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

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ACP InternistWeekly



In the News for the Week of 6-21-11




Highlights

Malpractice claim numbers similar for inpatient and outpatient settings

More than half of all malpractice claims involve outpatient care, although inpatient claims are more expensive on average, a study found. More...

Averaged home blood pressure readings are more accurate

As few as five averaged home blood pressure readings could more accurately assess hypertension control than those taken in the office, researchers suggest. More...


Test yourself

MKSAP Quiz: type 2 diabetes with a draining chronic foot ulcer

A 75-year-old man with type 2 diabetes mellitus is evaluated in the emergency department for a draining chronic ulcer on the left foot, erythema, and fever. This week's MKSAP Quiz asks readers to determine appropriate management. More...


Obesity

Bariatric surgery may not improve survival in middle-aged obese men, study suggests

Middle-aged obese men who undergo bariatric surgery may not see a survival benefit, according to a new study. More...


Adverse drug events

STOPP criteria work better than Beers

Adverse drug events in elderly patients could potentially be reduced by use of the STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, a new study suggested. More...


FDA update

Warning on pioglitazone and bladder cancer

A warning is being added to the label of diabetes medication pioglitazone (Actos) about the drug's possible association with bladder cancer, the FDA announced last week. More...


CMS update

New ICD-10 and version 5010 resources from CMS

CMS has posted new educational materials about the conversion to ICD-10 and version 5010 online. More...


From ACP Hospitalist

ACP Hospitalist is online and coming to your mailbox

The latest issue of ACP Hospitalist is now online, featuring stories on partial DNRs, antibiotic stewardship and ICU care, plus more. More...


From the College

Alliance for a Healthier Generation resources available to ACP members

ACP is collaborating with the Alliance for a Healthier Generation, an organization that seeks to reduce the nationwide prevalence of childhood obesity, to offer useful resources to ACP members. More...

ACP members invited to CDC lectures on anniversary of the HIV/AIDS epidemic

ACP members are invited to attend the CDC's lecture series in Atlanta: "HIV/AIDS: 30 Years of Leadership and Lessons," a series of moderated conversations with leaders describing defining moments that changed the course of the HIV/AIDS epidemic. More...

Take survey on critical care for ACP's LEAP program

ACP is collaborating with Medscape to obtain a grant to help deploy ACP's LEAP (Learn Expressively about Patients) program on pulmonary critical care. More...

Subjects sought for study of chronic kidney disease in adult type 2 diabetes patients

The National Kidney Foundation is looking for primary care physicians and their patients to participate in a multi-site cross-sectional study to estimate the prevalence of chronic kidney disease in adult type 2 diabetes patients. More...


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...


Physician editor: Patrick Alguire, FACP




Highlights


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Malpractice claim numbers similar for inpatient and outpatient settings

More than half of all malpractice claims involve outpatient care, although inpatient claims are more expensive on average, a study found.

To report and compare the number, magnitude, and type of paid malpractice claims for each setting, researchers conducted a retrospective analysis of malpractice claims recorded by the National Practitioner Data Bank from 2005 through 2009. Results appeared in the June 15 Journal of the American Medical Association.

Researchers evaluated claims paid by setting, characteristics of paid claims, and factors associated with payment amount. In 2009, 10,739 malpractice claims were paid. Of these payments, 4,910 (47.6%) were for inpatient events and 4,448 (43.1%) were for outpatient events. Another 966 (9.4%) involved events in both settings.

While the overall number of malpractice claims decreased significantly from 2005 to 2009 in all three categories, inpatient claims declined the most. Inpatient claims declined from 6,515 in 2005 to 4,910 in 2009 while outpatient claims declined from 5,511 in 2005 to 4,448 in 2009 (P<0.001). The proportion of payments that were made for events in the outpatient setting increased a small but significant amount, from 41.7% in 2005 to 43.1% in 2009 (P<0.001).

For inpatient care, the events that led to the claims were most commonly surgical (34.1%), diagnostic (21.1%) and treatment (20.3%). In the outpatient setting, the most common were diagnostic (45.9%), treatment (29.5%) and surgical (14.4%). Major injury was the most common outcome in the inpatient (37.8%) and outpatient (36.1%) settings. Death was the next most common outcome in the inpatient (36.1%) and outpatient (30.6%) settings.

The mean payment amount of $362,965 for inpatient events was significantly higher than the amount of $290,111 for outpatient events (P<0.001), as was the median payment amount (inpatient, $195,000 [interquartile ratio, $77,500-$495,000]; outpatient, $145,000 [interquartile ratio, $47,500-$375,000]; P<0.001). Mean payment amount (in 2009 U.S. dollars) did not increase significantly in either setting (P<0.05 for all settings).

The authors wrote, "Events related to diagnosis may be particularly important in the outpatient setting, where follow-up is more difficult than in the hospital and where patients often present with symptoms and signs that may be subtle or not adequately noted amid the many short-term, long-term, and preventive care activities often undertaken in a single outpatient visit."

But, they added, improving patient safety is more difficult in the outpatient setting because many practices are too small to have well-trained staff devoted to patient safety.

"Because the amount per claim paid is higher in the inpatient setting and inpatient patient safety efforts may be easier to undertake, it is understandable that efforts to date have focused on inpatient care," the authors concluded. "However, the high volume of outpatient malpractice claims and the serious nature of many of these claims suggest that the relative neglect of outpatient safety should not persist."

An accompanying editorial described the situation as good news-bad news. While malpractice claims are decreasing overall, current ambulatory risk management is insufficient. "It is likely that with the continued shift to care delivery in ambulatory settings, the medical home, and the growth of hospital-based ambulatory networks, the risk of malpractice in the ambulatory setting will continue to increase," the editorial concluded.

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Averaged home blood pressure readings are more accurate

As few as five averaged home blood pressure readings could more accurately assess hypertension control than those taken in the office, researchers suggest.

annals.jpg

To compare strategies for home or clinic blood pressure measurement, researchers conducted a secondary analysis of the Hypertension Intervention Nurse Telemedicine Study. A subset of 444 veterans with long-standing hypertension was followed for 18 months in primary care clinics affiliated with the Durham Veterans Affairs Medical Center. The sample was 92% men, about half of whom were black, with a mean age of 64 years who had been selected on the basis of previous poor blood pressure control. Three-quarters of them had had hypertension for at least 10 years. Study results appeared in the June 21 Annals of Internal Medicine.

In the study, blood pressure was measured repeatedly by using three methods: research blood pressure measurements at 6-month intervals, clinic blood pressure measurements obtained at varying intervals during outpatient visits, and home blood pressure measurements taken at least three times a week using a digital home monitor and telemedicine device.

Patients provided 111,181 systolic blood pressure measurements (3,218 research, 7,121 clinic, and 100,842 home measurements) over 18 months. Systolic blood pressure control rates at baseline (mean systolic blood pressure <140 mm Hg for clinic or research measurement; <135 mm Hg for home measurement) varied substantially, with 28% classified as in control by clinic measurement, 47% by home measurement, and 68% by research measurement.

In the clinic, no single systolic blood pressure measurement from 120 mm Hg to 157 mm Hg allowed correct classification of a patient's blood pressure control with 80% or greater certainty. For systolic blood pressure measurements from 136 mm Hg to 144 mm Hg, at least 10 measurements are required before a patient can be correctly classified with at least 80% probability.

Results for home blood pressure measurements are similar to clinic results. For a single observed measurement, only readings of 123 mm Hg or less or 153 mm Hg or more could be correctly classified as in or out of control with at least 80% probability. Most observed mean systolic blood pressures could be accurately categorized with 80% probability based on the mean of five home measurements.

The results support reimbursement for home blood pressure monitoring, the authors suggested. "Current decisions about medication therapy are often made on the basis of one or two clinic measurements; these data suggest that this could be substantially improved for patients with a history of elevated blood pressure measurements when decisions are based on the average of several measurements, regardless of the setting," they wrote.

An editorial pointed out that the American Heart Association called for blood pressure guidelines in 1939, but that clinical adoption has lagged and poor practices still include such habits as taking blood pressure readings through clothing. "The importance of accurate and precise [blood pressure] measurement has largely been ignored," the editorialists wrote. "Given persistent problems in obtaining such measurements, a regulatory approach should be considered in which the Joint Commission, the National Committee for Quality Assurance, and other organizations set standards and monitor compliance. It is time to get serious about BP measurement."

A patient summary is available online.

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Test yourself


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MKSAP Quiz: type 2 diabetes with a draining chronic foot ulcer

A 75-year-old man with type 2 diabetes mellitus is evaluated in the emergency department for a draining chronic ulcer on the left foot, erythema, and fever. Drainage initially began 3 weeks ago. Current medications include metformin and glyburide.

On physical examination, he is not ill appearing. Temperature is 37.9 °C (100.2 °F); other vital signs are normal. The left foot is slightly warm and erythematous. A plantar ulcer that is draining purulent material is present over the fourth metatarsal joint. A metal probe makes contact with bone. The remainder of the examination is normal.

The leukocyte count is normal, and an erythrocyte sedimentation rate is 70 mm/h. A plain radiograph of the foot is normal.

Gram stain of the purulent drainage at the ulcer base shows numerous leukocytes, gram-positive cocci in clusters, and gram-negative rods.

Which of the following is the most appropriate management now?

A) Begin imipenem
B) Begin vancomycin and ceftazidime
C) Begin vancomycin and metronidazole
D) Perform bone biopsy

Click here or scroll to the bottom of the page for the answer and critique.

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Obesity


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Bariatric surgery may not improve survival in middle-aged obese men, study suggests

Middle-aged obese men who undergo bariatric surgery may not see a survival benefit, according to a new study.

Most studies of survival after bariatric surgery have focused mainly on populations of younger white women, but mortality related to obesity has been found to be highest in men and in minority patients with comorbid conditions. Researchers performed a retrospective cohort study to compare survival in mostly middle-aged severely obese veterans who had undergone bariatric surgery at a Veterans Affairs medical center from January 2000 to December 2006 and in a group of severely obese veterans who had not had bariatric surgery. Patients were followed for a mean of 6.7 years, and the primary outcome measure was all-cause mortality through December 2008. The study results were published online June 12 by the Journal of the American Medical Association.

The surgery group included 850 veterans who had had bariatric surgery (mean age, 49.5 years; mean body mass index [BMI], 47.4 kg/m2) and 41,244 controls who had not (mean age, 54.7 years; mean BMI, 42.0 kg/m2). Approximately 74% of the surgical patients and approximately 92% of the controls were men. The 1-, 2- and 6-year crude mortality rates were 1.5%, 2.2% and 6.8%, respectively, in the surgical group, and 2.2%, 4.6% and 15.2% in the control group. Bariatric surgery was associated with a mortality reduction in unadjusted Cox regression analysis (hazard ratio [HR], 0.64; 95% CI, 0.51 to 0.80) and after covariate adjustment (HR, 0.80; 95% CI, 0.63 to 0.995). However, in an analysis of 1,694 propensity-matched patients, 847 in each group, no significant association was seen between surgery and reduced mortality in unadjusted (HR, 0.83; 95% CI, 0.61 to 1.14) or time-adjusted (HR, 0.94; 95% CI, 0.64 to 1.39) Cox regressions.

The authors acknowledged that their study results may not be generalizable to other groups of patients and that they did not include patients who had had laparoscopic banding procedures. They also noted that Roux-en-Y gastric bypass is more difficult to perform and yields higher mortality rates in larger male patients than in female patients, which may have contributed to the lack of survival benefit. Finally, they wrote that the large CIs in the propensity-matched analysis cannot exclude the possibility that some patients may derive clinical benefit or harm from bariatric surgery, and that their results may be subject to unobserved confounding.

However, they concluded that middle-aged obese men do not see a survival benefit within seven years of bariatric surgery, although longer follow-up may be needed to observe a protective effect. Future studies, they said, should include larger samples and should try to determine which subgroups of patients would benefit most from surgery. "Even though bariatric surgery is not associated with reduced mortality among older male patients, many patients may still choose to undergo bariatric surgery, given the strong evidence for significant reductions in body weight and comorbidities and improved quality of life," they wrote.

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Adverse drug events


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STOPP criteria work better than Beers

Adverse drug events in elderly patients could potentially be reduced by use of the STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, a new study suggested.

The prospective study included 600 patients 65 years or older admitted to an Irish teaching hospital. Researchers observed 329 adverse drug events in the records of 158 of the patients. About 66% of those adverse events had contributed to or caused the hospital admission, according to the researchers' evaluation. Of those causal/contributory events, 68.9% were avoidable or potentially avoidable. The study was published in the June 13 Archives of Internal Medicine.

The study authors then compared the drugs that had caused the adverse events with two established criteria for avoiding potentially inappropriate medications in elderly patients—the STOPP and the Beers criteria. They found that the drugs involved in the adverse events were 2.54 times more likely to meet STOPP criteria than Beers criteria. Looking only at the events that were avoidable and contributory to the hospitalization, the researchers found that they were 2.8 times more likely to be on the STOPP list (P<0.001).

After adjustment for a number of factors, the researchers found that patients taking a medication on the STOPP list were 85% more likely to have an adverse drug event than those who weren't (odds ratio, 1.847; 95% CI, 1.506 to 2.264; P<0.001). No significant association was found with the Beers criteria. The results strengthen the argument for using STOPP criteria as a routine screening tool in everyday clinical practice, the authors concluded. Further research is needed to determine definitively whether use of the STOPP reduces adverse events, medication costs and health care utilization, the authors said.

Tools such as STOPP cannot capture all potentially inappropriate prescribing, the authors cautioned, and should be used to enhance, rather than replace, clinical judgment in prescribing for older patients. An accompanying commentary also noted that tools have to be implemented effectively to provide benefit. Greater incorporation of electronic prescribing into clinicians' workflows should help with this, the commentary author wrote. He also suggested that future research assess any unintended consequences of efforts to avoid potentially dangerous medications, for example, pain in a patient taken off opiate therapy to reduce the risk of falls.

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FDA update


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Warning on pioglitazone and bladder cancer

A warning is being added to the label of diabetes medication pioglitazone (Actos) about the drug's possible association with bladder cancer, the FDA announced last week.

The warning is based on an interim analysis of an ongoing 10-year study by the manufacturer. The study found overall that patients who had taken pioglitazone had no increase in bladder cancer compared to those who had never been exposed. However, compared to never taking pioglitazone, a duration of pioglitazone therapy longer than 12 months was associated with a 40% increase in risk (HR, 1.4; 95% CI, 0.9 to 2.1), the FDA reported.

Use of the drug was recently suspended in France due to the results of a different study, which found statistically significant increases in bladder cancer with pioglitazone compared to other diabetes drugs (HR, 1.22; 95% CI, 1.03 to 1.43). The results also showed a dose effect for a cumulative dose greater than 28,000 mg (HR, 1.75; 95% CI, 1.22 to 2.5) and for exposures longer than 1 year (HR, 1.34; 95% CI, 1.02 to 1.75).

In the new warning, the FDA recommends that clinicians not use pioglitazone in patients with active bladder cancer and use it cautiously, weighing risks and benefits, in patients with a prior history of bladder cancer. Patients should be encouraged to report any signs or symptoms of blood in the urine, urinary urgency, pain on urination, or back or abdominal pain. Pioglitazone is also sold in combination with metformin (Actoplus Met, Actoplus Met XR) and glimepiride (Duetact).

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CMS update


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New ICD-10 and version 5010 resources from CMS

CMS has posted new educational materials about the conversion to ICD-10 and version 5010 online.

The materials were developed for a "Code-a-thon" that was jointly sponsored by CMS and the American Academy of Professional Coders in April. The new materials can be found in the Latest News section of the website.

Additional information about what the new ICD-10 coding system and the accompanying version 5010 electronic standards will mean for physician practices is also available from ACP.

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From ACP Hospitalist


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ACP Hospitalist is online and coming to your mailbox

The latest issue of ACP Hospitalist is now online.

acpi-20110621-cover.jpg

Features include:

Partial DNRs cause problems for physicians, patients. Partial DNRs can be attractive to patients, but they may cause more problems than they solve.

Expert details the drugs that best fight the most common bugs. Ten years ago, infection control was the biggest trend in tackling hospital-based infectious diseases. Now the new hot area is antibiotic stewardship.

ID specialist describes other causes of elevated temperature. When you see a patient with a temperature of 101, what do you note in the chart? Probably "fever," right? Maybe not.

Are you involved in hospital medicine? Then you should be getting ACP Hospitalist, the monthly publication from the American College of Physicians that keeps hospitalists informed about the latest trends and issues in the field. Subscribe online.

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From the College


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Alliance for a Healthier Generation resources available to ACP members

ACP is collaborating with the Alliance for a Healthier Generation, an organization that seeks to reduce the nationwide prevalence of childhood obesity, to offer useful resources to ACP members.

The Alliance works to positively influence the environments that can make a difference in a child's health, including homes, schools, doctor's offices and communities, and provides resources for clinicians on how to work with patients and their families around the prevention, assessment, and treatment of childhood obesity.

The Alliance also offers CME webinars to physicians to learn more about the resources available related to the treatment of childhood obesity. More information on the Alliance for A Healthier Generation is available on the organization's website.

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ACP members invited to CDC lectures on anniversary of the HIV/AIDS epidemic

ACP members are invited to attend the CDC's lecture series in Atlanta: "HIV/AIDS: 30 Years of Leadership and Lessons," a series of moderated conversations with leaders describing defining moments that changed the course of the HIV/AIDS epidemic.

The series began on June 10 and extends through the summer, culminating with a session at CDC's National HIV Prevention Conference on August 17, 2011. For more information on the series, please go to the website or contact the CDC by e-mail.

ACP is a partner with the CDC's "HIV Screening. Standard Care" initiative that is designed to help physicians make HIV testing a standard part of the medical care they provide to patients. ACP's guidance statement, "Screening for HIV in Health Care Settings," is available online.

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Take survey on critical care for ACP's LEAP program

ACP is collaborating with Medscape to obtain a grant to help deploy ACP's LEAP (Learn Expressively about Patients) program on pulmonary critical care.

ACP members are invited to take part in the survey that will help the College document the need for the curriculum on pulmonary critical care. Participation in the three-question survey is voluntary and confidential. To participate in the survey, please go to the website.

Top


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Subjects sought for study of chronic kidney disease in adult type 2 diabetes patients

The National Kidney Foundation is looking for primary care physicians and their patients to participate in a multi-site cross-sectional study to estimate the prevalence of chronic kidney disease in adult type 2 diabetes patients.

Patients and physicians will be compensated for their time. Commitment is one office visit for each participant. Those who are interested can learn more online.

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Cartoon caption contest


.
Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acpi-20110621-cartoon.jpg

E-mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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MKSAP Answer and Critique



The correct answer is D) Perform bone biopsy. This item is available to MKSAP 15 subscribers as item 8 in the Infectious Disease section.

Contact with bone (when using a sterile, blunt, stainless steel probe) in the depth of an infected pedal ulcer in patients with diabetes mellitus is strongly correlated with the presence of underlying osteomyelitis, with a positive predictive value of 90%. Patients with diabetes require bone biopsy to obtain deep pathogens, identification of which is the only way to establish a definitive diagnosis and guide therapy. Although it may seem intuitive that drainage from a superficial site such as an ulcer or a sinus tract would contain the causative pathogens, superficial cultures usually do not include the deep organisms responsible for the infection. Failure to identify the causative deep-bone pathogens may lead to spread of infection to adjacent bones or soft tissues and the need for extensive debridement or amputation. The one exception is Staphylococcus aureus, which, even if found in superficial cultures, correlates well with findings on deep cultures.

This patient appears well enough to wait for the bone biopsy to be completed before starting empiric antibiotic therapy (and adjusting the antibiotics based on culture results) or until bone culture results become available. Empiric therapy should include activity against streptococci, methicillin-resistant S. aureus (MRSA), aerobic gram-negative bacilli, and anaerobes. Therapy with imipenem alone will not adequately cover MRSA, vancomycin and ceftazidime will not adequately cover anaerobic bacteria, and vancomycin and metronidazole will not adequately cover gram-negative organisms.

Key Point

  • Cultures obtained from a sinus tract or ulcer base often do not reflect the bacterial etiology of an underlying osteomyelitis; bone biopsy is indicated to identify the causative pathogens and guide antibiotic therapy.

Click here to return to the rest of ACP InternistWeekly.

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