Annals for Hospitalists - 18 February 2020
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2020)

Web Exclusives18 February 2020Annals for Hospitalists - 18 February 2020FREEDavid 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/AWHO202002180 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesAnnals for Hospitalists Inpatient Notes - Optimizing Inpatient Nutrition—Why Hospitalists Should Get Involved—Philipp Schuetz, MD, MPH, and Jeffrey L. Greenwald, MDIn this month's commentary, the authors explain how emerging evidence is changing the way hospitalists think about inpatient nutritional assessment and support.Highlights of Recent Articles from Annals of Internal MedicineCost-Effectiveness of Transitional Care Services After Hospitalization With Heart FailureAnn Intern Med. 2020;172:248-257. Published 28 January 2020. doi:10.7326/M19-1980The investigators used a decision analytic microsimulation model to estimate the cost-effectiveness of postdischarge transitional care services vs. standard care among patients with heart failure aged 75 years or older. Compared with standard care (e.g., patient education and provider follow-up), nurse home visits (NHVs) after hospitalization for HF was estimated to increase quality-adjusted life-years (QALYs) by 0.24, increase survival by 4 months, and decrease the number of lifetime hospitalizations by 0.1, with an incremental cost-effectiveness ratio of $19 570 per QALY gained. Both disease management clinics and nurse case management interventions were also superior to standard care.Key points for hospitalists include:The authors conclude that any of the 3 studied postdischarge care models are superior to standard care, and suggest that these transitional care models should become the standard of care for patients discharged after heart failure hospital admissions.The model assumptions were based on heterogeneous trials involving a small number of patients, which might limit the generalizability of the findings. However, the assumptions were very conservative, and the effects were relatively consistent across a wide range of sensitivity analyses.An editorialist points out that these interventions do not reduce costs. Rather, they appear to increase QALYs at a cost that is lower than other widely accepted interventions. The added expense, including upfront costs to set up the programs, are one of the barriers to widespread implementation of these interventions.Using High-Sensitivity Cardiac Troponin for the Exclusion of Inducible Myocardial Ischemia in Symptomatic Patients: A Cohort StudyAnn Intern Med. Published 7 January 2020. doi:10.7326/M19-0080.In this prospective diagnostic cohort study, the authors examined whether very low concentrations of high-sensitivity cardiac troponin I (hs-cTnI) allow for exclusion of inducible myocardial ischemia in symptomatic patients with coronary artery disease (CAD). The study included 1896 patients with CAD and stable angina. The study assessed whether an hs-cTnI cutoff of 2.5 ng/L (derived previously in mostly asymptomatic patients with CAD) could exclude inducible myocardial ischemia in those patients, with predefined negative predictive value (NPV) and sensitivity of at least 90%. After having their hs-cTnI measured in blood samples, patients underwent inducible cardiac ischemia assessment with myocardial perfusion imaging, and coronary angiography, where available. Overall, 865 patients (46%) had inducible myocardial ischemia. An hs-cTnI of ≤ 2.5 ng/L was unable to rule out inducible ischemia with the prespecified NPV and sensitivity. Similar results were seen with alternative assays of an hs-cTnT and a second hs-cTnI assay with even higher analytic sensitivity.Key points for hospitalists:Currently, no hs-cTnI cutoff level can safely exclude inducible myocardial ischemia in patients with CAD and stable angina.hs-Tn levels provided prognostic information, independent of whether inducible ischemia was present.An editorialist suggests that the demonstration of inducible ischemia and significant coronary stenosis may not prove to be the best predictor of risk in patients with stable CAD symptoms.Who Owns Sepsis?Ann Intern Med. 2020;172:210-211. Published 28 January 2020. doi:10.7326/M19-2966In this Ideas and Opinions piece, the authors suggest that the current perception of sepsis may be skewed by the fact that it has always been seen as a dire emergency that is best managed by critical care specialists. When studying sepsis, the focus has been on the most severely ill patients. Aggressive, early treatment has, reasonably, emerged as the goal of care. However, the authors point out that the vast majority of septic patients do not develop shock—or even require admission to the intensive care unit—and they explore the possibility that different degrees of sepsis may necessitate different levels of clinical urgency and intensity.Key points for hospitalists:The authors call for a more nuanced understanding of the entire spectrum of the sepsis syndrome, and they suggest including a broader group of providers on the committees that are responsible for sepsis definitions and guidelines.The perspectives of hospitalists, primary care providers, and infectious disease specialists, in addition to critical care specialists, may highlight the need for different approaches to patients with sepsis that are treated outside of the ICU.The Latest Highlights From Journal ClubAre there new recommendations for venous thromboembolism (VTE) in patients with cancer?ASCO updated recommendations for preventing and treating VTE in adults with cancerAnn Intern Med. 2020;172:JC2. doi: 10.7326/ACPJ202001210-002This guideline incorporates new evidence to offer updated recommendations on the prophylaxis and management of VTE in cancer patients, including a recommendation for thromboprophylaxis in some high-risk chemotherapy patients, and a recommendation for using rivaroxaban for VTE treatment.In patients with both stable coronary artery disease (CAD) and atrial fibrillation (AF), how does rivaroxaban alone compare with rivaroxaban plus an antiplatelet agent?In AF and stable CAD, rivaroxaban reduced cardiovascular events and mortality more than rivaroxaban plus an antiplateletAnn Intern Med. 2020;172:JC2. doi: 10.7326/ACPJ202001210-006This trial randomly assigned 2236 patients with both AF (CHADS2 score ≥ 1) and CAD (stable, with no interventions in the past year) to either rivaroxaban alone or paired with an antiplatelet medication (either aspirin or a P2Y12 inhibitor) and found that rivaroxaban alone was associated with a lower composite outcome of cardiovascular events and all-cause mortality than rivaroxaban plus an antiplatelet agent.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 - Optimizing Inpatient Nutrition—Why Hospitalists Should Get Involved Philipp Schuetz and Jeffrey L. Greenwald Metrics 18 February 2020Volume 172, Issue 4Page: HO4KeywordsCancer treatmentHospitalistsIschemiaNegative predictive valueNursesPatientsQuality adjusted life yearsResearch quality assessmentSepsisStable coronary artery disease ePublished: 18 February 2020 Issue Published: 18 February 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...