Annals for Hospitalists - 19 June 2018
Authors: David H. Wesorick, Vineet Chopra
Journal: Annals of Internal Medicine (2018)

Web Exclusives19 June 2018Annals for Hospitalists - 19 June 2018FREEDavid 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/AFHO201806190 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesMedical Uncertainty as a Driver of Resource Use—Examining the “Gray Zones” of Clinical Care—Charlie M. Wray, DO, MS, and Hyung J. Cho, MDHow should hospitalists deal with uncertainty in clinical practice? This month's Inpatient Notes highlights the importance of simply acknowledging clinical uncertainty. This acknowledgement helps clinicians to thoughtfully address the uncertainty and avoid inappropriate reflex testing.Highlights of Recent Articles From Annals of Internal MedicinePreventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine PatientsAnn Intern Med. 2018;168:766-774. Published 1 May 2018. doi:10.7326/M17-1724This prospective cohort study examined 822 adult patients who were readmitted to academic general medicine services in the United States. For each readmission, 2 reviewers assessed the preventability of the readmission, using objective criteria. Overall, 27.9% of the readmissions were deemed preventable. However, 36.2% of early (0-7 days) readmissions were deemed preventable compared with only 23% of late (8-30 days) readmissions. The reviewers also determined that most issues leading to early readmissions (such as physician decision making and premature discharge) were attributable to the care provided in the hospital, whereas those leading to late readmissions (such as postdischarge monitoring and end-of-life issues) were more likely to be attributable to care in the outpatient arena.Key points for hospitalists include:The authors conclude that readmissions occurring within 7 days of discharge are more likely to be attributable to care provided in the hospital than readmissions occurring from 8 to 30 days, which appear more attributable to outpatient care.The authors suggest that a 7-day readmission cutoff might be a more reasonable accountability measure for hospitals than the established 30-day cutoff. However, they also acknowledge that no cutoff will perfectly distinguish the accountability for readmissions between inpatient and outpatient care. Instead, they call for a better model of collaboration between inpatient and outpatient providers and shared accountability for readmissions.Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012Ann Intern Med. 2018;168:837-845. Published 22 May 2018. doi:10.7326/M17-3065This observational study examined opioid use data from a large national database to compare outcomes for Medicare enrollees exhibiting potential misuse patterns with those without such patterns. The primary outcome was a diagnosis of opioid overdose. The investigators reported that certain opioid prescribing patterns (e.g., obtaining opioids from more than one prescriber, from more than one pharmacy, or in higher quantities) were positively associated with subsequent overdose or death within 30 days of an opioid overdose.Key points for hospitalists include:This study shows that it is possible to utilize information about opioid prescribing patterns (e.g., information from prescription drug monitoring programs [PDMPs]) to identify patients who are at high risk for opioid-related complications.Almost all of the studied misuse patterns (even ones that might be beneath the conventional thresholds for suspicious use) were associated with an increased risk for opioid overdose.An accompanying editorial notes that current PDMPs are limited by a lack of standardization and a failure to present complex data in a way that is useful to clinicians (i.e., in a way that allows clinicians to easily recognize the high-risk patterns). The authors suggest that approaches aimed at these factors may lead to improvements in PDMPs and better stewardship of these medications. Amyloid-β (1-40) and Mortality in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome: A Cohort StudyAnn Intern Med. 2018;168:855-865. Published 22 May 2018. doi:10.7326/M17-1540This retrospective cohort study used data from 2 prior prospective cohort trials to examine the association of circulating amyloid-β (1-40) (Aβ40) with mortality in patients presenting with non–ST-segment elevation acute coronary syndrome (NSTE-ACS). Aβ40 is a peptide fragment of the amyloid precursor protein found in brain deposits in Alzheimer disease. Its proinflammatory and prothrombotic properties seem to play a pathophysiologic role in cardiovascular disease. In this study, circulating Aβ40 was found to be associated with mortality in patients presenting with NSTE-ACS, even after multivariate adjustment for other known risk factors and the Global Registry of Acute Coronary Events score.Key points for hospitalists include:Circulating Aβ40 seems to accurately predict mortality in patients presenting with NSTE-ACS, and the clinical use of this test may ultimately allow for improved risk stratification of these patients.The authors note that, although this test may not yet be ready for clinical application, prospective studies evaluating the use of this biomarker in patients with NSTE-ACS seem necessary.The Latest Highlights From ACP Journal ClubAre antibiotics necessary after incision and drainage of a skin abscess?Guideline: TMP–SMX is recommended after uncomplicated skin abscess incision and drainageAnn Intern Med. 2018;168:JC50. doi:10.7326/ACPJC-2018-168-10-050This guideline, based on a systematic review of 14 randomized controlled trials, recommends that patients who are treated with antibiotics after incision and draining of an uncomplicated skin abscess be treated with trimethoprim–sulfamethoxazole (TMP-SMX) or clindamycin instead of a cephalosporin (strong recommendation). It also recommends that most patients with such abscesses be treated with both incision and drainage and antibiotics (as opposed to incision and drainage alone), and that TMP-SMX should be preferred over clindamycin (weak recommendations).Does a preoperative physiotherapy session reduce pulmonary complications after upper abdominal surgery?A single preoperative physiotherapy session reduced pulmonary complications after upper abdominal surgeryAnn Intern Med. 2018;168:JC51. doi:10.7326/ACPJC-2018-168-10-051This study randomly assigned 441 adults having upper abdominal surgery to either an information booklet alone or an information booklet plus a session with a physiotherapist (including education about postoperative pulmonary complications, a personalized risk assessment, and coaching on breathing exercises). Patients receiving the educational session experienced significantly lower rates of postoperative pulmonary complications and hospital-acquired pneumonia. Given some of the study's limitations (e.g., high rates of pneumonia in the control group and imbalances between the 2 study groups), these results will need to be replicated before they can be adopted into clinical practice.Can the pulmonary embolism rule-out criteria (PERC) improve the diagnosis of PE in low-risk patients?PERC strategy was noninferior to the usual strategy for ruling out PE in low-risk patients in the EDAnn Intern Med. 2018;168:JC54. doi:10.7326/ACPJC-2018-168-10-054In this cluster randomized, crossover, controlled trial, patients who were deemed to be at low risk for PE were assigned to risk stratification via PERC or to a standard approach (beginning with D-dimer testing). Using the PERC strategy, PE is ruled out if the patient has none of the following clinical features: oxygen saturation ≤94%, pulse rate ≥100 beats/min, age ≥50 years, unilateral leg swelling, hemoptysis, recent trauma or surgery, previous PE or deep venous thrombosis, and exogenous estrogen use. Use of the PERC strategy resulted in fewer PE diagnoses in the emergency department (1.5% vs. 2.7%) and did not result in a significant difference in new thromboembolic events at 3 months (0.1% vs. 0%). At the same time, PERC patients received 10% fewer computed tomography scans and had shorter emergency department stays and lower admission rates.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 - Medical Uncertainty as a Driver of Resource Use—Examining the “Gray Zones” of Clinical Care Charlie M. Wray and Hyung J. Cho Metrics 19 June 2018Volume 168, Issue 12Page: HO12KeywordsCohort studiesEmergency departmentHospitalistsInpatientsMortalityOpioidsOutpatient clinicsOutpatientsPneumoniaSkin abscesses ePublished: 19 June 2018 Issue Published: 19 June 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.Loading ...