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

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ACP Internist® Weekly



In the News for the Week of August 19, 2014




Highlights

Rates of preventable hospital admissions appear lower in smaller primary care practices

Rates of preventable hospital admissions appeared to be lower in smaller primary care practices compared with larger ones, according to a recent study. More...

Atypical antipsychotics associated with increased AKI risk

Use of atypical antipsychotics is associated with increased risk for acute kidney injury (AKI), according to a new study. More...


Test yourself

MKSAP Quiz: Follow-up for a wrist fracture

This week's quiz asks readers to reevaluate a 55-year-old man during a follow-up examination for a wrist fracture and anemia. More...


Influenza

High-dose flu vaccine may work better in elderly people

A high-dose flu vaccine induced significantly higher antibody responses and provided better protection against laboratory-confirmed influenza than did its standard-dose counterpart among persons 65 years of age or older, an industry-funded study found. More...


Cardiology

Hospitals vary widely in adhering to aspirin guidelines

There was a 25-fold variation in the proportion of U.S. hospitals that adhered to guidelines about prescribing high-dose aspirin at discharge, with some hospitals discharging fewer than 10% of patients on high-dose aspirin and other hospitals discharging 100% of patients on the regimen, a study found. More...


From the College

Are patient portals a gateway or barrier to patient-centered care and communication?

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com. 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


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Rates of preventable hospital admissions appear lower in smaller primary care practices

Rates of preventable hospital admissions appeared to be lower in smaller primary care practices compared with larger ones, according to a recent study.

Researchers used survey data from the National Study of Small and Medium-Sized Physician Practices to examine whether ambulatory care-sensitive admission rates were associated with physician practice characteristics such as size and ownership, processes used to improve care, or external incentives to improve quality and cost control. A total of 1,745 practices (63.2%) responded to the survey. The current study involved data only from the 1,045 practices that were made up of at least 33% primary care physicians, were not community health centers, and saw patients in 2008. Medicare data from 2008 were used to determine practices' rates of ambulatory care-sensitive hospital admissions. Practices were divided into 3 different groups: 1 to 2 physicians (small), 3 to 9 physicians (medium), and 10 to 19 physicians (large). The study results were published early online and will appear in the September Health Affairs.

Most practices included in the study had 1 to 2 or 3 to 9 physicians (54.5% and 40.4%, respectively). Practices that included 10 to 19 physicians made up 5.1% of the sample. A total of 16.7% of practices were owned by hospitals. Compared with practices that had 3 to 9 physicians, those with 1 to 2 had significantly more patients who were covered by Medicaid and Medicare (i.e., dual-eligible), patients who were ethnic or racial minorities, and patients with multiple chronic conditions. Practices with 10 to 19 physicians used 24.1% of available patient-centered medical home processes compared with 25.6% in practices with 3 to 9 physicians and 19.1% in practices with 1 to 2 physicians.

Overall, the mean ambulatory care-sensitive admission rate was 4.6 per 100 beneficiaries annually. Rates in unadjusted bivariate analysis were 4.2, 5.1, and 6.1 per 100 patients annually for small, medium, and large practices, respectively. Ambulatory care-sensitive admission rates were significantly lower for physician-owned compared with hospital-owned practices (4.3 vs. 6.4 per 100 patients annually, respectively).

In adjusted analyses that looked at associations with the patient-centered medical home score, pay-for-performance incentives, acceptance of risk for hospital care costs, and public reporting, small practices had significantly lower ambulatory care-sensitive admission rates than large practices (4.31 vs. 6.47 per 100 patients annually, respectively) and physician-owned practices had significantly lower rates than hospital-owned practices (4.63 vs. 5.31 per 100 patients annually, respectively).

The authors noted that their study is observational, that their results may not represent all U.S. practices, that they did not include practices made up primarily of subspecialists or practices with more than 20 physicians, and that data on practice characteristics were self-reported, among other limitations. However, they concluded that small practices with 1 to 2 physicians and medium-sized practices with 3 to 9 physicians had 33% and 27% fewer preventable admissions than large practices with 10 to 19 physicians and that physician-owned practices had lower rates than hospital-owned practices.

The authors noted that they could not determine a causal relationship between practice size and ownership and preventable admission rates and noted that larger practices are usually better able to implement organized performance improvement processes. However, they speculated that smaller practices may be able to offer patients better service and that physicians, staff, and patients at smaller practices may know each other better; these advantages, the authors said, may help lead to lower rates of preventable admissions.

"Our results suggest that the common assumption that bigger is better should not be accepted without question, at least in practices of nineteen or fewer physicians," the authors wrote. They suggested that independent practice organizations, for example, "might provide a viable alternative, in the era of health care reform, for physicians who do not want to become employed by hospitals and do not have the desire or the opportunity to join a large medical group." They called for more research comparing the performance of different types of practices, since evidence on how physician practice structure affects practices and outcomes is scarce.


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Atypical antipsychotics associated with increased AKI risk

Use of atypical antipsychotics is associated with increased risk for acute kidney injury (AKI), according to a new study.

annals.jpg

Researchers performed a population-based cohort study in Ontario, Canada, from 2003 to 2012 to examine the risk for AKI and other adverse outcomes associated with atypical antipsychotic use versus nonuse. Patients 65 years of age or older who got a new outpatient prescription for an oral atypical antipsychotic drug were matched with patients who didn't get an atypical antipsychotic prescription. The study's primary outcome measure was hospitalization with AKI within 90 days of receiving an atypical antipsychotic prescription. The results appear in the Aug. 19 Annals of Internal Medicine.

The study included a total of 97,777 drug recipients and 97,777 matched nonrecipients. Mean age was 80.7 years. A total of 23.8% of patients lived in long-term care facilities, and 53.8% had been diagnosed with dementia. Risperidone was the most common atypical antipsychotic prescribed (44,707 patients, 45.7%), followed by quetiapine (34,498 patients, 35.3%) and olanzapine (18,572 patients, 19.0%).

Overall, atypical antipsychotic drug use was associated with higher risk for hospitalization with AKI (1.02% vs. 0.62%; relative risk [RR], 1.73 [95% CI, 1.55 to 1.92]; absolute risk increase, 0.41% [95% CI, 0.33% to 0.49%]) compared with nonuse. The association remained consistent in a subpopulation with available information on serum creatinine levels (5.46% vs. 3.34%; RR, 1.70 [95% CI, 1.22 to 2.38]; absolute risk increase, 2.12% [95% CI, 0.80% to 3.43%]). Associations were also seen between atypical antipsychotic drug use and 90-day risk of hospitalization for hypotension (RR, 1.91 [95% CI, 1.60 to 2.28]), acute urinary retention (RR, 1.98 [95% CI, 1.63 to 2.40]), and 90-day risk for all-cause mortality (RR, 2.39 [95% CI, 2.28 to 2.50]).

The authors noted that their study was observational, included only older adults, and involved only 3 atypical antipsychotic drugs, among other limitations. However, they concluded that new use of atypical antipsychotic drugs is common and is associated with increased AKI risk as well as with additional adverse outcomes, such as hypotension and acute urinary retention, that could explain this association.

"The current available evidence calls for a careful reevaluation of prescribing atypical antipsychotic drugs in older adults, especially for the unapproved indication of managing behavioral symptoms of dementia," the authors wrote. "The drugs should be used only after other approaches have been exhausted; when prescribed, patients must be warned about potential adverse effects." The authors suggested that proactive clinical monitoring "seems reasonable," including serum creatinine testing, blood pressure measurement, and a bladder scan for urinary retention, shortly after the drugs are initiated, along with consideration of the drugs as a potential cause in patients who present with AKI and prompt discontinuation if feasible.



Test yourself


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MKSAP Quiz: Follow-up for a wrist fracture

A 55-year-old man is reevaluated during a follow-up examination for a wrist fracture and anemia. The patient is otherwise asymptomatic. He was treated in the emergency department 2 weeks ago after he slipped in his driveway and sustained a right wrist fracture; mild iron deficiency anemia was detected at that time. He had normal results of a routine screening colonoscopy 5 years ago. Since his emergency department evaluation, 3 stool samples have been negative for occult blood. He takes no medication.

mksap.gif

On physical examination, vital signs are normal; BMI is 19. Other than a cast on his right wrist, all other findings are normal.

Hemoglobin level is 11.9 g/dL (119 g/L), and 25-hydroxyvitamin D level is 17 ng/mL (42 nmol/L). Results of a comprehensive metabolic profile and urinalysis are normal.

A dual-energy x-ray absorptiometry (DEXA) scan shows T-scores of −1.6 in the lumbar spine, −2.2 in the femoral neck, and −1.9 in the total hip.

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

A: Begin alendronate
B: Begin teriparatide
C: Repeat DEXA scan in 1 year
D: Screen for celiac disease

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


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Influenza


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High-dose flu vaccine may work better in elderly people

A high-dose flu vaccine induced significantly higher antibody responses and provided better protection against laboratory-confirmed influenza than did its standard-dose counterpart among persons 65 years of age or older, an industry-funded study found.

The high-dose version of a trivalent, inactivated flu vaccine (Fluzone High-Dose) contains 4 times as much hemagglutinin (60 μg per strain) as the standard dose (Fluzone, 15 μg per strain). It was licensed for use in the United States in December 2009 with a requirement to show clinical benefit. Researchers conducted a phase IIIb-IV, multicenter, randomized, double-blind, active-controlled trial to compare relative efficacy, effectiveness, safety (serious adverse events), and immunogenicity (hemagglutination-inhibition titers) during the 2011-2012 and the 2012-2013 flu seasons. The study was funded by Sanofi Pasteur, which makes both vaccines.

Results appeared in the Aug. 14 New England Journal of Medicine.

The study enrolled 31,989 people ages 65 or older from 126 research centers in North America; 15,991 received the high-dose vaccine, and 15,998 received the standard dose. In the intention-to-treat analysis, 228 participants in the high-dose group (1.4%) and 301 participants in the standard dose group (1.9%) had laboratory-confirmed flu and accompanying illness (relative efficacy, 24.2%; 95% CI, 9.7% to 36.5%). Relative vaccine efficacy against laboratory-confirmed, flulike illness caused by similar strains of the flu was 35.4% (95% CI, 12.5% to 52.5%).

During the safety surveillance period of 6 to 8 months after vaccination, 1,323 participants (8.3%) in the high-dose group and 1,442 participants (9.0%) in the standard-dose group had at least 1 serious adverse event. The relative risk for having at least 1 serious adverse event with the high-dose vaccine, as compared with the standard dose, was 0.92 (95% CI, 0.85 to 0.99).

Three high-dose recipients had serious adverse events related to vaccination: cranial-nerve VI palsy starting 1 day after vaccination, hypovolemic shock associated with diarrhea starting 1 day after vaccination, and acute disseminated encephalomyelitis starting 117 days after vaccination. All 3 events resolved before the end of the study, and none resulted in discontinuation from the study. There were no serious events among standard-dose recipients.

The researchers noted that the relative efficacy shows that about one-quarter of all breakthrough flus could be prevented if the high-dose vaccine were used instead of the standard-dose version and that more than a third of breakthrough flus caused by strains similar to the vaccine could be prevented.

"Since influenza infections with type A (H3N2) viruses are considered more burdensome than other viral types and subtypes in older adults, it is expected that a benefit of IIV3-HD [the high-dose version] in this population will remain even in the context of quadrivalent standard-dose vaccines," the authors wrote.

In other flu news, the CDC's Advisory Committee on Immunization Practices (ACIP) released its recommendations for the 2014-2015 flu season on Aug. 15. They are available online.



Cardiology


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Hospitals vary widely in adhering to aspirin guidelines

There was a 25-fold variation in the proportion of U.S. hospitals that adhered to guidelines about prescribing high-dose aspirin at discharge, with some hospitals discharging fewer than 10% of patients on high-dose aspirin and other hospitals discharging 100% of patients on the regimen, a study found.

Researchers used data from 221,199 patients with myocardial infarction (MI) from 525 U.S. hospitals enrolled from the National Cardiovascular Data Registry's Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (ACTION Registry-GWTG) to identify patient- and hospital-level factors associated with discharge regimens for aspirin. Currently, clinical trial evidence and current practice guidelines recommend low-dose aspirin (81 mg) after MI. Although aspirin dosing after percutaneous coronary intervention (PCI) largely reflected the guidelines before 2012, the authors explained, high-dose aspirin (325 mg) was prescribed with similar frequency in medically managed patients and those at high risk for bleeding.

Results appeared online Aug. 12 at Circulation: Cardiovascular Quality and Outcomes.

Between January 2007 and March 2011, 60.9% of patients with acute MI were discharged on high-dose aspirin, 35.6% on low-dose aspirin, and 3.5% on other doses. Compared with patients discharged on low-dose aspirin, those discharged on high-dose aspirin were younger and more commonly men and were less likely to have atrial fibrillation, a history of congestive heart failure, stroke, peripheral arterial disease, diabetes, or hypertension. High-dose aspirin was prescribed at discharge to 73.0% of patients who had undergone PCI and to 44.6% of patients managed medically. Among 9,075 patients discharged on aspirin, thienopyridine, and warfarin, 44.0% were prescribed high-dose aspirin. Also, 56.7% of patients with an in-hospital major bleeding event were discharged on high-dose aspirin.

PCI was strongly associated with high-dose aspirin use at discharge, including percutaneous transluminal coronary angioplasty (odds ratio [OR], 2.21; 95% CI, 2.09 to 2.33; P<0.0001); PCI with a bare metal stent (OR, 2.98; 95% CI, 2.87 to 3.08; P<0.0001); or PCI with a drug-eluting stent (OR, 3.06; 95% CI, 2.96 to 3.16; P<0.0001).

Also associated to a lesser extent were age per 5-year increase (OR, 0.93; 95% CI, 0.93 to 0.94; P<0.0001); female sex (OR, 0.88; 95% CI, 0.86 to 0.90; P<0.0001), smoking (OR, 1.06; 95% CI, 1.03 to 1.09; P<0.0001), and presentation with ST-segment elevation MI versus non-ST-segment elevation MI (OR, 1.16; 95% CI, 1.13 to 1.19; P<0.0001).

Compared with aspirin alone, there was a lower likelihood of high-dose aspirin use at discharge for concurrent users of thienopyridine (OR, 0.87; 95% CI, 0.84 to 0.90; P<0.0001), warfarin (OR, 0.31; 95% CI, 0.29 to 0.33; P<0.0001), or thienopyridine plus warfarin (OR, 0.25; 95% CI, 0.23 to 0.26; P<0.0001).

The authors wrote that the wide variability in aspirin dosing across hospitals suggests that local practice habits and uncertainty about appropriate aspirin dosing have a significant influence and that large-scale educational efforts would be needed to change clinical practice.

"Because a major influence of aspirin dosing seems to be hospital-level variation, an important target for rapid quality improvement will be redesigning hospital-based treatment pathways," the authors wrote. "Adding aspirin dosing to hospital-based quality reports, such as those from the ACTION Registry-GWTG, may be an important strategy to rapidly align practice patterns with the current evidence basis and guideline recommendations."



From the College


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Are patient portals a gateway or barrier to patient-centered care and communication?

Yul Ejnes, MD, MACP, a past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his monthly column at KevinMD.com. In this post, Dr. Ejnes looks at the pros and cons of patient portals.



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-20140819-cartoon.jpg

"I don't know, doc. I just feel funny all over."

This issue's winning cartoon caption was submitted by Elizabeth Spangler, MD, ACP Member, from Charleston, W.Va. Thanks to all who voted! The winning entry captured 48.24% of the votes.

The runners-up were:

"Mr. Smith, I asked you to change into a gown."

"I'm afraid I have to recommend a circus-ision."


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MKSAP Answer and Critique



The correct answer is D: Screen for celiac disease. This item is available to MKSAP 16 subscribers as item 59 in the Endocrinology & Metabolism section. More information is available online.

The most appropriate next step in management is to screen this 55-year-old man for celiac disease as part of the evaluation for secondary causes of his low bone mass and fracture. This patient has a history of fragility fracture (fracture sustained in a fall from a standing height), and his bone density results show osteopenia. In an otherwise healthy 55-year-old man, these findings raise concern for a secondary cause of his low bone mass and fragility fracture. Half of the men with osteoporosis will have an identifiable cause. Therefore, screening guided by history and physical examination findings may include testing for hypogonadism, vitamin D deficiency, primary hyperparathyroidism, calcium malabsorption, and multiple myeloma. Measurement of 24-hour urine calcium excretion while the patient consumes 1000 mg/d of calcium also may be useful. Low values for urine calcium may indicate calcium malabsorption, which can be seen in celiac disease. In light of this patient's low BMI, fragility fracture, and history of iron deficiency anemia, celiac disease is a concern, even if gastrointestinal symptoms are absent.

Initiation of alendronate or teriparatide can be considered after the evaluation for secondary causes is completed. These agents will be more effective once the secondary cause of low bone mass has been corrected.

Repeating the bone density test in 1 year without any intervention now would allow time for additional bone loss to occur and thus would not be the best management.

Key Point

  • Low urine calcium excretion in a patient with a fragility fracture may indicate calcium malabsorption.

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Test yourself

A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

Find the answer

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