0

Visit Annals Teaching Tools for more resources for educators from Annals and ACP.

March 5, 2013 Issue

Clinical Practice Points

An Automated Intervention With Stepped Increases in Support to Increase Uptake of Colorectal Cancer Screening. A Randomized Trial

This randomized trial found that, compared with usual care, patients completed recommended colorectal cancer screening more often when electronic health record–linked reminders and fecal occult blood testing kits were sent to them.

Screening Colonoscopy and Risk for Incident Late-Stage Colorectal Cancer Diagnosis in Average-Risk Adults

This case–control study found that colonoscopy was associated with an approximately 70% reduction in the risk for late-stage colorectal cancer in average-risk adults.

Use one or both of these studies to:

  • Review current recommendations for colorectal cancer screening. View the most recent USPSTF and ACP statements.
  • Discuss potential tradeoffs between screening with occult blood testing and colonoscopy. Which approach is a patient more likely to complete? Is it easier to get patients to complete occult blood testing on an annual basis than colonoscopy every 10 years?
  • Does your hospital’s electronic health record remind residents of the screening tests that their patients need? Do your residents ignore the alerts?
  • Discuss what a case–control study is. How does it work and what does it tell you?

Neisseria gonorrhoeae Antimicrobial Resistance Among Men Who Have Sex With Men and Men Who Have Sex Exclusively With Women: The Gonococcal Isolate Surveillance Project, 2005–2010

In this large observational study, isolates of Neisseria gonorrhoeae from men who have sex with men were significantly more likely than those from men who have sex exclusively with women to exhibit elevated cephalosporin minimal inhibitory concentrations and antimicrobial resistance.

Use this study to:

  • Discuss the clinical characteristics of sexually transmitted diseases.
  • Review the presentation of and treatment recommendations for gonorrhea infection. (Use last issue’s In The Clinic: Chlamydia and Gonorrhea for a concise review.)
  • Discuss the implications of this research study for practice. Because antimicrobial susceptibility testing is not routinely performed, should you monitor for treatment failures among MSM diagnosed with gonorrhea?

Ideas & Opinions

Coverage for Undocumented Migrants Becomes More Urgent

This short commentary discussed that with implementation of the Patient Protection and Affordable Care Act undocumented migrants will be the only large group without coverage, and that some provisions may make things more difficult for this group.

Use this article to:

  • Prompt your residents to think about the health care system in which they will practice.
  • Discuss how undocumented migrants receive care. How do things differ in Europe (the article discussed this)?
  • Discuss what your residents think should happen when humanitarian, public health, and ethical arguments collide with political and economic considerations. What do they think will happen?

Humanism and Professionalism: Putting Safety First

Making Health Care Safer: A Critical Review of Evidence Supporting Strategies to Improve Patient Safety

The supplement with this week’s Annals summarizes the evidence for several patient safety strategies.

Use this article to:

  • Start off with a cartoon! Yes, a graphic novel in this issue of Annalsportrays the haunting event we all fear—something we should not have missed that costs a patient’s life. Missed it!
  • Teach residents to consider how systems-based practices can impact the lives of their patients. Why did that last hospital-acquired infection occur? Might it have been prevented? Are there changes in your hospital’s care processes that should be considered?
  • Review the editors’ summary of practices that work and should be adopted now. See Table 2. Which of these are employed at your hospital? Always?

ITC logo

Transitions of Care

This clinical review provides concise answers to why the process by which we discharge a patient from the hospital may determine if a patient does well or not—and what we know about the best ways of doing it.

Use this article to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask and answer key questions (Who is at risk for adverse events after hospital discharge? What are the most effective ways to ensure safe, appropriate medication reconciliation?).
  • Review exactly how discharge orders and instructions should be written—and why.
  • Review the required elements of a discharge summary. Have each of your residents look at her/his last discharge summary. Was it adequate? How could it have been better?

In the Clinic Question

An 83-year-old man with a past history of coronary artery disease is admitted to the hospital with shortness of breath. An echocardiogram reveals a reduced left ventricular ejection fraction, which is new for the patient. He is diagnosed with congestive heart failure and started on appropriate medications. His discharge medications include a beta-blocker, ACE inhibitor, diuretic, aspirin, statin, multivitamin, and an antidepressant.

Medicare is his primary insurance. He is able to drive himself and carry out all of his activities of daily living and lives with his wife and daughter.

Which of the following patient characteristic is most likely to contribute to his risk for postdischarge adverse events?

A. His age
B. His home family support
C. His insurance status
D. His congestive heart failure

Answer: D. His congestive heart failure

Educational Objective: Recognize risk factors for postdischarge complications and identify interventions to alleviate that risk.

Key Points:

  • Patients with a new diagnosis, such as congestive heart failure, who are started on new medications are at increased risk for postdischarge complications, such as rehospitalization.
  • Risk assessment tools to help stratify patients’ posthospital care needs have been evaluated, and the health care team should identify individual risk factors and determine what interventions may be most beneficial for the patient.

Although there are validated, reliable, and generalizable risk stratification models to identify patients at increased risk for postdischarge complications, most prediction models have been difficult to generalize for all patients; however, some models may be useful in specific settings. More important, however, the goal of a risk tool should be to allow identification and addressing of individualized, specific high-risk variables by an interdisciplinary health care and social support team before hospital discharge. One such tool, called the “8 P’s,” identifies “principal diagnosis,” such as congestive heart failure, chronic obstructive pulmonary disease, cancer, and stroke, as high-risk factors for patients to develop postdischarge adverse events and recommends appropriate interdisciplinary health care support before and after hospital discharge.

Although such age-related conditions as cognitive dysfunction may lead to poor ability to cope with a new diagnosis and therapeutic regimen, the patient’s age alone is not the most important risk factor. Poor social support has been identified as a potential risk factor for postdischarge adverse events, but this patient seems to have good home support. Similarly, inability to obtain appropriate and timely medical care because of lack of insurance may place patients at risk for postdischarge adverse outcomes, but this patient seems to have adequate health care coverage.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Erin Ney, MD, FACP Assistant Residency Program Director, Department of Internal Medicine, Thomas Jefferson University.

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)