Hospitalists serving as attending physicians were overwhelmingly found in ICUs in hospitals where intensivists were used mostly as elective consultations, according to a study to be published in this month’s Journal of Hospital Medicine.

The report, "Characteristics of Intensive Care Units in Michigan: Not an Open and Closed Case" (JHM. 2010;5:4-9), is a cross-sectional survey of 115 ICUs in 72 Michigan hospitals. The way critical care is delivered is an issue many hospitalists pay mind to as they often are called upon to compensate for workforce shortages even though few are board-certified in critical care. The study reported that 25% of sites used a closed model of intensive care, and that those units were larger than sites with open ICUs (P<0.05). Hospitalists serving as attendings were "strongly associated with an open ICU" (odds ratio 95%; confidence interval=12.2).

"Because our study shows that hospitalists are already providing intensive care in many areas of Michigan … the best strategy [for hospitalists] would be to work within that context,” says lead researcher Robert C. Hyzy, MD, FCCM, associate professor in the Department of Internal Medicine and director of the Critical Care Medicine Unit at the University of Michigan in Ann Arbor.

Dr. Hyzy says hospitalists will "continue to play an important role" in ICU care as long as the intensivist shortage continues, even though many don’t have the extensive training to do so. Telemedicine has been used in recent years to help address the ICU physician shortage, although the debate continues as to its effectiveness on morbidity and mortality rates. In the meantime, Dr. Hyzy reports, only 20% of the sites in his study reported all attending physicians were board-certified in critical care; 60 sites had less than 50% board-certified attending physicians.

“Hospitalists can play a role in acknowledging the limitations of individuals who are not properly trained in critical care to advocate for transfer to larger centers under explicit clinical circumstances,” Dr. Hyzy says.

As a member of the Society of Critical Care Medicine’s (SCCM) fellowship program, Dr. Hyzy also urges any hospitalists who deliver critical-care services to investigate the SCCM’s certification track and to take advantage of any training opportunities available to them.

Hospitalists serving as attending physicians were overwhelmingly found in ICUs in hospitals where intensivists were used mostly as elective consultations, according to a study to be published in this month’s Journal of Hospital Medicine.

The report, "Characteristics of Intensive Care Units in Michigan: Not an Open and Closed Case" (JHM. 2010;5:4-9), is a cross-sectional survey of 115 ICUs in 72 Michigan hospitals. The way critical care is delivered is an issue many hospitalists pay mind to as they often are called upon to compensate for workforce shortages even though few are board-certified in critical care. The study reported that 25% of sites used a closed model of intensive care, and that those units were larger than sites with open ICUs (P<0.05). Hospitalists serving as attendings were "strongly associated with an open ICU" (odds ratio 95%; confidence interval=12.2).

"Because our study shows that hospitalists are already providing intensive care in many areas of Michigan … the best strategy [for hospitalists] would be to work within that context,” says lead researcher Robert C. Hyzy, MD, FCCM, associate professor in the Department of Internal Medicine and director of the Critical Care Medicine Unit at the University of Michigan in Ann Arbor.

Dr. Hyzy says hospitalists will "continue to play an important role" in ICU care as long as the intensivist shortage continues, even though many don’t have the extensive training to do so. Telemedicine has been used in recent years to help address the ICU physician shortage, although the debate continues as to its effectiveness on morbidity and mortality rates. In the meantime, Dr. Hyzy reports, only 20% of the sites in his study reported all attending physicians were board-certified in critical care; 60 sites had less than 50% board-certified attending physicians.

“Hospitalists can play a role in acknowledging the limitations of individuals who are not properly trained in critical care to advocate for transfer to larger centers under explicit clinical circumstances,” Dr. Hyzy says.

As a member of the Society of Critical Care Medicine’s (SCCM) fellowship program, Dr. Hyzy also urges any hospitalists who deliver critical-care services to investigate the SCCM’s certification track and to take advantage of any training opportunities available to them.

Hospitalists serving as attending physicians were overwhelmingly found in ICUs in hospitals where intensivists were used mostly as elective consultations, according to a study to be published in this month’s Journal of Hospital Medicine.

The report, "Characteristics of Intensive Care Units in Michigan: Not an Open and Closed Case" (JHM. 2010;5:4-9), is a cross-sectional survey of 115 ICUs in 72 Michigan hospitals. The way critical care is delivered is an issue many hospitalists pay mind to as they often are called upon to compensate for workforce shortages even though few are board-certified in critical care. The study reported that 25% of sites used a closed model of intensive care, and that those units were larger than sites with open ICUs (P<0.05). Hospitalists serving as attendings were "strongly associated with an open ICU" (odds ratio 95%; confidence interval=12.2).

"Because our study shows that hospitalists are already providing intensive care in many areas of Michigan … the best strategy [for hospitalists] would be to work within that context,” says lead researcher Robert C. Hyzy, MD, FCCM, associate professor in the Department of Internal Medicine and director of the Critical Care Medicine Unit at the University of Michigan in Ann Arbor.

Dr. Hyzy says hospitalists will "continue to play an important role" in ICU care as long as the intensivist shortage continues, even though many don’t have the extensive training to do so. Telemedicine has been used in recent years to help address the ICU physician shortage, although the debate continues as to its effectiveness on morbidity and mortality rates. In the meantime, Dr. Hyzy reports, only 20% of the sites in his study reported all attending physicians were board-certified in critical care; 60 sites had less than 50% board-certified attending physicians.

“Hospitalists can play a role in acknowledging the limitations of individuals who are not properly trained in critical care to advocate for transfer to larger centers under explicit clinical circumstances,” Dr. Hyzy says.

As a member of the Society of Critical Care Medicine’s (SCCM) fellowship program, Dr. Hyzy also urges any hospitalists who deliver critical-care services to investigate the SCCM’s certification track and to take advantage of any training opportunities available to them.

Clinical question: Are aldosterone antagonists appropriately used in heart failure patients?

Background: Aldosterone antagonists are Class 1 treatment for patients with heart failure (HF) and low left ventricular ejection fraction (LVEF), according to the latest American College of Cardiology/American Heart Association (ACC/AHA) Chronic HF Guidelines. However, acceptance of the guidelines has been slow, possibly because of contraindications and adverse effects in some patients.

Study design: Observational cohort.

Setting: Inpatients at 241 hospitals participating in an HF registry.

Synopsis: Eligible inpatients from a QI registry who were discharged home from January 2005 to December 2007 were analyzed for appropriate and inappropriate aldosterone antagonist use.

Among the 12,565 patients who met the criteria for aldosterone antagonist therapy, only 4,087 (32.5%) received the therapy at discharge. In contrast, of the 8,610 total patients with HF discharged on aldosterone antagonists, 269 (3.1%) met at least one criterion for inappropriate use, and 640 (7.4%) met at least one criteria for potentially inappropriate use.

Use of an aldosterone antagonist was more likely in certain patient groups, including those who were younger, African-American, had lower systolic blood pressure, had no history of renal insufficiency, and those with implantable cardioverter-defibrillators. The authors noted aldosterone use increased significantly during the study period.

The study was limited by the possibility that aldosterone antagonists were used for non-HF conditions and the fact that it was retrospective.

Bottom line: Aldosterone antagonists are used in less than one-third of eligible HF patients.

Citation: Albert NM, Yancy CW, Liang L, et al. Use of aldosterone antagonists in heart failure. JAMA. 2009;302(15):1658-1665.

Reviewed for TH eWire by Jill Goldenberg, MD, Alan Briones, MD, Dennis Chang, MD, Brian Markoff, MD, FHM, Erin Rule, MD, Andrew Dunn, MD, FACP, FHM, Division of General Internal Medicine, Mount Sinai School of Medicine, New York City

For more HM-related literature reviews, visit our Web site.

Clinical question: Are aldosterone antagonists appropriately used in heart failure patients?

Background: Aldosterone antagonists are Class 1 treatment for patients with heart failure (HF) and low left ventricular ejection fraction (LVEF), according to the latest American College of Cardiology/American Heart Association (ACC/AHA) Chronic HF Guidelines. However, acceptance of the guidelines has been slow, possibly because of contraindications and adverse effects in some patients.

Study design: Observational cohort.

Setting: Inpatients at 241 hospitals participating in an HF registry.

Synopsis: Eligible inpatients from a QI registry who were discharged home from January 2005 to December 2007 were analyzed for appropriate and inappropriate aldosterone antagonist use.

Among the 12,565 patients who met the criteria for aldosterone antagonist therapy, only 4,087 (32.5%) received the therapy at discharge. In contrast, of the 8,610 total patients with HF discharged on aldosterone antagonists, 269 (3.1%) met at least one criterion for inappropriate use, and 640 (7.4%) met at least one criteria for potentially inappropriate use.

Use of an aldosterone antagonist was more likely in certain patient groups, including those who were younger, African-American, had lower systolic blood pressure, had no history of renal insufficiency, and those with implantable cardioverter-defibrillators. The authors noted aldosterone use increased significantly during the study period.

The study was limited by the possibility that aldosterone antagonists were used for non-HF conditions and the fact that it was retrospective.

Bottom line: Aldosterone antagonists are used in less than one-third of eligible HF patients.

Citation: Albert NM, Yancy CW, Liang L, et al. Use of aldosterone antagonists in heart failure. JAMA. 2009;302(15):1658-1665.

Reviewed for TH eWire by Jill Goldenberg, MD, Alan Briones, MD, Dennis Chang, MD, Brian Markoff, MD, FHM, Erin Rule, MD, Andrew Dunn, MD, FACP, FHM, Division of General Internal Medicine, Mount Sinai School of Medicine, New York City

For more HM-related literature reviews, visit our Web site.

Clinical question: Are aldosterone antagonists appropriately used in heart failure patients?

Background: Aldosterone antagonists are Class 1 treatment for patients with heart failure (HF) and low left ventricular ejection fraction (LVEF), according to the latest American College of Cardiology/American Heart Association (ACC/AHA) Chronic HF Guidelines. However, acceptance of the guidelines has been slow, possibly because of contraindications and adverse effects in some patients.

Study design: Observational cohort.

Setting: Inpatients at 241 hospitals participating in an HF registry.

Synopsis: Eligible inpatients from a QI registry who were discharged home from January 2005 to December 2007 were analyzed for appropriate and inappropriate aldosterone antagonist use.

Among the 12,565 patients who met the criteria for aldosterone antagonist therapy, only 4,087 (32.5%) received the therapy at discharge. In contrast, of the 8,610 total patients with HF discharged on aldosterone antagonists, 269 (3.1%) met at least one criterion for inappropriate use, and 640 (7.4%) met at least one criteria for potentially inappropriate use.

Use of an aldosterone antagonist was more likely in certain patient groups, including those who were younger, African-American, had lower systolic blood pressure, had no history of renal insufficiency, and those with implantable cardioverter-defibrillators. The authors noted aldosterone use increased significantly during the study period.

The study was limited by the possibility that aldosterone antagonists were used for non-HF conditions and the fact that it was retrospective.

Bottom line: Aldosterone antagonists are used in less than one-third of eligible HF patients.

Citation: Albert NM, Yancy CW, Liang L, et al. Use of aldosterone antagonists in heart failure. JAMA. 2009;302(15):1658-1665.

Reviewed for TH eWire by Jill Goldenberg, MD, Alan Briones, MD, Dennis Chang, MD, Brian Markoff, MD, FHM, Erin Rule, MD, Andrew Dunn, MD, FACP, FHM, Division of General Internal Medicine, Mount Sinai School of Medicine, New York City

For more HM-related literature reviews, visit our Web site.

A Case Studies Compendium supplement to Internal Medicine News. This supplement was sponsored by Daiichi Sankyo, Inc.

•Case 1 Topics
•Case 2 Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Case 2 Topics

• Background
• Current Visit: Exam Findings
• Current Treatment Regimen
• Health History
• Laboratory Results
• Clinical Discussion
• Cardiologist Visit
• Three Months After Visiting the Cardiologist
• Add-On Therapy With Welchol for Patients With T2DM and CHD
• Treatment Goals for Alice
• Conclusions

Faculty/Faculty Disclosures

Yehuda Handelsman, MD, FACP, FACE
Medical Director
Metabolic Institute of America
Chair and Program Director
7th World Congress on InsulinResistance
Chair, International Committeefor Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web Site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb

Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Tethys,

and Xoma; he has received clinical research grant funding from Daiichi Sankyo, Inc., GlaxoSmithKline, Novo Nordisk, and Takeda; and he ison the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo, Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Peter H. Jones, MD, FACP
Co-Director, Lipid Metabolism
and Atherosclerosis Clinic
Medical Director, Weight
Management Center
The Methodist Hospital
Associate Professor of Medicine
Section of Atherosclerosis andLipid Research
Baylor College of Medicine
Houston, TX 77030
E-mail: [email protected]
Dr Jones has disclosed that he has received support in the form of consulting agreements from Abbott Laboratories, AstraZeneca Pharmaceuticals LP, Daiichi Sankyo, Inc., and Merck.

Copyright © 2010 Elsevier Inc.

A Case Studies Compendium supplement to Internal Medicine News. This supplement was sponsored by Daiichi Sankyo, Inc.

•Case 1 Topics
•Case 2 Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Case 2 Topics

• Background
• Current Visit: Exam Findings
• Current Treatment Regimen
• Health History
• Laboratory Results
• Clinical Discussion
• Cardiologist Visit
• Three Months After Visiting the Cardiologist
• Add-On Therapy With Welchol for Patients With T2DM and CHD
• Treatment Goals for Alice
• Conclusions

Faculty/Faculty Disclosures

Yehuda Handelsman, MD, FACP, FACE
Medical Director
Metabolic Institute of America
Chair and Program Director
7th World Congress on InsulinResistance
Chair, International Committeefor Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web Site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb

Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Tethys,

and Xoma; he has received clinical research grant funding from Daiichi Sankyo, Inc., GlaxoSmithKline, Novo Nordisk, and Takeda; and he ison the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo, Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Peter H. Jones, MD, FACP
Co-Director, Lipid Metabolism
and Atherosclerosis Clinic
Medical Director, Weight
Management Center
The Methodist Hospital
Associate Professor of Medicine
Section of Atherosclerosis andLipid Research
Baylor College of Medicine
Houston, TX 77030
E-mail: [email protected]
Dr Jones has disclosed that he has received support in the form of consulting agreements from Abbott Laboratories, AstraZeneca Pharmaceuticals LP, Daiichi Sankyo, Inc., and Merck.

Copyright © 2010 Elsevier Inc.

A Case Studies Compendium supplement to Internal Medicine News. This supplement was sponsored by Daiichi Sankyo, Inc.

•Case 1 Topics
•Case 2 Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Case 2 Topics

• Background
• Current Visit: Exam Findings
• Current Treatment Regimen
• Health History
• Laboratory Results
• Clinical Discussion
• Cardiologist Visit
• Three Months After Visiting the Cardiologist
• Add-On Therapy With Welchol for Patients With T2DM and CHD
• Treatment Goals for Alice
• Conclusions

Faculty/Faculty Disclosures

Yehuda Handelsman, MD, FACP, FACE
Medical Director
Metabolic Institute of America
Chair and Program Director
7th World Congress on InsulinResistance
Chair, International Committeefor Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web Site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb

Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Tethys,

and Xoma; he has received clinical research grant funding from Daiichi Sankyo, Inc., GlaxoSmithKline, Novo Nordisk, and Takeda; and he ison the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo, Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Peter H. Jones, MD, FACP
Co-Director, Lipid Metabolism
and Atherosclerosis Clinic
Medical Director, Weight
Management Center
The Methodist Hospital
Associate Professor of Medicine
Section of Atherosclerosis andLipid Research
Baylor College of Medicine
Houston, TX 77030
E-mail: [email protected]
Dr Jones has disclosed that he has received support in the form of consulting agreements from Abbott Laboratories, AstraZeneca Pharmaceuticals LP, Daiichi Sankyo, Inc., and Merck.

Copyright © 2010 Elsevier Inc.

A Journal Scan supplement to Family Practice News

A Journal Scan supplement to Family Practice News

A Journal Scan supplement to Family Practice News

A supplement to Internal Medicine News. This supplement was sponsored by Daiichi Sankyo, Inc.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Faculty

Yehuda Handelsman, MD, FACP, FACE
Medical Director, Metabolic Institute of America
Chair and Program Director, 7th World Congress on Insulin Resistance Chair, International Committee for Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Xoma, and Tethys;he has received clinical research grant funding from Takeda, Daiichi Sankyo Inc., GlaxoSmithKline, and Novo Nordisk; and he is on the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Copyright © 2010 Elsevier Inc.

A supplement to Internal Medicine News. This supplement was sponsored by Daiichi Sankyo, Inc.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Faculty

Yehuda Handelsman, MD, FACP, FACE
Medical Director, Metabolic Institute of America
Chair and Program Director, 7th World Congress on Insulin Resistance Chair, International Committee for Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Xoma, and Tethys;he has received clinical research grant funding from Takeda, Daiichi Sankyo Inc., GlaxoSmithKline, and Novo Nordisk; and he is on the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Copyright © 2010 Elsevier Inc.

A supplement to Internal Medicine News. This supplement was sponsored by Daiichi Sankyo, Inc.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Background
• Current Visit
• Laboratory Results
• Clinical Discussion
• Endocrinologist Consultation
• New Treatment Regimen With Add-On Therapy
• Conclusions

Faculty

Yehuda Handelsman, MD, FACP, FACE
Medical Director, Metabolic Institute of America
Chair and Program Director, 7th World Congress on Insulin Resistance Chair, International Committee for Insulin Resistance
18372 Clark Street, Suite 212
Tarzana, CA 91356
E-mail:[email protected]
Web site:www.TheMetabolicCenter.com
Dr Handelsman is a consultant for Bristol-Myers Squibb Company, Daiichi Sankyo, Inc., GlaxoSmithKline, Medtronic, Merck, Xoma, and Tethys;he has received clinical research grant funding from Takeda, Daiichi Sankyo Inc., GlaxoSmithKline, and Novo Nordisk; and he is on the speakers bureau for AstraZeneca, Bristol-Myers Squibb, Daiichi Sankyo Inc., GlaxoSmithKline, Merck, and Novartis. He also serves on the advisory board for CLINICAL ENDOCRINOLOGY NEWS.

Copyright © 2010 Elsevier Inc.

A new study questioning the efficacy of telemedicine in reducing length of stay (LOS) and improving patient care in the ICU is further proof that remote patient care only works when there is a strong support structure behind it, according to a former SHM president.

“The studies in the past have not shown that just because you have an intensivist available that you are going to get a lot of bang for the buck. You need to have a real process. … If you don’t implement something properly, you can’t expect to get results,” says Mary Jo Gorman, MD, MBA, FHM, former SHM president and CEO of St. Louis-based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine.

Investigators at the University of Texas Health Science Center at Houston reviewed some 4,000 patients in six ICUs at five hospitals in a large U.S. healthcare system by measuring outcomes before and after implementation of a “tele-ICU” from 2003 to 2006. No statistically significant impacts were seen in mortality rates, complications, or LOS (JAMA. 2009;302[24]:2671-2678). Conversely, an accompanying editorial in the Journal of the American Medical Association argued that “tele-ICU is a potentially valuable change in ICU care, but its complexity means that ‘tele-ICU improves care’ is not a testable hypothesis.”

The use of off-site intensivists to monitor patients has been used in recent years to address the shortage of ICU physicians. Still, the study team argues that “there are few data in the peer-reviewed literature evaluating its effect on morbidity and mortality.”

Dr. Gorman suggests that HM groups looking to partner with telemedicine providers consider the importance of:

• Following the costs and intricacies of technical implementation; 
• Getting local physician buy-in;
• Creating a multidisciplinary approach that includes nurses and pharmacists; and
• Putting periodic reviews in place to measure quality metrics.

“The tool is not the problem,” Dr. Gorman adds. “It’s how do you implement the tool.”

A new study questioning the efficacy of telemedicine in reducing length of stay (LOS) and improving patient care in the ICU is further proof that remote patient care only works when there is a strong support structure behind it, according to a former SHM president.

“The studies in the past have not shown that just because you have an intensivist available that you are going to get a lot of bang for the buck. You need to have a real process. … If you don’t implement something properly, you can’t expect to get results,” says Mary Jo Gorman, MD, MBA, FHM, former SHM president and CEO of St. Louis-based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine.

Investigators at the University of Texas Health Science Center at Houston reviewed some 4,000 patients in six ICUs at five hospitals in a large U.S. healthcare system by measuring outcomes before and after implementation of a “tele-ICU” from 2003 to 2006. No statistically significant impacts were seen in mortality rates, complications, or LOS (JAMA. 2009;302[24]:2671-2678). Conversely, an accompanying editorial in the Journal of the American Medical Association argued that “tele-ICU is a potentially valuable change in ICU care, but its complexity means that ‘tele-ICU improves care’ is not a testable hypothesis.”

The use of off-site intensivists to monitor patients has been used in recent years to address the shortage of ICU physicians. Still, the study team argues that “there are few data in the peer-reviewed literature evaluating its effect on morbidity and mortality.”

Dr. Gorman suggests that HM groups looking to partner with telemedicine providers consider the importance of:

• Following the costs and intricacies of technical implementation; 
• Getting local physician buy-in;
• Creating a multidisciplinary approach that includes nurses and pharmacists; and
• Putting periodic reviews in place to measure quality metrics.

“The tool is not the problem,” Dr. Gorman adds. “It’s how do you implement the tool.”

A new study questioning the efficacy of telemedicine in reducing length of stay (LOS) and improving patient care in the ICU is further proof that remote patient care only works when there is a strong support structure behind it, according to a former SHM president.

“The studies in the past have not shown that just because you have an intensivist available that you are going to get a lot of bang for the buck. You need to have a real process. … If you don’t implement something properly, you can’t expect to get results,” says Mary Jo Gorman, MD, MBA, FHM, former SHM president and CEO of St. Louis-based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine.

Investigators at the University of Texas Health Science Center at Houston reviewed some 4,000 patients in six ICUs at five hospitals in a large U.S. healthcare system by measuring outcomes before and after implementation of a “tele-ICU” from 2003 to 2006. No statistically significant impacts were seen in mortality rates, complications, or LOS (JAMA. 2009;302[24]:2671-2678). Conversely, an accompanying editorial in the Journal of the American Medical Association argued that “tele-ICU is a potentially valuable change in ICU care, but its complexity means that ‘tele-ICU improves care’ is not a testable hypothesis.”

The use of off-site intensivists to monitor patients has been used in recent years to address the shortage of ICU physicians. Still, the study team argues that “there are few data in the peer-reviewed literature evaluating its effect on morbidity and mortality.”

Dr. Gorman suggests that HM groups looking to partner with telemedicine providers consider the importance of:

• Following the costs and intricacies of technical implementation; 
• Getting local physician buy-in;
• Creating a multidisciplinary approach that includes nurses and pharmacists; and
• Putting periodic reviews in place to measure quality metrics.

“The tool is not the problem,” Dr. Gorman adds. “It’s how do you implement the tool.”

Clinical question: What are the efficacy and safety of a simplified “1+1” pain protocol using 1-mg IV hydromorphone followed by an optional repeat dose at patient request 15 minutes later in patients with acute pain?

Background: ED patients receive inadequate treatment of pain. Previously studied protocols utilized weight-based dosing, complex pain scales, and frequent nurse contact to assess and treat pain, making them less useful in a busy ED. A 2-mg single dose hydromorphone protocol provided pain relief, but was associated with oxygen desaturation.

Study design: Prospective interventional cohort study.

Setting: Adult, urban, academic ED with an annual census of approximately 89,000.

Synopsis: Participants included 223 ED patients ages 21 to 64 years old presenting with acute pain (<7 days duration) of sufficient severity to warrant use of IV opioids. Notable exclusion criteria included use of opioids within the past seven days, history of chronic pain, room air saturation <95%, systolic blood pressure <90 mm/Hg, or contraindication to hydromorphone; thus, findings are applicable to a limited set of ED patients presenting with acute pain. The hydromorphone protocol achieved patient expectations of pain relief (defined by decision to forgo additional opioid medication) in 77% of patients within 15 minutes and 96% of patients within one hour. 5% of patients dropped their oxygen saturations to <95%, but all increased promptly with 4L nasal cannula. Only 1% of patients dropped their respiratory rate to <12 breaths/minute and systolic blood pressure to <100 mm/Hg; none required naloxone use.

Limitations include lack of comparison group, unblinded design, and findings from a single urban center (in which participants were 60% Hispanic, 29% black, and 65% female). While there were no serious adverse events, the sample size is not large enough to identify rare events.

Bottom line: In nonelderly adult ED patients without a history of chronic pain or recent opioids, a pain protocol of 1-mg IV hydromorphone repeated in 15 minutes if needed is effective and safe, assuming typical ED monitoring for hypoxia and respiratory depression.

Citation: Chang AK, Bijur PE, Campbell CM, Murphy MK, Gallagher EJ. Safety and efficacy of rapid titration using 1mg doses of intravenous hydromorphone in emergency department patients with acute severe pain: the “1+1” protocol. Ann Emerg Med. 2009;54(2):221-225.

Reviewed for TH eWire by Bhaskar Arora, MD, Thomas Barrett, MD, MCR, FHM, Honora Englander, MD, Stephanie Halvorson, MD, Alan J. Hunter, MD, David Kagen, MD, Blake Lesselroth, MD, MBI, Portland Veterans Affairs Medical Center and Division of Hospital Medicine, Oregon Health & Science University

For more HM-related literature reviews, visit our Web site.

Clinical question: What are the efficacy and safety of a simplified “1+1” pain protocol using 1-mg IV hydromorphone followed by an optional repeat dose at patient request 15 minutes later in patients with acute pain?

Background: ED patients receive inadequate treatment of pain. Previously studied protocols utilized weight-based dosing, complex pain scales, and frequent nurse contact to assess and treat pain, making them less useful in a busy ED. A 2-mg single dose hydromorphone protocol provided pain relief, but was associated with oxygen desaturation.

Study design: Prospective interventional cohort study.

Setting: Adult, urban, academic ED with an annual census of approximately 89,000.

Synopsis: Participants included 223 ED patients ages 21 to 64 years old presenting with acute pain (<7 days duration) of sufficient severity to warrant use of IV opioids. Notable exclusion criteria included use of opioids within the past seven days, history of chronic pain, room air saturation <95%, systolic blood pressure <90 mm/Hg, or contraindication to hydromorphone; thus, findings are applicable to a limited set of ED patients presenting with acute pain. The hydromorphone protocol achieved patient expectations of pain relief (defined by decision to forgo additional opioid medication) in 77% of patients within 15 minutes and 96% of patients within one hour. 5% of patients dropped their oxygen saturations to <95%, but all increased promptly with 4L nasal cannula. Only 1% of patients dropped their respiratory rate to <12 breaths/minute and systolic blood pressure to <100 mm/Hg; none required naloxone use.

Limitations include lack of comparison group, unblinded design, and findings from a single urban center (in which participants were 60% Hispanic, 29% black, and 65% female). While there were no serious adverse events, the sample size is not large enough to identify rare events.

Bottom line: In nonelderly adult ED patients without a history of chronic pain or recent opioids, a pain protocol of 1-mg IV hydromorphone repeated in 15 minutes if needed is effective and safe, assuming typical ED monitoring for hypoxia and respiratory depression.

Citation: Chang AK, Bijur PE, Campbell CM, Murphy MK, Gallagher EJ. Safety and efficacy of rapid titration using 1mg doses of intravenous hydromorphone in emergency department patients with acute severe pain: the “1+1” protocol. Ann Emerg Med. 2009;54(2):221-225.

Reviewed for TH eWire by Bhaskar Arora, MD, Thomas Barrett, MD, MCR, FHM, Honora Englander, MD, Stephanie Halvorson, MD, Alan J. Hunter, MD, David Kagen, MD, Blake Lesselroth, MD, MBI, Portland Veterans Affairs Medical Center and Division of Hospital Medicine, Oregon Health & Science University

For more HM-related literature reviews, visit our Web site.

Clinical question: What are the efficacy and safety of a simplified “1+1” pain protocol using 1-mg IV hydromorphone followed by an optional repeat dose at patient request 15 minutes later in patients with acute pain?

Background: ED patients receive inadequate treatment of pain. Previously studied protocols utilized weight-based dosing, complex pain scales, and frequent nurse contact to assess and treat pain, making them less useful in a busy ED. A 2-mg single dose hydromorphone protocol provided pain relief, but was associated with oxygen desaturation.

Study design: Prospective interventional cohort study.

Setting: Adult, urban, academic ED with an annual census of approximately 89,000.

Synopsis: Participants included 223 ED patients ages 21 to 64 years old presenting with acute pain (<7 days duration) of sufficient severity to warrant use of IV opioids. Notable exclusion criteria included use of opioids within the past seven days, history of chronic pain, room air saturation <95%, systolic blood pressure <90 mm/Hg, or contraindication to hydromorphone; thus, findings are applicable to a limited set of ED patients presenting with acute pain. The hydromorphone protocol achieved patient expectations of pain relief (defined by decision to forgo additional opioid medication) in 77% of patients within 15 minutes and 96% of patients within one hour. 5% of patients dropped their oxygen saturations to <95%, but all increased promptly with 4L nasal cannula. Only 1% of patients dropped their respiratory rate to <12 breaths/minute and systolic blood pressure to <100 mm/Hg; none required naloxone use.

Limitations include lack of comparison group, unblinded design, and findings from a single urban center (in which participants were 60% Hispanic, 29% black, and 65% female). While there were no serious adverse events, the sample size is not large enough to identify rare events.

Bottom line: In nonelderly adult ED patients without a history of chronic pain or recent opioids, a pain protocol of 1-mg IV hydromorphone repeated in 15 minutes if needed is effective and safe, assuming typical ED monitoring for hypoxia and respiratory depression.

Citation: Chang AK, Bijur PE, Campbell CM, Murphy MK, Gallagher EJ. Safety and efficacy of rapid titration using 1mg doses of intravenous hydromorphone in emergency department patients with acute severe pain: the “1+1” protocol. Ann Emerg Med. 2009;54(2):221-225.

Reviewed for TH eWire by Bhaskar Arora, MD, Thomas Barrett, MD, MCR, FHM, Honora Englander, MD, Stephanie Halvorson, MD, Alan J. Hunter, MD, David Kagen, MD, Blake Lesselroth, MD, MBI, Portland Veterans Affairs Medical Center and Division of Hospital Medicine, Oregon Health & Science University

For more HM-related literature reviews, visit our Web site.

A supplement to Internal Medicine News.
This supplement was sponsored by Amylin.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Introduction
• Should Minimal Blood Glucose Variability Become the Gold Standard of Glycemic Control?
• Contributions of Fasting and Postprandial Plasma Glucose Increments to the Overall Diurnal Hyperglycemia of Type 2 Diabetic Patients
• Addition of Biphasic, Prandial, or Basal Insulin to Oral Therapy in Type 2 Diabetes
• Effects of Intensive Glucose Lowering in Type 2 Diabetes
• Pramlintide as an Adjunct to Insulin in Patients With Type 2 Diabetes in a Clinical Practice Setting Reduced A1C, Postprandial Glucose Excursions, and Weight
• Pramlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Patients With Type 2 Diabetes: A 1-Year Randomized Controlled Trial
• Amylin Replacement with Primlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Type 1 Diabetes Mellitus: A 1-Year, Randomized Controlled Trial
• Important Safety Information and SYMLIN Prescribing Information

Faculty/Faculty Disclosure

Steven V. Edelman, MD
Professor of Medicine, University of California, San Diego
Veterans Affairs Medical Center, San Diego, California
Founder and Director, Taking Control of Your Diabetes, 501(3)
Del Mar, California
Associate Clinical Professor of Medicine
Dr. Edelman is a consultant to and speaker for Amylin Pharmaceuticals, Inc., Eli Lilly and Company, Novo Nordisk A/S, and sanofi-aventis U.S., LLC.

A supplement to Internal Medicine News.
This supplement was sponsored by Amylin.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Introduction
• Should Minimal Blood Glucose Variability Become the Gold Standard of Glycemic Control?
• Contributions of Fasting and Postprandial Plasma Glucose Increments to the Overall Diurnal Hyperglycemia of Type 2 Diabetic Patients
• Addition of Biphasic, Prandial, or Basal Insulin to Oral Therapy in Type 2 Diabetes
• Effects of Intensive Glucose Lowering in Type 2 Diabetes
• Pramlintide as an Adjunct to Insulin in Patients With Type 2 Diabetes in a Clinical Practice Setting Reduced A1C, Postprandial Glucose Excursions, and Weight
• Pramlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Patients With Type 2 Diabetes: A 1-Year Randomized Controlled Trial
• Amylin Replacement with Primlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Type 1 Diabetes Mellitus: A 1-Year, Randomized Controlled Trial
• Important Safety Information and SYMLIN Prescribing Information

Faculty/Faculty Disclosure

Steven V. Edelman, MD
Professor of Medicine, University of California, San Diego
Veterans Affairs Medical Center, San Diego, California
Founder and Director, Taking Control of Your Diabetes, 501(3)
Del Mar, California
Associate Clinical Professor of Medicine
Dr. Edelman is a consultant to and speaker for Amylin Pharmaceuticals, Inc., Eli Lilly and Company, Novo Nordisk A/S, and sanofi-aventis U.S., LLC.

A supplement to Internal Medicine News.
This supplement was sponsored by Amylin.

•Topics
•Faculty/Faculty Disclosures

To view the supplement, click the image above.

• Introduction
• Should Minimal Blood Glucose Variability Become the Gold Standard of Glycemic Control?
• Contributions of Fasting and Postprandial Plasma Glucose Increments to the Overall Diurnal Hyperglycemia of Type 2 Diabetic Patients
• Addition of Biphasic, Prandial, or Basal Insulin to Oral Therapy in Type 2 Diabetes
• Effects of Intensive Glucose Lowering in Type 2 Diabetes
• Pramlintide as an Adjunct to Insulin in Patients With Type 2 Diabetes in a Clinical Practice Setting Reduced A1C, Postprandial Glucose Excursions, and Weight
• Pramlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Patients With Type 2 Diabetes: A 1-Year Randomized Controlled Trial
• Amylin Replacement with Primlintide as an Adjunct to Insulin Therapy Improves Long-Term Glycemic and Weight Control in Type 1 Diabetes Mellitus: A 1-Year, Randomized Controlled Trial
• Important Safety Information and SYMLIN Prescribing Information

Faculty/Faculty Disclosure

Steven V. Edelman, MD
Professor of Medicine, University of California, San Diego
Veterans Affairs Medical Center, San Diego, California
Founder and Director, Taking Control of Your Diabetes, 501(3)
Del Mar, California
Associate Clinical Professor of Medicine
Dr. Edelman is a consultant to and speaker for Amylin Pharmaceuticals, Inc., Eli Lilly and Company, Novo Nordisk A/S, and sanofi-aventis U.S., LLC.

A supplement to Family Practice News and Internal Medicine News.

•TOPIC HIGHLIGHTS/FACULTY

Letter From Guest Editor
Larry Culpepper, MD, MPH
Chief of Family Medicine
Boston Medical Center
Professor and Chairman of Family Medicine
Boston University School of Medicine
Boston, Mass.

Special Populations in Depression: Clinical Implications of Depression in Patients With Cardiovascular Disease
Alexander Glassman, MD
Professor of Clinical Psychiatry
College of Physicians and Surgeons
Columbia University
Chief, Clinical Psychopharmacology
New York State Psychiatric Institute
New York, N.Y.
Dr. Glassman has nothing to disclose.

Practical Bits: Quick and Practical Diagnostic Tools

Case Files
• Depression or Anxiety?
• ADHD or Anxiety?
Thomas L. Schwartz, MD
Associate Professor of Psychiatry
Director of Adult Outpatient Services
Director of the Depression and Anxiety Disorders Research Program
Assistant Director of Residency Training
State University of New York (SUNY) Upstate Medical University
Syracuse, N.Y.
Dr. Schwartz has disclosed that he is a consultant to Wyeth. He has also received funding for clinical grants from Wyeth, Forest Laboratories, Inc., and Bristol-Myers Squibb Company.

Strategies for Managing Patients with Migraine
Carolyn Bernstein, MD
Assistant Professor of Neurology
Cambridge Hospital
Harvard Medical School
Cambridge, Mass.
Medical Director, Women's Headache Center
Somerville, Mass.
Dr. Bernstein has nothing to disclose.

A supplement to Family Practice News and Internal Medicine News.

•TOPIC HIGHLIGHTS/FACULTY

Letter From Guest Editor
Larry Culpepper, MD, MPH
Chief of Family Medicine
Boston Medical Center
Professor and Chairman of Family Medicine
Boston University School of Medicine
Boston, Mass.

Special Populations in Depression: Clinical Implications of Depression in Patients With Cardiovascular Disease
Alexander Glassman, MD
Professor of Clinical Psychiatry
College of Physicians and Surgeons
Columbia University
Chief, Clinical Psychopharmacology
New York State Psychiatric Institute
New York, N.Y.
Dr. Glassman has nothing to disclose.

Practical Bits: Quick and Practical Diagnostic Tools

Case Files
• Depression or Anxiety?
• ADHD or Anxiety?
Thomas L. Schwartz, MD
Associate Professor of Psychiatry
Director of Adult Outpatient Services
Director of the Depression and Anxiety Disorders Research Program
Assistant Director of Residency Training
State University of New York (SUNY) Upstate Medical University
Syracuse, N.Y.
Dr. Schwartz has disclosed that he is a consultant to Wyeth. He has also received funding for clinical grants from Wyeth, Forest Laboratories, Inc., and Bristol-Myers Squibb Company.

Strategies for Managing Patients with Migraine
Carolyn Bernstein, MD
Assistant Professor of Neurology
Cambridge Hospital
Harvard Medical School
Cambridge, Mass.
Medical Director, Women's Headache Center
Somerville, Mass.
Dr. Bernstein has nothing to disclose.

A supplement to Family Practice News and Internal Medicine News.

•TOPIC HIGHLIGHTS/FACULTY

Letter From Guest Editor
Larry Culpepper, MD, MPH
Chief of Family Medicine
Boston Medical Center
Professor and Chairman of Family Medicine
Boston University School of Medicine
Boston, Mass.

Special Populations in Depression: Clinical Implications of Depression in Patients With Cardiovascular Disease
Alexander Glassman, MD
Professor of Clinical Psychiatry
College of Physicians and Surgeons
Columbia University
Chief, Clinical Psychopharmacology
New York State Psychiatric Institute
New York, N.Y.
Dr. Glassman has nothing to disclose.

Practical Bits: Quick and Practical Diagnostic Tools

Case Files
• Depression or Anxiety?
• ADHD or Anxiety?
Thomas L. Schwartz, MD
Associate Professor of Psychiatry
Director of Adult Outpatient Services
Director of the Depression and Anxiety Disorders Research Program
Assistant Director of Residency Training
State University of New York (SUNY) Upstate Medical University
Syracuse, N.Y.
Dr. Schwartz has disclosed that he is a consultant to Wyeth. He has also received funding for clinical grants from Wyeth, Forest Laboratories, Inc., and Bristol-Myers Squibb Company.

Strategies for Managing Patients with Migraine
Carolyn Bernstein, MD
Assistant Professor of Neurology
Cambridge Hospital
Harvard Medical School
Cambridge, Mass.
Medical Director, Women's Headache Center
Somerville, Mass.
Dr. Bernstein has nothing to disclose.

A supplement to Family Practice News and Internal Medicine News.

•TOPIC HIGHLIGHTS/FACULTY

Letter From Guest Editor
Larry Culpepper, MD, MPH
Chief of Family Medicine
Boston Medical Center
Professor and Chairman of Family Medicine
Boston University School of Medicine
Boston, Mass.
Dr. Culpepper has disclosed that he is a consultant to Eli Lilly and Company, Forest Laboratories, Inc., Neurocrine Biosciences, Inc., Pfizer Inc. and Wyeth. He is also on the speaker's bureau for Forest, Pfizer, and Wyeth.

Special Populations in Depression: Managing Care for Patients With Depression and Comorbid Health Problems
Larry Culpepper, MD

Case Files
• Postherpetic Neuralgia
• Diabetes and Pain
Bill McCarberg, MD
Founder. Chronic Pain Management Program
Kaiser Permanente
Escondido, Calif.
Dr. McCarberg has disclosed that he is on the speaker's bureau for Alpharma Inc., Cephalon, Inc., Eli Lilly and Company, Endo Pharmaceuticals, Merck & Co., Inc., Ortho-McNeil Pharmaceutical, Inc., Pfizer Inc., and Pricara.

Practical Bits: Quick and Practical Diagnostic Tools

Clinical Approaches to Patient Concerns About Memory Loss
Richard J. Caselli, MD
Chair, Department of Neurology
Mayo Clinical Scottsdale (Arizona)
Professor of Neurology
Mayo Clinic College of Medicine
Rochester, Minn.
Dr. Caselli disclosed that he has received funding for clinical grants from Arizona Alzheimer's Consortium.

Social and Emotional Costs of Learning Disabilities
Carl C. Bell, MD
Chief Executive Officer and President
Community Mental Health Council Inc.
Director, Public and Community Psychiatry
University of Illinois, Chicago, Ill.

A supplement to Family Practice News and Internal Medicine News.

•TOPIC HIGHLIGHTS/FACULTY

Letter From Guest Editor
Larry Culpepper, MD, MPH
Chief of Family Medicine
Boston Medical Center
Professor and Chairman of Family Medicine
Boston University School of Medicine
Boston, Mass.
Dr. Culpepper has disclosed that he is a consultant to Eli Lilly and Company, Forest Laboratories, Inc., Neurocrine Biosciences, Inc., Pfizer Inc. and Wyeth. He is also on the speaker's bureau for Forest, Pfizer, and Wyeth.

Special Populations in Depression: Managing Care for Patients With Depression and Comorbid Health Problems
Larry Culpepper, MD

Case Files
• Postherpetic Neuralgia
• Diabetes and Pain
Bill McCarberg, MD
Founder. Chronic Pain Management Program
Kaiser Permanente
Escondido, Calif.
Dr. McCarberg has disclosed that he is on the speaker's bureau for Alpharma Inc., Cephalon, Inc., Eli Lilly and Company, Endo Pharmaceuticals, Merck & Co., Inc., Ortho-McNeil Pharmaceutical, Inc., Pfizer Inc., and Pricara.

Practical Bits: Quick and Practical Diagnostic Tools

Clinical Approaches to Patient Concerns About Memory Loss
Richard J. Caselli, MD
Chair, Department of Neurology
Mayo Clinical Scottsdale (Arizona)
Professor of Neurology
Mayo Clinic College of Medicine
Rochester, Minn.
Dr. Caselli disclosed that he has received funding for clinical grants from Arizona Alzheimer's Consortium.

Social and Emotional Costs of Learning Disabilities
Carl C. Bell, MD
Chief Executive Officer and President
Community Mental Health Council Inc.
Director, Public and Community Psychiatry
University of Illinois, Chicago, Ill.

A supplement to Family Practice News and Internal Medicine News.

•TOPIC HIGHLIGHTS/FACULTY

Letter From Guest Editor
Larry Culpepper, MD, MPH
Chief of Family Medicine
Boston Medical Center
Professor and Chairman of Family Medicine
Boston University School of Medicine
Boston, Mass.
Dr. Culpepper has disclosed that he is a consultant to Eli Lilly and Company, Forest Laboratories, Inc., Neurocrine Biosciences, Inc., Pfizer Inc. and Wyeth. He is also on the speaker's bureau for Forest, Pfizer, and Wyeth.

Special Populations in Depression: Managing Care for Patients With Depression and Comorbid Health Problems
Larry Culpepper, MD

Case Files
• Postherpetic Neuralgia
• Diabetes and Pain
Bill McCarberg, MD
Founder. Chronic Pain Management Program
Kaiser Permanente
Escondido, Calif.
Dr. McCarberg has disclosed that he is on the speaker's bureau for Alpharma Inc., Cephalon, Inc., Eli Lilly and Company, Endo Pharmaceuticals, Merck & Co., Inc., Ortho-McNeil Pharmaceutical, Inc., Pfizer Inc., and Pricara.

Practical Bits: Quick and Practical Diagnostic Tools

Clinical Approaches to Patient Concerns About Memory Loss
Richard J. Caselli, MD
Chair, Department of Neurology
Mayo Clinical Scottsdale (Arizona)
Professor of Neurology
Mayo Clinic College of Medicine
Rochester, Minn.
Dr. Caselli disclosed that he has received funding for clinical grants from Arizona Alzheimer's Consortium.

Social and Emotional Costs of Learning Disabilities
Carl C. Bell, MD
Chief Executive Officer and President
Community Mental Health Council Inc.
Director, Public and Community Psychiatry
University of Illinois, Chicago, Ill.