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June 2, 2015 Issue


Clinical Practice Points

Medical Knowledge
Patient Care

Screening for Type 2 Diabetes Mellitus: A Systematic for the U.S. Preventive Services Task Force

This systematic review found that screening for type 2 diabetes mellitus did not affect mortality but that treatment of impaired fasting glucose and impaired glucose tolerance delayed progression to diabetes.

Use this study to:

  • Review the potential benefits of screening for diabetes. Ask who should be screened? Ask your learners how screening should be performed. Use a recent In the Clinic: Type 2 Diabetes to quickly answer these questions.
  • Ask your readers whether they feel the results of this systematic review, finding a lack of evidence of a mortality benefit from screening, will alter their approach. Read the comments of an editorialist, who argues it should not. Do your learners agree?


Medical Knowledge
Patient Care
High Value Care

Incidental Findings in the Pancreas (and Elsewhere): Putting Our Patients (and Ourselves) in a Difficult Situation

New guidelines from the American Gastroenterological Association on the management of incidental pancreatic cysts recommend less aggressive evaluation than previous recommendations from other groups. This commentary discusses lessons extending beyond pancreatic cysts about how physicians should consider diagnostic testing and what types of recommendations merit their attention.

Use this paper to:

  • Arrange to have a radiologist show your team CT scans of the abdomen to review anatomy and to demonstrate examples of “incidental” findings at the pancreas, kidneys, liver, and adrenal glands.
  • Review the 2015 AGA recommendations in the Table, and compare them with the prior recommendation statements.
  • Ask your learners how they will approach an incidentally noted pancreatic cyst. Will they feel comfortable “waiting” if the lesion does not have the high-risk features noted by the AGA?
  • What are the consequences of an incidental finding? How should the risk for incidental findings alter our approach to ordering tests?


The Delivery of Health Care

Systems-based Practice
Practice-based Learning / Improvement

Differences Between Early and Late Readmissions Among Patients. A Cohort Study

Revisit Rates and Associated Costs After an Emergency Department Encounter. A Multistate Analysis

Revisits and readmissions may represent inadequate and/or poor coordination of care. This first study determined whether predictors of readmission change within 30 days after discharge and found that factors associated with readmissions during the early period after discharge may not be associated with readmissions during the late period, and vice versa. The second study found that 1 of every 5 patients discharged from an ED had at least 1 revisit within 30 days, one third of which were to a different ED.

Use these studies to:

  • Start a teaching session with a multiple-choice question. We've provided one below.
  • Ask your learners what factors they think contribute to readmissions. Which can be prevented? Ask if they think discharge planning at your institution does everything possible to maximize care and minimize the need for readmission. Use In the Clinic: Transitions of Care to review key concepts.
  • Ask why patients return to emergency rooms for the same problem. Do we know whether the revisits observed in this study represented inadequate initial care? Poor planning? Inadequate comprehension of instructions by patients or a failure to follow them?
  • Readmissions and revisits are being discussed as a means to evaluate the quality of care provided. How do your learners think these studies should inform these discussions? Use the accompanying editorial to frame your discussion.
  • Use this issue's Graphic Medicine (“Mr. S Changes Doctors”) to broaden your discussion.


In the Clinic

Medical Knowledge
Patient Care
Systems-based Practice

Chronic Kidney Disease

This concise and practical clinical review provides key information your residents need to know about the evaluation and management of CKD.

Use this review article to:

  • Ask your learners whether they should be screening their patients for CKD. How should it be done? Can CKD be prevented?
  • Review how the stages of CKD are defined. Ask why it matters.
  • How are the causes of CKD classified? Ask your learners to generate a differential diagnosis for each category. Use Table 3 to help.
  • Ask your learners when ACE inhibitors, or other medications, should be prescribed to patients with CKD. What about nonpharmacologic interventions that need consideration?
  • Do your learners know the indications for renal replacement therapy? Are they medical emergencies?
  • Download the teaching slide set to help prepare a teaching session, and the multiple-choice questions to help introduce teaching topics throughout. Log on and enter your answers to claim CME for yourself!


Humanism and Professionalism

Systems-based Practice
Professionalism
Interpersonal / Communication Skills

Annals Graphic Medicine: Mr. S Changes Doctors

Annals Graphic Medicine

This short graphic narrative succinctly tells the story of a patient whose blood work “fell through the cracks” during the transition from one primary care doctor to another.

Use this story to:

  • Ask your graduating senior residents how they will plan for the transition of their “clinic” patients to new physicians.
  • How will they prepare their patients? Will they discuss the transition with them?
  • Will they do anything differently in their patients' charts to help prevent what happened to Mr. S? Can they think of ways your program could make such transitions work well?


Professionalism

On Being a Doctor: Dr. Afshar's Grid

In his essay, Dr. Clark argues that the ready-availability of information technology does not alter the core cognitive skills required to be a good doctor.

Use this essay to:

  • Ask your learners how they search for information when seeking answers to clinical questions. Do they have to look the same information up again and again? Does that make them less-skilled clinicians? Are there things they should not have to look up repeatedly?
  • Ask what skills they acquire from practice at the bedside and those that cannot be learned from a textbook or online source.


mksap16

A 78-year-old woman was recently admitted to the hospital for an acute exacerbation of chronic heart failure. She has coronary artery disease and hypertension. During that admission she was treated with intravenous diuretics, with reduction of her weight to slightly below her established optimal weight goal and resolution of her heart failure symptoms. Upon discharge her dosages of lisinopril and oral furosemide were increased from their preadmission level, and spironolactone was started. She was scheduled for a follow-up appointment with her internist in 1 week.

Four days after discharge she presents to the emergency department because of worsening shortness of breath since hospital discharge and is readmitted for further treatment. She has no chest pain but has noticed increased swelling in her lower extremities. She states that she has been taking her medications as directed.

On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 115/78 mm Hg, and respiration rate is 18/min. Oxygen saturation on ambient air is 89%. The chest examination reveals mild bilateral crackles at the lung bases. Heart examination shows a regular rate without murmur. There is trace lower extremity edema. The remainder of the examination is unremarkable.

Laboratory studies are significant for normal serum electrolyte levels and a serum creatinine level of 1.2 mg/dL (106 µmol/L) (unchanged from discharge). A chest radiograph shows bilateral hilar infiltrates consistent with pulmonary edema.

Which of the following is the most likely cause of her readmission?

A. Diuretic resistance
B. Inadequate hospital follow-up
C. Medication nonadherence
D. Spironolactone intolerance

Correct Answer
C. Medication nonadherence

Key Point
Hospitalized patients should receive a list of medications at the time of discharge and be informed of previous medications that have been discontinued or changed.

Educational Objective
Prevent medication errors from occurring during a transition in care.

The most likely cause for this patient's readmission is a medication error stemming from her medication changes at discharge. It is likely that she either did not receive or did not take the medications at the increased dosages. One in five patients discharged from the hospital will suffer an adverse event related to medical management within 3 weeks of hospital discharge, with 66% of these being adverse events related to medications. Most medication errors result from inadequate communication by hospital caregivers with patients and their primary care clinicians. Medication reconciliation is the process by which medications are reviewed at every step of the care process, with a focus on ensuring that the patient is taking only those medications intended, and that this is clear to the patient and all others involved in that patient's care. Patients should receive a list of medications at the time of discharge, be informed of previous medications that have been discontinued or changed, any new medications that have been added, and the reasons for these changes.

True diuretic resistance is uncommon, although the bioavailability of oral diuretics may be highly variable, particularly in the edematous state. She responded to intravenous diuretics as an inpatient with a return of her weight to a nonedematous level, and her oral diuretic dose was appropriately increased at the time of discharge. Her rapid decompensation from her normal baseline weight on an increased dose of diuretic with the addition of a second agent at the time of discharge makes clinically significant resistance to diuretics unlikely.

Inadequate post-hospital follow-up is a potential cause for readmission, particularly with complex patients who have had extended hospitalizations and multiple changes to their treatment regimen. In general, for most patients admitted for heart failure exacerbation, a follow-up appointment in 1 week should be scheduled at the time of discharge, preferably with direct contact with the primary care physician. This patient was scheduled for a 1-week follow-up, but worsening of her symptoms shortly after discharge suggests an issue with treatment of her initial problem, or development of an additional medical complication.

Spironolactone has been shown to decrease mortality in selected patients with systolic heart failure. Its primary complications are hyperkalemia and other effects of aldosterone blockade. However, it is unlikely to be an independent cause of her acute heart failure decompensation.

Bibliography
Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314-323. PMID: 17935242

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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