several sophisticated elements, including continuous monitoring of patients' vital signs and activity; 24-hour access to video and texting; 24-hour physician coverage; and virtual subspecialist consultation, when needed. Editorialists point out that there is now substantial evidence that hospital-level care at home for selected patients can reduce overall costs while meeting quality standards. However, they also acknowledge the barriers to implementing this type of program, including massive clinical, administrative, and infrastructural demands of providing this level of care in the home and the lack of an established payment model. Compassionate End-of-Life Care: Mixed-Methods Multisite Evaluation of the 3 Wishes ProjectAnn Intern Med. Published 12 November 2019. doi:10.7326/M19-2438This article presents a mixed-methods, formative program evaluation of the 3 Wishes Project (3WP). The 3WP is a program that was offered to dying patients (and their families/friends) in the intensive care units of the 4 participating academic medical centers. The goal of the program was to grant the wishes of dying patients (n = 730) and their family members. The wishes could be elicited by the patients' family members or friends, clinicians, or the patients themselves. The wishes (3325 of which were implemented in this study) were intended to enhance the patients' dignity, reflect the patients' identity, and honor their preferences at the end of life. Examples of the wishes included dressing the patient in their own clothing, having a celebration in the patient's room, and providing transportation to enable others to visit the patient in the hospital. Information was gained through interviews and focus groups from a sampling of family members, clinicians, managers, and administrators who perceived that the program successfully honored patients, comforted families, and inspired compassionate care from clinicians. The program was affordable (mean cost $5.19 per wish).Key points for hospitalists include:The 3WP seems to be a low-cost end-of-life intervention that effectively shifts the focus away from the patient's terminal illness and toward their identity and preferences, enhancing the experience of care for the family, and making work more meaningful for the involved clinicians.The authors suggest that the program is feasible, portable, and scalable and that it can be adapted to suit the interests, resources, and needs of a variety of units.The Latest Highlights From Journal ClubIn patients with ischemic stroke and hyperglycemia, does intensive glycemic control improve outcomes compared with standard glycemic control?ln acute ischemic stroke with hyperglycemia, intensive vs standard glucose control did not improve 90-day outcomesAnn Intern Med. 2019;171:JC67. doi:10.7326/ACPJ201912170-067This multicenter randomized controlled trial compared the 90-day outcomes of patients presenting within 12 hours of acute ischemic stroke. Patients were randomly assigned to intensive glucose control (insulin infusion with target glucose levels of 80-130 mg/dL) or standard glucose control (subcutaneous insulin with target glucose levels of 80 to 179 mg/dL). Patients in the intensive group experienced higher levels of hypoglycemia, but there were no differences in the rate of favorable outcomes (as assessed by modified Rankin Scale and Barthel Index score) at 90 days.In older patients with atrial fibrillation (AF), are rate-lowering or antiarrhythmic drugs associated with falls or syncope?In older patients with AF, antiarrhythmic drugs were linked to fall-related injuries and syncope vs rate-lowering drugsAnn Intern Med. 2019;171:JC71. doi:10.7326/ACPJ201912170-071This large cohort study used national registries to examine data from 100 935 patients with AF. They related outcomes of falls and syncope to the types of medications that the patients were prescribed to manage AF. Using patients that were prescribed only a single rate-lowering drug as the reference standard, they found a significantly higher rate of fall-related injuries and syncope in patients who were receiving an antiarrhythmic drug (with or without a rate-lowering drug).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 - The Role of Hospitalists in the Creation of Learning Healthcare Systems Heather M. Gilmartin , Vincent X. Liu , and Robert E. Burke Metrics 21 January 2020Volume 172, Issue 2Page: HO2KeywordsCohort studiesDrugsGlucoseHealth careHospitalistsIschemic strokeMuscular dystrophiesSyncope ePublished: 21 January 2020 Issue Published: 21 January 2020 CopyrightCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...