David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
This study shows that the provision of unsolicited management recommendations by a virtual consultant leads to measurable improvements in glycemic control when applied to certain hospitalized patients.
The wide use of a dedicated inpatient glycemic management consultation service can be labor-intensive and costly. However, the virtual intervention in this study was efficient, requiring only 20 to 40 minutes of expert time each day. An editorial notes that this virtual approach is sure to lack some of the benefits of a full bedside consultation and suggests that a hybrid approach, including both virtual and bedside elements of consultation, should be investigated in the future.
The HEART score may provide a reliable method to risk stratify patients presenting with chest pain and allow for a significant subset of low-risk patients to be reassured and discharged.
In this study, use of the HEART score did not result in significant improvements in resource utilization. One possible explanation is the fact that providers did not adhere to the recommendations generated by the score in 41% of low-risk patients. Rather, many of these patients were admitted to the hospital or received additional testing despite recommendations to the contrary.
Although the rapid rule-out strategy was quite sensitive for MI in this meta-analysis, the authors recommend using careful local audits to ensure safety if implementing this strategy.
Some of the cohorts included in this meta-analysis demonstrated a significantly lower sensitivity for MI with this approach, indicating that this strategy may not be universally safe. Also, the minimal duration of symptoms sufficient to cause an elevation of hs-cTnT is not certain, so it is possible that patients with MI presenting very early after the onset of symptoms may not be detected with this approach.
An editorial notes that although this testing strategy holds promise for rapidly ruling out MI in some patients, it lacks specificity and will need to be combined with other testing to identify patients who do need treatment.
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Wesorick DH, Chopra V. Annals for Hospitalists - 16 May 2017. Ann Intern Med. ;166:HO1. doi: 10.7326/AFHO201705160
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Published: Ann Intern Med. 2017;166(10):HO1.
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