What are the risks for bad outcomes in patients admitted with influenza?

From a recent study:

Highlights

A history of OSAS/CSAS, myocardial infarction and BMI greater than 30 are risk factors for ICU admission.

Non-survivors suffer more often from diabetes mellitus and (pre-existent) renal failure.

ICU patients develop renal failure and bacterial/fungal co-infections more often.

Abstract

Purpose

While most influenza patients have a self-limited respiratory illness, 5–10% of hospitalized patients develop severe disease requiring ICU admission. The aim of this study was to identify influenza-specific factors associated with ICU admission and mortality. Furthermore, influenza-specific pulmonary bacterial, fungal and viral co-infections were investigated.

Methods

199 influenza patients, admitted to two academic hospitals in the Netherlands between 01-10-2015 and 01-04-2016 were investigated of which 45/199 were admitted to the ICU.

Results

A history of Obstructive/Central Sleep Apnea Syndrome, myocardial infarction, dyspnea, influenza type A, BMI greater than 30, the development of renal failure and bacterial and fungal co-infections, were observed more frequently in patients who were admitted to the ICU, compared with patients at the normal ward. Co-infections were evident in 55.6% of ICU-admitted patients, compared with 20.1% of patients at the normal ward, mainly caused by Staphylococcus aureus, Streptococcus pneumoniae, and Aspergillus fumigatus. Non-survivors suffered from diabetes mellitus and (pre-existent) renal failure more often.

Conclusions

The current study indicates that a history of OSAS/CSAS, myocardial infarction and BMI greater than 30 might be related to ICU admission in influenza patients. Second, ICU patients develop more pulmonary co-infections. Last, (pre-existent) renal failure and diabetes mellitus are more often observed in non-survivors.

Extending VTE prophylaxis post hospitalization for medical patients

This is not currently a recommended practice but it gets revisited from time to time. Here’s the latest systematic review and meta-analysis in PLOS Medicine. From the paper:

BACKGROUND:

The efficacy, safety, and clinical importance of extended-duration thromboprophylaxis (EDT) for prevention of venous thromboembolism (VTE) in medical patients remain unclear. We compared the efficacy and safety of EDT in patients hospitalized for medical illness.

METHODS AND FINDINGS:

Electronic databases of PubMed/MEDLINE, EMBASE, Cochrane Central, and ClinicalTrials.gov were searched from inception to March 21, 2019. We included randomized clinical trials (RCTs) reporting use of EDT for prevention of VTE. We performed trial sequential and cumulative meta-analyses to evaluate EDT effects on the primary efficacy endpoint of symptomatic VTE or VTE-related death, International Society on Thrombosis and Haemostasis (ISTH) major or fatal bleeding, and all-cause mortality. The pooled number needed to treat (NNT) to prevent one symptomatic or fatal VTE event and the number needed to harm (NNH) to cause one major or fatal bleeding event were calculated. Across 5 RCTs with 40,247 patients (mean age: 67-77 years, proportion of women: 48%-54%, most common reason for admission: heart failure), the duration of EDT ranged from 24-47 days. EDT reduced symptomatic VTE or VTE-related death compared with standard of care (0.8% versus 1.2%; risk ratio [RR]: 0.61, 95% confidence interval [CI]: 0.44-0.83; p = 0.002). EDT increased risk of ISTH major or fatal bleeding (0.6% versus 0.3%; RR: 2.04, 95% CI: 1.42-2.91; p less than 0.001) in both meta-analyses and trial sequential analyses. Pooled NNT to prevent one symptomatic VTE or VTE-related death was 250 (95% CI: 167-500), whereas NNH to cause one major or fatal bleeding event was 333 (95% CI: 200-1,000). Limitations of the study include variation in enrollment criteria, individual therapies, duration of EDT, and VTE detection protocols across included trials.

CONCLUSIONS:

In this systematic review and meta-analysis of 5 randomized trials, we observed that use of a post-hospital discharge EDT strategy for a 4-to-6-week period reduced symptomatic or fatal VTE events at the expense of increased risk of major or fatal bleeding. Further investigations are still required to define the risks and benefits in discrete medically ill cohorts, evaluate cost-effectiveness, and develop pathways for targeted implementation of this postdischarge EDT strategy.

This analysis does not make a good case for extending pharmacologic VTE prophylaxis beyond the period of hospitalization. Note that the ACCP guidelines recommend against this practice. According to those guidelines, post hospital continuation of pharmacologic VTE prophylaxis is recommended for only two situations: post major orthopedic surgery (10 days total minimum) and post cancer surgery (4 weeks).

ICU or stepdown for your DKA patient?

From a recent study:

Highlights

In some centers, all Diabetic Ketoacidosis (DKA) patients are admitted to ICU.

No difference in in-hospital mortality was found between DKA patients admitted to step-down units or ICU.

DKA patients admitted to step-down units had significantly lower costs than those admitted to ICU.

Hospitals should preferentially consider monitoring of DKA patients in step-down units.

Abstract

Purpose

There is wide variation in the utilization of Intensive Care Unit (ICU) beds for treatment and monitoring of adult patients with Diabetic Ketoacidosis (DKA). We sought to compare the outcomes and hospital costs of adult DKA patients admitted to ICUs as compared to those admitted to step-down units.

Materials and methods

We included consecutive adult patients from two hospitals with a diagnosis of DKA. Patients were either admitted to the ICU, or a step-down unit, which has a nurse-to-patient ratio of 2:1, but does not have capability for mechanical ventilation or administration of vasoactive agents. The primary outcome was in-hospital mortality.

Results

We included 872 patients in the analysis. 71 (8.1%) were admitted to ICU, while 801 (91.9%) were admitted to a step-down unit. We found no difference in in-hospital mortality between patients admitted to the ICU and those admitted to the step-down unit (adjusted odds ratio [OR]: 1.14, 95% confidence interval [CI]: 0.87–2.64). Mean total hospital costs were significantly higher for patients admitted to the ICU ($20,428 vs. $6484, P less than 0.001).

Conclusions

Adult DKA patients admitted to a step-down unit had comparable in-hospital mortality and lower hospital costs as compared to those admitted to the ICU.

Delirium in hospitalized patients predicts readmission and other forms of increased post hospital utilization

Report here.

This is not surprising, since delirium in the hospital is often a sign of frailty.

The cholesterol hypothesis is alive again!

From a recent paper in JAMA:

Key Points

Question Is consuming dietary cholesterol or eggs associated with incident cardiovascular disease (CVD) and all-cause mortality?

Findings Among 29 615 adults pooled from 6 prospective cohort studies in the United States with a median follow-up of 17.5 years, each additional 300 mg of dietary cholesterol consumed per day was significantly associated with higher risk of incident CVD (adjusted hazard ratio [HR], 1.17; adjusted absolute risk difference [ARD], 3.24%) and all-cause mortality (adjusted HR, 1.18; adjusted ARD, 4.43%), and each additional half an egg consumed per day was significantly associated with higher risk of incident CVD (adjusted HR, 1.06; adjusted ARD, 1.11%) and all-cause mortality (adjusted HR, 1.08; adjusted ARD, 1.93%).

Meaning Among US adults, higher consumption of dietary cholesterol or eggs was significantly associated with higher risk of incident CVD and all-cause mortality in a dose-response manner.

This paper has been wildly overhyped. It’s new data but concludes nothing we didn’t already know: cholesterol matters. The real problem is, so do a lot of other things. Those who would hype this finding lack an appreciation of the concept of population attributable risk.

Check point inhibitor induced colitis

An emerging entity.

Which patients post cardiac arrest need to go straight to the cath lab?

From a recent AHA scientific statement:

CAD is a common substrate, and its severity is a potential trigger for OHCA, especially in the case of shockable rhythms. Patients with VF/pVT OHCA should be considered at the highest severity of a continuum of acute coronary syndromes. Patients with VF/pVT have a significant burden of CAD: acute, chronic, or acute on chronic (Figure 8)…

Current guidelines recommend early CAG and reperfusion for postarrest patients manifesting ST-segment elevation after ROSC is achieved. However, because of a lack of conclusive randomized data and ongoing perceived clinical equipoise, there is no consensus guideline on the use of CAG and coronary revascularization in patients without ST-segment elevation on ECG. Multiple randomized trials addressing this question are underway. Until their completion, there is a significant body of observational studies that address the role of the CCL in this population.

The current evidence suggests that early access to the CCL in patients resuscitated from VF/pVT cardiac arrest is associated with 2- to 3-fold higher functionally favorable survival rates than more conservative approaches of late or no access to the CCL. This body of evidence, with potential for unmeasured selection bias, suggests that patients resuscitated from OHCA, especially those with presenting shockable rhythms, should be considered for early CAG, identification of reversible causes, and revascularization when indicated.

This is in line with the current ACLS guidelines, which say that if there’s ST elevation post ROSC an immediate trip to the cath lab carries a class I recommendation. For patients without STE, the guidelines give a IIa recommendation to go straight to the cath lab if the arrest is of suspected cardiac origin on clinical grounds.

Cardiorenal syndrome

The AHA scientific statement is available as free full text here.

Rates of cardiac testing prior to hip fracture surgery

From a recent report:

Hip fracture is a common reason for urgent inpatient surgery. In the past few years, several professional societies have identified preoperative echocardiography and stress testing for noncardiac surgeries as low-value diagnostics. We utilized data on hospitalizations with a primary diagnosis of hip fracture surgery between 2011 and 2015 from the State Inpatient Databases (SID) of Maryland, New Jersey, and Washington, combined with data on hospital characteristics from the American Hospital Association (AHA). We found that the rate of preoperative ischemic testing is surprisingly but encouragingly low (stress tests 1.1% and cardiac catheterizations 0.5%), which is consistent with studies evaluating the outpatient utilization of these tests for low- and intermediate-risk surgeries. The rate of echocardiograms was 12.6%, which was higher than other published reports. Our findings emphasize the importance of ensuring that quality improvement efforts are directed toward areas where quality improvement is, in fact, needed.

Blood stream infections: how long to treat? When is PO sufficient?

This review in the Journal of Hospital Medicine is an excellent resource.

Non invasive ventilation for acute hypoxemic respiratory failure: what’s the latest?

From a recent systematic review and meta-analysis:

Highlights

Noninvasive ventilation reduces the risk of intubation in subgroups of acute hypoxemic patients.

Immunosuppressed, acute pulmonary edema and pneumonia patients may benefit most from NIV.

Well designed randomized clinical trials are required to address the benefit in other populations.

Abstract

Purpose

Evaluate current recommendation for the use of noninvasive ventilation (Bi-level positive airway pressure- BiPAP modality) in hypoxemic acute respiratory failure, excluding chronic obstructive pulmonary disease.

Methods

Electronic searches in MEDLINE, Web of Science, Clinical Trials, and The Cochrane Central Register of Controlled Clinical Trials. We searched for randomized controlled trials comparing BiPAP to a control group in patients with hypoxemic acute respiratory failure. Endotracheal intubation and death were the assessed outcomes.

Results

Of the 563 studies found, nine met the inclusion criteria for this systematic review. The pooled RR (95% CI) for intubation in patients with acute pulmonary edema (APE)/community acquired pneumonia (CAP) and in immunosuppressed patients (cancer and transplants) were 0.61 (0.39–0.84) and 0.77 (0.60–0.93), respectively. For Intensive Care Units (ICU) mortality, the RR (95% CI) in patients with APE/CAP was 0.51 (0.22–0.79). The heterogeneity was low in all comparisons.

Conclusions

NIV showed a significant protective effect for intubation in immunosuppressed patients (cancer and transplants) and in patients with APE/CAP. However, the benefits of NIV for other etiologies are not clear and more trials are needed to prove these effects.

Biomarkers in midlife may predict physical decline years later

Here is a summary of findings published in Circulation:

Clinical Perspective

What Is New?

Lower levels of NT-proBNP (N-terminal pro-B-type natriuretic peptide) and interleukin-6 in middle-aged adults were independently associated with better physical capability (a key component of healthy aging) up to 9 years later.

Such associations were meaningfully stronger than those observed for conventional risk markers including lipids, blood pressure, and glycemia and were not explained by the onset of cardiovascular and kidney disease or diabetes mellitus.

What Are the Clinical Implications?

Elevated NT-proBNP and interleukin-6 in midlife could help identify (and thereby target) individuals set to have poor physical capability as they age.

Such findings may relate in part to such biomarkers capturing early end-organ damage, or cumulative stressor pathways that lead to physical decline.

Future trials targeting improvements in physical capability should include middle-aged as well as older adults and use measurements of cardio-renal biomarkers as intermediate outcomes.

Adverse drug reactions in the elderly: a clinical vignette and a reminder of the Beers list

The free full text article is here. The newly revised Beers list can be accessed here.

Antiplatelet therapy reduces mortality in sepsis

From a recent meta-analysis:

Highlights

Antiplatelet drugs can reduce the mortality rate in patients with sepsis.

Aspirin can effectively reduce mortality in patients with sepsis.

Antiplatelet drugs reduce mortality regardless of the timing of administration.

Abstract

Purpose

Abnormal platelet activation plays an important role in the development of sepsis. The effect of antiplatelet drugs on the outcome of patients with sepsis remains unclear. This meta-analysis aimed to determine the effect of antiplatelet drugs on the prognosis of patients with sepsis.

Materials and methods

PubMed, Cochrane Library, CBM, and Embase were searched for all related articles published from inception to April 2018. The primary end point was mortality. Adjusted data were used and statistically analysed.

Results

Ten cohort studies were included. The total number of patients with sepsis was 689,897. Data showed that the use of antiplatelet drugs could effectively reduce the mortality of patients with sepsis (odds ratio (OR) = 0.82, 95% CI: 0.81–0.83, p less than 0.05). Seven studies used aspirin for antiplatelet therapy, and subgroup analysis showed that aspirin effectively reduced ICU or hospital mortality in patients with sepsis (OR = 0.60, 95% CI: 0.53–0.68, p less than 0.05). A subgroup analysis on the timing of anti-platelet drug administration showed that antiplatelet drugs can reduce mortality when administered either before (OR = 0.78, 95% CI: 0.77–0.80) or after sepsis (OR = 0.59, 95% CI: 0.52–0.67).

Conclusions

Antiplatelet drugs, particularly aspirin, could be used to effectively reduce mortality in patients with sepsis.

Antithrombotic therapy for sepsis is not a new concept. The coagulation system is activated and accounts for some of the injury in sepsis. Activated protein C was found beneficial in selected septic patients and was approved as an adjunct in the treatment of sepsis with organ dysfunction in 2001. The company withdrew the product from the market in 2011.

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.

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.

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

From a recent study:

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.

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.

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 less.  That 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.

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.

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.