Hospitalist care in the U.S. has increased
Care provided by hospitalists increased rapidly and steadily between 1995 and 2006, a recent study reported.
Researchers in Texas used Medicare claims data to track hospitalist care over a defined time period and to determine whether care by a hospitalist was linked to any patient or hospital characteristics. For the purposes of the study, hospitalists were defined as “general internists who derived 90% or more of their Medicare claims for evaluation-and-management services from the care of hospitalized patients.” The results appear in the March 12 New England Journal of Medicine.
In 1995, approximately 6% of general internists were identified as hospitalists; by 2006, that figure had risen to 19%. The odds of hospitalized Medicare patients being cared for by a hospitalist increased by about 29% per year from 1997 through 2006. The percentage of hospitals with at least three hospitalists also increased, from 11.6% in 1995 to 41.9% in 2006. Although black patients were initially more likely to be cared for by a hospitalist than white patients, this difference disappeared by 2006. Teaching hospitals and larger hospitals were more likely to employ hospitalists earlier than were nonteaching and smaller hospitals. While acknowledging their study's limitations, including its exclusion of hospitalists from other specialties such as pediatrics, the authors concluded that hospitalist care rapidly became more common in the U.S. between 1995 and 2006.
In other hospitalist news, a systematic review of 33 English-language studies published in the March Mayo Clinic Proceedings reported that hospitalists were found in general to decrease the cost of hospital care and decrease length of stay. Hospitalist care also improved quality measures for orthopedic surgery, pneumonia and congestive heart failure but not for HIV or low-risk chest pain. The author noted that hospitalist care seemed to lead to greater improvements over time, with some programs showing no or less effect on outcomes until their second year.
Although many of the included studies were observational and publication bias was possible, the author concluded that hospitalist care improves cost, largely due to decreased length of stay, as well as some quality measures. Future studies should examine whether hospitalists and nonhospitalists differ in other aspects of care, the author wrote.
Guidelines on aneurysmal subarachnoid hemorrhage call for quick treatment
Quick treatment is key to survival in patients with aneurysmal subarachnoid hemorrhage, according to recent guidelines from the American Heart Association's Stroke Council, published in the March issue of Stroke. To update the 1994 guidelines on this topic, experts reviewed 38 relevant studies published between June 30, 1994, and Nov. 1, 2006 and developed new evidence-based recommendations. Key findings are as follows:
- Early definitive treatment is indicated for most patients and can reduce death and disability.
- Subarachnoid hemorrhage is a medical emergency and is misdiagnosed in up to 12% of patients, usually by failing to obtain a head CT.
- The severity of the initial bleed should be determined rapidly because it is the most useful indicator of outcome.
- Although new noninvasive diagnostic tools such as CT angiography and MR angiography can be useful, catheter angiography is still considered the gold standard for diagnosis and treatment.
- Patients with subarachnoid hemorrhage benefit when cared for at high-volume compared with low-volume hospitals.
- The rapid assessment and transport model widely adopted to optimize thrombolytic therapy in acute ischemic stroke needs to be broadened and reemphasized for hemorrhagic stroke.
- Standardized protocols should be used to manage subarachnoid hemorrhage in the emergency department.
- The current standard of practice calls for microsurgical clipping or endovascular coiling of the aneurysm neck whenever possible.
Updated heart failure guidelines address hospitalized patients
The American College of Cardiology and the American Heart Association released updated guidelines on heart failure in late March, including a new section specifically on care of hospitalized patients. The guidelines were published jointly online March 26 by the Journal of the American College of Cardiology and by Circulation. The recommendations for hospitalized patients with heart failure include the following:
- Intravenous loop diuretics should be started as soon as possible in patients admitted with heart failure and evidence of significant fluid overload.
- Long-term therapy with oral agents such as ACE inhibitors, ARBs, and beta-blockers should be continued in patients with reduced ejection fraction hospitalized for a symptomatic exacerbation of heart failure, as long as hemodynamic instability and contraindications are not present.
- Patients with clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pressures should receive intravenous inotropic or vasopressor drugs to maintain systemic perfusion and preserve end-organ performance while more definitive therapy is considered.
- Medication reconciliation should be done in every patient, and medications should be adjusted as appropriate at hospital admission and discharge.
- Comprehensive written discharge instructions should be provided for all patients hospitalized for heart failure and their caregivers.