Steven Z. Pantilat

The impact of follow-up telephone calls to patients after hospitalization.

We studied whether pharmacists involved in discharge planning can improve patient satisfaction and outcomes by providing telephone follow-up after hospital discharge. We conducted a randomized trial at the General Medical Service of an academic teaching hospital. We enrolled General Medical Service patients who received pharmacy-facilitated discharge from the hospital to home. The intervention consisted of a follow-up phone call by a pharmacist 2 days after discharge. During the phone call, pharmacists asked patients about their medications, including whether they obtained and understood how to take them. Two weeks after discharge, we mailed all patients a questionnaire to assess satisfaction with hospitalization and reviewed hospital records. Of the 1,958 patients discharged from the General Medical Service from August 1, 1998 to March 31, 1999, 221 patients consented to participate. We randomized 110 to the intervention group (phone call) and 111 to the control group (no phone call). Patients returned 145 (66%) surveys. More patients in the phone call than the no phone call group were satisfied with discharge medication instructions (86% vs. 61%, P = 0.007). The phone call allowed pharmacists to identify and resolve medication-related problems for 15 patients (19%). Twelve patients (15%) contacted by telephone reported new medical problems requiring referral to their inpatient team. Fewer patients from the phone call group returned to the emergency department within 30 days (10% phone call vs. 24% no phone call, P = 0.005). A follow-up phone call by a pharmacist involved in the hospital care of patients was associated with increased patient satisfaction, resolution of medication-related problems, and fewer return visits to the emergency department.

Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial.

IMPORTANCE For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy. OBJECTIVE To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach. INTERVENTIONS Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins. MAIN OUTCOMES AND MEASURES Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings. RESULTS A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, -3.5% to 10.5%; P=.36) and did not meet the noninferiority end point. Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P=.04). Few participants experienced cardiovascular events (13 in the discontinuation group vs 11 in the continuation group). Mean cost savings were

Hospitalists and the Practice of Inpatient Medicine: Results of a Survey of the National Association of Inpatient Physicians

3.37 per day and

Engagement in multiple steps of the advance care planning process: a descriptive study of diverse older adults.

716 per patient. CONCLUSIONS AND RELEVANCE This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs. Thoughtful patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01415934.

Code Status Discussions Between Attending Hospitalist Physicians and Medical Patients at Hospital Admission

The number of hospital-based physicians, or hospitalists, in the United States has grown rapidly, yet no published data have characterized hospitalists or their practices. A self-administered quest...

Depression and Functional Status Are Strongly Associated With Dyspnea in Interstitial Lung Disease

OBJECTIVES: To assess engagement in multiple steps of the advance care planning (ACP) process 6 months after exposure to an advance directive. In this study, ACP is conceptualized similarly to the behavior change model.

Improving primary care residents' proficiency in the diagnosis of skin cancer.

ABSTRACTBACKGROUNDBioethicists and professional associations give specific recommendations for discussing cardiopulmonary resuscitation (CPR).OBJECTIVETo determine whether attending hospitalist physicians’ discussions meet these recommendations.DESIGNCross-sectional observational study on the medical services at two hospitals within a university system between August 2008 and March 2009.PARTICIPANTSAttending hospitalist physicians and patients who were able to communicate verbally about their medical care.MAIN MEASURESWe identified code status discussions in audio-recorded admission encounters via physician survey and review of encounter transcripts. A quantitative content analysis was performed to determine whether discussions included elements recommended by bioethicists and professional associations. Two coders independently coded all discussions; Cohen’s kappa was 0.64–1 for all reported elements.KEY RESULTSAudio-recordings of 80 patients’ admission encounters with 27 physicians were obtained. Eleven physicians discussed code status in 19 encounters. Discussions were more frequent in seriously ill patients (OR 4, 95% CI 1.2–14.6), yet 66% of seriously ill patients had no discussion. The median length of the code status discussions was 1 min (range 0.2–8.2). Prognosis was discussed with code status in only one of the encounters. Discussions of patients’ preferences focused on the use of life-sustaining interventions as opposed to larger life goals. Descriptions of CPR as an intervention used medical jargon, and the indication for CPR was framed in general, as opposed to patient-specific scenarios. No physician quantitatively estimated the outcome of or provided a recommendation about the use of CPR.CONCLUSIONSCode status was not discussed with many seriously ill patients. Discussions were brief, and did not include elements that bioethicists and professional associations recommend to promote patient autonomy. Local and national guidelines, research, and clinical practice changes are needed to clarify and systematize with whom and how CPR is discussed at hospital admission.

Communicating with seriously ill patients: better words to say.

BACKGROUND Little is understood about the characteristics of dyspnea in patients with interstitial lung disease (ILD), and its severity is likely influenced by multiple factors. Depression and functional status are known to influence dyspnea in patients with COPD. The aim of this study was to determine the relationship of dyspnea with clinical parameters, including depression and functional status, in patients with ILD. METHODS Dyspnea was measured with the Baseline Dyspnea Index and the University of California San Diego Shortness of Breath Questionnaire. Clinical parameters were recorded. Regression analysis was performed to determine independent correlates of dyspnea. RESULTS Fifty-two subjects were enrolled. The two dyspnea scales were strongly correlated (r=-0.79; P<.00005). The mean levels of dyspnea were 6.5 and 41.0, representing a moderate degree of dyspnea. Clinically meaningful depressive symptoms were found in 23% of subjects. Independent correlates of dyspnea severity for each dyspnea scale were depression score (P=.002 and P<.0005), 4-m walk time (P=.001 and P=.06), FVC (P=.07 and P=.004), and diffusing capacity of the lung for carbon monoxide (P=.007). BMI had borderline significant association with the Baseline Dyspnea Index (P=.10). CONCLUSIONS In patients with ILD, dyspnea is associated with depression score, functional status, and pulmonary function. These results suggest that attention to depression and functional status is important in these patients and that treatment directed at these comorbidities may improve dyspnea and quality of life. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00611182 ; URL: www. clinicaltrials.gov.

Depression is a common and chronic comorbidity in patients with interstitial lung disease

OBJECTIVE: To determine whether a brief, multicomponent intervention could improve the skin cancer diagnosis and evaluation planning performance of primary care residents to a level equivalent to that of dermatologists.PARTICIPANTS: Fifty-two primary care residents (26 in the control group and 26 in the intervention group) and 13 dermatologists completed a pretest and posttest.DESIGN: A randomized, controlled trial with pretest and posttest measurements of residents’ ability to diagnose and make evaluation plans for lesions indicative of skin cancer.INTERVENTION: The intervention included face-to-face feedback sessions focusing on residents’s performance deficiencies; an interactive seminar including slide presentations, case examples, and live demonstrations; and the Melanoma Prevention Kit including a booklet, magnifying tool, measuring tool, and skin color guide.MEASUREMENTS AND MAIN RESULTS: We compared the abilities of a control and an intervention group of primary care residents, and a group of dermatologists to diagnose and make evaluation plans for six categories of skin lesions including three types of skin cancer—malignant melanoma, squamous cell carcinoma, and basal cell carcinoma. At posttest, both the intervention and control group demonstrated improved performance, with the intervention group revealing significantly larger gains. The intervention group showed greater improvement than the control group across all six diagnostic categories (a gain of 13 percentage points vs 5, p<.05), and in evaluation planning for malignant melanoma (a gain of 46 percentage points vs 36, p<.05) and squamous cell carcinoma (a gain of 42 percentage points vs 21, p<.01). The intervention group performed as well as the dermatologists on five of the six skin cancer diagnosis and evaluation planning scores with the exception of the diagnosis of basal cell carcinoma.CONCLUSIONS: Primary care residents can diagnose and make evaluation plans for cancerous skin lesions, including malignant melanoma, at a level equivalent to that of dermatologists if they receive relevant, targeted education.

End-of-Life Care for the Hospitalized Patient

WORDS MATTER. WHAT CLINICIANS SAY AND HOW they say it hugely affect patients. Communicating about emotionally and medically complex topics such as advance care planning, preferences for care, prognosis, and death and dying is challenging. Doing so requires clinicians to attend to their own and the patient’s cognitive reactions, tone, affect, and nonverbal cues. Communicating goals of care is so important that in California it is now the law. Although poor communication may harm patients by leading to unwanted invasive procedures, generating unnecessary anxiety, or creating feelings of abandonment, good communication can improve outcomes for patients and their families by promoting shared decision making and addressing patient concerns. A recent study described a novel communication model and a process through which it could be adopted by clinicians. The 4 parts of this model include seeing communication as a process that unfolds over many conversations, taking a patient-based approach to understand the patient’s values, making recommendations, and using positive and negative role models and experience to develop an effective personal approach to communication. Such role modeling can take the form of recommendations for specific words to say to facilitate clear communication. Many of these recommendations can be used daily to prevent poor communication and unfortunate choices of words that can create unintended and negative consequences. In this article, 4 common and problematic phrases are parsed; their potentially negative effects on patients, families, and clinicians are described; and in their stead, a lexicon aimed at improving communication based on clinical observations is modeled. While no data report how often these phrases are used or the effectiveness of the alternative lexicon, clinical observation can provide a useful evidence base for such recommendations and serves as a source of innovation.