Annals for Hospitalists - January 2024
Authors: David A. Fried
Journal: Annals of Internal Medicine (2024)

Web ExclusivesJanuary 2024Annals for Hospitalists - January 2024FREEDavid A. Fried, MDDavid A. Fried, MDFrom University of Michigan, Ann Arbor, Michigan (D.A.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202401160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Highlights of Recent Articles From Annals of Internal MedicineCumulative Incidence of Thiazide-Induced Hyponatremia: A Population-Based Cohort StudyAnn Intern Med. 2024;177:1-11. Published 19 December 2023. doi:10.7326/M23-1989This cohort study sought to determine the risk for developing moderate to severe hyponatremia (defined as a sodium level <130 mmol/L) in patients 40 years or older who were started on a thiazide diuretic treatment. The study had 2 wings: 37 786 patients prescribed bendroflumethiazide versus 44 936 prescribed a calcium-channel blocker and 11 943 patients receiving a combination pill of hydrochlorothiazide plus a renin-angiotensin system inhibitor versus 85 784 receiving a renin-angiotensin system inhibitor alone. Patients receiving a thiazide had a higher 2-year incidence of hyponatremia in both comparisons (the risk difference for bendroflumethiazide was 1.35% [95% CI, 1.04% to 1.66%] and the risk difference for hydrochlorothiazide plus a renin-angiotensin system inhibitor was 1.38% [CI, 1.01% to 1.75%]). The increased risk for hyponatremia was highest in the first 90 days after initiation treatment, but hazard ratios remained elevated at the end of the 2-year follow-up. Rates of serum sodium measurement were similar regardless of which medication patients received, which minimized the risk of ascertainment bias.Key points for hospitalists include:The authors found that thiazide diuretics had an increased risk for hyponatremia compared with other classes of antihypertensives that is higher than that provided on product labels.Risk for hyponatremia was higher for older patients and those with multiple comorbidities.Risk was highest in the first few months of treatment but never went away.Acute Hospital Care at Home in the United States: The Early National ExperienceAnn Intern Med. 2024;177:109-110. Published 9 January 2024. doi:10.7326/M23-2264This cohort study used Medicare Part A claims data to describe the sociodemographic characteristics, clinical characteristics, and clinical outcomes of 5132 patients admitted to acute hospital care at home programs throughout the United States from July 2022 to June 2023. Fifty-four percent were female, 61.8% were aged 75 years or older, 85.2% were White, and 1.7% were rural, and most patients were in the Northeast (31.4%) or southern (47.5%) regions. The mean case-mix index was 1.31 (SD, 0.49), with the most common discharge diagnoses being heart failure, respiratory infection, sepsis, urinary tract infection, and cellulitis. Most patients had common comorbidities seen in hospitalized patients, such as heart failure (42.5%), chronic obstructive pulmonary disease (43.3%), diabetes (46.4%), and cancer (22.1%). The mean length of stay was 6.3 days (SD, 4.7), the rate of escalation to in-hospital care was 6.2%, and the mortality rate was 0.5% during admission and increased to 3.2% at 30 days after discharge. At 30 days after discharge, nursing facility use was 2.6% and readmission rates were 15.6%.Key points for hospitalists include:The authors found that patients admitted to acute hospital care at home programs were medically complex and had low rates of mortality, escalation of care, discharge to nursing facilities, and readmission.Outcomes were similar among different socioeconomic groups and races, but patients were primarily White and middle class (mean household income of $83 932).Without a comparator, it is impossible to know if these outcomes differ from patients with similar acuity treated in the hospital.Acute hospital care at home is expanding throughout the country, as it seems to provide an important alternative to hospitalization, but further research will help elucidate which patient groups are best served in this setting.Adoption of Internal Medicine Milestone Ratings and Changes in Bias Against Black, Latino, and Asian Internal Medicine ResidentsAnn Intern Med. 2024;177:70-82. Published 26 December 2023. doi:10.7326/M23-1588This cross-sectional study (n = 59 835) estimated assessment bias in knowledge ratings of categorical internal medicine residents before and after adoption of a milestone-based ratings system in 2014. United States–born non-Latino White residents formed the comparator group. The authors converted the ratings into standardized Z scores (average = 0, positive scores = above average) and applied linear regressions to calculate the difference in knowledge ratings between racial and ethnic groups. After controlling for various factors, including using American Board of Internal Medicine certification scores as a proxy for underlying knowledge, the difference in ratings was interpreted to represent assessment bias. Pre-Milestone assessment bias against underrepresented minorities (Black or Latino residents) was estimated to be −0.40 SDs (95% CI, −0.48 to −0.31 SDs), equivalent to shifting from the 50th to the 35th percentile. Post-Milestone bias against underrepresented minorities was estimated to be −0.10 SDs (CI, −0.16 to −0.04 SDs), equivalent to shifting from the 50th to the 46th percentile. Residents of Asian descent also exhibited evidence of bias, although to a lesser extent. The post-Milestone reduction in bias was greater among residents born outside the United States.Key points for hospitalists include:The authors found an abrupt, significant decrease in medical knowledge assessment bias against non-White internal medicine residents after adoption of a milestone-based ratings system.The belief is that the Milestones system provides a more standardized and therefore objective measurement of resident ability. Despite this improvement, bias still exists under the current system.The American Board of Internal Medicine certification examination likely has its own unmeasured intrinsic biases and therefore serves as an imperfect control for underlying medical knowledge.Although this study only measured medical knowledge assessment bias, residents may experience other forms of interrelated bias throughout their training.Editorialists recommend various ways to mitigate bias, ranging from faculty education and training to mandating assessment data analysis on a program and national level.The Latest Highlights From Journal ClubDo antipsychotics have differing safety profiles when used postoperatively in older adults?In older adults, postoperative oral haloperidol vs. antipsychotics was linked to similar risk for in-hospital adverse eventsAnn Intern Med. 2023;176:JC141. doi:10.7326/J23-0102This retrospective cohort study (n = 17 115) of adults aged 65 years or older who received postoperative antipsychotics found similar risks for in-hospital adverse events regardless of which drug was used (haloperidol, olanzapine, quetiapine, or risperidone).What interventions work best to keep older patients out of long-term care?In older adults, specialty geriatrics care, multicomponent interventions, and cognitive stimulation reduce nursing home admissionAnn Intern Med. 2023;176:JC138. doi:10.7326/J23-0097This systematic review and meta-analysis of 283 trials found that specialty geriatrics care (odds ratio [OR], 0.77 [95% CI, 0.60 to 0.99]), multicomponent intervention (OR, 0.82 [CI, 0.67 to 0.99]), and cognitive stimulation (OR, 0.60 [CI, 0.38 to 0.96]) all reduced the odds of admission to long-term care, but several other interventions did not.Does catheter ablation therapy for atrial fibrillation help patients with end-stage heart failure?In symptomatic AF with end-stage HF, adding catheter ablation to medical therapy improved clinical outcomes at 18 moAnn Intern Med. 2023;176:JC137. doi:10.7326/J23-0096This randomized controlled trial (n = 194) of patients with end-stage heart failure with reduced ejection fraction and symptomatic atrial fibrillation found that adding catheter ablation to guideline-directed medical therapy improved a composite outcome of all-cause mortality, left ventricular assist device implantation, and urgent heart transplantation (relative risk reduction, 73% [95% CI, 44% to 87%]).Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David A. Fried, MDAffiliations: From University of Michigan, Ann Arbor, Michigan (D.A.F.)Disclosures:The author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Current Issue January 2024Volume 177, Issue 1 ePublished: 16 January 2024 Issue Published: January 2024 Copyright & PermissionsCopyright © 2024 by American College of Physicians. All Rights Reserved.Loading ...