In the News

Alcohol misuse screening, hepatitis C follow-up testing, and more.

Attendings often discuss patient care on rounds, but not at the bedside

Attending doctors often discuss patient care plans and medications during general medicine rounds, but other important topics are rarely discussed, according to a study.

In a cross-sectional observational study, researchers observed rounds for internal medicine inpatients at four teaching hospitals associated with the University of Colorado Denver School of Medicine. They observed 56 attending physicians and 279 trainees treating 807 patients over 90 days of rounds. Main measures were duration and location of rounds, composition of teams, and frequency of 19 potential activities during rounds. Results were published in the June 24 JAMA Internal Medicine.

In a typical day, one attending and three trainees visited a median of nine (range, 2-18) patients for a median of two hours. During rounds, the teams discussed the patient care plan for 96.7% of patients, reviewed lab and imaging studies for 90.7% of patients, communicated with 73.4% of patients, and talked about the medication list for 68.8% of patients. Conversely, topics that were discussed less frequently on rounds were nursing notes (6.2% of the time), invasive lines or tubes (9.3%), evidence-based medical topics (7.2%) and learner-identified topics (3.2%). Additionally, teams only communicated with nurses 12% of the time, and physical exam skills were taught just 14.6% of the time.

Most activities during rounds didn't occur at the bedside, such as general medical topic teaching (66.2% of episodes away from the bedside), feedback (64%), discussion of the patient care plan (59.5%), discussion of diagnostic studies (58.9%) and discussion of the patient medication list (58.7%). Activities that were done almost exclusively at the bedside were communication activities and physical exam skills teaching. Attendings who had gotten training that might have prepared them to teach on rounds were more likely to discuss deep venous thrombosis prophylaxis, to communicate with other hospital staff and to provide feedback.

The researchers noted that while communication with patients was frequent, communication with other hospital employees was “lacking.” An invited commenter stressed that academic institutions need to figure out ways to give attending physicians more time for patient care and trainee supervision. “Perhaps most striking is the ‘typical’ day consisted of rounds on a mean of 9 patients for 2.0 hours: less than 15 minutes per patient….No wonder many activities considered to positively affect patient care and education were found to occur infrequently,” he wrote.

Guidance released on use of new oral anticoagulants in nonvalvular afib

The European Heart Rhythm Association (EHRA) has published guidance on using new oral anticoagulants in patients with nonvalvular atrial fibrillation (AF).

The guide was funded by industry through unrestricted educational grants and covers use of dabigatran, rivaroxaban and apixaban, as well as one other drug, edoxaban, that has yet to be approved in the U.S. or Europe. The goal, the authors said, was “to coordinate a unified way of informing physicians on the use of [new oral anticoagulants]” and to serve as an adjunct to the European Society of Cardiology's AF guidelines.

A working group reviewed available evidence and developed advice on the following concrete clinical scenarios:

  • practical start-up and follow-up plans for patients taking new oral anticoagulants,
  • measurement of the drugs' anticoagulant effects,
  • drug-drug interactions and pharmacokinetics,
  • how to switch between anticoagulant regimens,
  • how to ensure compliance,
  • how to handle dosing errors,
  • use in patients with chronic kidney disease,
  • how to handle a suspected overdose without bleeding, or a clotting test that indicates a risk of bleeding,
  • management of bleeding complications,
  • management of a planned surgical intervention or ablation,
  • management of an urgent surgical intervention,
  • use in patients with AF and coronary artery disease,
  • cardioversion in a patient taking a new anticoagulant,
  • management of patients presenting with acute stroke while taking a new anticoagulant, and
  • comparison of new anticoagulants and vitamin K antagonists in patients with AF and a malignancy.

The guide was published in the May 5 Europace.

Task Force recommends screening all adults for alcohol misuse

Clinicians should screen all adults 18 and over, including pregnant women, for alcohol misuse and should provide brief behavioral counseling interventions to patients engaged in risky or hazardous drinking, the U.S. Preventive Services Task Force announced.

These recommendations differ from the 2004 statement in that the Task Force redefined alcohol misuse to include a broader spectrum of drinking habits from risky to dependent, rather than limiting the definition to just risky, hazardous or harmful drinking.

Although pregnant women are included, this recommendation is related to decreasing risky or hazardous drinking, not to complete abstinence, which is recommended for all pregnant women. These recommendations do not apply to persons who are actively seeking evaluation or treatment for alcohol misuse.

The Grade B recommendation appeared online first May 14 at Annals of Internal Medicine.

The Task Force found adequate evidence that brief behavioral counseling interventions are effective in reducing heavy drinking episodes in adults engaging in risky or hazardous drinking. These interventions also reduce weekly alcohol consumption rates and increase adherence to recommended drinking limits.

The most effective interventions were 6 to 15 minutes per contact delivered by primary care physicians with some additional support from a nurse or health educator. Limited evidence suggests that brief behavioral counseling interventions are generally ineffective as singular treatments for alcohol abuse or dependence. The Task Force did not formally evaluate other interventions (pharmacotherapy or outpatient treatment programs) for alcohol abuse or dependence, but the benefits of specialty treatment are well established and recommended for persons meeting the diagnostic criteria for alcohol dependence.

The Task Force emphasized that evidence on the effectiveness of brief behavioral counseling interventions in the primary care setting remains largely restricted to persons engaging in risky or hazardous drinking. Evidence is lacking to recommend an optimal screening interval. The Task Force also found insufficient evidence to make recommendations for screening or behavioral interventions for adolescents.

The Task Force considers three tools the instruments of choice for screening for alcohol misuse in the primary care setting: the Alcohol Use Disorders Identification Test (AUDIT), the abbreviated AUDIT-Consumption (AUDIT-C), and single-question screening (for example, the National Institute on Alcohol Abuse and Alcoholism recommends asking, “How many times in the past year have you had 5 [for men] or 4 [for women and all adults older than 65 years] or more drinks in a day?”).

More follow-up testing needed for positive hepatitis C antibody tests

Clinicians should perform an RNA hepatitis C virus (HCV) test to more definitively diagnose patients after a positive antibody test, the Centers for Disease Control and Prevention (CDC) recommended.

The CDC updated its guidance in May because of the availability of commercial HCV antibody tests, evidence that many people with positive HCV antibody tests aren't being evaluated for current infection, and development of antiviral agents with improved efficacy.

Testing for HCV begins with a rapid or laboratory-conducted assay for HCV antibody in blood, the guidance states. A reactive result indicates current HCV infection, resolved past HCV infection or a false positive.

A reactive result should be followed by nucleic acid testing (NAT) for HCV RNA in one of four ways:

  • Blood from a subsequent venipuncture is submitted for HCV NAT if the blood sample collected is reactive for HCV antibody during initial testing.
  • From a single venipuncture, two specimens are collected in separate tubes: one tube for initial HCV antibody testing and a second tube for HCV NAT if the HCV antibody test is reactive.
  • The same sample of venipuncture blood used for initial HCV antibody testing, if reactive, is reflexed to HCV NAT without another blood draw for NAT.
  • A separate venipuncture blood sample is submitted for HCV NAT if the OraQuick HCV Rapid Antibody Test for initial testing of HCV antibody has used fingerstick blood.

If HCV RNA is not detected, that indicates either past, resolved HCV infection or false HCV antibody positivity. Testing to distinguish between true positivity and biologic false positivity may be done with a second HCV antibody assay that is different from the first assay used. Biologic false positivity is unlikely when multiple tests are used on a single specimen.

In addition to the guidance, surveillance data on positive test results for HCV infection, reported to CDC from eight U.S. sites from 2005 to 2011, were analyzed in the MMWR.

Of 217,755 newly reported people, 107,209 (49.2%) were HCV antibody positive only, and 110,546 (50.8%) had a positive HCV RNA result that confirmed current HCV infection. In both groups, persons were most likely to have been born from 1945 to 1965 (58.5% of those who were HCV antibody positive only; 67.2% of those who were HCV RNA positive). The CDC amended testing recommendations in 2012 to include one-time HCV testing for everyone born from 1945 to 1965 regardless of other risk factors.