Annals for Hospitalists - 16 April 2019
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2019)

Web Exclusives16 April 2019Annals for Hospitalists - 16 April 2019FREEDavid 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/AWHO201904160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesJust What the Doctor Ordered—Checklists to Improve Diagnosis—Ashwin Gupta, MD, and Mark L. Graber, MDChecklists have been successfully used to improve the safety of surgical procedures. In this article, the authors suggest that they may also have a role in improving the complex process of diagnosis.Highlights of Recent Articles from Annals of Internal MedicineMedical Graphic Narratives to Improve Patient Comprehension and Periprocedural Anxiety Before Coronary Angiography and Percutaneous Coronary Intervention: A Randomized TrialAnn Intern Med. 2019;170:579-81. Published 9 April 2019. doi: 10.7326/M18-2976This nonblinded randomized study compared the standard informed consent procedure with a novel approach using a graphic narrative (comic book) to enhance the process for patients undergoing coronary catheterization (n = 125). Patients in the comic book group were found to have significantly better understanding of the procedure and less anxiety than those having the standard informed consent procedure.Key points for hospitalists include:This small proof-of-concept study introduces a new medium for health care communication: the comic book. This format offers all of the benefits of written information but with the added advantage of graphics to create a more visual experience.The results of the study suggest that adding a graphic narrative may improve the effectiveness of the information transfer and make the consent process less anxiety-provoking for the patient.The graphic narrative used in the study is available here. Dual Receipt of Prescription Opioids From the Department of Veterans Affairs and Medicare Part D and Prescription Opioid Overdose Death Among Veterans: A Nested Case–Control StudyAnn Intern Med. 2019;170:433-42. Published 11 March 2019. doi:10.7326/M18-2574In this case–control study, the authors identified 215 cases of veterans who died of prescription opioid overdose in 2012 or 2013. These cases were matched with 833 living control patients. The exposure in this study was the source of opioid prescription. The authors found that fatal opioid overdose was 2 to 3 times higher for patients who received opioids from both Veterans Affairs and Medicare Part D sources (dual users) than for those who received opioids from only one of these sources.Key points for hospitalists include:The authors conclude that dual opioid use (obtaining opioid prescriptions from 2 payer systems) is a risk factor for lethal overdose, possibly related to poor care coordination.The authors suggest that these data emphasize the importance of consistently using prescription drug monitoring systems (PDMS) when prescribing opioids.An editorial suggests that PDMS systems should be improved so that they are easier to use and provide more useful information (for example, integrated information for all states). Would You Refer This Patient With Cancer to a Palliative Care Specialist? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterAnn Intern Med. 2019;170:488-496. doi:10.7326/M19-0361This article presents the case of a patient with progressive metastatic neuroendocrine carcinoma who has a short life expectancy. A palliative care specialist and an oncologist discuss their perspectives on how best to deliver palliative care to such patients.Key point for hospitalists include:Both discussants recognize that provision of dedicated palliative care improves outcomes for patients with advanced cancer. The palliative care specialist points out that the involvement of a palliative care specialist increases patient prognostic understanding and quality of life while decreasing health care use. She argues that these benefits are a result of the special skills and resources of the palliative care team and that oncologists may lack the time or the expertise to provide this care.The palliative care specialist proposes that patients with advanced cancer should receive care from both an oncologist and a palliative care specialist and that the specialist should be consulted early in the disease course.The oncology discussant suggests that oncologists might be able to provide some of the palliative care (alleviating the need for palliative care specialist referral) by simply dedicating more time to it. He points out that the current shortage of palliative care providers is a major barrier to providing every advanced cancer patient with both an oncologist and a palliative care specialist.The oncologist suggests that the best way to meet the needs of these patients may be to augment the palliative care training of oncologists and to schedule more visit time in the oncology clinic to address palliative issues. That way, oncologists may be able to provide most of the palliative care, reserving specialty referrals for more difficult situations.The Latest Highlights From Journal ClubWhich hospitalized patients benefit from oxygen therapy?Guideline: Panel recommends maintaining SpO2 at no higher than 96% in most acutely ill hospitalized patientsAnn Intern Med. 2019;170:JC26. doi: 10.7326/ACPJ201903190-026This clinical practice guideline (based on a systematic review of the literature) offers guidance on which acutely ill patients should be treated with oxygen, based on diagnosis and SpO2 levels. The authors recommend prescribing oxygen therapy for patients who have had myocardial infarction or stroke only when SpO2 is <93%, and maintaining SpO2 at no higher than 96% in any patient. These recommendations are based on the observed harms of liberal oxygen use via oxidative stress and cellular inflammation and damage, and contradict the common practice of liberal oxygen therapy in many hospitals (which seems to be associated with increased mortality).Can the HEART score accurately predict major adverse cardiac events (MACE) in patients presenting with chest pain?Review: In adults with chest pain, a HEART score ≥4 has 96% sensitivity and 45% specificity for predicting MACEAnn Intern Med. 2019;170:JC35. doi: 10.7326/ACPJ201903190-035This systematic review examined data from 44 202 patients presenting to the emergency department with chest pain to evaluate the how well the HEART score predicts MACE (composite of death, myocardial infarction, or revascularization) within 3 months of admission. A HEART score ≥4 was found to have a pooled sensitivity of 96% (with specificity of 45%) for MACE in this population. It is unclear if clinical use of this score improves patient outcomes or reduces use of resources (compared with gestalt decision making), but it does seem to accurately identify low-risk patients when the score is <4.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 - Just What the Doctor Ordered—Checklists to Improve Diagnosis Ashwin Gupta and Mark L. Graber Metrics 16 April 2019Volume 170, Issue 8Page: HO8KeywordsHeartHospitalistsMyocardial infarctionOpioidsOxygenPalliative careQuality of lifeSpecificitySystematic reviewsTreatment guidelines ePublished: 16 April 2019 Issue Published: 16 April 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.Loading ...