Wednesday, August 7, 2013
QD: News Every Day--Tread lightly on adjusting inpatients’ drug regimens for chronic conditions
Hospital-based physicians would serve patients well by leaving ambulatory care drug regimens up to outpatient providers, a commentary reads.
Corresponding author Michael A. Steinman, MD, FACP, and a colleague outlined their ideas in an opinion piece in JAMA Internal Medicine after considering the case of an 82-year-old man with severe chronic obstructive pulmonary disease and remote coronary artery bypass grafting who was admitted for chest pain.
The man’s previously normal blood pressure rose after admission, likely because of his illness. Even though acute coronary syndrome was ruled out, the patient was prescribed losartan potassium, 25 mg daily, and low-dose metoprolol tartrate, twice daily and continued on the drugs after discharge. Outpatent follow-up three days later recorded the man’s blood pressure at 85/45 mm Hg.
Other examples of discordant care might include continuing blood glucose medications that result in hypoglycemia or adding statins and bisphosphonates that make medications regimens more complex, resulting in decreased adherence, the authors wrote.
It’s best just to improve coordination between inpatient and outpatient providers, the authors wrote.
“In most cases, the best approach to chronic disease in hospitalized patients is for physicians to be reluctant to intensify long-term therapies,” the authors wrote. “This approach requires a clear definition of the role of the inpatient physician in chronic disease management. Determining whether acute control of chronic disease benefits the patient’s near-term health is essential. If the answer is yes, it is usually appropriate to intensify therapy. If the answer is no, it is usually best to leave the outpatient regimen untouched.”
While this is particularly important for patients whose chronic conditions have been well-controlled on an outpatient basis, the lesson still applies to those with poor baseline control, the authors wrote.
“Many cases of suboptimal disease control in the outpatient setting reflect limited access to health care, prior adverse events when therapy was intensified, or medication nonadherence. In such situations, starting treatment with a drug and sending the patient home with the new medication will do little to improve long-term outcomes,” they wrote. “In contrast, hospitalization can provide an excellent opportunity to address underlying barriers to long-term disease control, for example, by referring a patient to primary care, involving social workers to address social and financial obstacles to care, or having pharmacists teach about proper medication use.”
In case you missed it
Uncertain about what medical specialty to choose (or why you chose yours, for you more-experienced doctors out there)? Cartoonist and physician Dr. Fizzy has posted a humorous online algorithm for what criteria define the medical specialties, and how internal medicine fits in for the undecided.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
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Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.