Diagnostic performance of multidetector computed tomography for suspected acute appendicitis.
Ann Intern Med. 2011 Jun 21;154(12):789-96
Authors: Pickhardt PJ, Lawrence EM, Pooler BD, Bruce RJ
Background: Use of preope…

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Omalizumab in severe allergic asthma inadequately controlled with standard therapy: a randomized trial.
Ann Intern Med. 2011 May 3;154(9):573-82
Authors: Hanania NA, Alpan O, Hamilos DL, Condemi JJ, Reyes-Rivera I, Zhu J, Rose…

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Comparison of Inhaled Long-Acting {beta}-Agonist and Anticholinergic Effectiveness in Older Patients With Chronic Obstructive Pulmonary Disease: A Cohort Study.
Ann Intern Med. 2011 May 3;154(9):583-92
Authors: Gershon A, Crox…

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Meta-analysis: Effect of Patient Self-testing and Self-management of Long-Term Anticoagulation on Major Clinical Outcomes.
Ann Intern Med. 2011 Apr 5;154(7):472-82
Authors: Bloomfield HE, Krause A, Greer N, Taylor BC, Macdonal…

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Comparative Effectiveness and Safety of Medications for Type 2 Diabetes: An Update Including New Drugs and 2-Drug Combinations.
Ann Intern Med. 2011 Mar 14;
Authors: Bennett WL, Maruthur NM, Singh S, Segal JB, Wilson LM, Chatt…

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Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial.
Ann Intern Med. 2011 Mar 15;154(6):373-83
Authors: Trouillet JL, Luyt CE, Guiguet M, Oua…

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What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study.
Ann Intern Med. 2011 Mar 15;154(6):384-90
Authors: Curry LA, Spatz E, Cherlin E, Thompson JW, Berg D, Ting HH, De…

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Meta-analysis: Diagnostic Performance of Low-Radiation-Dose Coronary Computed Tomography Angiography.
Ann Intern Med. 2011 Mar 15;154(6):413-20
Authors: von Ballmoos MW, Haring B, Juillerat P, Alkadhi H
Background: A n…

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Meta-analysis: Cardiac Resynchronization Therapy for Patients With Less Symptomatic Heart Failure.

Ann Intern Med. 2011 Feb 14;

Authors: Al-Majed NS, McAlister FA, Bakal JA, Ezekowitz JA

Background: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients with advanced symptoms of heart failure. Purpose: To assess the benefits and harms of CRT in patients with advanced heart failure and those with less symptomatic disease. Data Sources: A search of electronic databases (1950 to December 2010), hand-searching of reference lists, and unpublished data from principal investigators. Searches were not limited to the English language. Study Selection: Randomized, controlled trials of CRT compared with usual care and right or left ventricular pacing in adults with heart failure and a left ventricular ejection fraction of 0.40 or less. Data Extraction: Two reviewers performed independent study selection, data abstraction, and quality assessment by using the Cochrane tool for assessing risk for bias. Data Synthesis: There were 9082 patients in 25 trials. In patients with New York Heart Association (NYHA) class I and II symptoms, CRT reduced all-cause mortality (6 trials, 4572 participants; risk ratio [RR], 0.83 [95% CI, 0.72 to 0.96]) and heart failure hospitalizations (4 trials, 4349 participants; RR, 0.71 [CI, 0.57 to 0.87]) without improving functional outcomes or quality of life. In patients with NYHA class III or IV symptoms, CRT improved functional outcomes and reduced both all-cause mortality (19 trials, 4510 participants; RR, 0.78 [CI, 0.67 to 0.91]) and heart failure hospitalizations (11 trials, 2663 participants; RR, 0.65 [CI, 0.50 to 0.86]). The implant success rate was 94.4%; peri-implantation deaths occurred in 0.3% of trial participants, mechanical complications in 3.2%, lead problems in 6.2%, and infections in 1.4%. Limitation: Subgroup analyses were underpowered and lack data for persons with NYHA class I symptoms, atrial fibrillation, chronic kidney disease, or right bundle branch block. Conclusion: Cardiac resynchronization therapy is beneficial for patients with reduced left ventricular ejection fraction, symptoms of heart failure, and prolonged QRS, regardless of NYHA class. Primary Funding Source: None.

PMID: 21320922 [PubMed - as supplied by publisher]

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Determinants of medical expenditures in the last 6 months of life.

Ann Intern Med. 2011 Feb 15;154(4):235-42

Authors: Kelley AS, Ettner SL, Morrison RS, Du Q, Wenger NS, Sarkisian CA

Background: End-of-life medical expenditures exceed costs of care during other years, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs. Objective: To identify patient-level determinants of Medicare expenditures at the end of life and to determine the contributions of these factors to expenditure variation while accounting for regional characteristics. It was hypothesized that race or ethnicity, social support, and functional status are independently associated with treatment intensity and controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation. Design: Using data from the Health and Retirement Study, Medicare claims, and The Dartmouth Atlas of Health Care, relationships were modeled between expenditures and patient and regional characteristics. Setting: United States, 2000 to 2006. Participants: 2394 Health and Retirement Study decedents aged 65.5 years or older. Measurements: Medicare expenditures in the last 6 months of life were estimated in a series of 2-level multivariable regression models that included patient, regional, and patient and regional characteristics. Results: Decline in function (rate ratio [RR], 1.64 [95% CI, 1.46 to 1.83]); Hispanic ethnicity (RR, 1.50 [CI, 1.22 to 1.85]); black race (RR, 1.43 [CI, 1.25 to 1.64]); and certain chronic diseases, including diabetes (RR, 1.16 [CI, 1.06 to 1.27]), were associated with higher expenditures. Nearby family (RR, 0.90 [CI, 0.82 to 0.98]) and dementia (RR, 0.78 CI, 0.71 to 0.87]) were associated with lower expenditures, and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (RR, 1.09 [CI, 1.06 to 1.14]) and hospital beds per capita (RR, 1.01 [CI, 1.00 to 1.02]), were associated with higher expenditures. Patient characteristics explained 10% of overall variance and retained statistically significant relationships with expenditures after regional characteristics were controlled for. Limitation: The study limitations include the decedent sample, proxy informants, and a large proportion of unexplained variation. Conclusion: Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics. Primary Funding Source: The Brookdale Foundation.

PMID: 21320939 [PubMed - in process]

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Use of Intensive Insulin Therapy for the Management of Glycemic Control in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians.

Ann Intern Med. 2011 Feb 15;154(4):260-267

Authors: Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P,

Description: The American College of Physicians (ACP) developed this guideline to present the evidence for the link between the use of intensive insulin therapy to achieve different glycemic targets and health outcomes in hospitalized patients with or without diabetes mellitus. Methods: Published literature on this topic was identified by using MEDLINE and the Cochrane Library. Additional articles were obtained from systematic reviews and the reference lists of pertinent studies, reviews, and editorials, as well as by consulting experts; unpublished studies on ClinicalTrials.gov were also identified. The literature search included studies published from 1950 through March 2009. Searches were limited to English-language publications. The primary outcomes of interest were short-term mortality and hypoglycemia. This guideline grades the evidence and recommendations by using the ACP clinical practice guidelines grading system. Recommendation 1: ACP recommends not using intensive insulin therapy to strictly control blood glucose in non-surgical intensive care unit (SICU)/medical intensive care unit (MICU) patients with or without diabetes mellitus (Grade: strong recommendation, moderate-quality evidence). Recommendation 2: ACP recommends not using intensive insulin therapy to normalize blood glucose in SICU/MICU patients with or without diabetes mellitus (Grade: strong recommendation, high-quality evidence). Recommendation 3: ACP recommends a target blood glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) if insulin therapy is used in SICU/MICU patients (Grade: weak recommendation, moderate-quality evidence).

PMID: 21320941 [PubMed - as supplied by publisher]

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Intensive insulin therapy in hospitalized patients: a systematic review.

Ann Intern Med. 2011 Feb 15;154(4):268-82

Authors: Kansagara D, Fu R, Freeman M, Wolf F, Helfand M

Background: The benefits and harms of intensive insulin therapy (IIT) titrated to strict glycemic targets in hospitalized patients remain uncertain. Purpose: To evaluate the benefits and harms of IIT in hospitalized patients. Data Sources: MEDLINE and Cochrane Database of Systematic Reviews from 1950 to January 2010, reference lists, experts, and unpublished sources. Study Selection: English-language randomized, controlled trials comparing protocols titrated to strict or less strict glycemic targets. Data Extraction: Two reviewers independently abstracted data from each study on sample, setting, glycemic control interventions, glycemic targets, mean glucose levels achieved, and outcomes. Results were grouped by patient population or setting. A random-effects model was used to combine trial data on short-term mortality (?28 days), long-term mortality (90 or 180 days), infection, length of stay, and hypoglycemia. The Grading of Recommendations Assessment, Development, and Evaluation system was used to rate the overall body of evidence for each outcome. Data Synthesis: In a meta-analysis of 21 trials in intensive care unit, perioperative care, myocardial infarction, and stroke or brain injury settings, IIT did not affect short-term mortality (relative risk, 1.00 [95% CI, 0.94 to 1.07]). No consistent evidence showed that IIT reduced long-term mortality, infection rates, length of stay, or the need for renal replacement therapy. No evidence of benefit from IIT was reported in any hospital setting, although the best evidence for lack of benefit was in intensive care unit settings. Data combined from 10 trials showed that IIT was associated with a high risk for severe hypoglycemia (relative risk, 6.00 [CI, 4.06 to 8.87]; P < 0.001). Risk for IIT-associated hypoglycemia was increased in all hospital settings. Limitations: Methodological shortcomings and inconsistencies limit the data in perioperative care, myocardial infarction, and stroke or brain injury settings. Differences in insulin protocols and patient and hospital characteristics may affect generalizability across treatment settings. Conclusion: No consistent evidence demonstrates that IIT targeted to strict glycemic control compared with less strict glycemic control improves health outcomes in hospitalized patients. Furthermore, IIT is associated with an increased risk for severe hypoglycemia. Primary Funding Source: U.S. Department of Veterans Affairs Health Services Research and Development Service.

PMID: 21320942 [PubMed - in process]

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Effect of routine sterile gloving on contamination rates in blood culture: a cluster randomized trial.

Ann Intern Med. 2011 Feb 1;154(3):145-51

Authors: Kim NH, Kim M, Lee S, Yun NR, Kim KH, Park SW, Kim HB, Kim NJ, Kim EC, Park WB, Oh MD

Background: Blood culture contamination leads to inappropriate or unnecessary antibiotic use. However, practical guidelines are inconsistent about the routine use of sterile gloving in collection of blood for culture. Objective: To determine whether the routine use of sterile gloving before venipuncture reduces blood culture contamination rates. Design: Cluster randomized, assessor-blinded, crossover trial (ClinicalTrials.gov registration number: NCT00973063). Setting: Single-center trial involving medical wards and the intensive care unit. Participants: 64 interns in charge of collection of blood for culture were randomly assigned to routine-to-optional or optional-to-routine sterile gloving groups for 1854 adult patients who needed blood cultures. Intervention: During routine sterile gloving, the interns wore sterile gloves every time before venipuncture, but during optional sterile gloving, sterile gloves were worn only if needed. Measurements: Isolates from single positive blood cultures were classified as likely contaminant, possible contaminant, or true pathogen. Contamination rates were compared by using generalized mixed models. Results: A total of 10 520 blood cultures were analyzed: 5265 from the routine sterile gloving period and 5255 from the optional sterile gloving period. When possible contaminants were included, the contamination rate was 0.6% in routine sterile gloving and 1.1% in optional sterile gloving (adjusted odds ratio, 0.57 [95% CI, 0.37 to 0.87]; P = 0.009). When only likely contaminants were included, the contamination rate was 0.5% in routine sterile gloving and 0.9% in optional sterile gloving (adjusted odds ratio, 0.51 [CI, 0.31 to 0.83]; P = 0.007). Limitation: Blood cultures from the emergency department, surgical wards, and pediatric wards were not assessed. Conclusion: Routine sterile gloving before venipuncture may reduce blood culture contamination. Primary Funding Source: None.

PMID: 21282693 [PubMed - in process]

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Hospital spending and inpatient mortality: evidence from california: an observational study.

Ann Intern Med. 2011 Feb 1;154(3):160-7

Authors: Romley JA, Jena AB, Goldman DP

Background: Evidence shows that high Medicare spending is not associated with better health outcomes at a regional level and that high spending in hospitals is not associated with better process quality. The relationship between hospital spending and inpatient mortality is less well understood. Objective: To determine the association between hospital spending and risk-adjusted inpatient mortality. Design: Retrospective cohort study. Setting: Database of discharge records from 1999 to 2008 for 208 California hospitals included in The Dartmouth Atlas of Health Care. Patients: 2 545 352 patients hospitalized during 1999 to 2008 with 1 of 6 major medical conditions. Measurements: Inpatient mortality rates among patients admitted to hospitals with varying levels of end-of-life hospital spending. Results: For each of 6 diagnoses at admission-acute myocardial infarction, congestive heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and pneumonia-patient admission to higher-spending hospitals was associated with lower risk-adjusted inpatient mortality. During 1999 to 2003, for example, patients admitted with acute myocardial infarction to California hospitals in the highest quintile of hospital spending had lower inpatient mortality than did those admitted to hospitals in the lowest quintile (odds ratio, 0.862 [95% CI, 0.742 to 0.983]). Predicted inpatient deaths would increase by 1831 if all patients admitted with acute myocardial infarction were cared for in hospitals in the lowest quintile of spending rather than the highest. The association between hospital spending and inpatient mortality did not vary by region or hospital size. Limitation: Unobserved predictors of mortality create uncertainty about whether greater inpatient hospital spending leads to lower inpatient mortality. Conclusion: Hospitals that spend more have lower inpatient mortality for 6 common medical conditions. Primary Funding Source: National Institute on Aging and RAND Health Bing Center for Health Economics.

PMID: 21282695 [PubMed - in process]

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Competency-based education and training in internal medicine.

Ann Intern Med. 2010 Dec 7;153(11):751-6

Authors: Weinberger SE, Pereira AG, Iobst WF, Mechaber AJ, Bronze MS,

Recent efforts to improve medical education include adopting a new framework based on 6 broad competencies defined by the Accreditation Council for Graduate Medical Education. In this article, the Alliance for Academic Internal Medicine Education Redesign Task Force II examines the advantages and challenges of a competency-based educational framework for medical residents. Efforts to refine specific competencies by developing detailed milestones are described, and examples of training program initiatives using a competency-based approach are presented. Meeting the challenges of a competency-based framework and supporting these educational innovations require a robust faculty development program. Challenges to competency-based education include teaching and evaluating the competencies related to practice-based learning and improvement and systems-based practice, as well as implementing a flexible time frame to achieve competencies. However, the Alliance for Academic Internal Medicine Education Redesign Task Force II does not favor reducing internal medicine training to less than 36 months as part of competency-based education. Rather, the 36-month time frame should allow for remediation to address deficiencies in achieving competencies and for diverse enrichment experiences in such areas as quality of care and practice improvement for residents who have demonstrated skills in all required competencies.

PMID: 21135298 [PubMed - indexed for MEDLINE]

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