Physicians report feeling moral distress over hospital policies that force inadequate care

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1. Physicians report feeling moral distress over hospital policies that force inadequate care based on immigration status
Abstract: http://annals.org/aim/article/doi/10.7326/M18-0400
Editorial: http://annals.org/aim/article/doi/10.7326/M18-1267
URLs go live when the embargo lifts

Clinicians in safety-net hospitals describe feeling moral distress and being driven toward professional burnout because of policies that prevent them from performing hemodialysis to undocumented immigrants, except in the case of an emergency. Being forced to provide inferior care due to the patient's immigration status was a significant burden to the clinicians who reported feeling a sense of admiration for these patients and a desire to advocate on their behalf. Findings from a qualitative study are published in Annals of Internal Medicine.

In the U.S., nearly half of undocumented immigrants with end-stage kidney disease receive hemodialysis only when they are evaluated in an emergency department and are found to have life-threatening renal failure. This type of "emergency-only" hemodialysis, or EOHD, is nearly 4 times more costly than regularly scheduled hemodialysis and has a 14-fold higher mortality rate. This approach to care is distressing for the patient, but little is known about how it affects the clinician.

Researchers from the University of Colorado interviewed 50 interdisciplinary clinicians in a safety-net hospital in Denver, Colorado to determine how physicians feel about emergency-only hemodialysis. The clinicians reported that they felt emotionally and physically exhausted by daily organizational and system-level barriers to providing care. In addition, they were troubled by witnessing unnecessary suffering and high mortality. In their paper, the researchers identified and explained four high-level themes that emerged from their interviews: drivers of professional burnout, moral distress from propagating injustice, confusing and perverse financial incentives, and inspiration toward advocacy.

The researchers conclude that emergency-only hemodialysis is harmful to patients and is also harmful to clinicians that are forced to provide inadequate care to their patients. The burden on clinicians of providing emergency-only hemodialysis should inform policy discussions and systemic approaches to support provision of an adequate standard of care to all patients with end-stage renal disease.

Media contact: For an embargoed PDF, please contact Lauren Evans at [email protected] To interview the lead author, Lilia Cervantes, M.D., please contact Simon Crittle at [email protected] or 720-326-1789.

2. Physicians should look for misuse patterns that lead to overdose before prescribing opioids
Abstract: http://annals.org/aim/article/doi/10.7326/M17-3065
Editorial: http://annals.org/aim/article/doi/10.7326/M18-1146
URLs go live when the embargo lifts

Physicians should look for use patterns that are associated with overdose before prescribing opioids. Behaviors, such as overlapping prescriptions, use of more than one prescriber or pharmacy, and use of out-of-state prescribers or pharmacies were all strongly linked to an increased risk for overdose. Findings from an observational study are published in Annals of Internal Medicine.

Prescription drug monitoring databases (PDMPs) have become common and increasingly, states are requiring physicians to check them before prescribing opioids. However, there is very little evidence to guide physicians on how to interpret data in PDMPs, which includes information on when and how patients fill their opioid prescriptions.

Researchers from Harvard T.H. Chan School of Public Health, Cornell University, and Harvard Medical School studied opioid prescribing data for more than 600,000 Medicare beneficiaries from 2008 to 2012 to estimate how a range of patterns of potential opioid misuse related to adverse outcomes during the subsequent year. Over a 5-year period, the researchers found that patterns of potential opioid misuse were common, largely stable over time, and associated with a higher risk for adverse opioid-related outcomes in the following year, including opioid overdose, all-cause mortality, and death within 30 days of an opioid overdose diagnosis. All of these risks persisted even after the researchers controlled for the average daily dose of opioids patients received and patient demographics. The researchers noted that nearly any deviation from filling opioid prescriptions at one pharmacy from one provider was associated with a higher risk of overdose and the risk grew with increasing fragmentation of prescribing or higher quantities of overlapping prescriptions.

According to the researchers, their findings suggest that a broad range of patterns may be informative in identifying patients with high-risk opioid use. Physicians should look for these patterns before making prescribing decisions, and states should consider incorporating "dashboards" in their PDMPs to display these patterns easily.

Media contact: For an embargoed PDF, please contact Lauren Evans at [email protected] To interview the lead author, Michael Barnett, MD, MS, please contact Todd Datz at [email protected]

3. Amyloid-beta (1-40) is a strong predictor of mortality in acute coronary syndrome
AB40 predicts mortality and improves risk stratification over guideline-recommended GRACE score

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1540
URLs go live when the embargo lifts

Circulating amyloid-beta (1-40), or Aβ40, is a strong predictor of mortality in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Aβ40 may be a better way to stratify risk than the guideline-recommended GRACE (Global Registry of Acute Coronary Events) score. Findings from a retrospective cohort study are published in Annals of Internal Medicine.

Risk stratification of patients with NSTE-ACS is important for identifying those who should receive early coronary intervention. Current clinical practice guidelines agree on a standardized approach that uses the GRACE score to calculate a patient's risk and guide decisions about triage and management. However, this score uses standard coronary risk factors and does not take into consideration vascular inflammation, a hallmark of the pathophysiologic pathways of coronary artery disease. Aβ40 is implicated in mechanisms related to plaque destabilization and correlates with adverse outcomes in stable coronary artery disease. However, its role in risk prediction for NSTE-ACS is not known.

 <p>Researchers at the Cardiovascular Research Centre in Newcastle upon Tyne, United Kingdom, reviewed data from two independent prospective cohorts to determine the prognostic and reclassification value of baseline circulating levels of Aβ40 after adjustment for GRACE score. They found that Aβ40 circulating levels in NSTE-ACS were associated with a worse clinical risk profile; predicted increased mortality; and more often correctly reclassified risk categories over the GRACE score. According to the researchers, these findings suggest that Aβ40 may have clinical application for predicting risk in NSTE-ACS patients.</p>   <p>Media contact: For an embargoed PDF, please contact Lauren Evans at [email protected] To interview the lead author, Konstantinos Stellos, MD, please contact Karen Bidewell at [email protected]   </p>  <p><strong>Also new in this issue:</strong>  

Guidelines Versus Guidelines: What's Best for the Patient?
Boris Draznin, MD, PhD; David M. Nathan, MD; Mary T. Korytkowski, MD; Marie E. McDonnell, MD; Sherita Hill Golden, MD, MHS; Mark H. Schutta, MD; William T. Cefalu, MD
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M18-0939

An Independent Evaluation of the Accuracy and Usability of Electronic Adherence Monitoring Devices
Meghan E. McGrady, PhD; Christina E. Holbein, PhD; Aimee W. Smith, PhD; Caroline F. Morrison, PhD, RN; Kevin A. Hommel, PhD; Avani C. Modi, PhD; Ahna L.H. Pai, PhD; Rachelle R. Ramsey, PhD
Brief Research Report
Abstract: http://annals.org/aim/article/doi/10.7326/M17-3306

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