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October 15, 2013 Issue

Clinical Practice Points

Hospital Report Cards for Hospital-Acquired Pressure Ulcers: How Good Are the Grades?

Value-based purchasing programs use administrative data to compare rates of hospital-acquired pressure ulcers and rank hospitals. This study found that using administrative data in a manner planned for such reporting programs frequently misclassified high- and low-performing hospitals as compared to directly observed surveillance data.

Use this study for the Systems Based Practice Competency and Quality Improvement:

  • Introduce “value-based purchasing” and discuss its potential benefits and penalties. Here are a few slides to help introduce the topic.
  • Have your learners guess which local hospitals have the best outcomes. Use http://www.medicare.gov/ to show how your hospital compares to other local institutions (and discuss other measured outcomes). What are the potential limitations to these ratings?
  • Discuss system-based interventions to improve documentation of Present on Admission for those diagnoses designated as hospital-acquired.
  • Discuss system-based interventions that might improve documentation of present-on-admission ulcers. How might your hospital improve its prevention of ulcers?
  • Consider linking this teaching session to one discussing the risks for and prevention and care of pressure ulcers. Use the article highlighted in a recent Annals for Educators alert.

Lifestyle Interventions for Patients With and at Risk for Type 2 Diabetes. A Systematic Review and Meta-analysis

This systematic review found that multifaceted lifestyle interventions, including diet, exercise, and at least one other intervention, prevented progression to diabetes in high-risk individuals. It is less clear whether these interventions make a difference in cardiovascular and microvascular complications in patients already diagnosed with type 2 diabetes.

Use this review for the Practice Based Learning and Improvement and Patient Care competencies:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Discuss methods of evidence synthesis. How is a systemic review different than a narrative review? What is a meta-analysis? You can use this basic introduction to these concepts.
  • Discuss the interventions studied in this review and which populations benefited.
  • Ask if these results are surprising. What biases could account for the findings? How will you advise your patients with type 2 diabetes?
  • Review strategies for improving patients’ adherence to lifestyle modifications. (These are reviewed in the “Prevention” section of ACP Smart Medicine’s Type 2 Diabetes. Show your learners information, including videos they might provide to their patients.)

Ideas & Opinions

Increasing the "Smoking Age": The Right Thing to Do

New York City has proposed to increase the age at which one can purchase tobacco products from 18 to 21 years.

Use this article for the Professionalism competency:

  • Discuss the balance between patient autonomy and public health. Divide your learners into “pro” and “con” teams and have a debate.
  • Use the recent ACP Ethics Manual to help inform the discussion and review the ABIM, ACP, and European Federation of Internal Medicine Physician Charter.
  • Discuss whether increasing the age to purchase tobacco is different from limiting the size of a sugary beverage? Compare the push to increase the age to purchase tobacco to the movement to legalize marijuana.

History of Medicine

Corpulence and Correspondence: President William H. Taft and the Medical Management of Obesity

A collection of letters between William Howard Taft and his weight-loss physician reveal insights into the President’s battle with obesity and the effect of support and reinforcement from his physician on his ability to lose weight.

Use this article for the Interpersonal and Communication Skills and Patient Care competencies:

  • Discuss what we can learn from the correspondence between Taft and his weight-loss physician about the doctor–patient relationship?
  • Could social media be used to encourage our patients to adhere to treatment regimens? Consider discussing a recent trial in which social media was used to promote HIV screening.
  • Ask if physicians should be reimbursed for phone calls and e-mails to our patients.
  • Review treatment options for obesity. (Use the recent In the Clinic: Obesity.)

Video Learning

The Consult Guys logo Have fun and pick up some clinical pearls from The Consult Guys, Drs. Geno Merli and Howard Weitz. You’re called as the medical consultant to the OR—the patient’s urine turned what?? Oh no—what will you do?

Use this video for the Patient Care competency:

  • Relax a bit and have fun watching the video to learn together
  • Answer the quiz at the end with your residents (and enter the answers yourself later, to get free CME!)


mksap16

A 44-year-old man is evaluated during a routine examination. He is concerned about his general health and risk of diabetes mellitus. He has no medical problems. Both parents and his sister have type 2 diabetes mellitus.

On physical examination, temperature is normal, blood pressure is 130/79 mm Hg, pulse rate is 66/min, and respiration rate is 14/min. BMI is 28. The remainder of the physical examination is normal.

Laboratory studies

Glucose (fasting) 104 mg/dL (5.8 mmol/L)
Total cholesterol 247 mg/dL (6.40 mmol/L)
HDL cholesterol 50 mg/dL (1.30 mmol/L)
LDL cholesterol 177 mg/dL (4.58 mmol/L)
Triglycerides 100 mg/dL (1.13 mmol/L)

Which of the following interventions is the most appropriate initial strategy to decrease this patient's chance of developing type 2 diabetes mellitus?

A. Acarbose
B. Metformin
C. Pioglitazone
D. Weight loss and exercise

Correct Answer
D. Weight loss and exercise

Key Point
The most appropriate therapies to prevent type 2 diabetes mellitus are weight loss and exercise.

Educational Objective
Prevent type 2 diabetes mellitus in an overweight patient.

The most appropriate therapies to prevent type 2 diabetes mellitus in this patient are weight loss and exercise. This patient has a strong family history of type 2 diabetes mellitus and impaired fasting glucose, defined as a fasting plasma glucose level of 100 to 125 mg/dL (5.6 to 7.0 mmol/L). Based on multiple clinical trials, lifestyle modification has been shown to be the most effective intervention to prevent type 2 diabetes and its associated cardiovascular consequences. The Finnish Diabetes Prevention Study and the U.S. Diabetes Prevention Program (USDPP) both demonstrated a 58% relative risk reduction in the progression to diabetes with these methods in generally obese, middle-aged persons with impaired glucose tolerance. The American Diabetes Association recommends that lifestyle modifications continue to be the standard approach in diabetes prevention, with the goal being to increase regular physical activity by approximately 30 minutes on most days of the week and to reduce calories (to reduce weight) by 7%.

The USDPP reported a 31% risk reduction in the development of diabetes in patients treated with metformin. Acarbose reduced the risk of diabetes by 25% in the Study to Prevent Non-Insulin-Dependent Diabetes Mellitus (STOP-NIDDM) trial but had a high drop-out rate owing to gastrointestinal adverse effects. Other studies have shown a 62% reduction in progression to diabetes with rosiglitazone in patients with impaired glucose tolerance or impaired fasting glucose and an 82% reduction in the progression to diabetes with pioglitazone. However, the thiazolidinediones are associated with significant potential adverse effects, and the harm of these drugs may outweigh the benefit of their use in this patient population. Despite these findings, currently no drugs are FDA-approved for the prevention of diabetes. In patients with impaired fasting glucose and other risk factors (BMI ≥35, a strong family history, elevated triglyceride level, reduced HDL cholesterol level, hypertension, hemoglobin A1c >6.0%), some clinicians will use metformin if lifestyle modifications have not been successful.

Bibliography
Knowler WC, Fowler SE, Hamman RF, et al; Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702):1677-1686. PMID: 19878986

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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