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Attending physician workload, prescription opioids after overdose.

Attending physician workload may affect teaching, patient safety

A greater workload among attending physicians was associated with less effective teaching and possibly compromised safety in a recent retrospective study.

Researchers looked for associations among workload, teaching effectiveness, and patient outcomes for attending physicians supervising inpatient teaching services at a single facility from July 2, 2005, to July 1, 2011. Workload was assessed by hospital service census at midnight, length of stay, and daily admissions and discharges; outpatient duties were also measured as mean daily relative value units. Residents' evaluations of attending physicians were used to measure teaching effectiveness, while applicable patient safety indicators, ICU transfers, CPR and rapid-response team calls, and deaths were used to assess patient outcomes. The study results were published online Jan. 6 by the Journal of Hospital Medicine.

A total of 107 attending physicians who supervised 543 internal medicine residents were included in the study. Twenty-three percent of the attending physicians were women, and 77% were men; mean age was 42.6 years. During the study period, physicians who spent more days with their team and those who had a higher academic rank (professor vs. assistant professor or instructor/no academic rank) had significantly higher teaching evaluation scores. For workload measures, lower scores on teaching evaluations were associated with midnight census and with daily discharges (β for both variables, −0.026; P<0.0001 for both variables), while higher scores were associated with mean number of daily admissions (β, 0.021; P=0.001). Mean expected patient mortality and outpatient duties were not associated with teaching scores. For patient outcomes, higher workload and longer length of stay were significantly more likely to be associated with a patient safety indicator event.

The authors noted that their study sample was drawn from a single institution, that most of the attending physicians had substantial teaching experience, and that the effect on teaching effectiveness was small, among other limitations. However, they concluded that the workload of attending physicians may have an adverse effect on both teaching and patient safety. Future studies should examine the possibility of scheduling residents so as to maximize teaching continuity, and the relationship between admission volume and patient safety incidents should also be explored, the authors said. “Ongoing efforts by residency programs to optimize the learning environment should include strategies to manage the workload of supervising attendings,” they concluded.

Prescription opioids continued after overdose, study finds

Almost all patients continue to receive prescription opioids after an overdose, and 7% had a repeated overdose, researchers found in a study of commercially insured patients.

Researchers conducted a retrospective cohort study of a commercial insurer database that contained complete inpatient, outpatient, and pharmacy claims for patients from a large U.S. health insurer with members in all 50 states. The cohort represents 50 million commercially enrolled patients between May 2000 and December 2012 with a median follow-up of 15 months.

Nonfatal opioid overdose was identified using codes from emergency department or inpatient claims. The primary outcome was daily morphine-equivalent dosage (MED) of opioids dispensed from 60 days before to up to 730 days after the index overdose. Doses were categorized as large (≥100 mg MED), moderate (50 to <100 mg MED), low (<50 mg MED), or none (0 mg MED). Secondary outcomes included time to repeated overdose stratified by daily dosage as a time-varying covariate.

Results were published in the Jan. 5 Annals of Internal Medicine.

The final cohort involved 2,848 patients followed for a median duration of 299 days (interquartile range, 123 to 639 days) after the index overdose. The mean age was 44 years (SD, 11), and 40% of patients were men. In the 60 days before the index overdose, 46% of patients had an average daily dosage of 100 mg MED or more. In the 90 days before the index overdose, 56% of patients were dispensed a benzodiazepine, 59% had claims with a mental health diagnosis, and 41% had claims with a substance use disorder.

Over a median follow-up of 299 days, opioids were dispensed to 91% of patients after an overdose. Seven percent of patients (n=212) had a repeated opioid overdose. At 2 years, the cumulative incidence of repeated overdose was 17% (95% CI, 14% to 20%) for patients receiving high dosages of opioids after the index overdose, 15% (CI, 10% to 21%) for those receiving moderate dosages, 9% (CI, 6% to 14%) for those receiving low dosages, and 8% (CI, 6% to 11%) for those receiving no opioids.

Opioid discontinuation after overdose is associated with lower risk for repeated overdose, researchers noted.

“Our finding that almost all patients continue to be prescribed opioids after overdose is highly concerning,” they wrote. “Further research is needed to determine whether providers continuing to prescribe opioids after an overdose are aware of the event and, if so, how they respond in counseling patients. Determining whether patients in integrated health systems fare differently would also shed light on whether fragmented care is a contributing factor.”

An editorialist noted that opioids after an overdose were usually prescribed by the same clinician who initially prescribed them but that the problem goes well beyond individual prescribers' practices. After overdose events, prescribed opioid dosages decreased to levels that were substantially lower than those received in the 90 days before the event and dosages stabilized at those lower levels, signaling that either the physician lowered the dose or the patient asked for a lower dose.

“[H]ospitals and emergency departments must have systems in place to identify patients who are seeking care for problems directly related to substance abuse (such as abscesses, endocarditis, or overdose) and then connect them directly to services,” the editorial stated. “Research suggests that patients hospitalized for conditions related to substance abuse exhibit high readiness to change and that hospital-based interventions that provide in-reach services and referral can successfully discharge patients directly to the appropriate services for addiction treatment. This model turns a potentially devastating event into an opportunity for hope.”

For more details on this study, see the related story.