Monday, May 06, 2019

Management of acute kidney injury


From a review in the Journal of Hospital Medicine:

Acute kidney injury (AKI) is a common complication in hospitalized patients and is associated with mortality, prolonged hospital length of stay, and increased healthcare costs. This paper reviews several areas of controversy in the identification and management of AKI. Serum creatinine and urine output are used to identify and stage AKI by severity. Although standardized definitions of AKI are used in research settings, these definitions do not account for individual patient factors or clinical context which are necessary components in the assessment of AKI. After treatment of reversible causes of AKI, patients with AKI should receive adequate volume resuscitation with crystalloid solutions. Balanced crystalloid solutions generally prevent severe hyperchloremia and could potentially reduce the risk of AKI, but additional studies are needed to demonstrate a clinical benefit. Intravenous albumin may be beneficial in patients with chronic liver disease either to prevent or attenuate the severity of AKI; otherwise, the use of albumin or other colloids (eg, hydroxyethyl starch) is not recommended. Diuretics should be used to treat volume overload, but they do not facilitate AKI recovery or reduce mortality. Nutrition consultation may be helpful to ensure that patients receive adequate, but not excessive, dietary protein intake, as the latter can lead to azotemia and electrolyte disturbances disproportionate to the patient’s kidney failure. The optimal timing of dialysis initiation in AKI remains controversial, with conflicting results from two randomized controlled trials.

Friday, May 03, 2019

A fib ablation vs antiarrhythmic medication


From a recent study published in JAMA, the CAPTAF trial:

Key Points

Question Is pulmonary vein isolation more effective than optimized antiarrhythmic drug therapy for improving general health in patients with symptomatic atrial fibrillation?

Findings In this randomized clinical trial that included 155 patients with paroxysmal or persistent symptomatic atrial fibrillation despite use of antiarrhythmic medication, the improvement in quality of life at 12 months for those treated with catheter ablation compared with antiarrhythmic medication was 11.9 vs 3.1 points on the 0- to 100-point 36-Item Short-Form Health Survey questionnaire, a difference that was statistically and clinically significant.

Meaning In patients with either paroxysmal or persistent symptomatic atrial fibrillation despite medication, catheter ablation may help improve quality of life.

Abstract

Importance Quality of life is not a standard primary outcome in ablation trials, even though symptoms drive the indication.

Objective To assess quality of life with catheter ablation vs antiarrhythmic medication at 12 months in patients with atrial fibrillation.

Design, Setting, and Participants Randomized clinical trial at 4 university hospitals in Sweden and 1 in Finland of 155 patients aged 30-70 years with more than 6 months of atrial fibrillation and treatment failure with 1 antiarrhythmic drug or β-blocker, with 4-year follow-up. Study dates were July 2008–September 2017. Major exclusions were ejection fraction less than 35%, left atrial diameter greater than 60 mm, ventricular pacing dependency, and previous ablation.

Interventions Pulmonary vein isolation ablation (n = 79) or previously untested antiarrhythmic drugs (n = 76).

Main Outcomes and Measures Primary outcome was the General Health subscale score (Medical Outcomes Study 36-Item Short-Form Health Survey) at baseline and 12 months, assessed unblinded (range, 0 [worst] to 100 [best]). There were 26 secondary outcomes, including atrial fibrillation burden (% of time) from baseline to 12 months, measured by implantable cardiac monitors. The first 3 months were excluded from rhythm analysis.

Results Among 155 randomized patients (mean age, 56.1 years; 22.6% women), 97% completed the trial. Of 79 patients randomized to receive ablation, 75 underwent ablation, including 2 who crossed over to medication and 14 who underwent repeated ablation procedures. Of 76 patients randomized to receive antiarrhythmic medication, 74 received it, including 8 who crossed over to ablation and 43 for whom the first drug used failed. General Health score increased from 61.8 to 73.9 points in the ablation group vs 62.7 to 65.4 points in the medication group (between-group difference, 8.9 points; 95% CI, 3.1-14.7; P = .003). Of 26 secondary end points, 5 were analyzed; 2 were null and 2 were statistically significant, including decrease in atrial fibrillation burden (from 24.9% to 5.5% in the ablation group vs 23.3% to 11.5% in the medication group; difference –6.8% [95% CI, –12.9% to –0.7%]; P = .03). Of the Health Survey subscales, 5 of 7 improved significantly. Most common adverse events were urosepsis (5.1%) in the ablation group and atrial tachycardia (3.9%) in the medication group.

Conclusions and Relevance Among patients with symptomatic atrial fibrillation despite use of antiarrhythmic medication, the improvement in quality of life at 12 months was greater for those treated with catheter ablation compared with antiarrhythmic medication. Although the study was limited by absence of blinding, catheter ablation may offer an advantage for quality of life.


Tuesday, April 23, 2019

Should you get immunoglobulin levels on patients admitted with community acquired pneumonia?



BACKGROUND: Immunodeficiency is an underrecognized risk factor for infections, such as community-acquired pneumonia (CAP).

OBJECTIVE: We evaluated patients admitted with CAP for humoral immunodeficiency.

DESIGN: Prospective cohort study.

SETTING: Inpatients

PATIENTS, INTERVENTION, AND MEASUREMENTS: We enrolled 100 consecutive patients admitted with a diagnosis of CAP from February 2017 to April 2017. Serum IgG, IgM, IgA, and IgE levels were obtained within the first 24 hours of admission. CURB-65 score and length of hospital stay were calculated. The Wilcoxon rank-sum test, Kruskal-Wallis test, and simple linear regression analysis were used in data analysis.

RESULTS: The prevalence of hypogammaglobinemia in patients with CAP was 38% (95% CI: 28.47% to 48.25%). Twenty-seven of 100 patients had IgG hypogammaglobinemia (median: 598 mg/dL, IQ range: 459-654), 23 of 100 had IgM hypogammaglobinemia (median: 38 mg/dL, IQ range: 25-43), and 6 of 100 had IgA hypogammaglobinemia (median: 36 mg/dL, IQ range: 18-50). The median hospital length of stay for patients with IgG hypogammaglobinemia was significantly higher when compared to patients with normal IgG levels (five days, IQ range [3-10] vs three days, IQ range [2-5], P = .0085). Fourteen patients underwent further immune evaluation, resulting in one diagnosis of multiple myeloma, three patients diagnosed with specific antibody deficiency, and one patient diagnosed with selective IgA deficiency.

CONCLUSION: There is a high prevalence of hypogammaglobinemia in patients hospitalized with CAP, with IgG and IgM being the most commonly affected classes. IgG hypogammaglobinemia was associated with an increased length of hospitalization. Screening immunoglobulin levels in CAP patients may also uncover underlying humoral immunodeficiency or immuno-proliferative disorders.

Should docusate be removed from your hospital’s formulary?


According to this article it should.

Saturday, April 20, 2019

Prealbumin testing is not useful in the assessment for malnutrition


Prealbumin (aka transthyretin) is, like albumin, an acute phase reactant. It is, also like albumin, a negative acute phase reactant because it goes down during illness. It was originally proposed as better nutritional marker than albumin because of its shorter half life, giving more of a “right now” nutritional assessment. Nowadays, neither test is considered useful for nutritional assessment. Instead one should use a clinical instrument based on a nutrition focused H&P.

From the Journal of Hospital Medicine’s Things We Do for No Reason series.

What’s the value in diagnosing malnutrition in the first place? Well, it identifies you and your hospital as having a population of patients with a markedly higher mortality. That’s good for reimbursement and severity adjustment, as the linked article points out. Does it help patients? The evidence that it leads to interventions that improve outcome is scant to none as far as I know.  What I am prompted to do, at least, is give thiamine.

Friday, April 19, 2019

Very low utilization of advance care planning (ACP) CPT codes among hospitalists


From a recent study:

We analyzed advance care planning (ACP) billing for adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. Prompting hospitalists to answer the validated “surprise question” (SQ; “Would you be surprised if the patient died in the next year?”) for inpatient admissions served to prime hospitalists and triggered an icon next to the patient’s name. Among 113,621 hospital-based encounters, only 6,146 (5.4%) involved a billed ACP conversation: 8.3% among SQ-prompted who answered “no” and 4.1% SQ-prompted who answered “yes” (for non-SQ prompted cases, the fraction was 3.5%; P less than .0001). ACP conversations were associated with a comfort-focused care trajectory. Low ACP rates among even those with high hospitalist-predicted mortality risk underscore the need for quality improvement interventions to increase hospital-based ACP.

The last sentence is a non sequitur. The codes are an unreliable measure because many, I would wager most, ACP discussions are not billed with these particular codes. Many hospitalists don’t even know they exist. The codes, 99497 and 99498, were not even included in the fee schedule until 2016 so they were brand new at the time of the study.

Ten years ago similar codes were proposed under the Affordable Care Act but spurred fierce debate around “death panel” fears. Those provisions were dropped before final passage of the law. What’s interesting is how these provisions were slipped in out of most people’s awareness, with no public debate to speak of, seven years later. Political winds change and people are easily distracted.

Only the American Association of Physicians and Surgeons, (AAPS), a relatively minor player in the larger physician community, seemed to mind. They argued that the codes, which pay more than ordinary CPT codes, would incentivize doctors to talk patients out of life prolonging treatments. That’s an oversimplification, of course, because some ACP conversations produce decisions for more care, not lessThat said, the intent of the measure is to reward doctors for giving less care toward the end of life.  It creates the perception of a conflict of interest though based on the data above the measure has had minimal impact.

The public debate about the proposal in 2009 was confused. The idea of the “death panel” (merely an inflammatory term for an advance care discussion) was nothing new. We had been having those discussions for decades. Moreover, the pre-existing ordinary CPT codes already rewarded doctors for long discussions through the provision that a higher level of service could be coded if greater than half the encounter time was spent in counseling or care coordination. Nobody on either side of the debate seemed aware of those facts.

Thursday, April 18, 2019

Survey data on the state of research in hospital medicine


From a recent paper in the Journal of Hospital Medicine:

BACKGROUND: Little is known about the state of research in academic hospital medicine (HM) despite the substantial growth of this specialty.
METHODS: We used the Society of Hospital Medicine (SHM) membership database to identify research programs and their leadership. In addition, the members of the SHM Research Committee identified individuals who lead research programs in HM. A convenience sample of programs and individuals was thus created. A survey instrument containing questions regarding institutional information, research activities, training opportunities, and funding sources was pilot tested and refined for electronic dissemination. Data were summarized using descriptive statistics.
RESULTS: A total of 100 eligible programs and corresponding individuals were identified. Among these programs, 28 completed the survey in its entirety (response rate 28%). Among the 1,586 faculty members represented in the 28 programs, 192 (12%) were identified as engaging in or having obtained extramural funding for research, and 656 (41%) were identified as engaging in quality improvement efforts. Most programs (61%) indicated that they received $500,000 or less in research funding, whereas 29% indicated that they received greater than $1 million in funding. Major sources of grant support included the Agency for Healthcare Research and Quality, National Institutes of Health, and the Veterans Health Administration. Only five programs indicated that they currently have a research fellowship program in HM. These programs cited lack of funding as a major barrier to establishing fellowships. Almost half of respondents (48%) indicated that their faculty published between 11-50 peer-reviewed manuscripts each year.
CONCLUSION: This survey provides the first national summary of research activities in HM. Future waves of the survey can help determine whether the research footprint of the field is growing.

Are residents getting enough training in managing crashing patients in the hospital?


From a recent study in the Journal of Hospital Medicine:

BACKGROUND: Internal Medicine (IM) residency graduates should be able to manage hospital emergencies, but the rare and critical nature of such events poses an educational challenge. IM residents’ exposure to inpatient acute clinical events is currently unknown.
OBJECTIVE: We developed an instrument to assess IM residents’ exposure to and confidence in managing hospital acute clinical events.
METHODS: We administered a survey to all IM residents at our institution assessing their exposure to and confidence in managing 50 inpatient acute clinical events. Exposures assessed included mannequin-based simulation or management of hospital-based events as a part of a team or independently in a leadership role. Confidence was rated on a five-point scale and dichotomized to “confident” versus “not confident.” Results were analyzed by multivariable logistic regression to assess the relationship between exposure and confidence accounting for year in training.
RESULTS: A total of 140 of 170 IM residents (82%) responded. Postgraduate year 1 (PGY-1) residents had managed 31.3% of acute events independently vs 71.7% of events for PGY-3/4 residents (P less than .0001). In multivariable analysis, residents’ confidence increased with level of training (PGY-1 residents were confident to manage 24.9% of events vs 72.5% of events for PGY-3/4 residents, P less than .0001) and level of exposure, independent of training year (P = .001). Events with the lowest levels of exposure and confidence for graduating residents were identified.
CONCLUSIONS: IM residents’ confidence in managing inpatient acute events correlated with level of training and clinical exposure. We identified events with low levels of resident exposure and confidence that can serve as targets for future curriculum development.

Wednesday, April 10, 2019

Atul Gawande on the electronic medical record


Atul Gawande has a piece in the New Yorker titled Why Doctors Hate their Computers. The title is deceptive. In the first place doctors don’t hate computers (I’ve never met one who did, have you?). In the body of the paper Gawande doesn’t even seem to attempt to make that case. He does point out how doctors hated the way in which they were forced to adopt health information technology and the culture that went alongside. But, though he talks around it (and he talks a lot around it) he fails to answer the question of why. Is there something wrong with computers themselves in the current state of development? Is it the way policymakers and administrators have forced the implementation? Or is it that docs just need an attitude adjustment? He implies a little of each. Overall the article is incoherent.

Gawande has thrown together a mishmash of anecdotes, unreferenced claims and quotes from supposed experts. And the qualifications of these experts? Well, consider this one:

Gregg Meyer sympathizes, but he isn’t sorry. As the chief clinical officer at Partners HealthCare, Meyer supervised the software upgrade. An internist in his fifties, he has the commanding air, upright posture, and crewcut one might expect from a man who spent half his career as a military officer.

Hmmm. A commanding air, an upright posture and a crewcut. I think I’m afraid of this guy. He seems to think doctors have too much autonomy and a bad attitude to boot. He says:

“But we think of this as a system for us and it’s not,” he said. “It is for the patients.” 

Emphasis his.

Meyer just gave himself away. He’s operating on the idea that the interests of doctors are opposed to the interests of patients. It’s an ethical question worth pondering but not a great starting premise. Gawande seems to accept it uncritically. A little further on Gawande says of Meyer, also uncritically:

Gregg Meyer is understandably delighted to have the electronic levers to influence the tens of thousands of clinicians under his purview. He had spent much of his career seeing his hospitals blighted by unsafe practices that, in the paper-based world, he could do little about.

Evidence based medicine, particularly its third pillar (the importance of the expertise of the individual clinician) opposes such a top down approach. Does Gawande see anything wrong with Meyer’s line of thinking? If he does he doesn’t say so.

It’s style over substance:

Jessica Jacobs, a longtime office assistant in my practice—mid-forties, dedicated, with a smoker’s raspy voice—

As if that’s supposed to be a convincer in some way. But what does it mean, exactly? That she’s got savvy? That her dedication to her work has taken its toll? It’s left to our imagination.

Gawande fails to even come close to making the case that doctors hate computers, let alone answer the question
of why, but he does point out some of the negative consequences of the EMR. Maybe this is progress, because it would have been nearly forbidden speech about a decade ago.