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

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In the News for the Week of 10-30-07

News highlights

  • Vulnerable elderly receive mediocre health care, study finds
  • Report: Doctors should monitor cancer patients’ mental health
  • Hysterectomy associated with stress incontinence surgery

Hospital medicine

  • New guidelines on use of anticoagulants for VTE
  • Certain errors more common with medical trainees, study finds
  • Chlorhexidine-based interventions reduced catheter-associated infections

Clinical news

  • More breast cancer patients choosing prophylactic mastectomies
  • Testing intention doesn’t breed action for those with high HIV risk

ACP publishing news

College news

  • College Fellow takes medical school presidency

News highlights

Vulnerable elderly receive mediocre health care, study finds

The quality of care for vulnerable elderly people on Medicaid and Medicare is “mediocre,” the authors of a new study concluded.

Researchers did a cohort study of 100,528 dual Medicaid/Medicare enrollees from 19 California counties who were age 75 and older in 1999 and 2000. They measured the care provided for 44 quality indicators (QIs) by condition, like heart failure, and intervention, such as medication, using QIs developed by the Assessing Care of Vulnerable Elders project. The article was published in the October Medical Care.

The rate of successful care was about 65%.QIs with the lowest pass rates included dementia evaluation and cardiac procedures, while those with the highest pass rates measured appropriate medication use and avoidance of adverse medications. ACE inhibitors and beta-blockers were used in about half or less of the ischemic heart disease cases in which they were recommended, and less than half of patients with atrial fibrillation were anticoagulated. Pharmacologic treatment for osteoporosis and depression was administered less than half the time, and only 42% of diabetes patients had their hemoglobin checked in one year.

There were no QIs that measured important aspects of care like prescription of an assistive device, history taking or nursing care for older patients, the authors noted. Improving and integrating claims data, and implementing electronic health records, has the potential of improving quality measurement, as well as quality itself, the authors said. “A noncomprehensive, relatively small set of QIs—reflecting general medical care rather than geriatric care—demonstrates that quality of care tends to be mediocre among vulnerable older patients dually enrolled in both Medicare and Medicaid,” the authors said. “Administrative data offers a bridge across the quality chasm, but we must develop the necessary data elements to measure the aspects of care important for older patients.”

An abstract from Medical Care is online.

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Report: Doctors should monitor cancer patients’ mental health

Physicians should do more to ensure their cancer patients’ psychological and social needs are being met, according to a new report by the Institute of Medicine.

Cancer patients commonly experience anxiety, depression or other emotional problems through the course of their illness, as well as disruptions in work, school and family life. Because they often lack the information, skills and resources such as transportation to deal with their illness, their suffering is magnified, causing poorer adherence to treatment and an additional threat to health, the report said.

An IOM panel last week said that physicians can help by routinely screening patients for mental distress and connecting those with problems to outside resources, Reuters reported Oct. 23. Doctors should also re-evaluate patients from time to time to see if their needs have changed. Needs might include depression treatment, information on treatment side effects and assistance with daily activities patients can no longer perform, the article said.

Separately, a new study found that neither positive nor negative emotional states predict how long a person with cancer will survive, according to the Oct. 22 Washington Post. The study, expected to be published in the Dec. 1 Cancer, looked at 1,100 patients enrolled in phase III clinical trials for head and neck cancer treatment, and found their emotional status didn’t affect survival or the cancer’s course. The findings shouldn’t discourage cancer patients from getting mental health treatment to improve their quality of life; rather, the results might offer relief to those who blame themselves for not staying upbeat when their cancer worsens, the authors said in the article.

The Institute of Medicine report is online.

The Reuters article is online.

The Washington Post is online.

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Hysterectomy associated with stress incontinence surgery

Women who have hysterectomies for benign indications are more likely to need stress-urinary incontinence surgery in the future, according to a new Swedish study.

In the population-based cohort study, researchers compared 165,000 women who had hysterectomies for benign conditions with 480,000 women who had not had the surgery. During the 30-year study period (from 1973 to 2003), the women in the surgical group had 179 incontinence surgeries per 100,000 person-years versus 76 surgeries per 100,000 in the non-hysterectomy cohort. The difference was greatest in the first five years after hysterectomy, when the women who had hysterectomies were 2.7 times more likely to have the incontinence surgery. The study was published in the Oct. 27 issue of The Lancet.

The study authors attributed the increased risk to surgical trauma resulting from the detachment of the uterus and cervix from the pelvic floor, according to the Oct. 25 Washington Post. The authors also concluded that based on their findings, women should be counseled on the risks associated with hysterectomies and that treatment options other than surgery should be considered.

An accompanying comment noted that other research, including some conducted by the authors of this study, have not confirmed a link between hysterectomy surgery and incontinence. The comment author suggested that the association found in this study could have other explanations, such as women who have hysterectomies being more likely to select a surgical treatment for incontinence.

The Lancet is online.

The Washington Post is online.

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Hospital medicine

New guidelines on use of anticoagulants for VTE

The American Society of Clinical Oncology (ASCO) has released new guidelines on the use of anticoagulants to treat venous thromboembolism (VTE) in cancer patients.

VTE and its complications are a leading cause of death in patients with cancer, affecting as many as 4% to 20% of patients at some point in their treatment, said an Oct. 29 ASCO news release. Major risk factors for developing VTE include age, primary site of cancer, hospitalization, a history of VTE, and active therapy such as chemotherapy, antiangiogenic drugs and hormonal therapy.

While anticoagulants may raise a patient’s risk of bleeding and lead to a hospital stay, the benefits outweigh the risks, according to the panel that developed the guideline. Key recommendations include:

  • All hospitalized patients with cancer should receive preventive anticoagulation;
  • All cancer patients who develop a blood clot should be treated with an anticoagulant for at least six months and possibly longer in those who continue treatment for active cancer;
  • Physicians should evaluate all cancer patients undergoing major surgery for administering anticoagulation, beginning before the operation or soon afterward;
  • Regular use of an anticoagulant for cancer patients who are not hospitalized and receiving chemotherapy is not recommended, except for patients with multiple myeloma receiving thalidomide or lenalidomide with chemotherapy or dexamethasone.

The ASCO guideline, "Recommendations for Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer," by Gary H. Lyman, et al., Duke University Medical Center, will be published in the Dec. 1 print issue of the Journal of Clinical Oncology.

The ASCO news release is online.

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Certain errors more common with medical trainees, study finds

Malpractice claims attributed to medical trainees are most often the results of errors in judgment, breakdowns in teamwork and lack of technical competence while providing care, a new study reports.

Researchers used data from the Malpractice Insurers Medical Error Prevention Study to determine the involvement of trainees in medical errors. Data were available on 1,452 closed malpractice claims from five insurers. Eight hundred eighty-nine claims in four clinical categories---obstetrics, surgery, missed and delayed diagnosis and medication---were judged to have an injury associated with a medical error, and of these, medical trainees played at least a moderately important role in 240 (27%). The study, which was funded by the Agency for Healthcare Research and Quality, appeared in the Oct. 22 Archives of Internal Medicine.

Eighty-seven percent of the 240 cases involved residents, while fellows and interns were each involved in 13%. Adverse outcomes were usually serious: One-third of the errors led to significant physical injury, one-fifth led to major physical injury, and one-third resulted in death. The most common factors contributing to medical errors among trainees were errors in judgment (173 of 240 [72%]), breakdowns in teamwork (167 of 240 [70%]) and lack of technical competence (139 of 240 [58%]).

Of teamwork problems, handoff problems and lack of supervision were the most common and were more likely to be seen in trainee than in nontrainee errors (20% vs. 12% and 54% vs. 7%, respectively). Trainee errors were also more likely than nontrainee errors to involve inpatients (70% vs. 52%). Lack of technical competence among trainees was most likely to involve diagnostic decision making and monitoring the patient or the situation.

The authors acknowledged that the errors examined in their study could have had other undetected contributing factors and that causal relationships could not be determined. Also, because the events in their study occurred before 2003, they were unable to examine the effect of the Accreditation Council for Graduate Medical Education's work-hour limits on trainees' medical errors. However, they wrote, their results point to areas that should be stressed in residency training, including teamwork and communication skills, and highlight the importance of appropriate trainee supervision.

Archives of Internal Medicine is online.

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Chlorhexidine-based interventions reduced catheter-associated infections

Chlorhexidine-based interventions worked better than other therapies in controlling catheter-associated infection, according to two new studies in the Oct. 22 Archives of Internal Medicine.

In the first study, French researchers randomly assigned patients with central venous catheters inserted in the jugular or subclavian vein to receive disinfection with a povidone-iodine solution or a chlorhexidine-based solution. Both solutions were used to disinfect skin before catheter insertion and subsequently during dressing changes.

Culture results were available for analysis from 481 of 538 randomized catheters. Patients who received the chlorhexidine solution had a 50% decrease in catheter colonization compared with those who received the povidone-iodine solution (11.6% vs. 22.2%). A trend toward lower rates of catheter-related bloodstream infection (1.7% vs. 4.2%) was also seen in the chlorhexidine group. Use of povidone-iodine solution was found to be an independent risk factor for catheter colonization, along with jugular vein insertion.

Although their trial was not blinded, the authors concluded that patients with central venous catheters who receive disinfection with a chlorhexidine-based solution are less likely to develop catheter-related infection than those for whom a povidone-iodine solution is used. They recommended that disinfection with chlorhexidine-based solution be considered as a replacement for povidone-iodine solution in this patient population.

In the second study, researchers in Chicago wanted to determine whether bathing with chlorhexidine gluconate would decrease incidence of primary bloodstream infections compared with soap and water. The study involved 836 patients in two 11-bed units that made up a medical ICU at a single hospital. During the first two-week study period, one unit was chosen randomly as the intervention unit, where patients were bathed daily with chlorhexidine gluconate. Patients in the other unit were bathed daily with soap and water. Researchers then imposed a two-week washout period before crossing the bathing methods over between the two units for an additional 24 weeks.

Patients who were bathed with chlorhexidine gluconate were much less likely to develop a primary bloodstream infection than those who were bathed with soap and water (4.1 infections per 1,000 patient-days vs. 10.4 infections per 1,000 patient-days). Rates of other infections were similar between the two units. The researchers concluded that bathing patients with chlorhexidine gluconate is an effective method of reducing primary bloodstream infections in the ICU.

The first and second studies are online (subscription required).

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Clinical news

More breast cancer patients choosing prophylactic mastectomies

An increasing number of women are choosing to have bilateral mastectomies when cancer is found in one of their breasts, a new study found.

Researchers used government databases to track 152,755 women who were treated for stage I, II or III breast cancer between 1998 and 2003. They found that 4,969 of the patients--3.3% of those treated surgically--had contralateral prophylactic mastectomy. The rate of contralateral mastectomies increased significantly over the course of the study, from 1.8% in 1998 to 4.5% in 2003. Women who were younger, white and had a previous cancer diagnosis were most likely to opt for bilateral mastectomies.

The findings represent a dramatic change toward more aggressive breast cancer surgery, and a growing tendency for women to choose between minimal surgery (lumpectomy) and the most aggressive options, the study authors concluded. The study found that lumpectomies remain the most common surgical treatment of breast cancer, and continue to increase, while the number of single mastectomies performed is declining. The study was released early online in the Journal of Clinical Oncology.

One study author expressed concern to the Oct. 23 Washington Post that women may be having the contralateral breast removed in the hopes of improving their chance of surviving the cancer when in fact the procedure may not affect their survival. The author is planning further research to determine why women are selecting bilateral mastectomies and to explore whether they are adequately warned about increased risks such as infection, the Washington Post reported.

The Journal of Clinical Oncology is online.

The Washington Post is online.

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Testing intention doesn’t breed action for those with high HIV risk

People with high risk of HIV infection are more likely to state a desire to get tested but less likely to follow through, a new study found.

Researchers conducted a pooled, cross-sectional analysis of 146,868 adults age 18-64 years from the 2000-2005 National Health Interview Surveys. They examined perceived risk for HIV infection, as well as planned and actual HIV testing, and how these varied with demographic characteristics, alcohol use and depression. Subjects were asked if they ever had an HIV test, when their last test was, and whether they were planning to get tested in the next year. The study was published in the Oct. 22 Archives of Internal Medicine.

Lifetime HIV testing rates stayed at about 37% between 2000 and 2005, with non-white women most likely to get tested and white men the least likely. While testing rates were higher in people who reported a lifetime risk of HIV infection (67%), the difference between those with a lifetime risk who planned to get and who actually did get a voluntary test was also highest (-16% vs. -5.6% for those with no risk). A high to moderate risk of HIV infection also led to a high testing difference (-15%), as did a high amount of alcohol consumption (-8.8% vs. -4.8% for no consumption) and depressive symptoms (-7.2% vs. -4.4% for no depressive symptoms).

Nearly half of HIV tests occurred as part of medical check-ups or prenatal care, the authors noted, which suggests that efforts to integrate testing into routine care may have been successful. Alcohol and mental health treatment sites are other potential venues for increased testing, they said. About 25% of people infected with HIV don’t know they have the virus, yet that 25% is responsible for more than half of new infections, the lead authors said in the Oct. 23 Washington Post.

The Archives of Internal Medicine is online. (subscription required)

The Oct. 23 Washington Post is online.

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ACP publishing news

November ACP Observer online

As patients become more interested in complementary and alternative medicine techniques, physicians have to bone up on the evidence. Read about CAM, as well as the rising impact of sleep disorders and how internists are reacting to a sharp increase in adolescent prescriptions, in the November/December 2007 issue of ACP Observer, now online.

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Caption contest: Put words in our mouth

ObserverWeekly wants readers to create captions for this cartoon--and help choose the winner.

E-mail all entries to observerstaff@acponline.org by Nov. 12. ACP staff will choose three finalists and post them Nov. 13 for an online vote by readers that week. The winner will appear in the Nov. 20 issue of Weekly.

Pen the winning caption and win "Medicine in Quotations," ACP's comprehensive collection of famous sayings.

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New issue of IMpact

The October issue of IMPact, ACP’s newsletter for medical residents, is online.

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For the record

The teaser for last week's story on the CDC's updated immunization schedule was misstated. The schedule recommends varicella vaccine for all adults without evidence of immunity to varicella.

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College news

College Fellow takes medical school presidency

Meharry Medical College in Nashville, Tenn., installed Wayne J. Riley, FACP, as the school’s tenth president. Dr. Riley has acted as president and CEO of the medical college since January. During his tenure, school officials credit him with securing federal funding for the institution, initiating collaborative discussions with local leaders and organizations, and raising awareness of the school.

Dr. Riley previously served the Baylor College of Medicine (BCM) in Houston as vice-president and vice dean for health affairs and governmental relations and associate professor of medicine. At Houston’s Ben Taub General Hospital, he was assistant chief of medicine and a practicing general internist.

More information is online.

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