‘Update in Hospital Medicine’ offered practice pearls at HM19

Studies that question common practices


On the big stage at HM19 in late March, Carrie Herzke, MD, FAAP, FACP, SFHM, and Christopher Moriates, MD, FACP, SFHM, undertook the daunting task of summarizing a year’s worth of research relevant to the practice of hospital medicine – all within the span of an hour.

Dr. Carrie Herzke is associate vice chair for clinical affairs in the department of medicine at Johns Hopkins Medicine in Baltimore

Dr. Carrie Herzke

As has been standard with the “Update in Hospital Medicine” session at previous SHM Annual Conferences, the presenters touched on lighter topics in the medical literature: a prospective cohort study that found drinking coffee was inversely associated with mortality, even for those who drink up to eight cups a day; a cross-sectional observational study in which patients noted that what a physician wears is an important consideration for them during care, with a white coat preferred over formal attire as the most highly rated preference in a clinical care setting; and a study from a pediatric journal in which researchers calculated the average transit time for a Lego figurine head ingested by an adult.

But Dr. Herzke and Dr. Moriates mainly covered more serious subjects. In an interview before the session, Dr. Herzke, associate vice chair for clinical affairs in the department of medicine at Johns Hopkins Medicine in Baltimore, said she and Dr. Moriates chose studies across the fields of infectious diseases, cardiology, and hematology that should make hospitalists question common practices and consider changing how they practice medicine at their home institution.

Dr. Moriates, assistant dean for health care value at the University of Texas at Austin, said in an interview that their topic choices reflected the breadth and diversity of patients taken care of by hospitalists.

Dr. Christopher Moriates, University of Texas, Austin, hospitalist

Dr. Christopher Moriates

For example, he noted during the HM19 session that results from several studies suggest hospitalists may soon choose oral antibiotics over IV antibiotics for care of certain patient populations: the recent POET trial suggests use of oral antibiotics for patients with left-sided infective endocarditis resulted in a lower length of stay in hospital (19 inpatient days) when compared with use of IV antibiotics (3 inpatient days and 17 additional treatment days post discharge), while the OVIVA trial found a lower but noninferior treatment failure rate among patients who received oral antibiotics for bone and joint infection, compared with IV antibiotics. Although these were both well-done studies, Dr. Moriates and Dr. Herzke emphasized that the results challenge widely accepted standards of care, and it may not yet be time for a paradigm shift.

Direct oral anticoagulants (DOACs) also are being studied in patients with end-stage renal disease (ESRD) and cancer, Dr. Herzke said, and apixaban (Eliquis) 5 mg appears to be the preferred dose for a lower risk of stroke and mortality in patients with ESRD and atrial fibrillation. The speakers said there are further studies being developed for management of AF in patients with heart failure and DOACs for patients with ESRD.

Another retrospective cohort study from research in the Massachusetts Public Health Dataset found that buprenorphine may have a number needed to treat of 50 for opioid use disorder, which Dr. Moriates said is close in proximity for the number needed to treat for aspirin. “It seems like it’s time for this to become standard of care,” he said.

The speakers also highlighted common practices hospitalists should stop performing based on the latest evidence.

In one example, they revealed that there is conflicting research on angiotensin-converting enzyme (ACE) inhibitors. One study found transient preoperative interruption of ACE inhibitors was associated with a reduction in intraoperative hypotension during a noncardiac, nonvascular surgery. A second study linked ACE inhibitor use with a reduction in all-cause mortality. However, long-term use of ACE inhibitors also appears to be associated with a 14% increase in lung cancers, with an increased incidence based on longer use duration.

Hospitalists should also be aware of recommendations from a study on oxygen therapy, Dr. Herzke noted, which found that extra oxygen therapy may harm patients with MI or stroke; as a result, hospitalists should “wean oxygen as tolerated” in these patients. In addition, hospitalists also may want to consider using oral vancomycin (Vancocin) or fidaxomicin (Dificid) for treatment of Clostridium difficile infections, based on new evidence that found there is a higher cure rate for those treatments, compared with metronidazole.

Dr. Moriates and Dr. Herzke had no relevant financial conflicts.

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