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Although the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10), is used elsewhere around the globe, U.S. proposals to move from the ninth to the 10th revision have faltered because of congressional delays, among other reasons. The most recent delay will expire on 1 October 2015, and the ICD-10 will then become a legal standard for diagnosis coding in the United States. Physician reimbursements and quality scores will increasingly depend on the completeness, as well as accuracy and specificity, of diagnosis coding for risk adjustments. This commentary explains why it is time to move to the ICD-10.
Topics: international classification of diseases
Many physicians dislike the process of assessing patient satisfaction. This commentary, which references a 1925 speech delivered by Dr. Francis Weld Peabody, explains why physicians should pay attention to patient satisfaction and the process by which it is assessed.
Topics: client satisfaction, hate
The authors argue that clinicians, public health experts, and representatives of the public should be involved in examining the advisability of performing experiments intended to create potential pandemic pathogens, providing important perspectives on how to reduce the risks of such research, and increasing public confidence in scientists as responsible stewards.
Topics: engineering, genome, pathogenic organism, pandemic
Position Papers | 
Hilary Daniel, BS; Lois Snyder Sulmasy, JD, for the ACP Health and Public Policy Committee*
Telemedicine—the use of technology to deliver care at a distance—is rapidly growing and can potentially expand access for patients, enhance patient–physician collaboration, improve health outcomes, and reduce medical costs. However, the potential benefits of telemedicine must be measured against the risks and challenges associated with its use, including the absence of the physical examination, variation in state practice and licensing regulations, and issues surrounding the establishment of the patient–physician relationship. This paper offers policy recommendations for the practice and use of telemedicine in primary care and reimbursement policies associated with telemedicine use. The positions put forward by the American College of Physicians highlight a meaningful approach to telemedicine policies and regulations that will have lasting positive effect for patients and physicians.
Topics: telemedicine
Editorials | 
David A. Asch, MD, MBA
This issue contains an American College of Physicians position paper on telemedicine. The editorialist believes that the gains from telemedicine will come from delivering care to populations—sometimes highly specialized care, in totally different ways. The innovation that telemedicine promises is not just doing the same thing remotely that used to be done face to face but awakening us to the many things that we thought required face-to-face contact but actually do not.
Topics: telemedicine, economics
Ideas and Opinions | 
Thomas Rea, MD, MPH; and Mickey Eisenberg, MD, PhD
The survival of patients who have sudden cardiac arrest may differ markedly among communities. The Institute of Medicine recently evaluated the causes for such disparities and issued a “call to action” for improvement. The authors discuss the steps that should help bring about the improvements needed.
Topics: sudden cardiac death, institute of medicine (u.s.)
Original Research | 
Patrick S. Twomey, MD; Bryan L. Smith, MD; Cathy McDermott, RN, MPH; Anne Novitt-Moreno, MD; William McCarthy, PhD; S. Patrick Kachur, MD; and Paul M. Arguin, MD
Background:Quinidine gluconate, the only U.S. Food and Drug Administration–approved treatment for life-threatening malaria in the United States, has a problematic safety profile and is often unavailable in hospitals. Objective:To assess the safety and clinical benefit of intravenous artesunate as an alternative to quinidine. Design:Retrospective case series. Setting:U.S. hospitals. Patients:102 patients aged 1 to 72 years (90% adults; 61% men) with severe and complicated malaria. Patients received 4 weight-based doses of intravenous artesunate (2.4 mg/kg) under a treatment protocol implemented by the Centers for Disease Control and Prevention between January 2007 and December 2010. At baseline, 35% had evidence of cerebral malaria, and 17% had severe hepatic impairment. Eligibility required the presence of microscopically confirmed malaria, need for intravenous treatment, and an impediment to quinidine. Measurements:Clinical and laboratory data from each patient's hospital records were abstracted retrospectively, including information from baseline through a maximum 7-day follow-up, and presented before a physician committee to evaluate safety and clinical benefit outcomes. Results:7 deaths occurred (mortality rate, 6.9%). The most frequent adverse events were anemia (65%) and elevated hepatic enzyme levels (49%). All deaths and most adverse events were attributed to the severity of malaria. Patients' symptoms generally improved or resolved within 3 days, and the median time to discharge from the intensive care unit was 4 days, even for patients with severe liver disease or cerebral malaria. More than 100 concomitant medications were used, with no documented drug–drug interactions. Limitation:Potential late-presenting safety issues might occur outside the 7-day follow-up. Conclusion:Artesunate was a safe and clinically beneficial alternative to quinidine. Primary Funding Source:Office of the Surgeon General, Department of the U.S. Army.
Topics: malaria, artesunate, malaria, falciparum, severe and complicated, investigational new drugs, quinidine
Ideas and Opinions | 
Adrian F. Hernandez, MD, MHS; Rachael L. Fleurence, PhD; and Russell L. Rothman, MD, MPP
Growing complexity and administrative burdens are making clinical trials less attractive to clinicians, health systems, sponsors, and patients. To address these challenges, the Patient-Centered Outcomes Research Institute created the National Patient-Centered Clinical Research Network (PCORnet), a “network of networks” to facilitate research that addresses important clinical questions. The authors discuss ADAPTABLE (Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness), which will compare 2 different aspirin doses in high-risk patients with a history of heart disease while simultaneously testing PCORnet's capacity to accomplish its core mission.
Topics: aspirin, heart diseases, patient-centered care, comparative effectiveness research, compare 1 trial, clinical research, myocardial infarction, hemorrhage, cerebrovascular accident, ischemic stroke, follow-up, electronic medical records
Ideas and Opinions | 
Lindsay M. Jaacks, PhD; Mohammed K. Ali, MBChB, MSc, MBA; John Bartlett, MD; Gerald S. Bloomfield, MD, MPH; William Checkley, MD; Thomas A. Gaziano, MD, MSc; Douglas C. Heimburger, MD, MS; Sandeep P. Kishore, MD, PhD; Racquel E. Kohler, PhD, MSPH; Kasia J. Lipska, MD, MHS; Olivia Manders, MA; Christine Ngaruiya, MD, DTM&H; Robert Peck, MD, MS; Melissa Burroughs Pena, MD, MS; David A. Watkins, MD, MPH; Karen R. Siegel, PhD, MPH; and K.M. Venkat Narayan, MD, MSc, MBA
Noncommunicable diseases (NCDs) are among the leading causes of death and disability throughout the world. In September 2014, U.S. researchers met to discuss the challenges and opportunities in conducting global NCD research. This essay summarizes 4 strategies for moving forward on a global NCD research agenda.
Topics: communicable diseases, investments, mentors, world health, united states national institutes of health, disability
Ideas and Opinions | 
Jonathan Purtle, DrPH, MSc; John A. Rich, MD, MPH; Joel A. Fein, MD, MPH; Thea James, MD; and Theodore J. Corbin, MD, MPP
Violently injured patients are at risk for reinjury, violence perpetration, and posttraumatic stress; however, they have traditionally received in-hospital care that addresses only their physical injuries. The authors describe the organizational components of multidimensional, hospital-based violence intervention programs; evidence of the success of such initiatives; and how the Affordable Care Act may affect them.
Topics: hospitals, violence prevention
Reviews | 
Reed A.C. Siemieniuk, MD; Maureen O. Meade, MD; Pablo Alonso-Coello, MD, PhD; Matthias Briel, MD, MSc; Nathan Evaniew, MD; Manya Prasad, MBBS; Paul E. Alexander, MSc, PhD; Yutong Fei, MD, PhD; Per O. Vandvik, MD, PhD; Mark Loeb, MD, MSc; and Gordon H. Guyatt, MD, MSc
Background:Community-acquired pneumonia (CAP) is common and often severe. Purpose:To examine the effect of adjunctive corticosteroid therapy on mortality, morbidity, and duration of hospitalization in patients with CAP. Data Sources:MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through 24 May 2015. Study Selection: Randomized trials of systemic corticosteroids in hospitalized adults with CAP. Data Extraction:Two reviewers independently extracted study data and assessed risk of bias. Quality of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation system by consensus among the authors. Data Synthesis:The median age was typically in the 60s, and approximately 60% of patients were male. Adjunctive corticosteroids were associated with possible reductions in all-cause mortality (12 trials; 1974 patients; risk ratio [RR], 0.67 [95% CI, 0.45 to 1.01]; risk difference [RD], 2.8%; moderate certainty), need for mechanical ventilation (5 trials; 1060 patients; RR, 0.45 [CI, 0.26 to 0.79]; RD, 5.0%; moderate certainty), and the acute respiratory distress syndrome (4 trials; 945 patients; RR, 0.24 [CI, 0.10 to 0.56]; RD, 6.2%; moderate certainty). They also decreased time to clinical stability (5 trials; 1180 patients; mean difference, −1.22 days [CI, −2.08 to −0.35 days]; high certainty) and duration of hospitalization (6 trials; 1499 patients; mean difference, −1.00 day [CI, −1.79 to −0.21 days]; high certainty). Adjunctive corticosteroids increased frequency of hyperglycemia requiring treatment (6 trials; 1534 patients; RR, 1.49 [CI, 1.01 to 2.19]; RD, 3.5%; high certainty) but did not increase frequency of gastrointestinal hemorrhage. Limitations:There were few events and trials for many outcomes. Trials often excluded patients at high risk for adverse events. Conclusion:For hospitalized adults with CAP, systemic corticosteroid therapy may reduce mortality by approximately 3%, need for mechanical ventilation by approximately 5%, and hospital stay by approximately 1 day. Primary Funding Source:None.
Topics: community acquired pneumonia, glucocorticoids, inpatient, mechanical ventilation, steroid therapy, adrenal corticosteroids, mineralocorticoids, respiratory distress syndrome, adult
Editorials | 
Marcos I. Restrepo, MD, MSc; Antonio Anzueto, MD; and Antoni Torres, MD, PhD
In this issue, Siemieniuk and colleagues report a systematic review and meta-analysis of 13 randomized, controlled trials of adjunctive therapy with systemic corticosteroids versus placebo for patients hospitalized with community-acquired pneumonia. The editorialists discuss the review and call for changes in clinical practice.
Topics: adrenal corticosteroids, community acquired pneumonia, glucocorticoids, mineralocorticoids
Ideas and Opinions | 
Arif H. Kamal, MD, MHS; Jennifer M. Maguire, MD; and Diane E. Meier, MD
The United States is currently in the midst of a national crisis in providing accessible and responsive palliative care due to a shortage of professionals trained to provide this care. The authors suggest one possible approach for dealing with this crisis.
Topics: palliative care, workforce
Reviews | 
Jennifer H. Han, MD, MSCE*; Nancy Sullivan, BA*; Brian F. Leas, MS, MA*; David A. Pegues, MD; Janice L. Kaczmarek, MS; and Craig A. Umscheid, MD, MSCE
The cleaning of hard surfaces in hospital rooms is critical for reducing health care–associated infections. This review describes the evidence examining current methods of cleaning, disinfecting, and monitoring cleanliness of patient rooms, as well as contextual factors that may affect implementation and effectiveness. Key informants were interviewed, and a systematic search for publications since 1990 was done with the use of several bibliographic and gray literature resources. Studies examining surface contamination, colonization, or infection with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci were included. Eighty studies were identified—76 primary studies and 4 systematic reviews. Forty-nine studies examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges or facilitators to implementation. Only 5 studies were randomized, controlled trials, and surface contamination was the most commonly assessed outcome. Comparative effectiveness studies of disinfecting methods and monitoring strategies were uncommon. Future research should evaluate and compare newly emerging strategies, such as self-disinfecting coatings for disinfecting and adenosine triphosphate and ultraviolet/fluorescent surface markers for monitoring. Studies should also assess patient-centered outcomes, such as infection, when possible. Other challenges include identifying high-touch surfaces that confer the greatest risk for pathogen transmission; developing standard thresholds for defining cleanliness; and using methods to adjust for confounders, such as hand hygiene, when examining the effect of disinfecting methods.
Topics: disinfection, patients' rooms, therapeutic touch, healthcare associated infections, pathogenic organism, microbial colonization, touch sensation, contextual factors
In this issue, Han and colleagues' systematic review identifies gaps in the evidence base for hospital environmental cleaning. Unlike near-universal acceptance of the importance of hand hygiene, the prevailing view of the contribution of the inanimate health care environment to the spread of health care–associated infections swings back and forth. The editorialists underscore the need for carefully designed studies to help us understand the magnitude of contribution of the inanimate environment to the pathogenesis of these infections.
Topics: healthcare associated infections
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