In the News

Overuse of tests, reproductive-age women and opioids, counseling on sexual activity after MI, and more.

Hospitalists know guidelines but overuse tests to reassure selves, patients

The majority of hospitalists would expect their colleagues to overuse testing in preoperative evaluation and syncope treatment, a study found.

Researchers surveyed 1,500 physicians practicing adult hospital medicine in the U.S. and got a 68% response rate. The surveys included vignettes (which differed slightly among the surveys) about preoperative evaluation and syncope, and the respondents were asked to identify what they believed most hospitalists at their institution would recommend in each vignette. Results were published in the Jan. 20 Annals of Internal Medicine.

In response to the preoperative evaluation vignette, 52% to 65% of the respondents chose an answer that would use more testing than recommended by guidelines. Some vignettes said that the patient's son was a physician and some said that the son was requesting additional testing; both of those factors increased the likelihood of overuse. For syncope, 82% to 85% reported overuse of testing. The variation in this case included a wife who was an attorney or not and requesting testing or not, but the variation had little impact on the physicians' answers.

The survey respondents were also asked to choose the most likely primary driver of the hospitalist's use of testing in the scenarios. In both scenarios, only about a third of physicians who chose overuse said that scientific evidence was the motivator. More commonly, they cited desire for reassurance, either for the patient and family (28% of preop overuse and 43% of syncope overuse) or themselves (23% and 15%, respectively).

The results are striking, not only because they show overuse is common, but because they suggest that the targets of current initiatives to reduce overuse may be wrong, the study authors said. Initiatives have largely focused on reducing financial incentives for overuse and educating clinicians about evidence-based recommendations, but this study shows reassurance may be a bigger factor.

The current push to improve patient satisfaction could amplify this issue, leading clinicians to order tests that patients and families request, the authors noted. Efforts to reduce overuse of testing may need to directly engage patients and families to make them understand the perils of overtesting. Liability reform, such as safe harbor provisions, could help with physicians' use of testing to reassure themselves, the authors added, concluding “we will need methods that help physicians reassure patients, as well as themselves, that less can indeed be more.”

Reproductive-age women widely prescribed opioid medications

Opioid-containing medications are widely prescribed among reproductive-age women with either private insurance or Medicaid, with approximately one-fourth of privately insured and more than one-third of Medicaid-enrolled women filling a prescription for an opioid each year from 2008 to 2012.

Researchers at the Centers for Disease Control and Prevention's National Center on Birth Defects and Developmental Disabilities used a commercially available database of a convenience sample of employed persons with private employer-sponsored insurance and their dependents, as well as an annual sample of Medicaid data, to assess outpatient pharmacy prescription drug claims for opioids among women ages 15 to 44. Results appeared in MMWR on Jan. 23.

There were between 4.4 million and 6.6 million privately insured and 400,000 to 800,000 Medicaid-enrolled reproductive-age women in the study sample each year from 2008 to 2012. Of these, an average 27.7% of privately insured and 39.4% of Medicaid-enrolled women filled a prescription for an opioid from an outpatient pharmacy each year (P<0.001). Opioid prescription claims were highest in 2009, with 29.1% of privately insured women and 41.4% of Medicaid-enrolled women filling a prescription for an opioid.

Opioid prescription claims were consistently higher among Medicaid-enrolled women when compared with privately insured women each year of the study. In 2012, there were 0.7 and 1.6 prescriptions filled per woman among privately insured and Medicaid-enrolled women, respectively. Of those who filled an opioid prescription, an average of 2.6 and 4.3 prescriptions were filled, respectively.

The most commonly prescribed opioids were hydrocodone (17.5% of privately insured and 25% of Medicaid-enrolled women annually), codeine (6.9% and 9.4%), and oxycodone (5.5% and 13%). Privately insured women ages 30 to 34 and Medicaid-enrolled women ages 40 to 44 were most likely to fill prescriptions for opioids. Women ages 15 to 19 were least likely to fill a prescription for an opioid, regardless of the type of insurance.

The authors noted that the consistently higher frequency of opioid prescribing to Medicaid-enrolled women is of concern because they deliver about half of all births.

“Many women need to take opioid-containing medications to appropriately manage their health conditions; however, in some instances safer alternative treatments are available and use of opioids is unnecessary,” the authors concluded. “Having a better understanding of prescription opioid use just before and during early pregnancy can help inform targeted interventions to reduce unnecessary prescribing of opioids and provide evidence-based information to health care providers and women about the risks of prenatal opioid exposure.”

Counseling lacking on sexual activity after MI

Most patients are not given advice about resuming sexual activity after a myocardial infarction (MI), and the counseling that is given does not often follow clinical guidelines, according to a new study.

Researchers in the United States and Spain performed a prospective, longitudinal study to examine differences between genders in baseline sexual activity, function, and physician counseling after an acute MI. Data on demographic characteristics, sexual partner status, and sexual activity and attitudes were collected by in-person interview at baseline; data on sexual activity, attitudes, function, and physician counseling and recommendations about sexual activity were assessed by telephone interview at 1 month. Study results were published online Dec. 15 by Circulation.

A total of 2,349 women and 1,152 men treated at 127 hospitals participated in the study. Patients were between 18 and 55 years of age with a median age of 48 years. Seventy-six percent of women and 92% of men reported that sex was somewhat or very important at baseline; these percentages were 73% and 92% at 1 month after acute MI. Overall, 12% of women and 19% of men said they had discussed sexual activity with a physician in the month after their acute MI. Most patients in the United States said that they had initiated the discussion, and most patients in Spain said that their physician had (P<0.001).

Of those who had discussed sex with their physicians, 32% said they were told they could resume sexual activity without restrictions and 68% said that restrictions were recommended. In the latter group, 35% reported that they were told to limit sex, 26% said they were told to take a more passive role, and 23% said they were told to keep their heart rate down. Practice guidelines currently state that patients who have had an uncomplicated acute MI can safely resume sexual activity soon afterward if they can tolerate mild to moderate physical activity, the authors noted.

Risk-adjusted analyses found that female gender (relative risk, 1.07; 95% CI, 1.03 to 1.11), age (relative risk, 1.05 per 10 years; 95% CI, 1.02 to 1.08), and lack of sexual activity at baseline (relative risk, 1.11; 95% CI, 1.08 to 1.15) were associated with not discussing sexual activity with a physician. Women in Spain were more likely to be counseled about post-MI sexual activity than men, while U.S. women were less likely to be counseled than men. Restrictions on sexual activity were significantly more likely to be recommended to Spanish women than to U.S. women (adjusted relative risk, 1.36; 95% CI, 1.11 to 1.66).

The authors noted that their study used self-reported data and that the sample size was too small to determine the effects of specific factors on sexual outcomes after acute MI. However, they concluded that counseling about sexual activity as recommended by current guidelines is frequently not provided to younger patients with acute MI. “Patients want permission from the cardiologist ‘who knows my heart best’ that resuming sex is safe,” the authors wrote. “Physicians could meaningfully narrow the gap between guidelines and practice by adding permission to resume sex to routine counseling about returning to work and exercise.”

Nine transitional care interventions for heart failure may help optimize outcomes

Nine interventions for transitions of care in heart failure may assist in achieving optimal clinical and patient-centered outcomes, according to a scientific statement that addressed patient, hospital, and clinician barriers.

The scientific statement focused on the transition component of care models and appeared online Jan. 20 in Circulation: Heart Failure.

The 9 interventions are as follows.

Systematically implement principles of transition of care programs in high-risk patients with chronic heart failure, such as medication reconciliation, very early postdischarge contact and communication between hospital clinicians and patients or outpatient clinicians, an office follow-up within a week of discharge, patient education about self-care, and sharing of patient's health records with the patient and postdischarge providers.

Routinely assess patients for high-risk characteristics that may be associated with poor postdischarge clinical outcomes, such as cognitive difficulties, impaired learning capabilities, language barriers, and long travel time to clinicians.

Ensure that qualified and trained heart failure nurses or other clinicians treat patients, by assessing clinician knowledge and comfort on patient education and interdisciplinary care coordination services.

Allot adequate time in the hospital and postacute setting to deliver complex interventions, including assessing patients' or caregivers' capabilities to independently understand and complete self-management interventions.

Implement handoff procedures at hospital or post-acute care discharge, and provide a record in a timely manner that includes key details such as medications used, discharge medications, procedures, treatments, postdischarge care expectations, planned rehospitalization and/or follow-up services, known psychosocial issues, and medication reconciliation.

Develop, monitor, and ensure transparency of quality measures, using a structure, process, and outcome framework.

Consider patients' perceptions of quality of life as a surrogate for physical, psychological, and social concerns that require support during the transition.

Ensure transition of care component details are in writing, such as a training manual, to promote adherence and consistent application by clinicians.

Use health informatics technology that is patient- and clinician-centric to assist with program sustainability.

“Patient experiences during transitions of care can be stressful, particularly when post-hospitalization care is poorly executed as a result of inadequate coordination of resources or follow-up,” the scientific statement said. “Health care leaders must facilitate and ensure follow-through of transition interventions, continuity of services, and continuous quality improvement monitoring to ensure high-quality intervention implementation and minimization of gaps and disparities.”