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The Vitals - February 2016

Internal Medicine Alert - Infectious Disease Alert - Clinical Cardiology Alert
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- OB/GYN Clinical Alert - Primary Care Reports
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- Neurology Alert

Best Prescription? Tell Patients to Get More Sleep.

ATLANTA – One of the simplest prescriptions you can offer also might be the most effective. Physicians are being strongly urged to advise patients to get adequate shut-eye.

An article in the Morbidity & Mortality Weekly Report notes that a third of U.S. adults suffer from short sleep duration, defined as less than seven hours a night and associated with greater likelihoods of obesity, high blood pressure, diabetes, coronary heart disease, stroke, frequent mental distress, and death.

Researchers from the national Centers for Disease Control and Prevention are urging physicians and other healthcare professionals to discuss the importance of healthy sleep duration with patients and address reasons for poor sleep health.

The problem is most acute in the southeastern United States and in states along the Appalachian Mountains, regions which also have the highest rates of obesity and other chronic conditions, according to the CDC. Conversely, those in the Great Plains states reported the most sleep.

Non-Hispanic black, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander, and multiracial populations all report a lower prevalence of seven hours of sleep or more compared with the rest of the U.S. population, study authors point out.

Inadequate sleep not only has physical health effects, according to the report, it also can impair cognitive performance, increasing the likelihood of motor vehicle and other transportation accidents, industrial accidents, medical errors, and loss of work productivity.

Information on sleep duration was obtained from the Behavioral Risk Factor Surveillance System (BRFSS) survey in 2014. Respondents were asked, “On average, how many hours of sleep do you get in a 24-hour period?” Among 444,306 respondents, 11.8% reported a sleep duration of five hours or less, 23.0% reported six hours, 29.5% reported seven hours, 27.7% reported eight hours, 4.4% reported nine hours, and 3.6% reported 10 hours or more. Overall, 65.2% reported the recommended healthy sleep duration, with respondents 65 or older most likely to be getting enough sleep, according to the results.

Interestingly, employed respondents had higher rates of getting enough sleep -- 64.9% -- than those who reported themselves as being unemployed or unable to work.

Researchers urge more sleep health education, reducing racial/ethnic and economic disparities, changes in work shift policies, and routine medical assessment of patients’ sleep concerns in healthcare systems.

“Based on recent recommendations for healthy sleep duration, these findings suggest that, although almost two-thirds of U.S. adults sleep ≥7 hours in a 24-hour period, an estimated 83.6 million U.S. adults sleep <7 hours,” the study authors concluded. “Therefore, clinicians might find routine discussion of sleep health with their patients as well as pursuit of explanations for poor sleep health an important component of providing health care.”

The CDC also notes that no professional sleep organizations have issued consensus statements or recommendations about the efficacy or safety of either over-the-counter or prescription sleep aids for improving sleep duration in the general adult population.

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Patients Unable to Identify Physicians Also Unlikely to Understand Instructions

MANHASSET, NY – Physicians often have a difficult time determining whether hospitalized stroke patients understand instructions and are likely to adhere to their medications.

A recent presentation at the International Stroke Conference 2016 in Los Angeles offers a simple solution: Just ask them who you are.

Researchers from the Northwell Health system in New York point out that stroke survivors are much more likely than general neurology or neurosurgery patients to be unable to identify their attending physician -- increasing the odds that those patients also will misunderstand their medication instructions and care plan, according to the study performed on a neuroscience ward.

For the study, the researchers administered a five-question survey to 146 patients, including 55 stroke patients, 91 general neurology and neurosurgery (non-stroke) patients, or their representatives. The survey assessed patient understanding of their condition leading to admission, care plan, medications, primary attending physician, and follow-up plan. If the patient was unable to communicate, their healthcare representative was interviewed.

Results indicate that 60% of stroke patients were unable to properly identify their primary attending physician, compared to 38.5% of non-stroke patients.

Of those who couldn't identify their care providers, nearly 70% of stroke patients also lacked knowledge of their medication and care plan, compared with 40% of non-stroke patients, the study points out.

"These findings tell us we need to be more vigilant about identifying ourselves as physicians and informing stroke patients about their medications and care plan," explained co-author Jeffrey M. Katz, MD, chief of Neurovascular Services and director of the Stroke Center at North Shore University Hospital. "Patients who do not know their medications well show an increased risk for subsequent strokes, and dissatisfaction with their care. This is, in essence, a patient satisfaction study telling us what we can do to increase patient satisfaction and compliance."

Confusion about caregivers is somewhat understandable, according to co-author Paul Wright, MD, chair of Neurology at North Shore University Hospital and Long Island Jewish Medical Center.

"In the past, you'd have one doctor come into your hospital room and that would be your physician,” Wright said in a Northwell press release. “But over the years we've started developing specialties and subspecialties, and now there are 10 or 15 physicians who show up. The key point is we as healthcare professionals have to inform the patient who's in charge of their care."

The study authors concluded that “stroke patients may require different, extra or more robust communication and education than the general neurology and neurosurgery population. Additionally, emphasis on attending physician identification may improve patient satisfaction and medication compliance.”

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MDs Likely to Pay Malpractice Penalties Have Distinct Characteristics

STANFORD, CA – The small percentage of physicians most likely to be involved in successful malpractice claims usually fit a profile distinctive from the average clinician, according to a new study.

The report, published recently in the New England Journal of Medicine, points out that that only 1.0% of practicing physicians accounted for 32% of paid malpractice claims over the decade measured.

"The fact that these frequent flyers looked quite different from their colleagues -- in terms of specialty, gender, age and several other characteristics -- was the most exciting finding," said lead author David Studdert, LLB, ScD, MPH, professor of medicine and of law at Stanford University. "It suggests that it may be possible to identify high-risk physicians before they accumulate troubling track records, and then do something to stop that happening."

In a Stanford press release, Studdert called the degree to which claims were concentrated within a small group of physicians “really striking.”

For the study, researchers analyzed information from the U.S. National Practitioner Data Bank, looking at a 66,426 malpractice claims paid against 54,099 physicians between January 2005 and December 2014. Almost a third of the claims were related to patient deaths, while another 54% were associated with serious injury.

Out-of-court settlements occurred in nearly all cases, with only 3% litigated with verdicts for the plaintiff. Settlements and court-ordered payments together averaged $371,054.

The study found that the physician’s claim history was the most important predictor of incurring repeated claims. Compared to physicians with only one prior paid claim, physicians who had two paid claims had almost twice the risk of another one. At the same time, physicians with three paid claims had three times the risk of recurrence; and physicians with six or more paid claims had more than 12 times the risk of recurrence.

Risk also showed wide variation based on specialty. Compared to internal medicine physicians, results indicate that the risk of recurrence was almost double among neurosurgeons, orthopedic surgeons, general surgeons, plastic surgeons, and obstetrician-gynecologists. Psychiatrists and pediatricians had the lowest risks of recurrence.

Researchers also report that male physicians had a 40% higher risk of recurrence than female physicians, and physicians younger than 35 had about one-third the risk compared to their older colleagues.

"If it turns out to be feasible to predict accurately which physicians are going to become frequent flyers, that is something liability insurers and hospitals would be very interested in doing," Studdert said, adding that he hoped the information “would be used in a more constructive way, to target measures like peer counseling, retraining, and enhanced supervision.”

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Nearly 30% of Patients Had Unnecessary Pre-Colonoscopy Visits

BALTIMORE – Gastroenterology office visits usually aren’t required before screening colonoscopy, according to a new study which finds that nearly 30% of patients have them anyway.

Widely used guidelines for colon cancer screening and polyp surveillance and the generally low risks associated with the colonoscopy procedure have made the prescreening office visit unnecessary in most cases, according to a research letter recently published in JAMA.

For the study, Johns Hopkins University School of Medicine researchers and colleagues analyzed billing data for privately insured patients under 65 to determine the proportion of colonoscopies for colon cancer screening and polyp surveillance that were preceded by office visits. Researchers also looked at the cost of those visits.

Background information in the article notes that open-access endoscopy, which allows patients to be referred for endoscopies without a prior gastroenterology office visit, began in the United States in the 1990s but that little research is available on the prevalence of the practice.

The researchers used MarketScan Commercial Claims and Encounters from Truven Health Analytics, a database that contains use and expenditure data for individuals with employer-sponsored private health insurance from several hundred U.S. employers and health plans, from 2010 through 2013. From the data, which includes approximately 43 to 55 million beneficiaries each year from all 50 states, study authors included patients age 50 to 64 years with continuous insurance coverage for 12 months prior to an outpatient colonoscopy performed in the gastroenterology setting that included a diagnosis for screening or polyp surveillance.

Results indicate that, of 842,849 patients who underwent colonoscopy, 29% had a pre-colonoscopy office visit. While patients with office visits had a higher Charlson Comorbidity Index (CCI) in general, 66% had a CCI of 0. Of the diagnoses for the office visits, 77% were related either to screening or preoperative evaluation.

With an average payment for office visits of $124 distributed across all patients, pre-colonoscopy office visits added an average of $36 per colonoscopy.

"Although the pre-colonoscopy office visits added a modest $36 per colonoscopy in this population, there are an estimated 7 million screening colonoscopies performed in the United States annually, so the cumulative costs are significant,” the study authors pointed out. “Identifying which patients benefit from a pre-colonoscopy office visit and targeting those patients could increase the value of colon cancer screening.”

Researchers note that the study is limited by their inability to determine why office visits were required.

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