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

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ACP InternistWeekly



In the News for the Week of July 3, 2012




Highlights

Postdischarge med errors common in heart patients despite pharmacist intervention

Postdischarge medication errors were common in patients with acute coronary syndromes (ACS) or acute decompensated heart failure even with a pharmacist-led intervention, a new study has found. More...

Statins' effects on men and women compared

Statin therapy reduced women's risk of cardiovascular events but did not significantly affect mortality or stroke risks in a recent meta-analysis. More...


Test yourself

MKSAP Quiz: 2-year history of bloating and abdominal cramping

This week's quiz asks readers to evaluate a 25-year-old woman for a 2-year history of almost daily bloating and lower abdominal cramping. More...


Health information technology

EHRs associated with fewer malpractice claims, study indicates

Physicians who use electronic health records (EHRs) may be less likely to have malpractice claims filed against them, according to a new study. More...


Diabetes

Linagliptin non-inferior to glimepiride in two-year trial

Linagliptin was non-inferior to glimepiride in lowering hemoglobin A1c in type 2 diabetes patients, according to a study designed, conducted and analyzed by linagliptin's manufacturer, Boehringer Ingelheim. More...


Readmissions

Majority of rehospitalizations after MI are for unrelated causes

More than 40% of 30-day rehospitalizations after a myocardial infarction (MI) were related to the MI, while the rest were due to other causes or for unclear reasons, reported a study. More...


From ACP Internist

The next issue of ACP Internist is online

The July/August issue of ACP Internist is available online, including stories on baby boomers, hepatitis C, and more. More...


From ACP Hospitalist

Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its fifth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine. More...


From the College

Supreme Court upholds health care reform law

Last week the Supreme Court announced its decision to uphold the Affordable Care Act. More...


For the record

Clarification to a previous issue

The critique section of last week's MKSAP Quiz in ACP InternistWeekly has been updated. More...


Cartoon caption contest

And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...


Physician editor: Daisy Smith, MD, FACP



Highlights


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Postdischarge med errors common in heart patients despite pharmacist intervention

Postdischarge medication errors were common in patients with acute coronary syndromes (ACS) or acute decompensated heart failure even with a pharmacist-led intervention, a new study has found.

annals.jpg

Researchers performed a randomized, controlled trial at two tertiary care academic hospitals to determine whether a tailored, pharmacist-led intervention would affect clinically important medication errors after hospital discharge among patients with ACS or acute decompensated heart failure. The intervention consisted of pharmacist-assisted medication reconciliation, inpatient counseling by a pharmacist, low-literacy adherence aids, and individualized postdischarge follow-up by telephone.

The number of clinically important medication errors per patient in the first 30 days after discharge, including preventable or ameliorable adverse drug events (ADEs) and potential ADEs caused by discrepancies or lack of adherence, was the study's primary outcome. Preventable or ameliorable ADEs, potential ADEs caused by discrepancies or lack of adherence, and preventable or ameliorable ADEs considered to be serious, life-threatening or fatal were the secondary outcomes. The study appeared in the July 3 Annals of Internal Medicine.

Four hundred thirty patients were assigned to the intervention group, and 432 were assigned to usual care, defined as medication reconciliation and discharge counseling by the treating physicians and nurses. Seven patients in the intervention group and four in the usual care group died in the hospital or withdrew their consent, meaning 851 patients were included in the intention-to-treat analysis. The patients' mean age was 60 years, and 41.4% were women. Health literacy was inadequate in approximately 10% and marginal in 8.7%; in addition, 11.5% had some cognitive impairment. Sixty-one percent had only ACS, 31% had only acute heart failure, and 7% had both.

Overall, 432 patients (50.8%) had at least one clinically important medication error, 22.9% of which were considered serious and 1.8% of which were considered life-threatening. Two hundred fifty-eight patients (30.3%) had ADEs and 253 (29.7%) had potential ADEs. The per-patient numbers of clinically important medication errors and ADEs were not significantly affected by the intervention (unadjusted incidence rate ratios, 0.92 [95% CI, 0.77 to 1.10] and 1.09 [95% CI, 0.86 to 1.39], respectively). Potential ADEs tended to be less common in the intervention group (unadjusted incidence rate ratio, 0.80 [95% CI, 0.61 to 1.04]).

The authors acknowledged that their study involved patients from only two hospitals and that the results therefore may not be generalizable, among other limitations. However, they concluded that clinically important medication errors are common within 30 days after hospitalization for a cardiac condition, and that the pharmacist-led intervention they tested did not improve overall medication safety. "Reducing ADEs and potential ADEs in the postdischarge period is becoming more critical as hospitals have increasing financial penalties tied to rehospitalization rates," they wrote. "Further work is needed to develop and test interventions in this setting, including strategies for higher-risk populations, as well as additional methods, such as postdischarge medication reconciliation …or closer postdischarge surveillance."


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Statins' effects on men and women compared

Statin therapy reduced women's risk of cardiovascular events but did not significantly affect mortality or stroke risks in a recent meta-analysis.

The meta-analysis included 11 randomized, double-blind trials with more than 40,000 patients in which statins were compared to placebo. Researchers calculated statin effects in women versus men. Compared to placebo, statin therapy was associated with a significantly reduced risk of cardiovascular events in both sexes (relative risk [RR], 0.81 [95% CI, 0.74 to 0.89] in women and 0.82 [95% CI, 0.78 to 0.85] in men).

However, women did not see the same benefit in the outcomes of all-cause mortality and stroke. Men on statins had a relative risk for mortality of 0.79 (95% CI, 0.72 to 0.87) compared to placebo, while statin-taking women's decrease in relative risk was insignificant at 0.92 (95% CI, 0.76 to 1.13). Also with stroke, men saw a significant benefit (RR, 0.81 [95% CI, 0.72 to 0.92]) and women didn't (RR, 0.92 [95% CI, 0.76 to 1.10]). Sensitivity analysis of the trials also suggested that lipophilic statins might be better for women than hydrophilic statins, meta-analysis authors concluded.

The authors also noted that women made up only 20% of the studies' population and they offered several possible explanations for their findings, including that women in the trials had worse cardiovascular profiles than men and were less likely to receive antiplatelet drugs. Overall, the analysis supports the use of statins in women for secondary prevention of cardiovascular events, they concluded.

A commentary that accompanied the analysis, in the June 25 Archives of Internal Medicine, criticized the research methods of the authors and pointed out that the confidence intervals for women's and men's outcomes overlapped. The commentary authors concluded that "statins work just as well in women as in men." An editor's note about the analysis said that it was evidence of the need for greater inclusion of women in clinical trials and more reporting of sex-specific data.



Test yourself


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MKSAP Quiz: 2-year history of bloating and abdominal cramping

A 25-year-old woman is evaluated for a 2-year history of almost daily bloating and lower abdominal cramping; the symptoms are associated with constipation, relieved with bowel movements, and seem worse when she is under stress. She has one or two small bowel movements a week and often has a feeling of incomplete evacuation. She never has diarrhea and has not had blood in the stool, nocturnal awakening with pain or for bowel movements, or weight loss. She has taken a fiber supplement without relief. The patient is otherwise healthy, and her only medication is an oral contraceptive pill that she has been taking for 1 year. Her mother had a similar condition when she was younger, but both her parents are alive and well.

mksap.jpg

On physical examination, vital signs are normal; there is mild lower abdominal tenderness with no rebound, guarding, or palpable abdominal masses. Laboratory studies reveal a hemoglobin level of 13.1 g/dL (131 g/L); results of serum biochemistry tests, including thyroid-stimulating hormone, are normal.

Which of the following is the most appropriate next step in the management of this patient?

A) Colonoscopy
B) CT scan of the abdomen and pelvis
C) Discontinue the oral contraceptive
D) Reassurance and polyethylene glycol

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


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Health information technology


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EHRs associated with fewer malpractice claims, study indicates

Physicians who use electronic health records (EHRs) may be less likely to have malpractice claims filed against them, according to a new study.

Researchers used a major malpractice insurer's closed-claims data for Massachusetts physicians who were covered between 1995 and 2007 and merged them with data from surveys given to a random sample of Massachusetts physicians in 2005 and 2007. Closed-claims data were available for 275 physicians, while survey data from both surveys were available for 189 physicians. For each physician, the authors calculated the number of insured years before and after adoption of EHRs and examined whether an association existed between EHR use and malpractice claims. The results were published online as a research letter June 25 by Archives of Internal Medicine.

Twenty-seven (14.3%) of the 189 physicians surveyed in both 2005 and 2007 were named in one or more malpractice claims. The 275 physicians who were surveyed in 2005, 2007, or both years had 51 unique malpractice claims, 49 of which occurred before EHRs were adopted and two of which occurred afterward. A lower rate of malpractice claims was associated with EHR use (estimated relative risk, 0.16 [95% CI, 0.04 to 0.71]).

The authors acknowledged that unmeasured variables, such as the extent of a physician's experience with EHRs, may have affected their results and that their findings may not be generalizable to other settings, among other limitations. However, they concluded that although their study was relatively small, it suggested that EHRs may reduce and do not appear to increase malpractice claims. "The reduction in claims seen in this study among physicians who adopted EHRs lends support to the push for widespread implementation of health information technology," they wrote.



Diabetes


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Linagliptin non-inferior to glimepiride in two-year trial

Linagliptin was non-inferior to glimepiride in lowering hemoglobin A1c (HbA1c) in type 2 diabetes patients, according to a study designed, conducted and analyzed by linagliptin's manufacturer, Boehringer Ingelheim.

Researchers conducted a randomized, double-blind, parallel-group, active controlled, non-inferiority trial at 209 sites in 16 countries. Results appeared online June 28 at The Lancet. Study participants were aged 18 to 80 years, had type 2 diabetes and a body mass index less than 40 kg/m2, were receiving metformin at a stable dose of at least 1,500 mg/d (alone or with one other oral antidiabetic drug), and had an HbA1c of 6.5% to 10% on metformin alone or 6% to 9% on metformin and one additional oral antidiabetic drug.

After a washout period of the patients' second diabetes drugs, linagliptin (5 mg once daily) or glimepiride (initially 1 mg once daily) was added to metformin. The dose of glimepiride was increased in 1-mg increments up to a maximum of 4 mg once daily, at four-week intervals during the first 12 weeks of treatment. The dose of glimepiride was increased if the patients' self-monitored fasting plasma glucose values were greater than 6.1 mmol/L (110 mg/dL). At any time, the dose of glimepiride could be decreased to prevent hypoglycemia.

The primary efficacy endpoint was change in HbA1c from baseline to week 104. The two key secondary endpoints were occurrence of hypoglycemic episodes and change in body weight. After two years of treatment, linagliptin was non-inferior to glimepiride in reducing HbA1c. At week 104, adjusted mean changes in HbA1c from a baseline of 7.7% were −0.16% with linagliptin and −0.36% with glimepiride; the difference between treatment groups was 0.20% (97.5% CI, 0.09 to 0.30; P=0.0004).

An HbA1c of less than 7% at week 104 was achieved by 232 (30%) of 764 patients on linagliptin and 263 (35%) of 755 patients on glimepiride. An HbA1c less than 6.5% was achieved by 92 (12%) of 764 patients in the linagliptin group and 120 (16%) of 755 patients in the glimepiride group. Overall, 200 (26%) of 764 patients on linagliptin and 253 (34%) of 755 patients on glimepiride achieved an HbA1c reduction of 0.5% or greater.

There were 4.8 times fewer hypoglycemic events with linagliptin than with glimepiride (58 [7%] of 776 patients vs. 280 [36%] of 775 patients; P<0.0001). Severe hypoglycemia occurred in one patient receiving linagliptin compared with 12 patients receiving glimepiride. The proportion of patients who had an HbA1c less than 7% and at least one hypoglycemic event was four times lower with linagliptin than with glimepiride (31 [4%] of 776 vs. 152 [20%] of 775 patients). Body weight decreased with linagliptin (−1.4 [SE, 0.2] kg) but increased with glimepiride (1.3 [SE, 0.2] kg) from similar mean baseline values (86.0 [SE, 0.7] kg vs. 87.0 [SE, 0.6] kg).

An accompanying editorial commented that linagliptin was non-inferior to glimepiride after two years, although the non-inferiority of 0.20% was lower than the predefined criterion of 0.35%.

"Only a longer follow-up (presumably at least 4 years) would allow investigators to show whether a more durable glucose-lowering effect can be achieved with a DPP-4 inhibitor than with a sulphonylurea," the editorialists stated. "If so, stabilization of metabolic control would be of great interest by decreasing the future treatment burden for patients with diabetes, thus justifying the higher cost of DPP-4 inhibitors."



Readmissions


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Majority of rehospitalizations after MI are for unrelated causes

More than 40% of 30-day rehospitalizations after a myocardial infarction (MI) were related to the MI, while the rest were due to other causes or for unclear reasons, reported a study.

annals.jpg

Also, comorbid conditions, longer length of stay, and complications of angiography and revascularization or reperfusion were associated with increased 30-day rehospitalization risk, according to results published in the July 3 Annals of Internal Medicine. The retrospective cohort study used a population-based registry in Olmsted County, Minn., of 3,010 patients who were hospitalized with first-ever MI from 1987 to 2010.

A total of 643 rehospitalizations occurred among 561 (18.6%) patients within 30 days of discharge. The most common reasons were ischemic heart disease, respiratory or chest symptoms, and heart failure. Overall, 42.6% of the rehospitalizations were related to the first MI or its treatment, whereas 30.2% were unrelated and 27.2% had an unclear relationship (most often cited as atypical chest pain). Unrelated rehospitalizations were more common in women and patients with non-ST-elevated MI.

Among the conditions independently associated with increased risk for rehospitalization after MI were:

  • diabetes mellitus (hazard ratio [HR], 1.34; 95% CI, 1.10 to 1.63),
  • chronic obstructive pulmonary disease (HR, 1.43; 95% CI, 1.15 to 1.79),
  • anemia (HR, 1.25; 95% CI, 1.03 to 1.50),
  • Killip class 2 to 4 at presentation (HR, 1.22; 95% CI, 1.01 to 1.46),
  • four- to seven-day length of stay during index MI hospitalization (HR, 1.34; 95% CI, 1.05 to 1.70),
  • more than seven-day length of stay during index hospitalization (HR, 1.65; 95% CI, 1.27 to 2.14),
  • complication of angiography during index hospitalization (HR, 2.40; 95% CI, 1.43 to 4.01) and
  • complication of reperfusion or revascularization during index hospitalization (HR, 2.12; 95% CI, 1.61 to 2.80).

"[P]atients affected by a vascular or bleeding complication, stroke, or acute kidney injury after angiography or revascularization or reperfusion represent a high-risk population for rehospitalization," the authors concluded. "Prevention of complications and close follow-up for patients who have had a complication may be of particular importance for preventing rehospitalizations.…[P]atients with MI have many comorbid conditions, which may affect rehospitalization. The management of patients with multiple comorbid conditions and competing risks is of increasing importance as the population ages."



From ACP Internist


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The next issue of ACP Internist is online

The July/August issue of ACP Internist is available online.

acpi-20120703-internist.jpg

Baby boomers' health isn't what they expect. The normal aspects of aging will place extraordinary demands on the health care system as the baby boomers enter their retirement years. Sheer numbers, coupled with high expectations of this population, pose a problem for primary care. Learn more, and take our poll on how this trend impacts your practice.

Better treatment, low awareness for hepatitis C. Amid rising rates of long-term hepatitis C infection, particularly among older populations, better treatments are available to treat the condition. But first, patients have to know they have it, and internists can provide the diagnosis.

Advance directives are the beginning of care, not the end. Despite the best planning, patients may change their minds at the end of life once they recognize their unique situations, and can make sometimes surprising decisions.

More stories and the latest MKSAP Quiz are now online.



From ACP Hospitalist


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Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its fifth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine.

Let us know what your colleagues have accomplished in 2012. Do they always go out of their way to educate patients or help new physicians? Did they take charge of a key quality or safety initiative? Maybe they are wizards at solving tricky diagnoses, or selfless about volunteer outreach. Whatever the contribution, if it helped further hospital medicine, we'd like to hear about it.

Recommending a physician is easy: Just visit our online form and tell us which hospitalist you think we should feature and why. We look forward to receiving your suggestions!

Note: ACP Hospitalist's Top Hospitalist issue is not part of the ACP National Awards Program. Self-nomination is not permitted. Candidates need not be ACP members. The selection process is not scientific. Editorial board members are solely responsible for determining those profiled in the Top Hospitalists issue.



From the College


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Supreme Court upholds health care reform law

Last week the Supreme Court announced its decision to uphold the Affordable Care Act (ACA). In a statement, ACP's president, David L. Bronson, MD, FACP, said that the decision "is a victory for improving health care for all Americans." Find out more about what the College has to say to members about both the law and the Supreme Court decision.



For the record


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Clarification to a previous issue

The critique section of last week's MKSAP Quiz in ACP InternistWeekly has been updated to note that contraindication of basal insulin co-administration with exenatide was removed from the product label in fall 2011.



Cartoon caption contest


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And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acpi-20120703-cartoon.jpg

"To improve emergency room throughput we've replaced the front door with a CT scanner."

This issue's winning cartoon caption was submitted by Brett Montgomery, MD, from Richmond, Va. Thanks to all who voted! The winning entry captured 78.5% of the votes.

The runners-up were:

"Ticklish?"

"I used to say it sounds like a garbage disposal but that hasn't seemed to help folks."


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MKSAP Answer and Critique



The correct answer is D) Reassurance and polyethylene glycol. This item is available to MKSAP 15 subscribers as item 38 in the Endocrinology and Metabolism section. MKSAP 16 will release Part A on July 31. More information is available online.

This patient has irritable bowel syndrome. As a young woman, she fits the demographic profile, and she also meets the Rome III criteria, with abdominal pain relieved by defecation and a change in bowel habits. The most recent formal criteria are the Rome II criteria, which require the presence of at least two of three symptoms occurring for 3 months (not necessarily consecutive) during a 12-month period. These symptoms include pain relieved with defecation, onset associated with change in stool frequency, or onset associated with change in the consistency of the stool. In clinical practice, these criteria have a positive predictive value of 98%. Importantly, she has no alarm indicators, including older age, male sex, nocturnal awakening, rectal bleeding, weight loss, or family history of colon cancer. In the absence of alarm symptoms, additional tests have a diagnostic yield of 2% or less. Furthermore, laboratory studies indicate no anemia or thyroid deficiency.

Irritable bowel syndrome is a clinical diagnosis, and there are no laboratory, radiographic, or endoscopic findings that aid in diagnosis. Additional evaluation is not only unnecessary and expensive but also potentially harmful, especially when invasive procedures are ordered; additionally, confidence in the diagnosis is undermined when serial testing is ordered. The patient should be reassured that although this problem is annoying and inconvenient, it is not life-threatening. The patient has constipation-predominant irritable bowel syndrome, and her symptoms will likely be alleviated if she has more frequent and satisfying bowel movements. Because fiber supplementation has not been helpful, a nonabsorbed osmotic laxative such as polyethylene glycol will likely provide her significant relief.

There is no indication for the patient to undergo a CT scan or colonoscopy. Oral contraceptives are not typically associated with the syndrome, and she began taking the medication after the onset of her symptoms.

Key Point

  • Irritable bowel syndrome is a clinical diagnosis that can be made confidently when patients meet the Rome III criteria and do not have alarm indicators.

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Test yourself

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