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New statin guidelines

December 2013

Published in the December 2013 issue of Today’s Hospitalist

New statin guidelines

REVISED GUIDELINES released by the American College of Cardiology/American Heart Association no longer recommend treating patients to specific LDL cholesterol targets. Instead, the guidelines spell out four categories of patients who should receive some level of statin therapy.

The categories include patients who have atherosclerotic cardiovascular disease (ASCVD); patients with an LDL level of 190 mg/dL or higher; patients with diabetes age 40-75 with LDL levels of 70-189; and patients without clinical ASCVD or diabetes with an LDL of 70-189 who have an estimated 10-year ASCVD risk of at least 7.5%.

According to coverage in the New York Times, physicians are being encouraged to use a new risk calculator to determine patients 10-year risk. For the first time, the guidelines incorporate stroke risk in that calculation.

However, an editorial questioned the new guidelines’ recommendation to prescribe statins to patients with a 7.5% 10-year risk of heart disease, pointing out that evidence suggests that statins are ineffective for people with a less than 20% 10-year risk. The new guidelines, the editorialists wrote, could lead to many more inappropriate statin prescriptions.

The prevalence of burnout

ARE HOSPITALISTS MORE PRONE TO BURNOUT than outpatient physicians? Not so, according to meta-analysis results published online in October by the Journal of Hospital Medicine. Researchers analyzed more than two dozen studies “some of which were international “and debunked what they called “the long-held belief” that physicians who work in the inpatient setting are more apt to burn out.

Instead, authors found that more outpatient physicians than inpatient physicians reported emotional exhaustion. The two groups did, however, post similar rates of feeling depersonalized or of having a sense of low personal accomplishment.

The authors suggested that the shift work prevalent among hospitalists may better protect work-life balance and that physicians working in hospitals may experience more teamwork and collegiality than their outpatient colleagues. The research was limited, the authors pointed out, by the variety of instru- ments used in studies to measure burnout and the lack of information on practice settings.

The research also called for comparative studies to gauge burnout among hospitalists, ED physicians, intensivists and anesthesiologists.

Pushing the development of telemedicine

WHILE MANY IN HEALTH CARE have high hopes for telemedicine, reimbursement issues remain in several states, and hospital systems continue to face hurdles related to licensing, credentialing, and the need to standardize technology and equipment.

But according to an article in the October issue of HealthLeaders, many large hospital systems around the country are going all-in for telemedicine. Utah’s Intermountain Healthcare, for instance, has begun building in telemedicine capacity for every inpatient bed in its 22 hospitals, as well as every outpatient exam room in the system.

That infrastructure, which was originally designed to accommodate physician consults, is also being used for consultations with case managers, pharma- cists and nutritionists. When providers aren’t using the equipment, patients are allowed to access it to communicate with family members.

The article also pointed out that Mercy Health in St. Louis, a 32-hospital system, now has 70 telemedicine projects in four states that will soon be ex- panded to a fifth. At the same time, the UC Davis Health System now provides telemedicine access to 30 specialty services to both adults and children. It has reported that the use of telemedicine has prompted more pediatric transfers ” and revenue “from connected hospitals.

What to do about a colleague’s error

WHAT PHYSICIANS SHOULD DO when they uncover a colleague’s potential error can be a very complicated question, according to a commentary published in the Oct. 31 issue of the New England Journal of Medicine.

Physicians may have little first-hand knowledge or pertinent information from the medical record. At the same time, the authors wrote, talking with colleagues about possible errors can be difficult in the face of a culture of solidarity, a fear of how colleagues may react, a significant power differential or the threat of disrupting referral patterns.

But the commentary, which was written by an expert panel of patient safety and malpractice experts, concluded that patients’ need for information trumps the possibility of damaging professional relationships. Authors also wrote that doctors should discuss possible errors with the colleagues involved.

They also recommended that institutions take the lead in establishing policies about disclosing colleagues’ errors. According to the commentary, hospitals are developing coaching programs on error disclosure. Coaches could help “facilitate peer-to-peer discussions.”