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

Advertisement

ACP InternistWeekly



In the News for the Week of July 23, 2013




Highlights

Missed diagnoses and drug errors make up bulk of primary care malpractice claims

Missed or delayed diagnoses, particularly of cancer and myocardial infarction in adults and meningitis in children, were the most common cause of malpractice claims brought against doctors in primary care, a British meta-analysis of studies performed in different countries found, while medication errors were the second most common reason for claims. More...

Concomitant aspirin common in afib patients taking oral anticoagulants

Concomitant aspirin use appears common in patients with atrial fibrillation (AF) who are taking oral anticoagulants and is associated with significantly increased bleeding risk, a new study has found. More...


Test yourself

MKSAP Quiz: 3-week history of fatigue, weight loss

A 58-year old woman is evaluated for a 3-week history of fatigue and weight loss. The patient has no significant medical history and takes no prescription medication, but she does take a daily over-the-counter multivitamin and a calcium supplement. She has a 50-pack-year smoking history. Following a physical exam, lab tests and chest radiograph, what is the most likely cause of her hypercalcemia? More...


Vascular testing

Appropriate use criteria offered for noninvasive vascular tests of more than 100 clinical scenarios

Eleven medical societies drafted detailed criteria to help clinicians optimize the appropriate use of noninvasive vascular tests in patients with known or suspected disorders of the venous system, such as venous insufficiency; varicose veins; blood clots in the leg, arm or abdomen; and pulmonary embolism. More...


Infectious diseases

Specialty groups offer guide on which lab tests are best for diagnosing infectious diseases

The Infectious Diseases Society of America and the American Society for Microbiology have published a guide to help physicians determine which tests are most useful in diagnosing infectious diseases. More...


Opioids

Education program for prescribing opioids now available

ACP and its curriculum partner Pri-Med have launched "SAFE Opioid Prescribing," an online training program to educate clinicians about safety and efficacy when prescribing opioids. More...


Health care reform

IOM report calls for overhaul of nation's health care system

A new report published by the Institute of Medicine (IOM) is calling for an overhaul of America's health care system. The report, "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America (2012)," provides evidence that the nation's system is too costly to sustain and suffers from inefficiencies, an overwhelming amount of data, and quality barriers that hinder progress in improving health. More...


From ACP Hospitalist

Who's tops at your hospital? Tell us by tomorrow!

ACP Hospitalist is seeking candidates for its sixth 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 2013. 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: Philip Masters, MD, FACP



Highlights


.
Missed diagnoses and drug errors make up bulk of primary care malpractice claims

Missed or delayed diagnoses, particularly of cancer and myocardial infarction in adults and meningitis in children, were the most common cause of malpractice claims brought against doctors in primary care, a British meta-analysis of studies performed in different countries found, while medication errors were the second most common reason for claims.

Researchers included 34 studies of 10 or more malpractice claims and recorded the prevalence of, reasons for, outcomes of and compensation awarded for claims. Among the studies, 28 were from medical indemnity malpractice claims databases and the other six presented survey data. Fifteen studies were based in the U.S., nine were based in the U.K., seven were based in Australia, one was based in Canada and two were based in France.

Results appeared in the online journal BMJ Open on July 18.

Failure to diagnosis or delay of diagnosis was involved in 26% to 63% of all claims across the studies. Following cancer and heart attacks, the most common missed diagnoses were appendicitis, ectopic pregnancy and fractures. Medication errors represented the second most common reason for claims, with 5.6% to 20% of all claims across included studies. Death was the most commonly recorded patient outcome, ranging from 15% to 48% of outcomes noted in malpractice claims. In the U.S. and Australia, primary disciplines ranked in the top five specialties accounting for the most claims, representing 7.6% to 20% of all claims, when compared with other types of physician practices.

Researchers noted that in the U.K., general practitioners made up the greatest proportion of an overall 20% increase in claims between 2009 and 2010, with claims against them more than doubling between 1994 and 1999. In Australia, general practitioners comprised the highest proportion of claims and the highest number of new claims on the national Medical Indemnity National Collection database for both 2009 and 2010.

A substantial proportion of claims were unsuccessful, with only one-third of U.S. claims and half of U.K. claims resulting in a payment. But while the number of claims brought against U.S. doctors has remained fairly stable over the past two decades, those brought against Australian and U.K. GPs have been rising, the authors noted.

The researchers wrote, "The increasing recognition of primary care as a setting for adverse events places the development of fit-for-purpose educational strategies and risk management systems as a priority for those interested in promoting patient safety."


.
Concomitant aspirin common in afib patients taking oral anticoagulants

Concomitant aspirin use appears common in patients with atrial fibrillation (AF) who are taking oral anticoagulants and is associated with significantly increased bleeding risk, a new study has found.

Researchers used data from the Outcomes Registry for Better Informed Consent (ORBIT) of Atrial Fibrillation registry to examine concomitant aspirin use and its relationship to clinical outcomes among AF patients who were taking oral anticoagulants. Patients in ORBIT-AF were enrolled from 176 U.S. practices from June 2010 through August 2011. The researchers used hierarchical multivariable logistic regression models to analyze factors associated with concomitant aspirin use. Six-month bleeding, hospitalization, ischemic events and mortality were the primary outcomes. The study results were published early online July 16 by Circulation.

The study population included 7,347 AF patients who were taking oral anticoagulants. The median patient age was 75 years, 43% were women, and 89% were white. Thirty-five percent of AF patients taking oral anticoagulants (n=2,543) were also taking aspirin. Patients who were receiving both aspirin and oral anticoagulants were more likely to be men (66% vs. 53%; P<0.0001) and had more comorbidities than patients receiving oral anticoagulants alone. Among patients taking both aspirin and oral anticoagulants, 39% had no history of atherosclerotic disease and 17% had increased risk for bleeding (ATRIA bleeding risk score ≥5). Patients taking both aspirin and oral anticoagulants also had higher risk for major bleeding and bleeding hospitalizations compared with patients taking oral anticoagulants alone (adjusted hazard ratios, 1.53 [95% CI, 1.20 to 1.96] and 1.52 [95% CI, 1.17 to 1.97], respectively). Ischemic event rates were low in both of the study groups.

The researchers acknowledged that their data came from a prospective national registry and that the treatment groups were not randomly assigned. In addition, they pointed out that the overall rates of ischemic events were low and that data on aspirin use could have been affected by recall bias. However, they concluded that concomitant aspirin use is relatively common in AF patients who have been prescribed oral anticoagulant therapy, even when vascular disease is not present, and that patients with AF who do have cardiovascular disease often receive oral anticoagulants alone. Bleeding risk in patients taking oral anticoagulants and aspirin was independently associated with use of both agents compared with oral anticoagulants alone.

These data, along with those from other studies, appear to support the potential of a "less is more" strategy in AF patients taking oral anticoagulants, the researchers concluded. They called for additional studies to assess benefits and harms and determine optimal antithrombotic treatment in AF patients.

"In the interim, clinicians need to carefully weigh whether the potential benefits of adding aspirin is worth the risk among patients with AF on [oral anticoagulants]," the researchers wrote. "In lieu of clinical trials, automatic risk assessment tools that calculate ischemic risk and bleeding risk might help guide concomitant antiplatelet therapy."

The authors of an accompanying editorial compared the differences between U.S. and European guidelines on this issue, pointing out that concomitant use of oral anticoagulants and low-dose aspirin in patients with nonvalvular atrial fibrillation and stable atherothrombotic vascular disease is under debate because the efficacy and safety of such combination therapy have not yet been definitively determined. They also recommended that other elements be included in this discussion, including availability of three new oral anticoagulants and two P2Y12 blockers, the advent of drug-eluting stents with lower risk for thrombosis, and increased awareness of aspirin's potential long-term benefits in areas besides cardiovascular health.

"It is hoped that these novel therapeutic options and areas of knowledge will be integrated with more widespread assessment of the individual AF patient's ischemic and bleeding risks as well [as] his/her values and preferences to inform personalized antithrombotic therapy in this setting," the editorialists concluded.



Test yourself


.
MKSAP Quiz: 3-week history of fatigue, weight loss

A 58-year old woman is evaluated for a 3-week history of fatigue and weight loss. The patient has no significant medical history and takes no prescription medication, but she does take a daily over-the-counter multivitamin and a calcium supplement. She has a 50-pack-year smoking history.

mksap.gif

Physical examination reveals a lethargic, ill-appearing woman. Temperature is 37.3 °C (99.1 °F), blood pressure is 136/78 mm Hg, pulse rate is 95/min, and respiration rate is 12/min. Other physical examination findings are unremarkable.

Laboratory studies:

Hemoglobin 8.3 g/dL (83 g/L)
Albumin 4.6 g/dL (46 g/L)
Blood urea nitrogen 43 mg/dL (15.4 mmol/L)
Calcium 14.5 mg/dL (3.6 mmol/L)
Creatinine 2.4 mg/dL (212 µmol/L)
Sodium 145 mEq/L (145 mmol/L)

A chest radiograph shows a 5-cm mass in the right lower lobe of the lung but is otherwise unremarkable.

Which of the following is the most likely cause of her hypercalcemia?

A: Malignancy
B: Primary hyperparathyroidism
C: Sarcoidosis
D: Vitamin D intoxication

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


.

Vascular testing


.
Appropriate use criteria offered for noninvasive vascular tests of more than 100 clinical scenarios

Eleven medical societies drafted detailed criteria to help clinicians optimize the appropriate use of noninvasive vascular tests in patients with known or suspected disorders of the venous system, such as venous insufficiency; varicose veins; blood clots in the leg, arm or abdomen; and pulmonary embolism.

Also included for the first time are recommendations for when and how to use these tests to plan for or evaluate dialysis access placement.

The document states, "Due to the diversity of peripheral vascular disorders, it is likely that many potential clinical indications are not included in this document. Rather than an exhaustive compendium of clinical indications, it is intended that this document address the most common and important clinical scenarios encountered in the patient with manifestations of peripheral vascular disease."

All recommendations are rated as appropriate (median score, 7 to 9; effective option for individual care plans, although not always necessary depending on physician judgment and patient-specific preferences); possibly appropriate (median score, 4 to 6; variable evidence or agreement regarding the benefits/risks ratio, potential benefit based on practice experience in the absence of evidence, and/or variability in the population); or rarely appropriate (median score, 1 to 3; lack of a clear benefit/risk; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option).

The report appeared online July 19 at the website of the American College of Cardiology, and will appear in the Aug. 13 Journal of the American College of Cardiology.

Overall, vascular studies were deemed appropriate when clinical signs and symptoms are the main reason for testing. For example, if a patient has swelling, discoloration or pain in one leg, the document states that it is reasonable to order a duplex ultrasound evaluation of the legs to determine whether there might be deep venous thrombosis (DVT) or a clot. In contrast, it is rarely appropriate to use these tests to screen for DVT in patients without symptoms, even in those who are more prone to clotting or who have had an extended intensive care unit or hospital stay, recent (major) orthopedic surgery or a positive D-dimer blood test.

The report also shows that the vascular lab plays a central role in evaluating patients with chronic venous insufficiency, a condition in which blood pools in the veins of the legs and causes swelling, non-healing ulcers and worsening varicose veins. The document also rates preoperative vascular testing for preparing a dialysis access site as appropriate as long as it is done within three months of the procedure; however, vascular testing is rarely appropriate for general surveillance of a functional dialysis fistula or graft unless there is some indication of a problem, such as a palpable mass or arm swelling, or low volume flow during dialysis sessions.

The authors noted that controversial areas included in the report are whether patients with blood clots in their calf should be treated with blood-thinning medication versus duplex ultrasound surveillance. Another area requiring more research is how ultrasound of the veins in the legs and arms can be used as part of clinical algorithms to diagnose and manage pulmonary embolism. Similarly, the authors wrote, the role of duplex ultrasound for follow-up after venous procedures such as stents or to assess dialysis access maturity is not as well established.

The appropriate use criteria were developed in collaboration with the American College of Cardiology, American College of Radiology, American Institute of Ultrasound in Medicine, American Society of Echocardiography, American Society of Nephrology, Intersocietal Accreditation Commission, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery.



Infectious diseases


.
Specialty groups offer guide on which lab tests are best for diagnosing infectious diseases

The Infectious Diseases Society of America and the American Society for Microbiology have published a guide to help physicians determine which tests are most useful in diagnosing infectious diseases.

The guide outlines the appropriate contexts for various tests and also discusses tests that have little or no value for diagnosis. It is organized by anatomic systems, such as central nervous system infections, intraabdominal infections, and skin and soft tissue infections. Each section includes introductory concepts, a summary of key points, and tables that list the following:

  • suspected agents,
  • the most reliable tests to order,
  • the samples and volumes to collect in order of preference,
  • specimen transport devices, procedures, times, and temperatures, and
  • notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times.

In particular, the guide emphasizes key tenets of specimen management, including precise labeling, rejection of poor-quality specimens, preference for specimens over swabs of specimens, collecting specimens before antibiotics are administered, and not demanding that a laboratory report "everything that grows."

The guide was published online July 10 by Clinical Infectious Diseases.



Opioids


.
Education program for prescribing opioids now available

ACP and its curriculum partner Pri-Med have launched "SAFE Opioid Prescribing," an online training program to educate clinicians about safety and efficacy when prescribing opioids. The program is available through the ACP and Pri-Med websites.

The curriculum was developed with grant money received from a group of manufacturers of extended-release/long-acting opioid analgesics, a funding strategy established by the U.S. Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy (REMS) program. The program marks the first time that an FDA-required REMS program included a continuing medical education (CME) component supported by education grants from industry.

REMS-funded training programs for opioid prescribers adhere to the curriculum guidelines put forth in the FDA's Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid (ER/LA) Analgesics. ACP's curriculum covers all aspects of the FDA blueprint and provides a comprehensive educational program for primary care clinicians to safely and effectively manage patients with chronic pain.



Health care reform


.
IOM report calls for overhaul of nation's health care system

A new report published by the Institute of Medicine (IOM) is calling for an overhaul of America's health care system. The report, "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America (2012)," provides evidence that the nation's system is too costly to sustain and suffers from inefficiencies, an overwhelming amount of data, and quality barriers that hinder progress in improving health.

According to the report, approximately 30% of health care spending in 2009, or roughly $750 billion, was wasted on unnecessary services, excessive administrative costs, fraud and other problems. The authors of the report claim that inefficiencies in health care not only inflate costs but cause needless suffering for patients. They offer several recommendations for transforming the current system. ACP's High Value Care initiative addresses similar issues.



From ACP Hospitalist


.
Who's tops at your hospital? Tell us by tomorrow!

ACP Hospitalist is seeking candidates for its sixth 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 2013. Did they take charge of a key quality or safety initiative? Do they always go out of their way to educate patients or help new physicians? Maybe they are amazing at 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 physician you think we should feature and why. The deadline is July 24, 2013. 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.



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.

acpi-20130723-cartoon.jpg

"So then they said I was dehydrated. That's when I thought I should get a second opinion."

This issue's winning cartoon caption was submitted by Rebekah S. Bartsch, MD, ACP Member. Thanks to all who voted! The winning entry captured 49.5% of the votes.

The runners-up were:

"Tell me more about your Irritable Bowl Syndrome."

"We might need to increase your Lasix."


.


MKSAP Answer and Critique



The correct answer is A: Malignancy. This item is available to MKSAP 16 subscribers as item 17 in the Endocrinology and Metabolism section. More information is available online.

This patient has severe hypercalcemia in the setting of a lung mass. This scenario is highly suggestive of humoral hypercalcemia of malignancy (HHM), which results from tumor production of a circulating factor, parathyroid hormone (PTH)–related protein (PTHrP), that acts on skeletal calcium release, calcium handling by the kidney, and intestinal calcium absorption. Tumors that cause HHM by secreting PTHrP are typically squamous cell carcinomas (often of the lung). Rarely, this disorder can be caused by unregulated production of 1,25-dihydroxyvitamin D (as in B-cell lymphomas) or other mediators that interfere with calcium homeostasis. Although PTHrP assays are now available commercially, results may not be available for up to 10 days. Because endogenous PTH secretion is suppressed in the setting of hypercalcemia, a low PTH level provides indirect but strong evidence of the nature of this patient's hypercalcemia. Because HHM results in a fairly rapid rise in the serum calcium level, patients tend to be more symptomatic than patients with hypercalcemia from other, more chronic causes.

Primary hyperparathyroidism is the most common cause of hypercalcemia in the outpatient setting and typically presents at an asymptomatic stage. This disorder is usually due to a benign parathyroid adenoma and not to a lung mass.

Hypercalcemia is frequently associated with sarcoidosis, with 30% to 50% of patients with the disease demonstrating some degree of abnormal calcium metabolism. However, this patient has no history or physical examination findings suggestive of sarcoidosis, and her lung mass would be an atypical manifestation of primary pulmonary sarcoidosis.

The patient takes a daily multivitamin and calcium supplement in over-the-counter dosages. The recommended daily allowance of vitamin D is 600 units. Although the point at which toxicity occurs is not clear, the Institute of Medicine's recommended tolerable intake of vitamin D is 4,000 units daily, although substantially greater amounts are usually needed for clinically significant hypervitaminosis to occur. It is unlikely that the amount of vitamin D in her daily multivitamin is enough to cause acute toxicity and hypercalcemia.

Key Point

  • Humoral hypercalcemia of malignancy results from tumor production of a circulating factor (parathyroid hormone–related protein [PTHrP]) that acts on skeletal calcium release, calcium handling by the kidney, or intestinal calcium absorption and often involves squamous cell carcinomas of the lung.

Click here to return to the rest of ACP InternistWeekly.

Top




About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

Test yourself

A 69-year-old woman is evaluated for a lump under her arm found on self-examination. She is otherwise healthy and has no other symptoms. Medical and family histories are unremarkable, and she takes no medications. A needle aspirate of the right axillary mass reveals adenocarcinoma. Bilateral mammography and breast MRI are normal. CT scan of the chest, abdomen, and pelvis demonstrates the enlarged axillary lymph node and no other abnormalities. What is the most appropriate initial treatment?

Find the answer

What will you learn from your Annals Virtual Patient?

Reviews of the World's Top Medical Journals—FREE to ACP Members! Annals Virtual Patients is a unique patient care simulator that mirrors real patient care decisions and consequences. CME Credit and MOC Points are available. Start off with a FREE sample case. Start your journey now.

Products and Resources for Patients

Products and Resources for PatientsACP has developed easy- to-use materials designed to help educate your patients on self-management of a wide variety of common health conditions. Order yours today!