Darrell W. Harrington

Capturing the Diagnosis: An Internal Medicine Education Program to Improve Documentation

BACKGROUND Specific and accurate documentation of patient diagnoses and comorbidities in the medical record is critical to drive quality improvement and to ensure accuracy of publicly reported data. Unfortunately, inpatient documentation is taught to internal medicine trainees and practitioners sporadically, if at all. At Harbor-UCLA Medical Center, a public, tertiary care, academic medical center, we implemented an educational program to enhance documentation of diagnoses and comorbidities by internal medicine resident and attending physicians. METHODS The program consisted of a series of lectures and the creation of a pocket card. These were designed to guide providers in accurate documentation of common diagnoses that group to different levels of disease severity, achieved by capturing Centers for Medicare and Medicaid Services complication codes and major complication codes. We started the educational program in January 2010 and used a pre-post design to compare outcomes. The programs impact on complication codes and major complication codes capture rates, mortality index, and case mix index was evaluated using the University Health Consortium database. RESULTS The median quarterly complication codes and major complication codes capture rate for inpatients on the internal medicine service was 42% before the intervention versus 48% after (P = .003). Observed mortality did not change but expected mortality increased, resulting in a 30% decline in median quarterly mortality index (P = .001). The median quarterly case mix index increased from 1.27 to 1.36 (P = .004). CONCLUSIONS Thus, implementation of an internal medicine documentation curriculum improved accuracy in documenting diagnoses and comorbidities, resulting in improved capture of complication codes.

Peripheral Vascular Surgery Using Targeted Beta Blockade Reduces Perioperative Cardiac Event Rate

BACKGROUND Recent studies suggest that preoperative cardiac stress testing is unnecessary in low to intermediate cardiac risk patients undergoing operations, and that targeted beta blockade is cardiac protective. STUDY DESIGN A cohort study of patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, but without cardiac stress testing, was performed. Targeted beta blockade was initiated preoperatively. The primary end point was a composite of adverse cardiac outcomes. A comparison was made with historical controls who received selective stress testing and selective nontargeted beta blockade. RESULTS One hundred consecutive patients were prospectively enrolled, and 80 retrospective controls were identified. There were no differences between groups with respect to median revised cardiac index (RCI; 0 versus 1). In the retrospective group, 14% underwent preoperative cardiac stress testing versus none in the prospective group (p=0.0002). Nontargeted beta blockade was given in 61% of the retrospective group. The median heart rate for the prospective group was significantly lower (66 versus 77 beats/minute; p=0.0007). The composite cardiac complication rate was 2% in the prospective group versus 10% in the retrospective group (p=0.02). There were no deaths. On multivariate analysis, after adjusting for revised cardiac index score, there was a lower cardiac complication rate in the prospective group (odds ratio, 2.46; 95% CI, 1.3 to 4.5; p=0.003). CONCLUSIONS In patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, preoperative targeted beta blockade alone is more effective than selective cardiac stress testing and nontargeted beta blockade in preventing cardiac morbidity.

A Controlled Investigation of Optimal Internal Medicine Ward Team Structure at a Teaching Hospital

Background The optimal structure of an internal medicine ward team at a teaching hospital is unknown. We hypothesized that increasing the ratio of attendings to housestaff would result in an enhanced perceived educational experience for residents. Methods Harbor-UCLA Medical Center (HUMC) is a tertiary care, public hospital in Los Angeles County. Standard ward teams at HUMC, with a housestaff∶attending ratio of 5∶1, were split by adding one attending and then dividing the teams into two experimental teams containing ratios of 3∶1 and 2∶1. Web-based Likert satisfaction surveys were completed by housestaff and attending physicians on the experimental and control teams at the end of their rotations, and objective healthcare outcomes (e.g., length of stay, hospital readmission, mortality) were compared. Results Nine hundred and ninety patients were admitted to the standard control teams and 184 were admitted to the experimental teams (81 to the one-intern team and 103 to the two-intern team). Patients admitted to the experimental and control teams had similar age and disease severity. Residents and attending physicians consistently indicated that the quality of the educational experience, time spent teaching, time devoted to patient care, and quality of life were superior on the experimental teams. Objective healthcare outcomes did not differ between experimental and control teams. Conclusions Altering internal medicine ward team structure to reduce the ratio of housestaff to attending physicians improved the perceived educational experience without altering objective healthcare outcomes.

Choosing the right heparin prophylaxis strategy in medical patients at risk for developing VTE: an evidence-based approach.

Abstract Many acutely ill medical patients are at significant risk for developing venous thromboembolism (VTE) during hospitalization. Venous thromboembolism risk arises from both the presenting clinical condition as well as predisposing risk factors, such as advanced age. Thromboprophylaxis is underprescribed in these patients. Thrombotic risk assessment could encourage the prescribing of thromboprophylaxis and, therefore, improve patient protection against VTE. Current guidelines from the American College of Chest Physicians and the International Union of Angiology (IUA) recommend thromboprophylaxis with low-dose unfractionated heparin (UFH), a low-molecular-weight heparin (LMWH), or fondaparinux for acutely ill medical patients with VTE risk factors. However, the optimal dose regimen for UFH is unclear. The 2006 evidence-based guidelines from the IUA recommend a 3-times-daily dose regimen for UFH. However, UFH is usually administered twice daily despite a lack of evidence for the superiority of this regimen. Both heparin-induced thrombocytopenia and bleeding are associated with UFH, and to a lesser degree with alternative anticoagulants, such as the LMWHs. If utilized, an appropriate prophylaxis regimen in medical patients can reduce the risk of VTE and its burden.

Update in General Internal Medicine

The current Update in General Internal Medicine reviews the past years most important articles relevant to the practicing internist. The general internist is confronted with a wide variety of clinical scenarios and must maintain a broad database and skill set that often overlap with those of subspecialists. We discuss influential articles from 2006 that have important implications for common therapeutic and diagnostic challenges in internal medicine. The Table (19) shows changes to clinical practice that should emerge from these articles. Table. Changes to Clinical Practice Emerging from Articles Important to General Internal Medicine in 2006* Cardiovascular Amarenco P Bogousslavsky J Callahan A 3rd et al Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006 355 549 59 Question: Is high-dose atorvastatin safe and effective for the secondary prevention of stroke? Study Design: Randomized, controlled trial. Patients: 4731 patients older than 18 years (mean age, 63 years; 60% men) who had ischemic or hemorrhagic stroke or transient ischemic attack 1 to 6 months before randomization; were ambulatory; and had a modified Rankin score less than 3, a low-density lipoprotein cholesterol (LDL) level of 2.6 to 4.9 mmol/L (100 to 190 mg/dL), and no known history of coronary heart disease. Patients with atrial fibrillation, embolism from other cardiac sources, and subarachnoid hemorrhage were excluded. Setting: 205 medical centers in Australia, Africa, Europe, North America, Central America, and South America from September 1998 to March 2001. Intervention: Atorvastatin, 80 mg/d (2365 patients), or placebo (2366 patients). Outcomes: The primary outcome was time to first fatal or nonfatal stroke. Secondary outcomes were all-cause death, stroke or transient ischemic attack, and cardiovascular events (major coronary event [cardiac death, nonfatal myocardial infarction, or resuscitation after cardiac arrest]; major cardiovascular event [stroke plus any major coronary event], acute coronary event [major coronary event or unstable angina], any coronary event [acute coronary event plus coronary revascularization, unstable angina, or angina or ischemia requiring hospitalization], or revascularization procedure [coronary, carotid, or peripheral]; or any cardiovascular event [any previous composite end point plus peripheral vascular disease]). Follow-up: Median, 4.9 years (range, 4.0 to 6.6 years). Sponsor: Pfizer. Results: Atorvastatin reduced occurrence of the primary end point (265 [11.2%] atorvastatin recipients vs. 311 [13.1%] placebo recipients; adjusted hazard ratio, 0.84 [95% CI, 0.71 to 0.99]; P= 0.03). The effect was attributable to a reduction in fatal stroke (24 [1.0%] atorvastatin recipients vs. 41 [1.7%] placebo recipients; adjusted hazard ratio, 0.57 [CI, 0.35 to 0.95]; P= 0.03). In addition, atorvastatin decreased the frequency of all secondary outcomes except all-cause death. In post hoc analyses, effects differed by stroke type (hazard ratio, 0.78 [CI, 0.66 to 0.94] for ischemic stroke, 1.66 [CI, 1.08 to 2.55] for hemorrhagic stroke, and 0.55 [CI, 0.21 to 1.40] for unclassified stroke). Atorvastatin conferred no increase in adverse outcomes except more frequent persistent elevation of alanine aminotransferase or aspartate aminotransferase level to greater than 3 times the upper limit of normal at 2 consecutive measures (51 [2.2%] atorvastatin recipients vs. 11 [0.5%] placebo recipients; P< 0.001). Conclusions: Atorvastatin, 80 mg/d, prevented the combined outcome of first nonfatal or fatal stroke. Only recurrent fatal stroke was significantly reduced. It had no statistically significant effect on nonfatal stroke and increased the frequency of hemorrhagic stroke and abnormal liver enzyme levels. Commentary: The increase in risk for hemorrhagic stroke observed in this trial was also observed with simvastatin in the Heart Protection Study (10). The Heart Protection Study found no differences in incidence of other kinds of stroke, but patients were enrolled later (average of 4.3 years) after their initial event. The authors also noted that an association between brain hemorrhage and low cholesterol levels was seen in previous epidemiologic studies. The benefit of atorvastatin exceeded its risks: The number needed to treat to prevent 1 nonfatal or fatal stroke was about 51, whereas the number needed to treat to cause 1 hemorrhagic stroke was about 110. In addition, atorvastatin decreased the risk for many cardiovascular secondary end points. Nevertheless, one should be cautious when using atorvastatin to prevent stroke in patients with risk factors for hemorrhagic stroke, including chronic hypertension, older age, male sex, and use of anticoagulants. At the end of the trial, the mean LDL cholesterol level was 1.89 mmol/L (72.9 mg/dL) in the atorvastatin group and 3.33 mmol/L (128.5 mg/dL) in the placebo group. The current trial compared a single dose of atorvastatin with no treatment. One may question the use of placebo, because some patients would have required a reduction in LDL cholesterol level (such as the 16.9% of patients who were diabetic). A reduction in LDL cholesterol level of 30% and a target value of less than 2.59 mmol/L (<100 mg/dL) may have decreased the differences in outcomes. Currently, an LDL cholesterol level less than 70 mg/dL is suggested only for patients at highest risk; because this group includes persons with coronary artery disease, this target value does not apply to any patient in the current trial. Conclusions regarding the benefits of other statins or a different dose are therefore difficult to make. Clinical Bottom Line: Consider prescribing atorvastatin, 80 mg/d, for secondary prevention of stroke in patients with stroke or transient ischemic attack and characteristics similar to those of patients in the study. Given the possible increased risk for hemorrhagic stroke, providers must weigh the risks and benefits in patients with an identifiably higher risk for hemorrhagic stroke. Bhatt DL Fox KA Hacke W et al CHARISMA Investigators Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) Investigators. N Engl J Med 2006 354 1706 17 Question: Is the combination of clopidogrel and aspirin more effective than aspirin alone for preventing atherothrombotic events in high-risk groups? Study Design: Randomized, placebo-controlled trial. Patients: 15603 patients 45 years of age or older (median age, 64 years; 70% men; 80% white) with either clinically evident cardiovascular disease or 2 major, 3 minor, or 1 major and 2 minor risk factors. Major risk factors were type 1 or 2 diabetes, diabetic nephropathy, anklebrachial index less than 0.9, asymptomatic carotid stenosis of 70% or greater of the luminal diameter, and 1 or more carotid plaque. Minor risk factors were systolic blood pressure of 150 mm Hg or greater despite at least 3 months of treatment, primary hypercholesterolemia, smoking habit of more than 15 cigarettes/d, or advanced age (men65 years or women70 years). Patients receiving long-term therapy with nonsteroidal anti-inflammatory drugs or oral anticoagulants were excluded. Setting: 768 sites in 32 countries. Intervention: Clopidogrel (75 mg/d) plus low-dose aspirin (75 to 162 mg/d) or placebo plus low-dose aspirin. Outcomes: The primary efficacy outcome was a composite of first occurrence of myocardial infarction, stroke (any cause), or death from cardiovascular causes (including hemorrhage). The secondary efficacy outcome was a composite of first occurrence of myocardial infarction; stroke; death from cardiovascular causes; or hospitalization for unstable angina, transient ischemic attack, or a revascularization procedure [coronary, cerebral, or peripheral]. Death from any cause and death from cardiovascular causes; stroke; and hospitalization for unstable angina, transient ischemic attack, or revascularization were further secondary efficacy outcomes. The primary safety outcome was severe bleeding, and the secondary safety outcome was moderate bleeding. Follow-up: Median, 28 months. Sponsor: Sanofi-Aventis, Bristol-Myers Squibb, and National Institutes of Health. Results: The groups did not differ in the primary efficacy end point (6.8% of clopidogrel recipients vs. 7.3% of placebo recipients; relative risk, 0.93 [CI, 0.83 to 1.05]; P= 0.22), but clopidogrel recipients experienced a borderline reduction in the secondary efficacy end point (16.7% vs. 17.9% of placebo recipients; relative risk, 0.92 [CI, 0.86 to 0.995]; P= 0.04). More clopidogrel recipients than placebo recipients had severe bleeding (1.7% vs. 1.3%; relative risk, 1.25 [CI, 0.97 to 1.61]; P= 0.09). In a prespecified analysis of asymptomatic patients with multiple risk factors, a nonstatistically significant increase in the primary efficacy end point was seen with clopidogrel (6.6% vs. 5.5%; relative risk, 1.2 [CI, 0.91 to 1.59]; P= 0.20), as was an increase in death from cardiovascular causes (3.9% vs. 2.2%; P= 0.01). In a prespecified analysis of symptomatic patients with atherothrombosis, the primary end point occurred less often in the clopidogrel group (6.9% vs. 7.9%; relative risk, 0.88 [CI, 0.77 to 0.998]; P= 0.046). Conclusions: The combination of clopidogrel and aspirin was no better than aspirin alone for preventing atherothrombotic events in a high-risk sample, although subgroup analyses suggested benefit in patients with symptoms (secondary prevention) and harm in high-risk patients without symptoms (primary prevention). Commentary: The combination of clopidogrel and aspirin has proved useful in the setting of acute vascular injury (for example, acute coronary syndrome [11, 12]). Unfortunately, the benefits of combination antiplatelet therapy cannot