American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP HospitalistWeekly



In the News for the Week of 10-19-11




Highlights

Inpatient continuity of care declined in decade ending in 2006

Inpatients experienced a decline in continuity of care between 1996 and 2006, but the hospitalist model doesn't seem to be to blame, the authors of a new analysis concluded. More...

Higher risk of death, morbidity in noncardiac surgery patients with preoperative anemia

Preoperative anemia in patients who underwent major noncardiac surgery was associated with a higher morbidity and mortality risk in the 30 days after surgery, a new study found. More...


Cardiology

Same-day discharge may be safe after elective PCI, study indicates

Patients who have undergone elective percutaneous coronary intervention (PCI) may be able to leave the hospital the same day without a negative effect on outcomes, a new study suggests. More...


Readmissions

Little evidence supports interventions to reduce hospital readmissions

There's no definitive evidence that any single intervention reduces 30-day hospital readmissions, a literature review concluded. More...


From ACP Hospitalist

The latest issue is online

The October issue of ACP Hospitalist is online. It includes feature articles on drug shortages and getting along with the emergency department, and a humorous tale of personal illness from editorial advisor Jamie Newman, MD, FACP. More...


From the College

ACP launches new online discussion group for hospitalists

ACP members are invited to participate in ACP's Special Interest Groups, a private online community that allows members to share experiences, questions and creative solutions with like-minded physicians at their own convenience. More...


Cartoon caption contest

Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner. More...


Physician editor: A. Scott Keller, MD, FACP




Highlights


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Inpatient continuity of care declined in decade ending in 2006

Inpatients experienced a decline in continuity of care between 1996 and 2006, but the hospitalist model doesn't seem to be to blame, the authors of a new analysis concluded.

In a retrospective cohort study, the researchers analyzed claims data for 528,453 Medicare fee-for-service patients who were hospitalized between 1996 and 2006 at 4,859 hospitals for chronic obstructive pulmonary disease, pneumonia, or congestive heart failure. Only patients cared for by general internists (including hospitalists), general practitioners, geriatricians or family physicians were included in the study. Patients with a length of stay greater than 18 days were excluded. Continuity of care was defined as receiving inpatient care from a single generalist physician (as opposed to two or more physicians). Researchers calculated the percentage of patients who received care from one, two, or three or more generalist physicians during hospitalization and stratified them by patient and hospital characteristics and by whether the patients were cared for by hospitalists (or not) or their outpatient primary care physicians (or not). Patients were classified as having received care from either non-hospitalist generalist physicians, a combination of generalist physicians and hospitalists, or hospitalists only. Hospitalists were defined as general internal medicine physicians who derived at least 90% of their Medicare claims for evaluation and management services from the care of hospitalized patients. Results were published in the October Journal of Hospital Medicine.

In 1996, 70.7% of patients received care from just one generalist physician; this fell to 59.4% in 2006 (P<0.001). Likewise, the percentage of patients who were cared for by three or more generalist physicians rose from 6.5% in 1996 to 10.7% in 2006 (P<0.001). The trends didn't vary by medical condition. Patients who were seen by more physicians didn't receive more visits overall. In unadjusted models, the odds of experiencing complete continuity of care decreased by 5.5% per year from 1996 through 2006; after adjustment for all other variables, the yearly decrease was still 4.8%. Younger patients, females, black patients, and patients with low socioeconomic status were slightly more likely to experience continuity of care. Patients admitted on weekends, emergency admissions, and those with ICU stays were less likely to experience continuity. Continuity was twice as likely in the South as in New England, and was greatest in smaller metropolitan areas compared to rural and large metropolitan areas. There was an overall decrease in length of stay between 1996 and 2006, from a mean of 5.7 days in 1996 to 4.9 days a decade later (P<0.001).

In the multivariable model, patients who had a hospitalist involved in care at some point during the stay had more discontinuity. However, this finding seemed to be an artifact of defining the hospitalist variable as having been seen by any hospitalist during the hospitalization; those who had hospitalist-only care had the same level of continuity as those who had other generalist care. This suggests that the discontinuity associated with hospitalist involvement "is likely the result of system issues rather than hospitalist care per se," the authors noted. Generalists might choose to involve hospitalists at any point due to "a change in patient acuity requiring the involvement of hospitalists who are present in the hospital more," they wrote. Future research should examine why patients would see both generalists and hospitalists during a single stay, a practice which increases the number of handoffs and thus the potential for missed information, the authors noted.

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Higher risk of death, morbidity in noncardiac surgery patients with preoperative anemia

Preoperative anemia in patients who underwent major noncardiac surgery was associated with a higher morbidity and mortality risk in the 30 days after surgery, a new study found.

Researchers sought to determine whether the increased risk that preoperative anemia seems to confer on cardiac surgery patients also applied to patients undergoing major noncardiac surgery. They analyzed 2008 data on 227,425 patients from The American College of Surgeons' National Surgical Quality Improvement Program database (a prospective validated outcomes registry from 211 hospitals worldwide). Specifically, they examined the effect of anemia on 30-day mortality and 30-day morbidity for cardiac, respiratory, central nervous system, urinary tract, wound, sepsis, and venous thromboembolism outcomes. For study purposes, anemia was defined as mild (hematocrit concentration greater than 29% and less than 39% in men, and greater than 29% and less than 36% in women) or moderate-to-severe (29% or lower in men and women). Researchers also assessed the effect of several other preoperative risk factors—including age greater than 65 years and presence of cardiac and renal disease—on the association between anemia and outcomes. Results were published in the October 15 Lancet.

More than 69,000 patients, or about 31%, had preoperative anemia. After adjustment, mortality at 30 days after surgery was higher in patients with anemia than in those without anemia (odds ratio [OR], 1.42; 95% CI, 1.31 to 1.54). The difference held for patients with mild anemia (OR, 1.41; 95% CI, 1.30 to 1.53) and moderate-to-severe anemia (OR, 1.44; 95% CI, 1.29 to 1.60). Composite postoperative morbidity at 30 days was also higher in patients with anemia (adjusted OR, 1.35; 95% CI, 1.30 to 1.40), and the association held true for patients with mild anemia (adjusted OR, 1.31; 95% CI, 1.26 to 1.36) and moderate-to-severe anemia (adjusted OR, 1.56; 95% CI, 1.47 to 1.66). When compared with patients without anemia or a defined risk factor, patients with anemia and most risk factors had a higher adjusted OR for 30-day mortality and morbidity than did patients with anemia alone or a risk factor alone.

While it may seem that the 42% adjusted increase in mortality attributable to anemia could be explained by the association between anemia and other risk factors for death, the completeness and size of the study suggest the effect of anemia is independent, the authors wrote. While this increase might be considered a "modest effect" given that the mortality in patients without preoperative anemia was low at 0.78%, this 42% adjusted increase "means that around 500 extra people could die from even a mild degree of anemia." These mortality and morbidity associations should lead physicians to carefully consider interventions to correct preoperative anemia in most patients—particularly elective surgery patients, they concluded. An editorialist agreed, saying the findings could have an "enormous impact" worldwide, as preoperative diagnosis and treatment of anemia are almost never undertaken routinely. While additional studies are needed to determine the best treatment methods and procedures, the current study "strongly suggests" that anemia treatment "should become standard of care in patients undergoing elective surgical procedures, particularly in those where substantial blood loss is expected," the editorial said.

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Cardiology


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Same-day discharge may be safe after elective PCI, study indicates

Patients who have undergone elective percutaneous coronary intervention (PCI) may be able to leave the hospital the same day without a negative effect on outcomes, a new study suggests.

Researchers performed a multicenter cohort study using data from 107,018 patients 65 years of age or older who had elective PCI at 903 U.S. sites between November 2004 and December 2008. All sites were participating in the CathPCI Registry, a national registry developed by the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions, and all procedures were linked with claims for Medicare Part A. The researchers divided patients into two groups depending on whether they were discharged on the same day as the PCI procedure or whether they stayed overnight. The main study outcomes were death or rehospitalization 2 to 30 days after PCI. The study results were published in the Oct. 5 Journal of the American Medical Association.

Overall, 1.25% (95% CI, 1.19% to 1.32%) of patients who had PCI were discharged on the same day. Patients discharged on the same day and those who stayed overnight were similar, with the exception that same-day discharge patients were more likely to have had shorter, less complicated procedures. Rates of hospitalization or death at 2 days and at 30 days did not differ significantly between groups. The authors analyzed patients who had adverse outcomes and found that the median time to death or rehospitalization did not differ by timing of discharge. Same-day discharge showed no significant association with death or rehospitalization at 30 days after adjustment for characteristics of patients and procedures.

The authors noted that they had no information on costs and that some of their data may have been inaccurate because the source was a large data registry, among other limitations. However, the authors concluded that based on their results, same-day discharge after PCI might be appropriate in a select group of patients at low risk. "Our study should not be taken as evidence to widely implement same-day discharge," they cautioned. "Such decisions should be individualized to the specific patient." They called for an adequately powered randomized, controlled trial to confirm their findings.

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Readmissions


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Little evidence supports interventions to reduce hospital readmissions

There's no definitive evidence that any single intervention reduces 30-day hospital readmissions, a literature review concluded.

Researchers reviewed 43 studies that tested discharge interventions using an experimental or observational design and reported relative readmission outcomes for an intervention and control cohort.

They found that limitations in the literature prevented them from concluding that any single intervention was effective. For example, some study interventions weren't well described and couldn't be included in a meta-analysis. Many of the studies were single-institution assessments that lacked experimental designs while those that were randomized did not consistently show a significant effect. Several common interventions have not been studied outside of multicomponent "discharge bundles." Results appeared in the Oct. 18 Annals of Internal Medicine.

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The researchers were able to categorize 12 types of interventions into three domains: predischarge interventions (patient education, medication reconciliation, discharge planning, and scheduling follow-up appointments), postdischarge interventions (follow-up telephone calls, patient-activated hotlines, timely communication with ambulatory clinicians, timely ambulatory clinician follow-up, and postdischarge home visits), and bridging interventions before and after discharge (transition coaches, physician continuity across the inpatient and outpatient setting, and patient-centered discharge instructions).

Predischarge patient education and discharge planning were the most commonly evaluated interventions, appearing in 22 of the 43 studies. Of the 43 studies, 16 were randomized, controlled trials. Five of them documented statistically significant improvements in readmissions within 30 days. One of the five consisted of a single intervention in which high-risk patients received early discharge planning or usual care. Those randomly assigned to the treatment group experienced an absolute 11% reduction in 30-day rehospitalization.

Four randomized studies demonstrated statistically significant beneficial effects of multicomponent discharge bundles. Interventions common to these studies were the postdischarge telephone call and patient-centered discharge instructions. However, two randomized trials that included these two interventions among others in a bundle did not demonstrate significant reductions in 30-day rehospitalization. The other two randomized trials of follow-up calls as an isolated intervention also did not find a significant effect.

The authors wrote, "In this systematic review of studies evaluating interventions to reduce readmission within 30 days of hospital discharge, we did not identify a discrete intervention or bundle of interventions that appears to reliably reduce rehospitalization.... Overall, observational designs predominated, and studies were characterized by significant heterogeneity of intervention content and context. This has been acknowledged to be a common limitation in the patient safety literature."

Still, promising avenues remain for study, including discharge instructions and telephone follow-up. Even though Medicare is expected to penalize hospitals with higher-than-average readmission rates, "[T]he current evidence base may not be adequate to facilitate change even for highly incentivized hospitals, and reconsideration of planned penalties may be reasonable," the authors concluded.

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From ACP Hospitalist


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The latest issue is online

The October issue of ACP Hospitalist is now online. Featured stories include:

acph-20111019-cov.jpg

Drug shortages vex hospitalists. Medication shortages have become a way of life for many hospitalists, and there's little indication this will change soon. Learn strategies to plan for, and deal with, shortfalls of crucial drugs.

Getting along with ED colleagues. Emergency department docs and hospitalists often have different communication styles, thanks to different work environments and training experiences. Sloppy handoffs can result, but it's possible to bridge the gap for the sake of better patient care.

Newman's family medicine. In this side-splitting column, editorial advisor Jamie Newman, MD, FACP, explains how practicing internal medicine in his household is truly a family affair.

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From the College


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ACP launches new online discussion group for hospitalists

ACP members are invited to participate in ACP's Special Interest Groups, a private online community that allows members to share experiences, questions and creative solutions with like-minded physicians at their own convenience. The special interest group forums are free and exclusive to ACP members. Members can connect with fellow colleagues in hospital medicine to discuss topics such as work schedule, practice type, and inpatient vs. observation status as well as share tips for getting the most out of committee work. Signup is required as space is limited. More information is available online.

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Cartoon caption contest


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Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

acph-20111019-cartoon.jpg

"I asked you to put on an unna boot, not tuna boot."

"Well, to the untrained eye, this may appear to be a red herring."

"Clearly we can ALL benefit from tail coverage…."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service.

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