Lauren Block

Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations.

BACKGROUND Given the increase in medications for type 2 diabetes mellitus, clinicians and patients need information about their effectiveness and safety to make informed choices. PURPOSE To summarize the benefits and harms of metformin, second-generation sulfonylureas, thiazolidinediones, meglitinides, dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 receptor agonists, as monotherapy and in combination, to treat adults with type 2 diabetes. DATA SOURCES MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from inception through April 2010 for English-language observational studies and trials. The MEDLINE search was updated to December 2010 for long-term clinical outcomes. STUDY SELECTION Two reviewers independently screened reports and identified 140 trials and 26 observational studies of head-to-head comparisons of monotherapy or combination therapy that reported intermediate or long-term clinical outcomes or harms. DATA EXTRACTION Two reviewers following standardized protocols serially extracted data, assessed applicability, and independently evaluated study quality. DATA SYNTHESIS Evidence on long-term clinical outcomes (all-cause mortality, cardiovascular disease, nephropathy, and neuropathy) was of low strength or insufficient. Most medications decreased the hemoglobin A(1c) level by about 1 percentage point and most 2-drug combinations produced similar reductions. Metformin was more efficacious than the DPP-4 inhibitors, and compared with thiazolidinediones or sulfonylureas, the mean differences in body weight were about -2.5 kg. Metformin decreased low-density lipoprotein cholesterol levels compared with pioglitazone, sulfonylureas, and DPP-4 inhibitors. Sulfonylureas had a 4-fold higher risk for mild or moderate hypoglycemia than metformin alone and, in combination with metformin, had more than a 5-fold increased risk compared with metformin plus thiazolidinediones. Thiazolidinediones increased risk for congestive heart failure compared with sulfonylureas and increased risk for bone fractures compared with metformin. Diarrhea occurred more often with metformin than with thiazolidinediones. LIMITATIONS Only English-language publications were reviewed. Some studies may have selectively reported outcomes. Many studies were small, were of short duration, and had limited ability to assess clinically important harms and benefits. CONCLUSION Evidence supports metformin as a first-line agent to treat type 2 diabetes. Most 2-drug combinations similarly reduce hemoglobin A(1c) levels, but some increased risk for hypoglycemia and other adverse events. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Residency schedule, burnout and patient care among first-year residents

Background The 2011 US Accreditation Council for Graduate Medical Education (ACGME) mandates reaffirm the need to design residency schedules to augment patient safety and minimise resident fatigue. Objectives To evaluate which elements of the residency schedule were associated with resident burnout and fatigue and whether resident burnout and fatigue were associated with lower perceived quality of patient care. Methods A cross-sectional survey of first-year medicine residents at three hospitals in May–June 2011 assessed residency schedule characteristics, including hours worked, adherence to 2003 work-hour regulations, burnout and fatigue, trainee-reported quality of care and medical errors. Results Response rate was 55/76 (72%). Forty-two of the 55 respondents (76%) met criteria for burnout and 28/55 (51%) for fatigue. After adjustment for age, gender and residency programme, an overnight call was associated with higher burnout and fatigue scores. Adherence to the 80 h working week, number of days off and leaving on time were not associated with burnout or fatigue. Residents with high burnout scores were more likely to report making errors due to excessive workload and fewer reported that the quality of care provided was satisfactory. Conclusions Burnout and fatigue were prevalent among residents in this study and associated with undesirable personal and perceived patient-care outcomes. Being on a rotation with at least 24 h of overnight call was associated with higher burnout and fatigue scores, but adherence to the 2003 ACGME work-hour requirements, including the 80 h working week, leaving on time at the end of shifts and number of days off in the previous month, was not. Residency schedule redesign should include efforts to reduce characteristics that are associated with burnout and fatigue.

Do internal medicine interns practice etiquette‐based communication? A critical look at the inpatient encounter

Etiquette-based communication may improve the inpatient experience but is not universally practiced. We sought to determine the extent to which internal medicine interns practice behaviors that characterize etiquette-based medicine. Trained observers evaluated the use of 5 key communication strategies by internal medicine interns during inpatient clinical encounters: introducing ones self, explaining ones role in the patients care, touching the patient, asking open-ended questions, and sitting down with the patient. Participants at 1 site then completed a survey estimating how frequently they performed each of the observed behaviors. A convenience sample of 29 interns was observed on a total of 732 patient encounters. Overall, interns introduced themselves 40% of the time and explained their role 37% of the time. Interns touched patients on 65% of visits, asked open-ended questions on 75% of visits, and sat down with patients during 9% of visits. Interns at 1 site estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P < 0.01; 80% vs 37%, P < 0.01; and 58% vs 9%, P < 0.01, respectively). Resident physicians introduced themselves to patients, explained their role, and sat down with patients infrequently during observed inpatient encounters. Residents surveyed tended to overestimate their own practice of etiquette-based medicine.

We Could Have Done a Better Job: A Qualitative Study of Medical Student Reflections on Safe Hospital Discharge

Because safe transitions of care are critical to patient safety, it is important to prepare physician trainees to assist in patient transitions from the hospital. As part of a discharge skills workshop for medical students, a brief reflective exercise was used to understand student perceptions of discharge problems and encourage application of classroom learning. Written reflections completed before and after the workshop were analyzed qualitatively to identify barriers to discharge observed on clinical clerkships and evaluate how the discharge skills workshop influenced student understanding of safe discharges. Students also completed a quantitative evaluation of the workshop. Seventy‐eight of the 96 students (81%) at the Johns Hopkins University School of Medicine who participated in the discharge skills workshop volunteered to submit their written reflections. Eighteen themes were identified within two domains (barriers to safe discharges and solutions to improve discharges). The most commonly cited barrier was the sense that the discharge was rushed or premature. Three of the barrier themes and six of the solution themes were related to the importance of communication and collaboration in safe discharges. Students reported that the reflective exercise personalized the learning experience (mean 3.27 ± 0.86 on a scale of 1 (not at all) to 4 (a lot)). Students observed barriers to safe discharges on their clerkships related to poor communication, insufficient time spent planning discharges, and lack of patient education. Brief reflection encouraged students to apply lessons learned in a didactic session to consider solutions for providing safer patient care.

Inpatient safety outcomes following the 2011 residency work-hour reform

BACKGROUND The impact of the 2011 residency work-hour reforms on patient safety is not known. OBJECTIVE To evaluate the association between implementation of the 2011 reforms and patient safety outcomes at a large academic medical center. DESIGN Observational study using difference-in-differences estimation strategy to evaluate whether safety outcomes improved among patients discharged from resident and hospitalist (nonresident) services before (2008-2011) and after (2011-2012) residency work-hour changes. PATIENTS All adult patients discharged from general medicine services from July 2008 through June 2012. MEASUREMENTS Outcomes evaluated included length of stay, 30-day readmission, intensive care unit (ICU) admission, inpatient mortality, and presence of Maryland Hospital Acquired Conditions. Independent variables included time period (pre- vs postreform), resident versus hospitalist service, patient age at admission, race, gender, and case mix index. RESULTS Patients discharged from the resident services in the postreform period had higher likelihood of an ICU stay (5.7% vs 4.5%, difference 1.4%; 95% confidence interval [CI]: 0.5% to 2.2%), and lower likelihood of 30-day readmission (17.2% vs 20.1%, difference 2.8%; 95 % CI: 1.3 to 4.3%) than patients discharged from the resident services in the prereform period. Comparing pre- and postreform periods on the resident and hospitalist services, there were no significant differences in patient safety outcomes. CONCLUSIONS In the first year after implementation of the 2011 work-hour reforms relative to prior years, we found no change in patient safety outcomes in patients treated by residents compared with patients treated by hospitalists. Further study of the long-term impact of residency work-hour reforms is indicated to ensure improvement in patient safety.

Variability in hand hygiene practices among internal medicine interns

Hand hygiene compliance remains suboptimal among physicians despite quality improvement efforts. We observed hand hygiene compliance among 29 medicine interns at 2 large academic institutions. Overall compliance was 75%. Although 4 interns averaged <40% compliance, 14 averaged at least 80%. Given variability observed among individuals in the same training programs, targeting those with poor performance may be important in improving overall compliance.

Improving Access to Care for Uninsured Patients at an Academic Medical Center: The Access Partnership

Uninsured individuals face great challenges in accessing both primary and specialty care. The Access Partnership (TAP) is a novel collaboration between primary and specialty care providers at an urban academic medical center to provide care coordination and facilitate access to specialty services for uninsured patients. We reviewed administrative data and performed phone surveys of the 213 patients who entered the program over a one-year period. Specialty care visit attendance was analyzed from administrative data for these patients. We then surveyed patients by phone (60% response rate). Patient-reported access to care and satisfaction with care were significantly higher after TAP (33% vs. 87%, p<0.001 and 41% vs. 91%, p<0.001, respectively). 89% of referrals were completed within 90 days among TAP patients, a rate similar to studies involving insured patients. TAP enrollment was associated with significantly decreased patient-reported barriers to specialty care as well as improved access to and satisfaction with care.

Assessing intern handover processes.

New standards for resident work hours set in 2011 changed the landscape of patient care in teaching hospitals, and resulted in new challenges for US residency training programmes to overcome. One such challenge was a dramatic increase in the number of patient handovers performed by residents. As a result, there is a renewed focus for clinical teachers to develop educational strategies to optimise the patient handover process and improve the quality of patient care and safety.

Coverage Isn't Enough: Building Primary Care Capacity in the Setting of Health Reform

The Access Partnership is a program linking uninsured patients with primary and specialty care. Expansion of primary care access resulted in an influx of patients with multiple chronic conditions, causing the primary care practice to reach capacity after seven months. Our program may provide lessons in ensuring primary care access as the Affordable Care Act is implemented.

Do medical residents perform patient-centered medical home tasks? A mixed-methods study

ABSTRACT Background: Increasingly, residents are being trained in Patient-centered Medical Home (PCMH) settings. A set of PCMH entrustable professional activities (EPAs) for residents has been defined but not evaluated in practice. Objective: To understand whether residents trained at PCMH sites reported higher likelihood of engaging in PCMH tasks than those training in non-PCMH sites. Design: Survey and nominal group data from post-graduate trainees at three residency programs. Results: A total of 179 residents responded (80% response). Over half (52%) cared for patients at PCMH sites. Residents at PCMH sites were more likely to report engaging in tasks in the NCQA domains of enhancing access and continuity (p < 0.01 for 4/11 tasks), planning and managing care (p < 0.01 for 3/4 tasks), providing self-care and community support (p < 0.01 for 3/5 tasks), and identifying and managing patient populations (p < 0.01 for 1/6 tasks), but were not more likely to report tracking and coordinating care or measuring and improving performance. Residents at PCMH sites were more likely to report working with medical assistants (p < 0.01), but not other healthcare professionals. Qualitative data showed staff teamwork and continuity of care as facilitators of patient-centered care, and technological problems and office inefficiencies as barriers to care. Conclusions: Residents trained at PCMH sites were more likely to engage in tasks in several NCQA domains, but not care coordination and quality assessment. Similar facilitators and barriers to trainee provision of patient-centered care were cited regardless of PCMH status. Curricula on PCMH principles and workflows that foster continuity and communication may help to inform residents on PCMH tenets and incorporate residents into team-based care. Abbreviations: EPA: Entrustable professional activity; GIM: General Internal Medicine; NCQA: National Center for Quality Assurance; PCMH: Patient-centered medical home