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.
Blood pressure (BP)–lowering medications are now recommended for all patients with BP 140/90 mm Hg or higher and for patients with BP 130/80 to 139/89 mm Hg who also have diabetes, chronic kidney disease (stage 3 or higher), clinical cardiovascular disease, or an estimated 10-year risk for atherosclerotic cardiovascular disease of 10% or higher.
First-line antihypertensive medications include thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and-calcium channel blockers. Chlorthalidone or indapamide are recommended over hydrochlorothiazide by most experts because of their greater potency and duration and better clinical outcomes. β-Blockers are not a first-line choice for most patients unless specifically indicated to treat a comorbid condition.
Patients with resistant hypertension (i.e., BP still not at goal despite treatment with 3 antihypertensive medications) should be assessed for secondary causes of hypertension. Spironolactone is recommended for many patients with this condition because it is more effective than β-blockers or α-blockers in these patients (many patients with resistant hypertension have hyperaldosteronism).
No national standard outlines how hospitalists should be trained or how procedural competence should be demonstrated. This leads to interhospital variability in practice and use of non–evidence-based standards (e.g., employing an arbitrary number of procedures per year as a “measure” of competence).
Many procedural skills wane as a result of low procedural volumes, and most hospitals do not have established mechanisms to ensure that hospitalists maintain their skills.
The authors make several suggestions about how to rectify this problem. These include development of mandatory simulation-based procedure training programs, consolidating procedural responsibilities in select groups of “proceduralists” (to allow a subset of hospitalists to maintain adequate procedural volumes), and developing national standards for procedural competence assessment for hospitalists.
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Wesorick DH, Chopra V. Annals for Hospitalists - 21 May 2019. Ann Intern Med. 2019;170:HO1. doi: https://doi.org/10.7326/AWHO201905210
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Published: Ann Intern Med. 2019;170(10):HO1.
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