The article by Drs. Messinger-Rapport et al in this issue of the Cleveland Clinic Journal of Medicine makes several assertions about advance care planning with which I disagree. As a practicing oncologist and hospice medical director in a community setting for almost 20 years, I believe the authors’ attempt to reduce a complex physician-patient interaction to a practice algorithm oversimplifies the issues.

See related article

INTUITION, EXPERIENCE, AND TRAINING PLAY A VITAL ROLE

I agree with the authors that advance care planning is an oft-mentioned but underperformed function of being a physician in current American society. Our nation has become a people who deny physical vulnerability, frailty, and death. This area is not well taught in our medical schools and residency training programs.

However, the algorithms in the paper do not effectively address the timing and process of advance care planning. It is clearly not effective to have an end-of-life discussion at the bedside of a critically ill patient about to be intubated. It also seems futile to have a superficial discussion with patients about advance care planning at a time when they are healthy and in the setting of a routine and brief office visit. In this healthy population, the episodic discussions recommended by the authors could become background noise and could seem irrelevant to a patient. Physicians are already overburdened with responsibilities. Re-educating society that lives are not infinite is a social issue that needs to begin early in our lives.

In any setting, a social history, properly taken, should identify family structure, responsible next of kin, and family issues of discord that could affect treatment decisions and patient care. This is all that is needed as a minimal discussion about advance care planning.

Once patients develop significant illness, speaking to them about advance care planning becomes more relevant to their lives. As patients struggle with their illnesses and physical decline, the opportunity for further discussion grows and the impact of these interventions becomes greater. The energy and time it takes to have such discussions are better spent in these settings.

Discussing long-term planning with a patient is where intuition, experience, and training play a vital role. The balance between the pragmatic need for advance care planning and the need for allowing the patient to have hope of wellness is difficult to achieve and different for every patient, every family, and every care situation. It is for this reason that I find the flowcharts outlined in the paper difficult to follow and not very useful for the care of patients. Given the diversity of patients for whom we care, it seems impossible to me to condense the subject down to a care-flow matrix. This is an area in which the art of patient care and the art of being a physician come fully into play and cannot be replaced by an algorithm. Individual and small-group training with mentors, at all levels of medical education, would allow a physician to grow in comfort and skill in dealing with advance care planning.

LIVING WILLS CAN BE USEFUL

Another point on which I disagree with Dr. Messinger-Rapport et al is their assessment of the utility of the living will. They state that a living will applies only to patients who are terminally ill or in a persistent vegetative state. However, I find that it can also supply important information at all stages of illness. While it may lie “dormant” in a legal sense, it can give important information for a family by providing a window into the patient’s state of mind as it relates to the patient’s willingness to limit care in certain settings. Once a patient is able to articulate situations that warrant limiting care, a surrogate decision-maker (or the patient) can try to broaden those limits. It is up to the physician to articulate prognosis so the patient and family can decide how much they are willing to do to maintain that limited level of function. Any treatment can be declined at any time during a patient’s life or illness.

The living will also provides a framework in which to discuss end-of-life issues with a patient. It can open the discussion about current quality of life as perceived by the patient and what level of medical treatment the patient is willing to pursue. As the authors note in their article, those desires are fluid and can change over time. This does not render the living will useless. It shows that the living will needs to be adapted over time to suit the patient’s current situation.

The authors describe a patient with Alzheimer disease for whom a percutaneous endoscopic gastrostomy tube was recommended by a physician but declined by his wife. They assert that a living will does not offer guidance in this situation, since the patient was not, strictly speaking, terminally ill. I disagree. Medical care can delay death for years. If the patient’s quality of life is poor, that delay may violate the implied wishes of the patient and should be discussed. Before he became severely demented, the patient may not have wanted to have his life prolonged if the end result was a continued decline in his already compromised quality of life. The family should have been given that option to consider.

RE-EDUCATING PEOPLE ABOUT LIFE, ILLNESS, AND DEATH

Advance care planning is an essential component of being a physician and taking care of patients. A broad movement needs to be undertaken to re-educate people about the realities of life, illness, and death. The training of our physicians about advance care planning should begin early and should be continued throughout their medical education and careers. One-on-one or small-group mentoring would be an ideal method of training. The attempt to develop an algorithm to guide those discussions tries to simplify a process that is extraordinarily complex. Each situation is different and requires well-developed skills and practiced and mentored intuition. Experience and the art of being a physician cannot be reduced to a “model approach” or a flowchart.

The article by Drs. Messinger-Rapport et al in this issue of the Cleveland Clinic Journal of Medicine makes several assertions about advance care planning with which I disagree. As a practicing oncologist and hospice medical director in a community setting for almost 20 years, I believe the authors’ attempt to reduce a complex physician-patient interaction to a practice algorithm oversimplifies the issues.

See related article

INTUITION, EXPERIENCE, AND TRAINING PLAY A VITAL ROLE

I agree with the authors that advance care planning is an oft-mentioned but underperformed function of being a physician in current American society. Our nation has become a people who deny physical vulnerability, frailty, and death. This area is not well taught in our medical schools and residency training programs.

However, the algorithms in the paper do not effectively address the timing and process of advance care planning. It is clearly not effective to have an end-of-life discussion at the bedside of a critically ill patient about to be intubated. It also seems futile to have a superficial discussion with patients about advance care planning at a time when they are healthy and in the setting of a routine and brief office visit. In this healthy population, the episodic discussions recommended by the authors could become background noise and could seem irrelevant to a patient. Physicians are already overburdened with responsibilities. Re-educating society that lives are not infinite is a social issue that needs to begin early in our lives.

In any setting, a social history, properly taken, should identify family structure, responsible next of kin, and family issues of discord that could affect treatment decisions and patient care. This is all that is needed as a minimal discussion about advance care planning.

Once patients develop significant illness, speaking to them about advance care planning becomes more relevant to their lives. As patients struggle with their illnesses and physical decline, the opportunity for further discussion grows and the impact of these interventions becomes greater. The energy and time it takes to have such discussions are better spent in these settings.

Discussing long-term planning with a patient is where intuition, experience, and training play a vital role. The balance between the pragmatic need for advance care planning and the need for allowing the patient to have hope of wellness is difficult to achieve and different for every patient, every family, and every care situation. It is for this reason that I find the flowcharts outlined in the paper difficult to follow and not very useful for the care of patients. Given the diversity of patients for whom we care, it seems impossible to me to condense the subject down to a care-flow matrix. This is an area in which the art of patient care and the art of being a physician come fully into play and cannot be replaced by an algorithm. Individual and small-group training with mentors, at all levels of medical education, would allow a physician to grow in comfort and skill in dealing with advance care planning.

LIVING WILLS CAN BE USEFUL

Another point on which I disagree with Dr. Messinger-Rapport et al is their assessment of the utility of the living will. They state that a living will applies only to patients who are terminally ill or in a persistent vegetative state. However, I find that it can also supply important information at all stages of illness. While it may lie “dormant” in a legal sense, it can give important information for a family by providing a window into the patient’s state of mind as it relates to the patient’s willingness to limit care in certain settings. Once a patient is able to articulate situations that warrant limiting care, a surrogate decision-maker (or the patient) can try to broaden those limits. It is up to the physician to articulate prognosis so the patient and family can decide how much they are willing to do to maintain that limited level of function. Any treatment can be declined at any time during a patient’s life or illness.

The living will also provides a framework in which to discuss end-of-life issues with a patient. It can open the discussion about current quality of life as perceived by the patient and what level of medical treatment the patient is willing to pursue. As the authors note in their article, those desires are fluid and can change over time. This does not render the living will useless. It shows that the living will needs to be adapted over time to suit the patient’s current situation.

The authors describe a patient with Alzheimer disease for whom a percutaneous endoscopic gastrostomy tube was recommended by a physician but declined by his wife. They assert that a living will does not offer guidance in this situation, since the patient was not, strictly speaking, terminally ill. I disagree. Medical care can delay death for years. If the patient’s quality of life is poor, that delay may violate the implied wishes of the patient and should be discussed. Before he became severely demented, the patient may not have wanted to have his life prolonged if the end result was a continued decline in his already compromised quality of life. The family should have been given that option to consider.

RE-EDUCATING PEOPLE ABOUT LIFE, ILLNESS, AND DEATH

Advance care planning is an essential component of being a physician and taking care of patients. A broad movement needs to be undertaken to re-educate people about the realities of life, illness, and death. The training of our physicians about advance care planning should begin early and should be continued throughout their medical education and careers. One-on-one or small-group mentoring would be an ideal method of training. The attempt to develop an algorithm to guide those discussions tries to simplify a process that is extraordinarily complex. Each situation is different and requires well-developed skills and practiced and mentored intuition. Experience and the art of being a physician cannot be reduced to a “model approach” or a flowchart.

The article by Drs. Messinger-Rapport et al in this issue of the Cleveland Clinic Journal of Medicine makes several assertions about advance care planning with which I disagree. As a practicing oncologist and hospice medical director in a community setting for almost 20 years, I believe the authors’ attempt to reduce a complex physician-patient interaction to a practice algorithm oversimplifies the issues.

See related article

INTUITION, EXPERIENCE, AND TRAINING PLAY A VITAL ROLE

I agree with the authors that advance care planning is an oft-mentioned but underperformed function of being a physician in current American society. Our nation has become a people who deny physical vulnerability, frailty, and death. This area is not well taught in our medical schools and residency training programs.

However, the algorithms in the paper do not effectively address the timing and process of advance care planning. It is clearly not effective to have an end-of-life discussion at the bedside of a critically ill patient about to be intubated. It also seems futile to have a superficial discussion with patients about advance care planning at a time when they are healthy and in the setting of a routine and brief office visit. In this healthy population, the episodic discussions recommended by the authors could become background noise and could seem irrelevant to a patient. Physicians are already overburdened with responsibilities. Re-educating society that lives are not infinite is a social issue that needs to begin early in our lives.

In any setting, a social history, properly taken, should identify family structure, responsible next of kin, and family issues of discord that could affect treatment decisions and patient care. This is all that is needed as a minimal discussion about advance care planning.

Once patients develop significant illness, speaking to them about advance care planning becomes more relevant to their lives. As patients struggle with their illnesses and physical decline, the opportunity for further discussion grows and the impact of these interventions becomes greater. The energy and time it takes to have such discussions are better spent in these settings.

Discussing long-term planning with a patient is where intuition, experience, and training play a vital role. The balance between the pragmatic need for advance care planning and the need for allowing the patient to have hope of wellness is difficult to achieve and different for every patient, every family, and every care situation. It is for this reason that I find the flowcharts outlined in the paper difficult to follow and not very useful for the care of patients. Given the diversity of patients for whom we care, it seems impossible to me to condense the subject down to a care-flow matrix. This is an area in which the art of patient care and the art of being a physician come fully into play and cannot be replaced by an algorithm. Individual and small-group training with mentors, at all levels of medical education, would allow a physician to grow in comfort and skill in dealing with advance care planning.

LIVING WILLS CAN BE USEFUL

Another point on which I disagree with Dr. Messinger-Rapport et al is their assessment of the utility of the living will. They state that a living will applies only to patients who are terminally ill or in a persistent vegetative state. However, I find that it can also supply important information at all stages of illness. While it may lie “dormant” in a legal sense, it can give important information for a family by providing a window into the patient’s state of mind as it relates to the patient’s willingness to limit care in certain settings. Once a patient is able to articulate situations that warrant limiting care, a surrogate decision-maker (or the patient) can try to broaden those limits. It is up to the physician to articulate prognosis so the patient and family can decide how much they are willing to do to maintain that limited level of function. Any treatment can be declined at any time during a patient’s life or illness.

The living will also provides a framework in which to discuss end-of-life issues with a patient. It can open the discussion about current quality of life as perceived by the patient and what level of medical treatment the patient is willing to pursue. As the authors note in their article, those desires are fluid and can change over time. This does not render the living will useless. It shows that the living will needs to be adapted over time to suit the patient’s current situation.

The authors describe a patient with Alzheimer disease for whom a percutaneous endoscopic gastrostomy tube was recommended by a physician but declined by his wife. They assert that a living will does not offer guidance in this situation, since the patient was not, strictly speaking, terminally ill. I disagree. Medical care can delay death for years. If the patient’s quality of life is poor, that delay may violate the implied wishes of the patient and should be discussed. Before he became severely demented, the patient may not have wanted to have his life prolonged if the end result was a continued decline in his already compromised quality of life. The family should have been given that option to consider.

RE-EDUCATING PEOPLE ABOUT LIFE, ILLNESS, AND DEATH

Advance care planning is an essential component of being a physician and taking care of patients. A broad movement needs to be undertaken to re-educate people about the realities of life, illness, and death. The training of our physicians about advance care planning should begin early and should be continued throughout their medical education and careers. One-on-one or small-group mentoring would be an ideal method of training. The attempt to develop an algorithm to guide those discussions tries to simplify a process that is extraordinarily complex. Each situation is different and requires well-developed skills and practiced and mentored intuition. Experience and the art of being a physician cannot be reduced to a “model approach” or a flowchart.

Dear Dr. Mossman:

I work at a state mental hospital where all patients are adults who are court-committed, and at least 75% of them smoke. The hospital allows smoking in part of the only outdoor area where patients—smokers and nonsmokers—may go while in our most restrictive treatment phase. Patients come to us after spending at least 2 weeks in nonsmoking facilities where smokers receive nicotine replacement therapy. If patients want to smoke but have no money, in the past our hospital provided “unit cigarettes.”

In my state, a court commitment means the patient lacks the capacity to make decisions about psychiatric care. Of course nicotine is a psychoactive drug. If a patient starts smoking while in our care, would the hospital be liable for health-related expenses the patient may later incur?—Submitted by “Dr. A”

Speaking as one colleague to another about malpractice liability, letting psychiatric patients smoke is not breaching the standard of care toward smoking patients. But you care for nonsmoking patients as well, and other types of liability besides malpractice exist.

Doctors have moral duties for lots of things we can’t be sued for. Dr. A is right to be concerned. To explain, we’ll look at:

• changes in attitudes about smoking
• the link between smoking and mental illness
• smoking bans in psychiatric facilities
• malpractice potential
• other issues Dr. A’s hospital should consider, such as offering patients assistance with smoking cessation.

Changing attitudes about smoking

Thirty years ago, doctors smoked during medical meetings, and smoking on airplanes and in public was commonplace. I worked at an adolescent inpatient unit, and line staff carried lighters. We thought lighting kids’ cigarettes was a legitimate way to establish rapport. Times and attitudes have changed. No hospital condones smoking these days, let alone smoking by minor patients. Since the Surgeon General first declared in 1964 that smoking was hazardous, U.S. adult smoking rates have dropped from 42% to under 20%.¹

In the early 1990s, California issued the first statewide ban on smoking in work-places, including bars and restaurants.² Nearly 3,000 state or local jurisdictions require workplaces and/or commercial establishments to be smoke-free.³ Recently, the legislature in Virginia—a major tobacco-producing state—voted to prohibit smoking in restaurants,⁴ and many other state governments are considering smoking bans. Smoking bans are intended to protect nonsmokers—especially children—from risks of secondhand smoke,⁵ but they also discourage individuals from taking up the habit⁶ and encourage smokers to quit.⁷

Smoking and mental illness

Persons with serious psychiatric disorders have smoking rates 2 to 3 times higher than those of the general population.^8,9 As Dr. A notes, nicotine is a psychoactive drug. Smoking may be a genuine—although ultimately unhealthy—form of self-medication and may have positive psychological effects, such as antidepressant activity for many mentally ill persons.^10,11 The Joint Commission on Accreditation of Healthcare Organizations banned smoking in hospitals in 1992 but made an exception for psychiatric units. Out of sympathy for patients and concern about what could happen when they are deprived of a substance they intensely crave, many psychiatric wards continue to accommodate smokers.¹²

What some institutions have done

An increasing number of psychiatric facilities have instituted or are considering bans on smoking.¹³ The first psychiatric smoking bans were implemented despite fears that patient violence would increase and opposition from hospital employees—a group that often includes smokers. Experience shows that although not all smoking bans are successful or problem-free,¹⁴ they usually cause fewer problems than anticipated. We also know what factors help make smoke-free programs successful (Table).¹⁵

Table

Smoke-free plans that work: How to clear the air

Aggression, seclusion, discharges against medical advice, and “prn” medication use do not increase after smoking bans,^5,16,17 and many patients experience health benefits.¹⁸ After discharge, however, most patients resume tobacco use.^11,19,20

Smoking bans have been opposed on grounds that they abridge psychiatric patients’ rights and are unduly coercive.^21,22 In the United States and United Kingdom, however, legal actions to block smoking bans have not succeeded, and courts have not recognized a fundamental “right to smoke.”^23-25

Is allowing smoking malpractice?

Now that many psychiatric facilities have ended smoking, clinicians may worry—as does Dr. A—that we could incur malpractice liability if we let inpatients smoke. One of my University of Cincinnati law students, Amanda Smith, and I researched this topic and found no case report that said letting psychiatric inpatients smoke violated the standard of care.

This makes sense, because in the malpractice context, a practitioner is judged by what prudent, similarly situated physicians with similar training would do in similar circumstances. Many psychiatric facilities still permit smoking, so letting patients smoke does not breach the standard of care, even if it seems negligent.²⁶

The ill effects of smoking accrue over years, not weeks or months. Almost all patients who smoke in hospitals also have smoked before hospitalization, and most smokers who are barred from smoking while inpatients resume soon after discharge. To succeed, a malpractice lawsuit must show that the defendant’s actions caused damages. A jury might find it hard to conclude that a permissive hospital smoking policy was the primary cause of a long-term smoker’s health problems.

4 other concerns

Nonsmokers’ rights. Arrangements at Dr. A’s hospital expose nonsmokers to secondhand cigarette smoke, which raises the possibility of legal action by nonsmokers. In 1993, the U.S. Supreme Court held that a prison inmate’s heavy exposure to secondhand smoke violated the Eighth Amendment ban on cruel and unusual punishment.²⁷ Involuntary hospitalization is not punishment, but suits such as this might be brought on other grounds, such as violation of patients’ civil rights.²⁸

Competence. In some states, civil commitment requires a finding that the respondent is not competent to make treatment decisions. Can persons who are not competent to make treatment decisions make good decisions about whether to smoke? Shouldn’t the hospital deal with patients’ nicotine dependence more therapeutically—and paternalistically—by providing nicotine replacement and encouraging smoking cessation? Shouldn’t the hospital also discourage patients who don’t smoke from starting?

Protecting patients. Dr. A’s hospital provides cigarettes to patients. Though compassion may be the motive, is the hospital failing to protect its incompetent patients and abetting their self-injurious behavior?

Helping smokers quit. Does the hospital offer treatment to help smokers quit? Although the problems that lead to civil commitment are immediate and serious, addressing long-term health issues is consistent with treating acute psychiatric crises. Many hospitals that permit smoking also encourage participation in smoking-cessation programs. Having these available to patients might make claims that the hospital failed in its duties to care for patients less plausible.

Related resources

• Maryland Hospital Association. Smoke-free hospital campus tool-kit. www.mdhospitals.org/mha/Community_Health_Resources/Smoke_Free_Hospital_Campuses.shtml.
• National Association of State Mental Health Program Directors. Tobacco-free living in psychiatric settings: a best-practices toolkit promoting wellness and recovery. www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdated90707.pdf.

Dear Dr. Mossman:

I work at a state mental hospital where all patients are adults who are court-committed, and at least 75% of them smoke. The hospital allows smoking in part of the only outdoor area where patients—smokers and nonsmokers—may go while in our most restrictive treatment phase. Patients come to us after spending at least 2 weeks in nonsmoking facilities where smokers receive nicotine replacement therapy. If patients want to smoke but have no money, in the past our hospital provided “unit cigarettes.”

In my state, a court commitment means the patient lacks the capacity to make decisions about psychiatric care. Of course nicotine is a psychoactive drug. If a patient starts smoking while in our care, would the hospital be liable for health-related expenses the patient may later incur?—Submitted by “Dr. A”

Speaking as one colleague to another about malpractice liability, letting psychiatric patients smoke is not breaching the standard of care toward smoking patients. But you care for nonsmoking patients as well, and other types of liability besides malpractice exist.

Doctors have moral duties for lots of things we can’t be sued for. Dr. A is right to be concerned. To explain, we’ll look at:

• changes in attitudes about smoking
• the link between smoking and mental illness
• smoking bans in psychiatric facilities
• malpractice potential
• other issues Dr. A’s hospital should consider, such as offering patients assistance with smoking cessation.

Changing attitudes about smoking

Thirty years ago, doctors smoked during medical meetings, and smoking on airplanes and in public was commonplace. I worked at an adolescent inpatient unit, and line staff carried lighters. We thought lighting kids’ cigarettes was a legitimate way to establish rapport. Times and attitudes have changed. No hospital condones smoking these days, let alone smoking by minor patients. Since the Surgeon General first declared in 1964 that smoking was hazardous, U.S. adult smoking rates have dropped from 42% to under 20%.¹

In the early 1990s, California issued the first statewide ban on smoking in work-places, including bars and restaurants.² Nearly 3,000 state or local jurisdictions require workplaces and/or commercial establishments to be smoke-free.³ Recently, the legislature in Virginia—a major tobacco-producing state—voted to prohibit smoking in restaurants,⁴ and many other state governments are considering smoking bans. Smoking bans are intended to protect nonsmokers—especially children—from risks of secondhand smoke,⁵ but they also discourage individuals from taking up the habit⁶ and encourage smokers to quit.⁷

Smoking and mental illness

Persons with serious psychiatric disorders have smoking rates 2 to 3 times higher than those of the general population.^8,9 As Dr. A notes, nicotine is a psychoactive drug. Smoking may be a genuine—although ultimately unhealthy—form of self-medication and may have positive psychological effects, such as antidepressant activity for many mentally ill persons.^10,11 The Joint Commission on Accreditation of Healthcare Organizations banned smoking in hospitals in 1992 but made an exception for psychiatric units. Out of sympathy for patients and concern about what could happen when they are deprived of a substance they intensely crave, many psychiatric wards continue to accommodate smokers.¹²

What some institutions have done

An increasing number of psychiatric facilities have instituted or are considering bans on smoking.¹³ The first psychiatric smoking bans were implemented despite fears that patient violence would increase and opposition from hospital employees—a group that often includes smokers. Experience shows that although not all smoking bans are successful or problem-free,¹⁴ they usually cause fewer problems than anticipated. We also know what factors help make smoke-free programs successful (Table).¹⁵

Table

Smoke-free plans that work: How to clear the air

Aggression, seclusion, discharges against medical advice, and “prn” medication use do not increase after smoking bans,^5,16,17 and many patients experience health benefits.¹⁸ After discharge, however, most patients resume tobacco use.^11,19,20

Smoking bans have been opposed on grounds that they abridge psychiatric patients’ rights and are unduly coercive.^21,22 In the United States and United Kingdom, however, legal actions to block smoking bans have not succeeded, and courts have not recognized a fundamental “right to smoke.”^23-25

Is allowing smoking malpractice?

Now that many psychiatric facilities have ended smoking, clinicians may worry—as does Dr. A—that we could incur malpractice liability if we let inpatients smoke. One of my University of Cincinnati law students, Amanda Smith, and I researched this topic and found no case report that said letting psychiatric inpatients smoke violated the standard of care.

This makes sense, because in the malpractice context, a practitioner is judged by what prudent, similarly situated physicians with similar training would do in similar circumstances. Many psychiatric facilities still permit smoking, so letting patients smoke does not breach the standard of care, even if it seems negligent.²⁶

The ill effects of smoking accrue over years, not weeks or months. Almost all patients who smoke in hospitals also have smoked before hospitalization, and most smokers who are barred from smoking while inpatients resume soon after discharge. To succeed, a malpractice lawsuit must show that the defendant’s actions caused damages. A jury might find it hard to conclude that a permissive hospital smoking policy was the primary cause of a long-term smoker’s health problems.

4 other concerns

Nonsmokers’ rights. Arrangements at Dr. A’s hospital expose nonsmokers to secondhand cigarette smoke, which raises the possibility of legal action by nonsmokers. In 1993, the U.S. Supreme Court held that a prison inmate’s heavy exposure to secondhand smoke violated the Eighth Amendment ban on cruel and unusual punishment.²⁷ Involuntary hospitalization is not punishment, but suits such as this might be brought on other grounds, such as violation of patients’ civil rights.²⁸

Competence. In some states, civil commitment requires a finding that the respondent is not competent to make treatment decisions. Can persons who are not competent to make treatment decisions make good decisions about whether to smoke? Shouldn’t the hospital deal with patients’ nicotine dependence more therapeutically—and paternalistically—by providing nicotine replacement and encouraging smoking cessation? Shouldn’t the hospital also discourage patients who don’t smoke from starting?

Protecting patients. Dr. A’s hospital provides cigarettes to patients. Though compassion may be the motive, is the hospital failing to protect its incompetent patients and abetting their self-injurious behavior?

Helping smokers quit. Does the hospital offer treatment to help smokers quit? Although the problems that lead to civil commitment are immediate and serious, addressing long-term health issues is consistent with treating acute psychiatric crises. Many hospitals that permit smoking also encourage participation in smoking-cessation programs. Having these available to patients might make claims that the hospital failed in its duties to care for patients less plausible.

Related resources

• Maryland Hospital Association. Smoke-free hospital campus tool-kit. www.mdhospitals.org/mha/Community_Health_Resources/Smoke_Free_Hospital_Campuses.shtml.
• National Association of State Mental Health Program Directors. Tobacco-free living in psychiatric settings: a best-practices toolkit promoting wellness and recovery. www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdated90707.pdf.

Dear Dr. Mossman:

I work at a state mental hospital where all patients are adults who are court-committed, and at least 75% of them smoke. The hospital allows smoking in part of the only outdoor area where patients—smokers and nonsmokers—may go while in our most restrictive treatment phase. Patients come to us after spending at least 2 weeks in nonsmoking facilities where smokers receive nicotine replacement therapy. If patients want to smoke but have no money, in the past our hospital provided “unit cigarettes.”

In my state, a court commitment means the patient lacks the capacity to make decisions about psychiatric care. Of course nicotine is a psychoactive drug. If a patient starts smoking while in our care, would the hospital be liable for health-related expenses the patient may later incur?—Submitted by “Dr. A”

Speaking as one colleague to another about malpractice liability, letting psychiatric patients smoke is not breaching the standard of care toward smoking patients. But you care for nonsmoking patients as well, and other types of liability besides malpractice exist.

Doctors have moral duties for lots of things we can’t be sued for. Dr. A is right to be concerned. To explain, we’ll look at:

• changes in attitudes about smoking
• the link between smoking and mental illness
• smoking bans in psychiatric facilities
• malpractice potential
• other issues Dr. A’s hospital should consider, such as offering patients assistance with smoking cessation.

Changing attitudes about smoking

Thirty years ago, doctors smoked during medical meetings, and smoking on airplanes and in public was commonplace. I worked at an adolescent inpatient unit, and line staff carried lighters. We thought lighting kids’ cigarettes was a legitimate way to establish rapport. Times and attitudes have changed. No hospital condones smoking these days, let alone smoking by minor patients. Since the Surgeon General first declared in 1964 that smoking was hazardous, U.S. adult smoking rates have dropped from 42% to under 20%.¹

In the early 1990s, California issued the first statewide ban on smoking in work-places, including bars and restaurants.² Nearly 3,000 state or local jurisdictions require workplaces and/or commercial establishments to be smoke-free.³ Recently, the legislature in Virginia—a major tobacco-producing state—voted to prohibit smoking in restaurants,⁴ and many other state governments are considering smoking bans. Smoking bans are intended to protect nonsmokers—especially children—from risks of secondhand smoke,⁵ but they also discourage individuals from taking up the habit⁶ and encourage smokers to quit.⁷

Smoking and mental illness

Persons with serious psychiatric disorders have smoking rates 2 to 3 times higher than those of the general population.^8,9 As Dr. A notes, nicotine is a psychoactive drug. Smoking may be a genuine—although ultimately unhealthy—form of self-medication and may have positive psychological effects, such as antidepressant activity for many mentally ill persons.^10,11 The Joint Commission on Accreditation of Healthcare Organizations banned smoking in hospitals in 1992 but made an exception for psychiatric units. Out of sympathy for patients and concern about what could happen when they are deprived of a substance they intensely crave, many psychiatric wards continue to accommodate smokers.¹²

What some institutions have done

An increasing number of psychiatric facilities have instituted or are considering bans on smoking.¹³ The first psychiatric smoking bans were implemented despite fears that patient violence would increase and opposition from hospital employees—a group that often includes smokers. Experience shows that although not all smoking bans are successful or problem-free,¹⁴ they usually cause fewer problems than anticipated. We also know what factors help make smoke-free programs successful (Table).¹⁵

Table

Smoke-free plans that work: How to clear the air

Aggression, seclusion, discharges against medical advice, and “prn” medication use do not increase after smoking bans,^5,16,17 and many patients experience health benefits.¹⁸ After discharge, however, most patients resume tobacco use.^11,19,20

Smoking bans have been opposed on grounds that they abridge psychiatric patients’ rights and are unduly coercive.^21,22 In the United States and United Kingdom, however, legal actions to block smoking bans have not succeeded, and courts have not recognized a fundamental “right to smoke.”^23-25

Is allowing smoking malpractice?

Now that many psychiatric facilities have ended smoking, clinicians may worry—as does Dr. A—that we could incur malpractice liability if we let inpatients smoke. One of my University of Cincinnati law students, Amanda Smith, and I researched this topic and found no case report that said letting psychiatric inpatients smoke violated the standard of care.

This makes sense, because in the malpractice context, a practitioner is judged by what prudent, similarly situated physicians with similar training would do in similar circumstances. Many psychiatric facilities still permit smoking, so letting patients smoke does not breach the standard of care, even if it seems negligent.²⁶

The ill effects of smoking accrue over years, not weeks or months. Almost all patients who smoke in hospitals also have smoked before hospitalization, and most smokers who are barred from smoking while inpatients resume soon after discharge. To succeed, a malpractice lawsuit must show that the defendant’s actions caused damages. A jury might find it hard to conclude that a permissive hospital smoking policy was the primary cause of a long-term smoker’s health problems.

4 other concerns

Nonsmokers’ rights. Arrangements at Dr. A’s hospital expose nonsmokers to secondhand cigarette smoke, which raises the possibility of legal action by nonsmokers. In 1993, the U.S. Supreme Court held that a prison inmate’s heavy exposure to secondhand smoke violated the Eighth Amendment ban on cruel and unusual punishment.²⁷ Involuntary hospitalization is not punishment, but suits such as this might be brought on other grounds, such as violation of patients’ civil rights.²⁸

Competence. In some states, civil commitment requires a finding that the respondent is not competent to make treatment decisions. Can persons who are not competent to make treatment decisions make good decisions about whether to smoke? Shouldn’t the hospital deal with patients’ nicotine dependence more therapeutically—and paternalistically—by providing nicotine replacement and encouraging smoking cessation? Shouldn’t the hospital also discourage patients who don’t smoke from starting?

Protecting patients. Dr. A’s hospital provides cigarettes to patients. Though compassion may be the motive, is the hospital failing to protect its incompetent patients and abetting their self-injurious behavior?

Helping smokers quit. Does the hospital offer treatment to help smokers quit? Although the problems that lead to civil commitment are immediate and serious, addressing long-term health issues is consistent with treating acute psychiatric crises. Many hospitals that permit smoking also encourage participation in smoking-cessation programs. Having these available to patients might make claims that the hospital failed in its duties to care for patients less plausible.

Related resources

• Maryland Hospital Association. Smoke-free hospital campus tool-kit. www.mdhospitals.org/mha/Community_Health_Resources/Smoke_Free_Hospital_Campuses.shtml.
• National Association of State Mental Health Program Directors. Tobacco-free living in psychiatric settings: a best-practices toolkit promoting wellness and recovery. www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdated90707.pdf.

Medicare enrollment rules for retroactive billing implemented this month may catch some hospital medicine leaders by surprise—and cost them billing revenue.

The new rules from the Centers for Medicare and Medicaid Services (CMS), effective April 1, cut from 27 months to 30 days the window in which physicians can back-bill for services after successful enrollment or re-enrollment in Medicare. Most HM groups routinely allow new hospitalists to work prior to payor credentialing, then retroactively bill for those services once credentialing is completed, says Leslie Flores, MHA, a principal in Nelson/Flores Associates, an HM consulting firm in La Quinta, Calif., and director of SHM's Practice Management Institute.

Another provision of the rules states that practices must alert contractors of any changes in practice locations within 30 days, or risk expulsion from Medicare for as much as two years.

“This is likely to impact hospital medicine more than other specialties because of our rapid growth, the proportion of new graduates we hire, and the frequency with which hospitalists move around,” Flores says.

Marshall Maglothin, chief operating officer of Inpatient Specialists, which staffs 70 hospitalists at three Washington, D.C.-area hospitalists, suggests HM leaders read the new Medicare Provider Enrollment Toolkit, recently issued by the American Medical Association (AMA) and the Medical Group Management Association (MGMA). The resource includes an introduction to CMS’ Web-based version of the Provider Enrollment, Chain and Ownership System (PECOS), which became available this month for both HM groups and individual hospitalists. To download the toolkit, visit www.mgma.com.

“Until this gets worked over the next couple of months, there’s going to be a lot of missed revenue,” says Maglothin, who also runs HM advisory firm Blue Oak Consulting. “This is the ideal timeline, but it’s totally unrealistic when you’re dealing with over 600,000 physicians in the United States. There should have been an ease-in process.”

To help smooth the transition, CMS will hold a conference call to discuss provider issues at 2 p.m. (EST) Thursday. Capacity is limited, but to participate, call (800) 837-1935 and reference conference No. 94109369.

Medicare enrollment rules for retroactive billing implemented this month may catch some hospital medicine leaders by surprise—and cost them billing revenue.

The new rules from the Centers for Medicare and Medicaid Services (CMS), effective April 1, cut from 27 months to 30 days the window in which physicians can back-bill for services after successful enrollment or re-enrollment in Medicare. Most HM groups routinely allow new hospitalists to work prior to payor credentialing, then retroactively bill for those services once credentialing is completed, says Leslie Flores, MHA, a principal in Nelson/Flores Associates, an HM consulting firm in La Quinta, Calif., and director of SHM's Practice Management Institute.

Another provision of the rules states that practices must alert contractors of any changes in practice locations within 30 days, or risk expulsion from Medicare for as much as two years.

“This is likely to impact hospital medicine more than other specialties because of our rapid growth, the proportion of new graduates we hire, and the frequency with which hospitalists move around,” Flores says.

Marshall Maglothin, chief operating officer of Inpatient Specialists, which staffs 70 hospitalists at three Washington, D.C.-area hospitalists, suggests HM leaders read the new Medicare Provider Enrollment Toolkit, recently issued by the American Medical Association (AMA) and the Medical Group Management Association (MGMA). The resource includes an introduction to CMS’ Web-based version of the Provider Enrollment, Chain and Ownership System (PECOS), which became available this month for both HM groups and individual hospitalists. To download the toolkit, visit www.mgma.com.

“Until this gets worked over the next couple of months, there’s going to be a lot of missed revenue,” says Maglothin, who also runs HM advisory firm Blue Oak Consulting. “This is the ideal timeline, but it’s totally unrealistic when you’re dealing with over 600,000 physicians in the United States. There should have been an ease-in process.”

To help smooth the transition, CMS will hold a conference call to discuss provider issues at 2 p.m. (EST) Thursday. Capacity is limited, but to participate, call (800) 837-1935 and reference conference No. 94109369.

Medicare enrollment rules for retroactive billing implemented this month may catch some hospital medicine leaders by surprise—and cost them billing revenue.

The new rules from the Centers for Medicare and Medicaid Services (CMS), effective April 1, cut from 27 months to 30 days the window in which physicians can back-bill for services after successful enrollment or re-enrollment in Medicare. Most HM groups routinely allow new hospitalists to work prior to payor credentialing, then retroactively bill for those services once credentialing is completed, says Leslie Flores, MHA, a principal in Nelson/Flores Associates, an HM consulting firm in La Quinta, Calif., and director of SHM's Practice Management Institute.

Another provision of the rules states that practices must alert contractors of any changes in practice locations within 30 days, or risk expulsion from Medicare for as much as two years.

“This is likely to impact hospital medicine more than other specialties because of our rapid growth, the proportion of new graduates we hire, and the frequency with which hospitalists move around,” Flores says.

Marshall Maglothin, chief operating officer of Inpatient Specialists, which staffs 70 hospitalists at three Washington, D.C.-area hospitalists, suggests HM leaders read the new Medicare Provider Enrollment Toolkit, recently issued by the American Medical Association (AMA) and the Medical Group Management Association (MGMA). The resource includes an introduction to CMS’ Web-based version of the Provider Enrollment, Chain and Ownership System (PECOS), which became available this month for both HM groups and individual hospitalists. To download the toolkit, visit www.mgma.com.

“Until this gets worked over the next couple of months, there’s going to be a lot of missed revenue,” says Maglothin, who also runs HM advisory firm Blue Oak Consulting. “This is the ideal timeline, but it’s totally unrealistic when you’re dealing with over 600,000 physicians in the United States. There should have been an ease-in process.”

To help smooth the transition, CMS will hold a conference call to discuss provider issues at 2 p.m. (EST) Thursday. Capacity is limited, but to participate, call (800) 837-1935 and reference conference No. 94109369.

Now that more swine flu cases have been reported in New York City than in any other part of the U.S., local hospitalists are preparing to handle a potential influx of ill patients.

Dahlia Rizk, DO, FHM, director of the hospitalist program at Beth Israel Medical Center (BIMC) in New York City, says her 20-member team is receiving daily briefings from the hospital’s infection control expert. Hospitalists are learning about the latest confirmed cases and guidelines from the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the NYC Department of Health and Mental Hygiene. Dr. Rizk is sharing the information with the rest of the hospital staff.

"This is our home; this is where we spend 90% of our day, if not 100%," Dr. Rizk says. “The staff know us, they rely on us, recognize us, and expect information and help from us when it comes to these kinds of situations."

John Novotny, MD, associate director of the hospitalist program at BIMC, says the hospital's strategy focuses on containing the virus and protecting other patients and staff from becoming infected by placing suspected swine flu patients in an isolation room that prevents the illness from being transmitted through droplets in the air. In addition, staff members will be expected to wear an N95 respirator facemask when entering the rooms of swine flu patients. Patients who are placed in the isolation room will be administered a PCR nasal swab test to confirm whether they are infected with influenza.

Dr. Rizk says patients showing mild to moderate symptoms will be asked to go home and remain there for seven days to reduce the chances of infecting others. “During this emergency, it is especially important to limit admissions of suspected influenza to those patients with more serious clinical conditions or significant comorbidities," she explains. "We need to focus on the priority of avoiding exposing other vulnerable inpatients to influenza, such as the elderly, the immune-compromised, or those with chronic heart and lung conditions.”

Drs. Novotny and Rizk suggest hospitalists follow these swine flu preparation tips:

• Communicate. Keep nurses and other staff up to date about the latest treatment and containment guidelines.
• Establish expectations. Be aware that staffers are looking to hospitalists for guidance during this emergency situation.
• Monitor for updates. Stay informed through your infectious disease division, the CDC, the WHO, and your local public health department.

For more information, visit the CDC website.

Now that more swine flu cases have been reported in New York City than in any other part of the U.S., local hospitalists are preparing to handle a potential influx of ill patients.

Dahlia Rizk, DO, FHM, director of the hospitalist program at Beth Israel Medical Center (BIMC) in New York City, says her 20-member team is receiving daily briefings from the hospital’s infection control expert. Hospitalists are learning about the latest confirmed cases and guidelines from the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the NYC Department of Health and Mental Hygiene. Dr. Rizk is sharing the information with the rest of the hospital staff.

"This is our home; this is where we spend 90% of our day, if not 100%," Dr. Rizk says. “The staff know us, they rely on us, recognize us, and expect information and help from us when it comes to these kinds of situations."

John Novotny, MD, associate director of the hospitalist program at BIMC, says the hospital's strategy focuses on containing the virus and protecting other patients and staff from becoming infected by placing suspected swine flu patients in an isolation room that prevents the illness from being transmitted through droplets in the air. In addition, staff members will be expected to wear an N95 respirator facemask when entering the rooms of swine flu patients. Patients who are placed in the isolation room will be administered a PCR nasal swab test to confirm whether they are infected with influenza.

Dr. Rizk says patients showing mild to moderate symptoms will be asked to go home and remain there for seven days to reduce the chances of infecting others. “During this emergency, it is especially important to limit admissions of suspected influenza to those patients with more serious clinical conditions or significant comorbidities," she explains. "We need to focus on the priority of avoiding exposing other vulnerable inpatients to influenza, such as the elderly, the immune-compromised, or those with chronic heart and lung conditions.”

Drs. Novotny and Rizk suggest hospitalists follow these swine flu preparation tips:

• Communicate. Keep nurses and other staff up to date about the latest treatment and containment guidelines.
• Establish expectations. Be aware that staffers are looking to hospitalists for guidance during this emergency situation.
• Monitor for updates. Stay informed through your infectious disease division, the CDC, the WHO, and your local public health department.

For more information, visit the CDC website.

Now that more swine flu cases have been reported in New York City than in any other part of the U.S., local hospitalists are preparing to handle a potential influx of ill patients.

Dahlia Rizk, DO, FHM, director of the hospitalist program at Beth Israel Medical Center (BIMC) in New York City, says her 20-member team is receiving daily briefings from the hospital’s infection control expert. Hospitalists are learning about the latest confirmed cases and guidelines from the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the NYC Department of Health and Mental Hygiene. Dr. Rizk is sharing the information with the rest of the hospital staff.

"This is our home; this is where we spend 90% of our day, if not 100%," Dr. Rizk says. “The staff know us, they rely on us, recognize us, and expect information and help from us when it comes to these kinds of situations."

John Novotny, MD, associate director of the hospitalist program at BIMC, says the hospital's strategy focuses on containing the virus and protecting other patients and staff from becoming infected by placing suspected swine flu patients in an isolation room that prevents the illness from being transmitted through droplets in the air. In addition, staff members will be expected to wear an N95 respirator facemask when entering the rooms of swine flu patients. Patients who are placed in the isolation room will be administered a PCR nasal swab test to confirm whether they are infected with influenza.

Dr. Rizk says patients showing mild to moderate symptoms will be asked to go home and remain there for seven days to reduce the chances of infecting others. “During this emergency, it is especially important to limit admissions of suspected influenza to those patients with more serious clinical conditions or significant comorbidities," she explains. "We need to focus on the priority of avoiding exposing other vulnerable inpatients to influenza, such as the elderly, the immune-compromised, or those with chronic heart and lung conditions.”

Drs. Novotny and Rizk suggest hospitalists follow these swine flu preparation tips:

• Communicate. Keep nurses and other staff up to date about the latest treatment and containment guidelines.
• Establish expectations. Be aware that staffers are looking to hospitalists for guidance during this emergency situation.
• Monitor for updates. Stay informed through your infectious disease division, the CDC, the WHO, and your local public health department.

For more information, visit the CDC website.

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In This Edition

• Perioperative smoking cessation reduces postoperative complications.
• Quality of life is not diminished in heart failure patients receiving defibrillator therapy.
• Simplification of the revised Geneva score may be useful in assessing for pulmonary embolism.
• Non-cardiac surgery after drug eluting stents not associated with major cardiac risk.
• Major cardiac risk is lowest 90 days after bare metal stent percutaneous coronary intervention.
• Extensive cancer screening in unexplained VTE detects more malignancies, but does not affect cancer related mortality.
• Preadmission use of statins decreases after hospitalization mortality in pneumonia.
• Drug-eluting stents are better than bare-metal stents for PCI in acute MI, but additional randomized study is needed.

Does a short duration of perioperative smoking cessation lead to a reduction in postoperative complications?

Background: Prior studies have demonstrated a reduction in postoperative complications when patients stop smoking in the perioperative period. However, they have not clearly shown what effect a fairly short duration of cessation, such as a period of only four weeks, has on the frequency of complications.

Study design: Randomized controlled trial.

Setting: Four university-affiliated hospitals in Sweden.

Synopsis: Using 117 patients who were daily smokers for less than one year between the ages of 18-79 who were scheduled for elective general or orthopedic surgery, this study showed that a smoking-cessation intervention initiated as little as four weeks prior to surgery resulted in fewer postoperative complications. The complication rate was reduced from 41% in the control group to 21% in the intervention group, which received cessation counseling and nicotine-replacement therapy. The relative risk reduction was 49% (95% confidence interval, 3-40) with a number needed to treat of five.

Because this was a randomized controlled trial with a large observed benefit, it appears to be reasonable to endorse perioperative smoking cessation as late as four weeks before an elective surgery. The study was limited in its ability to detect a difference in wound infections by the small sample size and the possibility patients might have unblinded themselves to outcome assessors, causing an overestimation of the effect of the intervention on the primary outcome of all complications.

Bottom line: Perioperative smoking cessation reduces postoperative complications even when started just four weeks prior to surgery.

Citation: Lindstrom D, Azodi OS, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications. Ann Surg. 2008;248(5):739-745.

Does implantable-defibrillator therapy cause deterioration in quality of life for patients with heart failure?

Background: Patients with depressed left-ventricular function are known to have improved survival after receiving implantable cardioverter defibrillators (ICDs). However, there is concern ICD therapy can prolong survival at the expense of a diminished quality of life.

Study design: Randomized placebo-controlled trial.

Setting: Multiple centers in the U.S., Canada, and New Zealand.

Synopsis: Using 2,479 patients from the Sudden Cardiac Death in Heart Failure trial who were 18 and older and had stable heart failure and depressed left-ventricular function, this study demonstrated no significant quality-of-life difference at 30 months when compared with patients who received ICD, amiodarone, and state-of-the-art medical therapy or an amiodarone placebo and state-of-the-art medical therapy. While functional status did not differ at any time between the three groups, psychological well-being was improved in the ICD group at three months (p=0.01) and 12 months (p=0.03) when compared with the placebo group, but at 30 months there was no difference between the groups.

While the trial was randomized and placebo-controlled, the investigators were unable to blind patients or outcome assessors. Nevertheless, the lack of deterioration of quality of life in ICD patients is reassuring.

Bottom line: Placement of ICDs in heart failure patients with a high risk of sudden cardiac death does not appear to decrease quality of life.

Citation: Mark DB, Anstrom KJ, Sun JL, et al. Quality of life with defibrillator therapy or amiodarone in heart failure. N Engl J Med. 2008;359:999-1008.

Can a simplified, revised Geneva score retain diagnostic accuracy and clinical utility?

Background: The revised Geneva score is a validated and objective clinical decision rule, but has multiple variables with different weights. This can make the tool cumbersome and difficult to remember, and could lead to inaccurate calculations and misjudgments in patient care.

Study design: Retrospective cohort study.

Setting: Four university-affiliated European hospitals.

Synopsis: Using data from two prior prospective trials involving patients with suspected pulmonary embolism (PE), this study showed re-analysis of these patients with a simplified, revised Geneva score, which gives only one point to each clinical factor, resulted in the same level of diagnostic accuracy. Specifically, data from 1,049 patients was used to construct a receiver-operating characteristic curve analysis comparing the standardized and simplified Geneva score, which showed areas under the curve of 0.75 (95% confidence interval 0.71-0.78) and 0.74 (0.70-0.77), respectively. Additionally, the safety of using this clinical tool to rule out PE was demonstrated when using both a three-level (low-intermediate probability) and a dichotomized scheme (PE unlikely) in combination with a negative D-dimer test.

The retrospective nature of the study was its major limitation. The authors suggest a prospective study to complete validation of the simplified, revised Geneva score.

Bottom line: With prospective analysis, it might be possible to further validate a simplified, revised Geneva score.

Citation: Klok FA, Mos ICM, Nijkeuter M, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008;168(19):2131-2136.

Is the rate of postoperative major adverse cardiac events (MACEs) inversely related to time after percutaneous coronary intervention (PCI) with a drug-eluting stent (DES)?

Background: The American College of Cardiology and the American Heart Association recently released an advisory that included a recommendation to delay elective noncardiac surgery (NCS) for one year after DES placement. However, no large study addresses the timing of NCS after PCI with DES.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 520 patients who had NCS after DES at the Mayo Clinic, 5.4% experienced MACEs, but the rate of MACEs was not significantly associated with the time after stent placement to surgery (p=0.337). However, observed rates of MACEs were lower after one year. Elderly patients and those going for emergent surgery are at the highest risk for MACE. Bleeding complications were not associated with antiplatelet use.

Although this study does not provide a clear cutoff time for when it is safe to proceed to NCS after DES, it is somewhat reassuring to see the relatively small number of MACEs and the lack of bleeding complications associated with antiplatelet use. However, careful coordination between hospitalists, cardiologists, anesthesiologists, and surgeons is still needed when coordinating NCS after DES, especially in the elderly or during emergent situations.

Bottom line: While time to noncardiac surgery after drug-eluting stent placement is not associated with major adverse cardiac events, observed rates of events are lower after one year.

Citation: Rabbitts JA, Nuttall GA, Brown MJ, et al. Cardiac risk of non-cardiac surgery after percutaneous coronary intervention with drug-eluting stents. Anesthesiology.2008;109: 596-604.

Is the risk of MACEs and bleeding events for patients undergoing NCS related to the time interval between PCI with bare-metal stent?

Background: In order to prevent thrombosis of bare-metal stents (BMS) placed during percutaneous coronary intervention (PCI), antiplatelet therapy is used. This poses a risk of bleeding, if surgery is needed during the antiplatelet therapy. The American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 899 patients who had NCS within one year of PCI with BMS at the Mayo Clinic between Jan. 1, 1990, and Jan. 1, 2005, this study found that when NCS was done 30 days or less after PCI with BMS, the MACEs rate was 10.5%, compared with 2.8% when NCS was done 91 or more days after PCI with BMS. After a multivariable analysis, it also was shown bleeding events were not associated with time between PCI with BMS and NCS.

While the American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS, waiting at least 90 days would permit completion of antiplatelet therapy and re-endothelialization of the stent.

Bottom line: The risk of MACEs with noncardiac surgery is lowest when performed at least 90 days after PCI with bare-metal stent.

Citation: Nuttall GA, Brown MJ, Stombaugh JW, et al. Time and cardiac risk of surgery after bare-metal stent, percutaneous coronary intervention. Anesthesiology. 2008;109: 588-595.

Should we screen extensively for cancer in patients with newly diagnosed venous thromboembolism (VTE)?

Background: It is well known VTE can be the first manifestation of previously undiagnosed cancer. Retrospective studies have suggested “limited” cancer screening, including a history and physical examination, along with basic blood work, adequately identifies malignancy in patients with unexplained VTE. However, more recent prospective studies have suggested more extensive screening, which includes imaging studies or tumor-marker measurement, can increase the rate of cancer detection.

Study design: Systematic review.

Setting: Literature search using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, and evidence-based medicine reviews.

Synopsis: Thirty-six studies of 9,516 patients with VTE reported the period prevalence of previously undiagnosed cancer from baseline to 12 months was 6.3% (95% confidence interval (CI) of 5.6% to 6.9%) in all patients with VTE, and was even higher in patients with unprovoked VTE, 10% (95% CI 8.6% to 11.3%). Of the 34 articles used for prevalence assessment, an extensive screening strategy using CT scans of the abdomen and pelvis increased the proportion of previously undiagnosed cancer detection from 49.4% (CI, 40.2% to 58.5%; limited screening) to 69.7% (CI, 61.1% to 77.8%) in patients with unprovoked VTE. Ultrasonography of the abdomen and pelvis and tumor-marker screening did not result in a clinically significant increase in the frequency of cancer detection.

Four studies compared the rate of detection of early-stage, previously undiagnosed cancer between the limited and extensive screening strategies. Extensive screening led to an absolute decrease in cancer-related mortality of 1.9%, but this difference was not statistically significant.

In this systematic review, there is a great deal of heterogeneity in the studies. Most of the studies did not look at whether an increase in detection of new malignant conditions resulted in a change in the detection rate of early-stage cancer, or a decrease in cancer-related morbidity, cancer-related mortality, or overall mortality. Furthermore, the studies did not assess the consequences of extensive screening, such as patient anxiety and discomfort, testing complications, burden of additional tests for false-positive results, or cost-effectiveness. However, it is important for hospitalists to recognize undiagnosed cancer is common in unexplained VTE and warrants at least a limited-screening approach with more extensive screening.

Bottom line: Although the prevalence of undiagnosed cancer is common in VTE, extensive screening did not offer a cancer-related mortality benefit. CT of the abdomen and pelvis did, however, lead to a greater number of cancer diagnoses in patients with unexplained VTE.

Citation: Carrier M, Le Gal G, Wells PS, Fergusson D, Ramsay T, Rodger MA. Systematic review: the Trousseau syndrome revisited: should we screen extensively for cancer in patients with venous thromboembolism? Ann Intern Med. 2008;149: 323-333.

Does the use of preadmission statins decrease the risk of death, bacteremia, and pulmonary complications in patients admitted with pneumonia?

Background: Both experimental and clinical studies have suggested statins improve outcomes in severe infections, such as sepsis. This is thought to be due to the antithrombotic, anti-inflammatory, and immunomodulatory effects of statins. However, previous studies on the effect of statins on pneumonia have conflicting outcomes.

Study design: Population-based cohort study of 29,900 patients.

Setting: Danish Health Registry.

Synopsis: Researchers studied patients ages 15 years and older hospitalized with pneumonia for the first time between January 1997 and December 2004. While statin users had more co-morbidities than nonusers, the 30-day mortality was 10.3% in users, compared with 15.7% in nonusers, corresponding to an adjusted 30-day mortality rate ratio of 0.69 (95% CI of 0.58-0.82). The 90-day mortality ratio was 16.8% in users, compared with 22.4% in nonusers, corresponding to an adjusted 90-day mortality ratio of 0.75 (95% CI of 0.65-0.86). Former use of statins was not associated with a decreased risk of death. The adjusted risk for bacteremia and pulmonary complications was not significantly different between nonusers and users.

Because this was an observational study, a causal relationship cannot be determined. Hospitalists should be alerted to the possibility statins might, in the future, prove to be a standard treatment modality in pneumonia. A randomized, double-blind trial might help further determine the effect of the acute use of statins on pneumonia outcomes.

Bottom line: Preadmission statin use is associated with a decrease in 30- and 90-day mortality in pneumonia.

Citation: Thomsen RW, Riis A, Kornum JB, Christensen S, Johnsen SP, Sorensen HT. Preadmission use of statins and outcomes after hospitalization with pneumonia. Arch Intern Med. 2008;168(19):2081-2087.

Do outcomes differ when patients with acute myocardial infarction (MI) undergo PCI with drug-eluting stents (DES) compared with bare-metal stents?

Background: Randomized trials comparing drug-eluting stents with bare-metal stents in acute MI have been limited in size and duration. Concern exists regarding higher mortality among patients with ST-elevation MI treated with DES.

Study design: Observational, cohort study.

Setting: Patients were identified from a state-mandated database, in which all PCI performed in Massachusetts are reported.

Synopsis: Between April 2003 and September 2004, 7,217 eligible patients underwent stenting for acute MI. They were assigned to either the DES group or the bare-metal stent (BMS) group using propensity score matching. Patients in the DES group had lower mortality at two years, compared to a matched cohort of patients in the BMS group with MI (10.7% vs. 12.8%; absolute risk difference, -2.1%, CI, -3.8% to -0.4%). A statistically significant difference was noted among patients with or without ST-elevation MI.

The rates of target vessel revascularization at two years with MI were significantly lower among patients receiving DES than among those receiving BMS (9.6% vs. 14.5%; risk difference, -4.9%; CI, -6.1% to -3.1%).

The study is limited by its observational nature and residual confounding bias after matching. Importantly, this study was performed to determine if DESs were harmful, and the finding of reduced mortality was unanticipated.

Bottom line: Although patients with acute MI treated with drug-eluting stents had lower mortality and repeat revascularization rates compared with bare-metal stents, this outcome merits confirmation in randomized trials.

Citation: Mauri L, Silbaugh TS, Garg P, et al. Drug-eluting or bare-metal stents for acute myocardial infarction. N Engl J Med. 2008;359 (13):1330-1342.

In This Edition

• Perioperative smoking cessation reduces postoperative complications.
• Quality of life is not diminished in heart failure patients receiving defibrillator therapy.
• Simplification of the revised Geneva score may be useful in assessing for pulmonary embolism.
• Non-cardiac surgery after drug eluting stents not associated with major cardiac risk.
• Major cardiac risk is lowest 90 days after bare metal stent percutaneous coronary intervention.
• Extensive cancer screening in unexplained VTE detects more malignancies, but does not affect cancer related mortality.
• Preadmission use of statins decreases after hospitalization mortality in pneumonia.
• Drug-eluting stents are better than bare-metal stents for PCI in acute MI, but additional randomized study is needed.

Does a short duration of perioperative smoking cessation lead to a reduction in postoperative complications?

Background: Prior studies have demonstrated a reduction in postoperative complications when patients stop smoking in the perioperative period. However, they have not clearly shown what effect a fairly short duration of cessation, such as a period of only four weeks, has on the frequency of complications.

Study design: Randomized controlled trial.

Setting: Four university-affiliated hospitals in Sweden.

Synopsis: Using 117 patients who were daily smokers for less than one year between the ages of 18-79 who were scheduled for elective general or orthopedic surgery, this study showed that a smoking-cessation intervention initiated as little as four weeks prior to surgery resulted in fewer postoperative complications. The complication rate was reduced from 41% in the control group to 21% in the intervention group, which received cessation counseling and nicotine-replacement therapy. The relative risk reduction was 49% (95% confidence interval, 3-40) with a number needed to treat of five.

Because this was a randomized controlled trial with a large observed benefit, it appears to be reasonable to endorse perioperative smoking cessation as late as four weeks before an elective surgery. The study was limited in its ability to detect a difference in wound infections by the small sample size and the possibility patients might have unblinded themselves to outcome assessors, causing an overestimation of the effect of the intervention on the primary outcome of all complications.

Bottom line: Perioperative smoking cessation reduces postoperative complications even when started just four weeks prior to surgery.

Citation: Lindstrom D, Azodi OS, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications. Ann Surg. 2008;248(5):739-745.

Does implantable-defibrillator therapy cause deterioration in quality of life for patients with heart failure?

Background: Patients with depressed left-ventricular function are known to have improved survival after receiving implantable cardioverter defibrillators (ICDs). However, there is concern ICD therapy can prolong survival at the expense of a diminished quality of life.

Study design: Randomized placebo-controlled trial.

Setting: Multiple centers in the U.S., Canada, and New Zealand.

Synopsis: Using 2,479 patients from the Sudden Cardiac Death in Heart Failure trial who were 18 and older and had stable heart failure and depressed left-ventricular function, this study demonstrated no significant quality-of-life difference at 30 months when compared with patients who received ICD, amiodarone, and state-of-the-art medical therapy or an amiodarone placebo and state-of-the-art medical therapy. While functional status did not differ at any time between the three groups, psychological well-being was improved in the ICD group at three months (p=0.01) and 12 months (p=0.03) when compared with the placebo group, but at 30 months there was no difference between the groups.

While the trial was randomized and placebo-controlled, the investigators were unable to blind patients or outcome assessors. Nevertheless, the lack of deterioration of quality of life in ICD patients is reassuring.

Bottom line: Placement of ICDs in heart failure patients with a high risk of sudden cardiac death does not appear to decrease quality of life.

Citation: Mark DB, Anstrom KJ, Sun JL, et al. Quality of life with defibrillator therapy or amiodarone in heart failure. N Engl J Med. 2008;359:999-1008.

Can a simplified, revised Geneva score retain diagnostic accuracy and clinical utility?

Background: The revised Geneva score is a validated and objective clinical decision rule, but has multiple variables with different weights. This can make the tool cumbersome and difficult to remember, and could lead to inaccurate calculations and misjudgments in patient care.

Study design: Retrospective cohort study.

Setting: Four university-affiliated European hospitals.

Synopsis: Using data from two prior prospective trials involving patients with suspected pulmonary embolism (PE), this study showed re-analysis of these patients with a simplified, revised Geneva score, which gives only one point to each clinical factor, resulted in the same level of diagnostic accuracy. Specifically, data from 1,049 patients was used to construct a receiver-operating characteristic curve analysis comparing the standardized and simplified Geneva score, which showed areas under the curve of 0.75 (95% confidence interval 0.71-0.78) and 0.74 (0.70-0.77), respectively. Additionally, the safety of using this clinical tool to rule out PE was demonstrated when using both a three-level (low-intermediate probability) and a dichotomized scheme (PE unlikely) in combination with a negative D-dimer test.

The retrospective nature of the study was its major limitation. The authors suggest a prospective study to complete validation of the simplified, revised Geneva score.

Bottom line: With prospective analysis, it might be possible to further validate a simplified, revised Geneva score.

Citation: Klok FA, Mos ICM, Nijkeuter M, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008;168(19):2131-2136.

Is the rate of postoperative major adverse cardiac events (MACEs) inversely related to time after percutaneous coronary intervention (PCI) with a drug-eluting stent (DES)?

Background: The American College of Cardiology and the American Heart Association recently released an advisory that included a recommendation to delay elective noncardiac surgery (NCS) for one year after DES placement. However, no large study addresses the timing of NCS after PCI with DES.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 520 patients who had NCS after DES at the Mayo Clinic, 5.4% experienced MACEs, but the rate of MACEs was not significantly associated with the time after stent placement to surgery (p=0.337). However, observed rates of MACEs were lower after one year. Elderly patients and those going for emergent surgery are at the highest risk for MACE. Bleeding complications were not associated with antiplatelet use.

Although this study does not provide a clear cutoff time for when it is safe to proceed to NCS after DES, it is somewhat reassuring to see the relatively small number of MACEs and the lack of bleeding complications associated with antiplatelet use. However, careful coordination between hospitalists, cardiologists, anesthesiologists, and surgeons is still needed when coordinating NCS after DES, especially in the elderly or during emergent situations.

Bottom line: While time to noncardiac surgery after drug-eluting stent placement is not associated with major adverse cardiac events, observed rates of events are lower after one year.

Citation: Rabbitts JA, Nuttall GA, Brown MJ, et al. Cardiac risk of non-cardiac surgery after percutaneous coronary intervention with drug-eluting stents. Anesthesiology.2008;109: 596-604.

Is the risk of MACEs and bleeding events for patients undergoing NCS related to the time interval between PCI with bare-metal stent?

Background: In order to prevent thrombosis of bare-metal stents (BMS) placed during percutaneous coronary intervention (PCI), antiplatelet therapy is used. This poses a risk of bleeding, if surgery is needed during the antiplatelet therapy. The American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 899 patients who had NCS within one year of PCI with BMS at the Mayo Clinic between Jan. 1, 1990, and Jan. 1, 2005, this study found that when NCS was done 30 days or less after PCI with BMS, the MACEs rate was 10.5%, compared with 2.8% when NCS was done 91 or more days after PCI with BMS. After a multivariable analysis, it also was shown bleeding events were not associated with time between PCI with BMS and NCS.

While the American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS, waiting at least 90 days would permit completion of antiplatelet therapy and re-endothelialization of the stent.

Bottom line: The risk of MACEs with noncardiac surgery is lowest when performed at least 90 days after PCI with bare-metal stent.

Citation: Nuttall GA, Brown MJ, Stombaugh JW, et al. Time and cardiac risk of surgery after bare-metal stent, percutaneous coronary intervention. Anesthesiology. 2008;109: 588-595.

Should we screen extensively for cancer in patients with newly diagnosed venous thromboembolism (VTE)?

Background: It is well known VTE can be the first manifestation of previously undiagnosed cancer. Retrospective studies have suggested “limited” cancer screening, including a history and physical examination, along with basic blood work, adequately identifies malignancy in patients with unexplained VTE. However, more recent prospective studies have suggested more extensive screening, which includes imaging studies or tumor-marker measurement, can increase the rate of cancer detection.

Study design: Systematic review.

Setting: Literature search using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, and evidence-based medicine reviews.

Synopsis: Thirty-six studies of 9,516 patients with VTE reported the period prevalence of previously undiagnosed cancer from baseline to 12 months was 6.3% (95% confidence interval (CI) of 5.6% to 6.9%) in all patients with VTE, and was even higher in patients with unprovoked VTE, 10% (95% CI 8.6% to 11.3%). Of the 34 articles used for prevalence assessment, an extensive screening strategy using CT scans of the abdomen and pelvis increased the proportion of previously undiagnosed cancer detection from 49.4% (CI, 40.2% to 58.5%; limited screening) to 69.7% (CI, 61.1% to 77.8%) in patients with unprovoked VTE. Ultrasonography of the abdomen and pelvis and tumor-marker screening did not result in a clinically significant increase in the frequency of cancer detection.

Four studies compared the rate of detection of early-stage, previously undiagnosed cancer between the limited and extensive screening strategies. Extensive screening led to an absolute decrease in cancer-related mortality of 1.9%, but this difference was not statistically significant.

In this systematic review, there is a great deal of heterogeneity in the studies. Most of the studies did not look at whether an increase in detection of new malignant conditions resulted in a change in the detection rate of early-stage cancer, or a decrease in cancer-related morbidity, cancer-related mortality, or overall mortality. Furthermore, the studies did not assess the consequences of extensive screening, such as patient anxiety and discomfort, testing complications, burden of additional tests for false-positive results, or cost-effectiveness. However, it is important for hospitalists to recognize undiagnosed cancer is common in unexplained VTE and warrants at least a limited-screening approach with more extensive screening.

Bottom line: Although the prevalence of undiagnosed cancer is common in VTE, extensive screening did not offer a cancer-related mortality benefit. CT of the abdomen and pelvis did, however, lead to a greater number of cancer diagnoses in patients with unexplained VTE.

Citation: Carrier M, Le Gal G, Wells PS, Fergusson D, Ramsay T, Rodger MA. Systematic review: the Trousseau syndrome revisited: should we screen extensively for cancer in patients with venous thromboembolism? Ann Intern Med. 2008;149: 323-333.

Does the use of preadmission statins decrease the risk of death, bacteremia, and pulmonary complications in patients admitted with pneumonia?

Background: Both experimental and clinical studies have suggested statins improve outcomes in severe infections, such as sepsis. This is thought to be due to the antithrombotic, anti-inflammatory, and immunomodulatory effects of statins. However, previous studies on the effect of statins on pneumonia have conflicting outcomes.

Study design: Population-based cohort study of 29,900 patients.

Setting: Danish Health Registry.

Synopsis: Researchers studied patients ages 15 years and older hospitalized with pneumonia for the first time between January 1997 and December 2004. While statin users had more co-morbidities than nonusers, the 30-day mortality was 10.3% in users, compared with 15.7% in nonusers, corresponding to an adjusted 30-day mortality rate ratio of 0.69 (95% CI of 0.58-0.82). The 90-day mortality ratio was 16.8% in users, compared with 22.4% in nonusers, corresponding to an adjusted 90-day mortality ratio of 0.75 (95% CI of 0.65-0.86). Former use of statins was not associated with a decreased risk of death. The adjusted risk for bacteremia and pulmonary complications was not significantly different between nonusers and users.

Because this was an observational study, a causal relationship cannot be determined. Hospitalists should be alerted to the possibility statins might, in the future, prove to be a standard treatment modality in pneumonia. A randomized, double-blind trial might help further determine the effect of the acute use of statins on pneumonia outcomes.

Bottom line: Preadmission statin use is associated with a decrease in 30- and 90-day mortality in pneumonia.

Citation: Thomsen RW, Riis A, Kornum JB, Christensen S, Johnsen SP, Sorensen HT. Preadmission use of statins and outcomes after hospitalization with pneumonia. Arch Intern Med. 2008;168(19):2081-2087.

Do outcomes differ when patients with acute myocardial infarction (MI) undergo PCI with drug-eluting stents (DES) compared with bare-metal stents?

Background: Randomized trials comparing drug-eluting stents with bare-metal stents in acute MI have been limited in size and duration. Concern exists regarding higher mortality among patients with ST-elevation MI treated with DES.

Study design: Observational, cohort study.

Setting: Patients were identified from a state-mandated database, in which all PCI performed in Massachusetts are reported.

Synopsis: Between April 2003 and September 2004, 7,217 eligible patients underwent stenting for acute MI. They were assigned to either the DES group or the bare-metal stent (BMS) group using propensity score matching. Patients in the DES group had lower mortality at two years, compared to a matched cohort of patients in the BMS group with MI (10.7% vs. 12.8%; absolute risk difference, -2.1%, CI, -3.8% to -0.4%). A statistically significant difference was noted among patients with or without ST-elevation MI.

The rates of target vessel revascularization at two years with MI were significantly lower among patients receiving DES than among those receiving BMS (9.6% vs. 14.5%; risk difference, -4.9%; CI, -6.1% to -3.1%).

The study is limited by its observational nature and residual confounding bias after matching. Importantly, this study was performed to determine if DESs were harmful, and the finding of reduced mortality was unanticipated.

Bottom line: Although patients with acute MI treated with drug-eluting stents had lower mortality and repeat revascularization rates compared with bare-metal stents, this outcome merits confirmation in randomized trials.

Citation: Mauri L, Silbaugh TS, Garg P, et al. Drug-eluting or bare-metal stents for acute myocardial infarction. N Engl J Med. 2008;359 (13):1330-1342.

In This Edition

• Perioperative smoking cessation reduces postoperative complications.
• Quality of life is not diminished in heart failure patients receiving defibrillator therapy.
• Simplification of the revised Geneva score may be useful in assessing for pulmonary embolism.
• Non-cardiac surgery after drug eluting stents not associated with major cardiac risk.
• Major cardiac risk is lowest 90 days after bare metal stent percutaneous coronary intervention.
• Extensive cancer screening in unexplained VTE detects more malignancies, but does not affect cancer related mortality.
• Preadmission use of statins decreases after hospitalization mortality in pneumonia.
• Drug-eluting stents are better than bare-metal stents for PCI in acute MI, but additional randomized study is needed.

Does a short duration of perioperative smoking cessation lead to a reduction in postoperative complications?

Background: Prior studies have demonstrated a reduction in postoperative complications when patients stop smoking in the perioperative period. However, they have not clearly shown what effect a fairly short duration of cessation, such as a period of only four weeks, has on the frequency of complications.

Study design: Randomized controlled trial.

Setting: Four university-affiliated hospitals in Sweden.

Synopsis: Using 117 patients who were daily smokers for less than one year between the ages of 18-79 who were scheduled for elective general or orthopedic surgery, this study showed that a smoking-cessation intervention initiated as little as four weeks prior to surgery resulted in fewer postoperative complications. The complication rate was reduced from 41% in the control group to 21% in the intervention group, which received cessation counseling and nicotine-replacement therapy. The relative risk reduction was 49% (95% confidence interval, 3-40) with a number needed to treat of five.

Because this was a randomized controlled trial with a large observed benefit, it appears to be reasonable to endorse perioperative smoking cessation as late as four weeks before an elective surgery. The study was limited in its ability to detect a difference in wound infections by the small sample size and the possibility patients might have unblinded themselves to outcome assessors, causing an overestimation of the effect of the intervention on the primary outcome of all complications.

Bottom line: Perioperative smoking cessation reduces postoperative complications even when started just four weeks prior to surgery.

Citation: Lindstrom D, Azodi OS, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications. Ann Surg. 2008;248(5):739-745.

Does implantable-defibrillator therapy cause deterioration in quality of life for patients with heart failure?

Background: Patients with depressed left-ventricular function are known to have improved survival after receiving implantable cardioverter defibrillators (ICDs). However, there is concern ICD therapy can prolong survival at the expense of a diminished quality of life.

Study design: Randomized placebo-controlled trial.

Setting: Multiple centers in the U.S., Canada, and New Zealand.

Synopsis: Using 2,479 patients from the Sudden Cardiac Death in Heart Failure trial who were 18 and older and had stable heart failure and depressed left-ventricular function, this study demonstrated no significant quality-of-life difference at 30 months when compared with patients who received ICD, amiodarone, and state-of-the-art medical therapy or an amiodarone placebo and state-of-the-art medical therapy. While functional status did not differ at any time between the three groups, psychological well-being was improved in the ICD group at three months (p=0.01) and 12 months (p=0.03) when compared with the placebo group, but at 30 months there was no difference between the groups.

While the trial was randomized and placebo-controlled, the investigators were unable to blind patients or outcome assessors. Nevertheless, the lack of deterioration of quality of life in ICD patients is reassuring.

Bottom line: Placement of ICDs in heart failure patients with a high risk of sudden cardiac death does not appear to decrease quality of life.

Citation: Mark DB, Anstrom KJ, Sun JL, et al. Quality of life with defibrillator therapy or amiodarone in heart failure. N Engl J Med. 2008;359:999-1008.

Can a simplified, revised Geneva score retain diagnostic accuracy and clinical utility?

Background: The revised Geneva score is a validated and objective clinical decision rule, but has multiple variables with different weights. This can make the tool cumbersome and difficult to remember, and could lead to inaccurate calculations and misjudgments in patient care.

Study design: Retrospective cohort study.

Setting: Four university-affiliated European hospitals.

Synopsis: Using data from two prior prospective trials involving patients with suspected pulmonary embolism (PE), this study showed re-analysis of these patients with a simplified, revised Geneva score, which gives only one point to each clinical factor, resulted in the same level of diagnostic accuracy. Specifically, data from 1,049 patients was used to construct a receiver-operating characteristic curve analysis comparing the standardized and simplified Geneva score, which showed areas under the curve of 0.75 (95% confidence interval 0.71-0.78) and 0.74 (0.70-0.77), respectively. Additionally, the safety of using this clinical tool to rule out PE was demonstrated when using both a three-level (low-intermediate probability) and a dichotomized scheme (PE unlikely) in combination with a negative D-dimer test.

The retrospective nature of the study was its major limitation. The authors suggest a prospective study to complete validation of the simplified, revised Geneva score.

Bottom line: With prospective analysis, it might be possible to further validate a simplified, revised Geneva score.

Citation: Klok FA, Mos ICM, Nijkeuter M, et al. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008;168(19):2131-2136.

Is the rate of postoperative major adverse cardiac events (MACEs) inversely related to time after percutaneous coronary intervention (PCI) with a drug-eluting stent (DES)?

Background: The American College of Cardiology and the American Heart Association recently released an advisory that included a recommendation to delay elective noncardiac surgery (NCS) for one year after DES placement. However, no large study addresses the timing of NCS after PCI with DES.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 520 patients who had NCS after DES at the Mayo Clinic, 5.4% experienced MACEs, but the rate of MACEs was not significantly associated with the time after stent placement to surgery (p=0.337). However, observed rates of MACEs were lower after one year. Elderly patients and those going for emergent surgery are at the highest risk for MACE. Bleeding complications were not associated with antiplatelet use.

Although this study does not provide a clear cutoff time for when it is safe to proceed to NCS after DES, it is somewhat reassuring to see the relatively small number of MACEs and the lack of bleeding complications associated with antiplatelet use. However, careful coordination between hospitalists, cardiologists, anesthesiologists, and surgeons is still needed when coordinating NCS after DES, especially in the elderly or during emergent situations.

Bottom line: While time to noncardiac surgery after drug-eluting stent placement is not associated with major adverse cardiac events, observed rates of events are lower after one year.

Citation: Rabbitts JA, Nuttall GA, Brown MJ, et al. Cardiac risk of non-cardiac surgery after percutaneous coronary intervention with drug-eluting stents. Anesthesiology.2008;109: 596-604.

Is the risk of MACEs and bleeding events for patients undergoing NCS related to the time interval between PCI with bare-metal stent?

Background: In order to prevent thrombosis of bare-metal stents (BMS) placed during percutaneous coronary intervention (PCI), antiplatelet therapy is used. This poses a risk of bleeding, if surgery is needed during the antiplatelet therapy. The American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS.

Study design: Retrospective observational study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Looking at 899 patients who had NCS within one year of PCI with BMS at the Mayo Clinic between Jan. 1, 1990, and Jan. 1, 2005, this study found that when NCS was done 30 days or less after PCI with BMS, the MACEs rate was 10.5%, compared with 2.8% when NCS was done 91 or more days after PCI with BMS. After a multivariable analysis, it also was shown bleeding events were not associated with time between PCI with BMS and NCS.

While the American College of Cardiology and the American Heart Association recommends delaying NCS for at least six weeks after PCI with BMS, waiting at least 90 days would permit completion of antiplatelet therapy and re-endothelialization of the stent.

Bottom line: The risk of MACEs with noncardiac surgery is lowest when performed at least 90 days after PCI with bare-metal stent.

Citation: Nuttall GA, Brown MJ, Stombaugh JW, et al. Time and cardiac risk of surgery after bare-metal stent, percutaneous coronary intervention. Anesthesiology. 2008;109: 588-595.

Should we screen extensively for cancer in patients with newly diagnosed venous thromboembolism (VTE)?

Background: It is well known VTE can be the first manifestation of previously undiagnosed cancer. Retrospective studies have suggested “limited” cancer screening, including a history and physical examination, along with basic blood work, adequately identifies malignancy in patients with unexplained VTE. However, more recent prospective studies have suggested more extensive screening, which includes imaging studies or tumor-marker measurement, can increase the rate of cancer detection.

Study design: Systematic review.

Setting: Literature search using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, and evidence-based medicine reviews.

Synopsis: Thirty-six studies of 9,516 patients with VTE reported the period prevalence of previously undiagnosed cancer from baseline to 12 months was 6.3% (95% confidence interval (CI) of 5.6% to 6.9%) in all patients with VTE, and was even higher in patients with unprovoked VTE, 10% (95% CI 8.6% to 11.3%). Of the 34 articles used for prevalence assessment, an extensive screening strategy using CT scans of the abdomen and pelvis increased the proportion of previously undiagnosed cancer detection from 49.4% (CI, 40.2% to 58.5%; limited screening) to 69.7% (CI, 61.1% to 77.8%) in patients with unprovoked VTE. Ultrasonography of the abdomen and pelvis and tumor-marker screening did not result in a clinically significant increase in the frequency of cancer detection.

Four studies compared the rate of detection of early-stage, previously undiagnosed cancer between the limited and extensive screening strategies. Extensive screening led to an absolute decrease in cancer-related mortality of 1.9%, but this difference was not statistically significant.

In this systematic review, there is a great deal of heterogeneity in the studies. Most of the studies did not look at whether an increase in detection of new malignant conditions resulted in a change in the detection rate of early-stage cancer, or a decrease in cancer-related morbidity, cancer-related mortality, or overall mortality. Furthermore, the studies did not assess the consequences of extensive screening, such as patient anxiety and discomfort, testing complications, burden of additional tests for false-positive results, or cost-effectiveness. However, it is important for hospitalists to recognize undiagnosed cancer is common in unexplained VTE and warrants at least a limited-screening approach with more extensive screening.

Bottom line: Although the prevalence of undiagnosed cancer is common in VTE, extensive screening did not offer a cancer-related mortality benefit. CT of the abdomen and pelvis did, however, lead to a greater number of cancer diagnoses in patients with unexplained VTE.

Citation: Carrier M, Le Gal G, Wells PS, Fergusson D, Ramsay T, Rodger MA. Systematic review: the Trousseau syndrome revisited: should we screen extensively for cancer in patients with venous thromboembolism? Ann Intern Med. 2008;149: 323-333.

Does the use of preadmission statins decrease the risk of death, bacteremia, and pulmonary complications in patients admitted with pneumonia?

Background: Both experimental and clinical studies have suggested statins improve outcomes in severe infections, such as sepsis. This is thought to be due to the antithrombotic, anti-inflammatory, and immunomodulatory effects of statins. However, previous studies on the effect of statins on pneumonia have conflicting outcomes.

Study design: Population-based cohort study of 29,900 patients.

Setting: Danish Health Registry.

Synopsis: Researchers studied patients ages 15 years and older hospitalized with pneumonia for the first time between January 1997 and December 2004. While statin users had more co-morbidities than nonusers, the 30-day mortality was 10.3% in users, compared with 15.7% in nonusers, corresponding to an adjusted 30-day mortality rate ratio of 0.69 (95% CI of 0.58-0.82). The 90-day mortality ratio was 16.8% in users, compared with 22.4% in nonusers, corresponding to an adjusted 90-day mortality ratio of 0.75 (95% CI of 0.65-0.86). Former use of statins was not associated with a decreased risk of death. The adjusted risk for bacteremia and pulmonary complications was not significantly different between nonusers and users.

Because this was an observational study, a causal relationship cannot be determined. Hospitalists should be alerted to the possibility statins might, in the future, prove to be a standard treatment modality in pneumonia. A randomized, double-blind trial might help further determine the effect of the acute use of statins on pneumonia outcomes.

Bottom line: Preadmission statin use is associated with a decrease in 30- and 90-day mortality in pneumonia.

Citation: Thomsen RW, Riis A, Kornum JB, Christensen S, Johnsen SP, Sorensen HT. Preadmission use of statins and outcomes after hospitalization with pneumonia. Arch Intern Med. 2008;168(19):2081-2087.

Do outcomes differ when patients with acute myocardial infarction (MI) undergo PCI with drug-eluting stents (DES) compared with bare-metal stents?

Background: Randomized trials comparing drug-eluting stents with bare-metal stents in acute MI have been limited in size and duration. Concern exists regarding higher mortality among patients with ST-elevation MI treated with DES.

Study design: Observational, cohort study.

Setting: Patients were identified from a state-mandated database, in which all PCI performed in Massachusetts are reported.

Synopsis: Between April 2003 and September 2004, 7,217 eligible patients underwent stenting for acute MI. They were assigned to either the DES group or the bare-metal stent (BMS) group using propensity score matching. Patients in the DES group had lower mortality at two years, compared to a matched cohort of patients in the BMS group with MI (10.7% vs. 12.8%; absolute risk difference, -2.1%, CI, -3.8% to -0.4%). A statistically significant difference was noted among patients with or without ST-elevation MI.

The rates of target vessel revascularization at two years with MI were significantly lower among patients receiving DES than among those receiving BMS (9.6% vs. 14.5%; risk difference, -4.9%; CI, -6.1% to -3.1%).

The study is limited by its observational nature and residual confounding bias after matching. Importantly, this study was performed to determine if DESs were harmful, and the finding of reduced mortality was unanticipated.

Bottom line: Although patients with acute MI treated with drug-eluting stents had lower mortality and repeat revascularization rates compared with bare-metal stents, this outcome merits confirmation in randomized trials.

Citation: Mauri L, Silbaugh TS, Garg P, et al. Drug-eluting or bare-metal stents for acute myocardial infarction. N Engl J Med. 2008;359 (13):1330-1342.

It has been a good year for Eric Howell, MD, FHM. Not only is he the 2009 recipient of SHM’s Award for Excellence in Teaching, but he also is the society’s newest board member.

Dr. Howell, who studied engineering before becoming a hospitalist, is director of the hospitalist division at Johns Hopkins Bayview Medical Center in Baltimore. An SHM member since 2000, he mentors 120 medical students as an assistant professor at the Johns Hopkins School of Medicine.

Dr. Howell, who is chair of SHM’s Leadership Committee and a member of the Public Policy Committee, was added to the 12-seat board this spring. Dr. Howell recently spoke to TH eWire about his award and his new position.

Question: What do you hope to accomplish during your SHM board tenure?

Answer:I am passionate about hospital medicine and enjoy advocating for hospitalists. I thought being a board member would be a mix of these two passions. My goal is to help hospitalists improve the care of their patients.

Q: How did you develop this passion for HM?

A: I love fixing broken things—improving on the hospital processes. I am an electrical engineer, and there is no specialty more based on systems improvement than hospital medicine. When I started, hospitalists were the red-headed stepchildren. Now they are implementers of quality improvement. I love patients, but I really love looking at systems and improving them.

Q: What do you see as the future of HM?

A: I hope it becomes a national leader for patients in hospital and quality improvement. I hope we set the stage nationally for changes in healthcare, such as [President] Obama is proposing. Hospitalists as individuals have been instrumental in advocating for patients. I’d like to see hospital medicine become the doctor-patient advocate.

It has been a good year for Eric Howell, MD, FHM. Not only is he the 2009 recipient of SHM’s Award for Excellence in Teaching, but he also is the society’s newest board member.

Dr. Howell, who studied engineering before becoming a hospitalist, is director of the hospitalist division at Johns Hopkins Bayview Medical Center in Baltimore. An SHM member since 2000, he mentors 120 medical students as an assistant professor at the Johns Hopkins School of Medicine.

Dr. Howell, who is chair of SHM’s Leadership Committee and a member of the Public Policy Committee, was added to the 12-seat board this spring. Dr. Howell recently spoke to TH eWire about his award and his new position.

Question: What do you hope to accomplish during your SHM board tenure?

Answer:I am passionate about hospital medicine and enjoy advocating for hospitalists. I thought being a board member would be a mix of these two passions. My goal is to help hospitalists improve the care of their patients.

Q: How did you develop this passion for HM?

A: I love fixing broken things—improving on the hospital processes. I am an electrical engineer, and there is no specialty more based on systems improvement than hospital medicine. When I started, hospitalists were the red-headed stepchildren. Now they are implementers of quality improvement. I love patients, but I really love looking at systems and improving them.

Q: What do you see as the future of HM?

A: I hope it becomes a national leader for patients in hospital and quality improvement. I hope we set the stage nationally for changes in healthcare, such as [President] Obama is proposing. Hospitalists as individuals have been instrumental in advocating for patients. I’d like to see hospital medicine become the doctor-patient advocate.

It has been a good year for Eric Howell, MD, FHM. Not only is he the 2009 recipient of SHM’s Award for Excellence in Teaching, but he also is the society’s newest board member.

Dr. Howell, who studied engineering before becoming a hospitalist, is director of the hospitalist division at Johns Hopkins Bayview Medical Center in Baltimore. An SHM member since 2000, he mentors 120 medical students as an assistant professor at the Johns Hopkins School of Medicine.

Dr. Howell, who is chair of SHM’s Leadership Committee and a member of the Public Policy Committee, was added to the 12-seat board this spring. Dr. Howell recently spoke to TH eWire about his award and his new position.

Question: What do you hope to accomplish during your SHM board tenure?

Answer:I am passionate about hospital medicine and enjoy advocating for hospitalists. I thought being a board member would be a mix of these two passions. My goal is to help hospitalists improve the care of their patients.

Q: How did you develop this passion for HM?

A: I love fixing broken things—improving on the hospital processes. I am an electrical engineer, and there is no specialty more based on systems improvement than hospital medicine. When I started, hospitalists were the red-headed stepchildren. Now they are implementers of quality improvement. I love patients, but I really love looking at systems and improving them.

Q: What do you see as the future of HM?

A: I hope it becomes a national leader for patients in hospital and quality improvement. I hope we set the stage nationally for changes in healthcare, such as [President] Obama is proposing. Hospitalists as individuals have been instrumental in advocating for patients. I’d like to see hospital medicine become the doctor-patient advocate.