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ACP InternistWeekly



In the News for the Week of August 27, 2013




Highlights

Large-scale hypertension program nearly doubled rates of control

A multifaceted hypertension control program applied across a large health care system improved hypertension control compared to state and national averages, a study found. More...

New score predicts dementia risk for type 2 diabetics

A dementia risk score specific to patients with type 2 diabetes was derived and validated by a recent study. More...


Test yourself

MKSAP Quiz: follow-up visit for nephrolithiasis

A 54-year-old man is evaluated during a follow-up visit for five previous episodes of nephrolithiasis. Two of these stones were composed primarily of uric acid. After his third episode, potassium citrate was initiated. Medical history is notable for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Following a physical exam and lab results, what is the most appropriate treatment for this patient? More...


Lipids

Current cholesterol cutpoints may be inaccurate in high-risk patients, study finds

Current guideline-based treatment cutpoints using non-high-density lipoprotein cholesterol (non-HDL-C) may not be accurate for risk stratification and lipid-lowering therapy, especially in high-risk patients, according to a new study. More...


Transitions of care

Many patients don't understand discharge summaries

A week after hospital discharge, even patients who claim to have understood their discharge summaries often have difficulty describing their diagnosis and follow-up plan, a recent study found. 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...

Editorial note: ACP InternistWeekly will not be published next week due to the Labor Day holiday.


Physician editor: Philip Masters, MD, FACP



Highlights


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Large-scale hypertension program nearly doubled rates of control

A multifaceted hypertension control program applied across a large health care system improved hypertension control compared to state and national averages, a study found.

Researchers included insured patients with hypertension who were enrolled in Kaiser Permanente in Northern California from 2001 to 2009. The hypertension program's key elements included a system-wide registry, development and sharing of performance metrics within the system, development of evidence-based guidelines with algorithms for clinician use, medical assistant visits to measure blood pressure, and prescribing single-pill combination drugs.

The program's patients were compared to insured California patients assessed in the Healthcare Effectiveness Data and Information Set (HEDIS) as part of the National Committee for Quality Assurance (NCQA) quality measure reporting process from 2006 to 2009, and the national mean NCQA HEDIS hypertension control rates from 2001 to 2009.

Results appeared in the Aug. 21 JAMA.

There were 349,937 patients enrolled in Kaiser's hypertension program when it began in 2001, and this figure increased to 652,763 by 2009. Patients who participated in the program had a significant increase in hypertension control compared with state and national rates. The NCQA HEDIS measurement for hypertension control within the Kaiser system increased from 43.6% (95% CI, 39.4% to 48.6%) to 80.4% (95% CI, 75.6% to 84.4%) during the study period (P<0.001 for trend), compared to the national mean increase from 55.4% to 64.1% (P=0.24 for trend) and the California mean increase from 63.4% to 69.4% from 2006 to 2009 (P=0.37 for trend). Hypertension control within the Kaiser system continued to improve after the study ended, from 83.7% in 2010 to 87.1% in 2011.

Use of a single-pill combination drug, lisinopril-hydrochlorothiazide, increased within the Kaiser system from 13 prescriptions per month in 2001 to 23,144 prescriptions per month in 2009, as did single-pill combinations of angiotensin-converting enzyme inhibitor prescriptions, from less than 1% to 27.2%

According to study authors, the following factors aided the program's success:

  • The registry helped identify patients for treatment intensification;
  • Quarterly and monthly reports identified high-performing medical centers in which successful practices or innovations were found and then disseminated to other centers;
  • Evidence-based practice guidelines incorporated new evidence and new treatment options;
  • Medical assistant follow-up visits allowed patients greater access by eliminating co-payments, creating more scheduling flexibility, and reducing visit times; and
  • Single-pill drugs were included in 2005 and rapidly adopted across the Kaiser system.

An editorial noted that new value-based models of care should encourage more cost-effective, system-wide interventions like this one and that future guidelines might want to address such approaches.


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New score predicts dementia risk for type 2 diabetics

A dementia risk score specific to patients with type 2 diabetes was derived and validated by a recent study.

Researchers used longitudinal data from the Kaiser Permanente Northern California Diabetes Registry, including almost 30,000 diabetics age 60 and older, to create a prediction model for development of dementia over 10 years. The model was then validated in a separate cohort of more than 2,000 similar patients from Washington State. Results were published by The Lancet Diabetes and Endocrinology on Aug. 20.

The researchers developed a risk score including the factors that most predicted development of dementia in the studied patients: microvascular disease, diabetic foot, cerebrovascular disease, cardiovascular disease, acute metabolic events, depression, older age and less education. Point values were assigned to each factor, and patients were stratified into 14 risk categories, to create what the researchers called the type 2 diabetes-specific dementia risk score (DSDRS).

Patients with the lowest scores had a 10-year dementia risk of 5.3% compared to 73.3% in the highest-risk group. The C-statistic (a statistical measure indicating the predictive strength of a model, with 0.5 being the same as chance and values approaching 1.0 indicating a stronger predictive ability) for the DSDRS was 0.733 to 0.744, which is higher than other commonly used scores like the Framingham score, the researchers noted. The C-statistic for age alone was almost as high, however. This may lead to uncertainty about the value of the score, an accompanying editorial acknowledged, but use of the full score would show, for example, that a 60-year-old with diabetes complications and cardiovascular disease has similar dementia risk to an 80-year-old without those comorbidities.

Because the score uses easily gathered information, it may be useful in primary care to identify the diabetes patients who should be watched most vigilantly for cognitive deterioration and protected from hypoglycemia (which has been associated with cognitive impairment by other research), the study authors concluded. Ideally, this first dementia risk score for diabetes patients could eventually lead to development of measures to predict dementia earlier in life, which would allow more preventive action and motivate lifestyle changes, the accompanying editorial concluded.



Test yourself


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MKSAP Quiz: follow-up visit for nephrolithiasis

A 54-year-old man is evaluated during a follow-up visit for five previous episodes of nephrolithiasis. Two of these stones were composed primarily of uric acid. After his third episode, potassium citrate was initiated. Medical history is notable for type 2 diabetes mellitus, hypertension, and hyperlipidemia. He does not have a known history of gout. He eats a fairly high protein diet, and his fluid intake is inconsistent. Other medications are metformin, metoprolol, amlodipine, atorvastatin, and aspirin.

mksap.gif

On physical examination, blood pressure is 136/82 mm Hg, and pulse rate is 68/min. BMI is 32. There is no costovertebral angle tenderness. The remainder of the examination is unremarkable.

Laboratory studies:

Blood urea nitrogen 15 mg/dL (5.4 mmol/L)
Calcium 8.5 mg/dL (2.1 mmol/L)
Serum creatinine 1.1 mg/dL (97.2 µmol/L)
Uric acid 7.8 mg/dL (0.46 mmol/L)
Urine studies:
Calcium excretion 220 mg/24 h (5.5 mmol/24 h)
Citrate excretion 400 mg/24 h (normal range, 320-1240 mg/24 h)
Oxalate excretion 26 mg/24 h (296 µmol/24 h) (normal range, 9.7-40.5 mg/24 h [111-462 µmol/24 h])
Uric acid excretion 710 mg/24 h (4.19 mmol/24 h)
Urinalysis Specific gravity 1.025; pH 6.2; no blood, protein, or leukocyte esterase
Urine volume 1600 mL/24 h

In addition to increased fluid intake and dietary changes, which of the following is the most appropriate treatment for this patient?

A: Acetazolamide
B: Allopurinol
C: Calcium carbonate
D: Chlorthalidone

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


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Lipids


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Current cholesterol cutpoints may be inaccurate in high-risk patients, study finds

Current guideline-based treatment cutpoints using non-high-density lipoprotein cholesterol (non-HDL-C) may not be accurate for risk stratification and lipid-lowering therapy, especially in high-risk patients, according to a new study.

Low-density lipoprotein cholesterol (LDL-C) levels are the most commonly used treatment target for dyslipidemia management. LDL-C is usually estimated using the Friedewald equation, as follows: LDL-C=total cholesterol minus HDL-C minus (triglycerides/5) when measurements are in mg/dL. However, some guidelines base treatment cutpoints on non-HDL-C levels, which are calculated differently (non-HDL-C=total cholesterol minus HDL-C) and measure the cholesterol content in all of the atherogenic lipoproteins. Treatment goals for non-HDL-C have generally been considered to be approximately 30 mg/dL above established LDL-C levels, although this relationship had not previously been evaluated as in this study.

Researchers used data from the Very Large Database of Lipids to determine whether population percentiles of non-HDL-C and low-density lipoprotein cholesterol (LDL-C) varied within patients and could affect risk stratification. Friedewald-estimated LDL-C and non-HDL-C were calculated and population percentiles were assigned. The authors then determined which percentiles corresponded to current LDL-C cutpoints in clinical guidelines and whether patients would be reclassified to a higher treatment category based on non-HDL-C versus LDL-C. Guideline-based non-HDL-C cutpoints (30 mg/dL higher than LDL-C cutpoints) and percentile-based non-HDL-C cutpoints (equivalent percentiles to LDL-C cutpoints) were both examined. The study results were published online Aug. 21 by the Journal of the American College of Cardiology.

The study population included 1,310,440 U.S. adults who had triglyceride levels below 400 mg/dL. Their mean age was 59 years, and 52% were women. The authors found that LDL-C cutpoints of 70 mg/dL, 100 mg/dL, 130 mg/dL, 160 mg/dL and 190 mg/dL corresponded to the same population percentiles as non-HDL-C levels of 93 mg/dL, 125 mg/dL, 157 mg/dL, 190 mg/dL and 223 mg/dL, respectively. When patients were reclassified by non-HDL-C, a significant proportion moved to a higher treatment category compared with LDL-C, especially high-risk patients and patients with a triglyceride level of 150 mg/dL or greater.

Fifteen percent of patients with an LDL-C level below 70 mg/dL had a non-HDL-C level of 100 mg/dL, the guideline-based cutpoint, while 25% had a non-HDL-C of 93 mg/dL or greater, the percentile-based cutpoint. When triglyceride levels between 150 and 199 mg/dL were also considered, 22% of patients with an LDL-C level below 70 mg/dL had a non-HDL-C level of 100 mg/dL and 50% had a non-HDL-C of 93 mg/dL or greater.

The authors acknowledged that clinical and demographic data were limited and that they could not determine the effect of reclassification on clinical outcomes, among other limitations. However, they concluded that patient-level discordance exists between non-HDL-C and LDL-C percentiles, especially at lower LDL-C and higher triglyceride levels, when they said accuracy is most critical.

"Lowering conventional non-HDL-C cutpoints for high-risk patients to match percentiles of LDL-C cutpoints as well as wider adoption of non-HDL-C in clinical practice may potentially improve secondary prevention outcomes and residual risk assessment and treatment," the authors wrote.



Transitions of care


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Many patients don't understand discharge summaries

A week after hospital discharge, even patients who claim to have understood their discharge summaries often have difficulty describing their diagnosis and follow-up plan, a recent study found.

Researchers at Yale-New Haven Hospital enrolled 395 patients age 65 and older who had been hospitalized for acute coronary syndrome, heart failure or pneumonia between May 2009 and April 2010. The patients' medical records were reviewed and they were contacted by phone for an interview within a week after discharge. Results were published by JAMA Internal Medicine on Aug. 19.

Almost all of the patients (95.6%) reported that they understood the reason for their hospitalization, and 90.3% said they had received written instructions prior to discharge, which more than 85% reported were easy to read and understand. But when researchers compared patients' explanations of their hospitalizations to the medical records, they found that only 59.6% fully understood their diagnosis and an additional 32.2% could at least describe their symptoms. Thirty patients (8.2%) showed no understanding. About a quarter of discharge summaries did not describe the patient's diagnosis in lay language, the researchers found.

They also looked at patients' preparation for discharge and found that 30% reported receiving less than a day's advance notice before discharge and that 66.1% had been asked whether they would receive sufficient support at home. According to the records, 32.6% had a follow-up outpatient appointment scheduled before discharge, but only 43.9% of those patients could recall the details of the appointment during the phone interview.

Despite patients' positive reviews of their discharge experiences, discharge practices and patient comprehension are suboptimal, the researchers concluded, noting that asking patients about their understanding does not seem to be a good way to gauge the effectiveness of discharge preparation. "To better assess what was actually done, questions should be constructed to ask about practice rather than perceived understanding," they wrote. Other potential solutions include patient teach-back or a "universal precautions" approach of treating every patient as if he had cognitive impairment or low health literacy.

Among other limitations, the study was conducted at a single site and did not routinely assess caregivers' understanding, the researchers cautioned. Still, the inclusion of only patients who were discharged to home and could respond to interview questions by telephone may indicate that these results are a best-case scenario, with a more functional patient population than those typically admitted with the studied conditions.



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-20130827-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 B: Allopurinol. This item is available to MKSAP 16 subscribers as item 34 in the Nephrology section. More information is available online.

Allopurinol is indicated for this patient who has recurrent uric acid stones despite alkalinization of the urine. Patients who develop uric acid stones typically have low urine volume or hyperuricosuria. The latter may result from a high protein diet (as in this patient) or rapid purine metabolism as in tumor lysis syndrome. Other risk factors include gout, conditions associated with uric acid overproduction, diabetes mellitus, the metabolic syndrome, and chronic diarrhea. This patient also has inconsistent fluid intake, a relatively high urine uric acid level, and low urine volume, all of which are significant risk factors for development of uric acid nephrolithiasis. Treatment with potassium citrate to alkalinize the urine is often sufficient to decrease the risk for recurrent stones, with the goal of increasing the urine pH to greater than 6.0. This patient continues to have recurrent uric acid nephrolithiasis despite his urine pH being appropriately alkaline. In addition to encouraging more aggressive daily oral hydration and a diet with limited animal protein, seafood, and yeast, the next appropriate step in management is to begin a xanthine oxidase inhibitor to lower uric acid production and urine excretion.

Acetazolamide can alkalinize the urine, but chronic use may lead to a metabolic acidosis and is therefore not typically used for this purpose. Instead, efforts at increasing the urine alkalinization, if necessary, would focus on the dose and frequency of potassium citrate.

Calcium carbonate is often utilized for high urine oxalate excretion from enteric hyperoxaluria, which is not seen in this patient.

A thiazide diuretic such as chlorthalidone is not appropriate for this patient, because thiazide diuretics tend to increase the serum uric acid level and could increase his propensity to develop gout.

Key Point

  • In addition to urine alkalinization, treatment with allopurinol is indicated for patients who have recurrent uric acid stones.

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