The following cases and commentary focus on high-value care (HVC), or balancing benefits with harms and costs with the goals of improving outcomes and reducing waste. The cases and commentary are excerpted from ACP's Medical Knowledge Self-Assessment Program (MKSAP 17), which released Part A on July 31 and will release Part A Digital on Aug. 31. MKSAP 17 includes HVC recommendations at the start of each section, HVC key points highlighted throughout the text, and, in MKSAP 17 Digital, a custom quiz feature enabling users to focus on HVC questions.
Case 1: Preoperative evaluation
A 46-year-old man is evaluated in the hospital prior to undergoing an elective hernia repair. Medical history is significant for a bicuspid aortic valve and a mechanical aortic valve replacement 3 years ago for severe aortic stenosis. His only medication is warfarin.
On physical examination, blood pressure is 130/75 mm Hg, pulse rate is 82/min, and respiration rate is 14/min. Cardiac examination reveals a grade 1/6 midsystolic murmur at the right upper sternal border.
Which of the following is the most appropriate management option for endocarditis prophylaxis?
D. No antibiotic prophylaxis
Case 2: Abdominal pain and nausea
A 35-year-old man is evaluated in the emergency department for a 6-hour history of epigastric abdominal pain that radiates to the back. He also has nausea and occasional bilious vomiting. He has consumed between six and twelve beers daily for 10 to 15 years.
On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 110/65 mm Hg, pulse rate is 105/min, and respiration rate is 22/min. Abdominal examination discloses epigastric tenderness without guarding or rebound. Bowel sounds are present but hypoactive, and there is mild abdominal distention. No jaundice is noted.
Laboratory studies reveal a leukocyte count of 14,000/μL (14 × 109/L), a blood urea nitrogen level of 25 mg/dL (8.9 mmol/L), and a serum lipase level of 952 U/L.
Abdominal ultrasound shows a normal-appearing gallbladder and no biliary dilation. The patient is admitted to the hospital. Over the next 48 hours, he has ongoing abdominal pain, nausea, and poor appetite despite supportive therapy consisting of pain medication and aggressive intravenous fluid replacement. Subsequent contrast-enhanced CT of the abdomen shows nonenhancing areas of the head and body of the pancreas (consistent with necrosis) and several peripancreatic fluid collections.
Which of the following is the most appropriate management?
A. Drainage of the fluid collections
B. Endoscopic retrograde cholangiopancreatography
C. Enteral nutrition by nasojejunal tube
D. Total parenteral nutrition
Case 3: Chest pain after 12-hour flight
A 63-year-old man is evaluated in the emergency department for significant shortness of breath and pleuritic anterior chest pain of 48 hours' duration. Three days ago, he completed a 12-hour flight from Asia to the United States. Medical history is otherwise unremarkable and he takes no medications.
On physical examination, he is in mild respiratory distress. He is afebrile, blood pressure is 135/87 mm Hg, pulse rate is 108/min, and respiration rate is 18/min. Oxygen saturation breathing ambient air is 94%. The remainder of the physical examination is unremarkable.
Electrocardiography shows nonspecific ST- and T-wave changes. Echocardiography shows normal right ventricular function. CT angiography of the chest demonstrates multiple pulmonary artery filling defects in the distal branches of the right pulmonary artery consistent with pulmonary embolism.
Which of the following is the most appropriate next step in management?
A. Catheter-directed thrombolysis
B. Inpatient anticoagulation
C. Outpatient anticoagulation
D. Systemic thrombolysis
Case 4: Discharging a heart failure patient
A 66-year-old woman is evaluated prior to discharge. She has ischemic cardiomyopathy and was admitted to the hospital 5 days ago for worsening symptoms of heart failure. She skipped taking her diuretics during a recent business trip. Today, she feels well and is able to walk around the ward twice without any symptoms.
This was her first hospitalization in 3 years, although she has skipped her diuretics during other business trips during this time without apparent ill effect. She had an implantable cardioverter-defibrillator placed 3 years ago. An echocardiogram 1 month ago showed a left ventricular ejection fraction of 15% (stable for the past 6 years). Medications are captopril, metoprolol succinate, digoxin, furosemide, and spironolactone.
On physical examination, blood pressure is 110/72 mm Hg, pulse rate is 56/min, and respiration rate is 14/min. She has no jugular venous distention and no S3. Lungs are clear, and she has no edema.
Electrocardiogram shows sinus rhythm, a QRS interval of 90 ms, and Q waves in V1 through V4. There are no changes compared with the admission electrocardiogram recorded 3 years ago.
Which of the following is the most appropriate management?
A. Discharge and schedule follow-up within 7 days
B. Measure B-type natriuretic peptide
C. Obtain echocardiography prior to discharge
D. Upgrade to biventricular implantable cardioverter-defibrillator
Case 5: Acute myeloid leukemia and thrombocytopenia
A 52-year-old man is evaluated in follow-up. He was admitted to the hospital 2 weeks ago with a new diagnosis of acute myeloid leukemia. He has received induction chemotherapy with daunorubicin and cytarabine. Medical history is remarkable for an urticarial reaction to a platelet transfusion that resolved promptly with diphenhydramine. Other medications are posaconazole, valacyclovir, and cefepime.
On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 132/72 mm Hg, pulse rate is 84/min, and respiration rate is 18/min. Oxygen saturation is 94% breathing ambient air. Oropharyngeal examination is unremarkable. He has scattered petechiae over both ankles and an ecchymosis at the insertion site of his central venous catheter.
Laboratory studies show he is neutropenic and has a platelet count of 12,000/μL (12 × 109/L).
Which of the following is the most appropriate management of this patient's thrombocytopenia?
A. Transfuse leukoreduced, irradiated platelets
B. Transfuse leukoreduced, irradiated, HLA-matched platelets
C. Transfuse leukoreduced, irradiated, washed platelets
D. Recheck platelet count in 24 hours
Case 6: Melena, abdominal pain, and NSAID use
A 55-year-old man is hospitalized for a 3-day history of melena and a 2-week history of epigastric abdominal pain. His medical history is notable for degenerative arthritis of the knee, for which he takes an NSAID.
On physical examination, blood pressure is 139/65 mm Hg and pulse rate is 75/min. Other vital signs are normal. Abdominal examination reveals epigastric tenderness to light palpation.
Initial laboratory studies reveal a hemoglobin level of 12 g/dL (120 g/L). An intravenous proton pump inhibitor (PPI) and intravenous hydration are initiated.
Upper endoscopy reveals three cratered, clean-based gastric ulcers smaller than 1 cm. The esophagus, stomach, and small bowel are well visualized, and no other source of gastrointestinal bleeding is identified. Gastric biopsies are taken to test for Helicobacter pylori.
The patient is examined 24 hours after admission. Vital signs are stable and the abdominal examination reveals diminished tenderness to palpation. Laboratory studies reveal a hemoglobin level of 11.5 g/dL (115 g/L).
In addition to discontinuing the NSAID, which of the following is the most appropriate management?
A. Begin oral feeding, switch to an oral PPI, and observe for 24 hours
B. Continue intravenous PPI therapy for another 24 hours
C. Discharge and switch to oral PPI therapy
D. Perform repeat upper endoscopy before discharge
Case 7: Metastatic lung cancer
A 70-year-old woman is hospitalized for worsening generalized weakness, anorexia for several days associated with weight loss, and back pain responsive to NSAID administration. The patient recently completed chemotherapy for poorly differentiated adenocarcinoma of the right lung and metastasis-related pathologic compression of the L3 vertebral body without cord compression. Her Eastern Cooperative Oncology Group/World Health Organization performance status is 3 (confined to bed or chair more than 50% of waking hours).
At the time of diagnosis, the patient was treated with four cycles of carboplatin/paclitaxel chemotherapy. CT scans after completing chemotherapy showed an increase in the right lung mass, a new right pleural effusion, increased size of hilar and mediastinal lymph nodes, and new lesions in the liver, consistent with metastases.
On physical examination, the patient is afebrile, blood pressure is 95/57 mm Hg, pulse rate is 90/min, and respiration rate is 20/min. Oxygen saturation is 94% on ambient air. Decreased breath sounds are auscultated over the right lower lung field. There is tenderness over the lumbosacral area. Neurological examination is normal.
Which of the following is the most appropriate next step in management?
A. Comprehensive palliative care assessment
B. Initiation of a different chemotherapy regimen
C. Initiation of artificial nutrition support
D. Placement of a thoracostomy tube
E. Radiation therapy to the L3 vertebral body
Answers and commentary
Correct answer: D. No antibiotic prophylaxis.
For this patient with a mechanical valve preparing for hernia repair surgery, antibiotic prophylaxis to prevent bacterial endocarditis is not indicated. Prophylaxis to prevent bacterial endocarditis is appropriate before certain dental procedures for patients with specific indications placing them at high risk for an adverse outcome from infective endocarditis (class IIa recommendation). These indications include previous endocarditis, a history of cardiac transplantation, a prosthetic valve, and specific forms of complex congenital heart disease. However, prophylaxis is not recommended for nondental procedures, including transesophageal echocardiography and genitourinary or gastrointestinal procedures (such as upper endoscopy, colonoscopy, or hernia repair), in the absence of active infection (class III recommendation). Dental procedures for which antibiotic prophylaxis is reasonable include those that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. Prophylaxis is not recommended for routine dental procedures, including radiographs and orthodontics.
When antibiotic prophylaxis is indicated, it should be given as a single dose 30 to 60 minutes before the dental procedure. If the prophylactic medication is inadvertently not administered, it may be given up to 2 hours after the procedure. Options include amoxicillin, 2 g orally, or ampicillin, 2 g intravenously. For patients allergic to penicillin or amoxicillin, alternatives include clindamycin, 600 mg orally; azithromycin, 500 mg orally; or cefazolin/ceftriaxone, 1 g intramuscularly or intravenously.
- Antibiotic prophylaxis to prevent bacterial endocarditis is not recommended for nondental procedures, including transesophageal echocardiography and genitourinary or gastrointestinal procedures, in the absence of active infection.
Correct answer: C. Enteral nutrition by nasojejunal tube.
Enteral feeding is the most appropriate management. Enteral feeding has been shown to reduce infectious complications, multiple organ failure, operative interventions, and mortality compared with feeding by total parenteral nutrition in patients with severe acute pancreatitis. This patient has moderately severe acute pancreatitis based on evidence of pancreatic necrosis and peripancreatic fluid collections. He also has several risk factors for severe disease based on the presence of three of four Systemic Inflammatory Response Syndrome (SIRS) criteria (pulse rate >90/min, leukocyte count >12,000/μL [12 × 109/L], and respiration rate >20/min) and a blood urea nitrogen level greater than 23 mg/dL (8.2 mmol/L). Nasogastric and nasojejunal feeding appear to be comparable in safety and efficacy. The optimal time to start enteral nutrition remains under investigation, but it should commence no later than 72 hours after presentation. In mild acute pancreatitis, oral feeding may start when nausea and vomiting resolve.
Drainage of acute peripancreatic fluid collections (APFCs) is not appropriate at this time because most collections resolve without intervention. Asymptomatic APFCs require no treatment. Symptomatic APFCs can be treated medically with bowel rest, jejunal feeding, pancreatic enzymes, octreotide, and rarely pancreatic duct stenting. Rarely, APFCs persist beyond 4 weeks, when they become encapsulated and are labeled a pancreatic pseudocyst. Pseudocysts are amenable to drainage if clinically indicated based on persistent pain despite medical therapy, infected pseudocyst, or obstruction of the gastric outlet or biliary tract.
Endoscopic retrograde cholangiopancreatography in acute pancreatitis should be used only in the following clinical scenarios: (1) in a patient with ascending cholangitis (fever, right upper quadrant pain, and jaundice) concomitant with acute pancreatitis, or (2) in a patient with gallstone pancreatitis who is not improving clinically and has worsening liver chemistry test results. Patients with gallstone pancreatitis and no complications should have a cholecystectomy prior to discharge.
- Enteral feeding has been shown to reduce infectious complications, multiple organ failure, operative interventions, and mortality compared with feeding by total parenteral nutrition in patients with severe acute pancreatitis.
Correct answer: C. Outpatient anticoagulation.
This patient can receive anticoagulant therapy in the outpatient setting. When treating acute pulmonary embolism (PE), it is essential to initiate anticoagulation immediately and achieve therapeutic levels of anticoagulation within 24 hours; failure to do so correlates with an increased risk of clinical progression and recurrence. Anticoagulation can be achieved with unfractionated heparin (either intravenous or subcutaneous), subcutaneous low-molecular-weight heparin (LMWH), or the pentasaccharide fondaparinux. Outpatient management is safe for up to 50% of patients with PE, including some with mild right heart strain on cardiac echocardiography. However, hospital admission is appropriate for patients who are too ill to be managed at home (those needing supplemental oxygen or requiring intravenous pain medications) and those with comorbid conditions that may contribute to rapid clinical deterioration (for example, high bleeding risk).
A 2012 guideline from the American College of Chest Physicians (ACCP) recommends thrombolytic therapy for patients with PE and a systolic blood pressure less than 90 mm Hg and without contraindications (for example, high bleeding risk). Thrombolytic therapy does not appear to have therapeutic benefit in unselected patients with acute PE and is associated with an increased risk for major hemorrhage. No clear evidence indicates thrombolytic therapy should be used in patients with evidence of pulmonary hypertension or right ventricular dysfunction detected by echocardiography, positive cardiac enzymes, or both. This patient has no indications for thrombolytic therapy. If thrombolytic therapy were appropriate, the ACCP's guidelines recommend systemic administration rather than catheter-directed thrombolysis.
- Outpatient anticoagulation management is possible for patients with pulmonary embolism, unless they require supplemental oxygen, intravenous pain medications, or management of comorbid conditions that may contribute to rapid clinical deterioration or if home circumstances make outpatient therapy unfeasible.
Correct answer: A. Discharge and schedule follow-up within 7 days.
This patient should be discharged home, with a follow-up appointment scheduled within 7 days. She has had one heart failure hospitalization in the past 3 years and her nonadherence with her diuretic medication was the most likely cause of the admission. With any heart failure hospitalization, it is important to reassess several factors before discharge. First, patients must be adequately diuresed prior to discharge. It is important to know that measuring a serum B-type natriuretic peptide level will not help with that assessment. Patients should be examined for flat neck veins, resolution of peripheral or abdominal edema (if possible), and resolution of the signs and symptoms of acute heart failure (S3, exertional dyspnea and fatigue, orthopnea, paroxysmal nocturnal dyspnea). Second, patients should be on appropriate medical therapy for their stage of heart failure. For this patient, appropriate medications include an ACE inhibitor or angiotensin receptor blocker, β-blocker, aldosterone antagonist, and an adequate dosage of diuretic to prevent readmission. Third, it has been demonstrated that a patient being seen within 1 week after discharge is associated with a reduction of future heart failure hospitalizations. This patient is adequately diuresed and is on appropriate medications. Reducing her risk of readmission requires a follow-up visit within 7 days of discharge and appropriate patient education.
An echocardiogram performed 1 month ago demonstrated that the patient's left ventricular function is stable. There is no suggestion of ischemia or change in valvular function as a precipitant of this hospitalization. If this patient had not had an echocardiogram in at least 6 months, it would be reasonable to repeat the echocardiogram during the hospitalization; otherwise unless there is a suspicion of a change, there is no reason to do so.
Patients are candidates for a biventricular pacemaker if they have all of the following indications: on guideline-directed medical therapy, a reduced ejection fraction (≤35%), a wide QRS interval (≥150 ms) or a left bundle branch block, and New York Heart Association functional class III or IV symptoms. This patient has a narrow QRS interval and therefore would not be a candidate for upgrading to a biventricular implantable cardioverter-defibrillator.
- Patients hospitalized for heart failure who are scheduled for a follow-up appointment within 1 week after discharge have a reduced risk of future heart failure hospitalization.
Correct answer: D. Recheck platelet count in 24 hours.
The platelet count should be rechecked in 24 hours. Although this patient is significantly thrombocytopenic, phase III clinical trial data do not support the use of prophylactic platelet transfusions for patients with acute myeloid leukemia (AML) whose platelet count is 10,000/μL (10 × 109/L) or higher. Randomized studies have been published comparing a platelet transfusion threshold of 10,000/μL (10 × 109/L) to 20,000/μL (20 × 109/L) in stable patients with AML undergoing induction or consolidation chemotherapy; all have demonstrated equivalent outcomes with respect to clinically significant bleeding, need for erythrocyte transfusions, and mortality during induction chemotherapy. Therefore, these data support and guidelines recommend a threshold of 10,000/μL (10 × 109/L) for prophylactic platelet transfusion in hospitalized patients with thrombocytopenia due to decreased bone marrow production. Patients with acute promyelocytic leukemia (APL), fever, clinically significant bleeding, or a need for invasive procedures were not evaluated in these studies and are typically transfused at a threshold of 20,000/μL (20 × 109/L).
Transfusion of leukoreduced, irradiated platelets would be appropriate if the patient's platelet count decreases to less than 10,000/μL (10 × 109/L). HLA-matched platelets would only be used if the patient had a history of platelet transfusion refractoriness attributed to platelet alloantibodies. Washing of platelets leads to loss of platelet numbers and function and is reserved for patients with a history of a severe allergic reaction to a transfused blood product (such as anaphylaxis in a patient with IgA deficiency).
- Clinically stable patients with chemotherapy-induced thrombocytopenia who are not bleeding do not benefit from platelet transfusion when the platelet count is 10,000/μL (10 × 109/L) or greater.
Correct answer: C. Discharge and switch to oral PPI therapy.
The most appropriate management is prompt discharge on oral proton pump inhibitor (PPI) therapy. In addition, NSAIDs should be discontinued. Upper endoscopy identified several small gastric ulcers as this patient's bleeding source. Patients with low-risk stigmata (a clean-based ulcer [rebleeding risk with medical therapy 3%-5%] or a nonprotuberant pigmented spot in an ulcer bed [rebleeding risk with medical therapy 5%-10%]) can be fed within 24 hours, should receive oral PPI therapy, and can undergo early hospital discharge. This patient's ulcers did not require endoscopic therapy and are at low risk for rebleeding, especially with the daily use of an oral PPI and discontinuation of NSAIDs. Other clinical predictors that justify prompt discharge are this patient's stable vital signs, stable hemoglobin level, and absence of serious comorbidities.
Several studies have demonstrated similar outcomes in patients with low-risk ulcers who were discharged on the first hospital day compared with those hospitalized for longer periods of time. There is no benefit to another day of hospitalization for observation.
With a low-risk ulcer, feeding can be initiated and PPI therapy can be promptly switched from continuous intravenous infusion to an oral formulation. An additional 24 hours of an intravenous PPI therapy is unnecessary and needlessly expensive.
More than 90% of uncomplicated NSAID-induced gastric ulcers will heal with standard-dose PPI therapy if NSAID therapy is discontinued. This patient could be considered for upper endoscopy in 2 to 3 months to document healing of his gastric ulcers if dyspeptic symptoms persist despite therapy, the initial endoscopy was not complete in evaluating the stomach, gastric biopsies were not obtained on initial endoscopy, or the appearance of the gastric ulcer was suspicious for malignancy. If NSAID therapy is reinitiated in the future, co-therapy with a PPI should be employed to prevent a recurrent peptic ulcer. Misoprostol at 800 μg total daily dosing is an alternative to PPI therapy, but gastrointestinal side effects at this dose may be limiting.
Twice-daily H2-blocker therapy offers some benefit, but protection is inferior to that of PPI therapy. There is no need to routinely perform second-look endoscopy during hospitalization for an acute peptic ulcer bleed. Indications for repeat endoscopy in the hospital setting would include concern for ongoing gastrointestinal bleeding or an incomplete endoscopic evaluation with concern for missing a bleeding source.
- Peptic ulcers at low risk for bleeding (clean based or with a nonprotuberant pigmented spot) can be managed with oral proton pump inhibitor therapy and early hospital discharge.
Correct answer: A. Comprehensive palliative care assessment.
Recommending comprehensive palliative care assessment for possible hospice care is indicated. Stage IV (metastatic) non–small cell lung cancer (NSCLC) is incurable. Because metastatic NSCLC is a systemic process, systemic chemotherapy is typically used as the primary treatment modality. Chemotherapy for stage IV NSCLC has been shown to prolong survival and improve quality of life. However, patients with poor performance status and advanced disease have a limited prognosis (less than 4 months) despite therapy. Goals of therapy for these patients are symptom palliation and possible prolongation of survival. This patient has progressive metastatic lung cancer based on imaging studies that were obtained after she completed four cycles of chemotherapy. She also has a clear decline in functional status. Based on these findings, hospice care would be most appropriate.
The response rate to second-line chemotherapy is very low in patients with NSCLC. In addition, all available evidence indicates that patients with an Eastern Cooperative Oncology Group/World Health Organization performance status of 2 or worse do not derive benefit from chemotherapy.
Providing artificial nutrition for patients with advanced cancer has not been shown to improve outcomes and is not usually recommended.
The pleural effusion identified on the most recent imaging studies is small and is not causing respiratory compromise. Thoracostomy tube drainage is therefore not indicated.
Radiation therapy should be considered to relieve pain, particularly bony pain, visceral pain (when secondary to capsular distension), or pain due to nerve/nerve root compression. Although this patient has pain due to a metastatic lesion involving the L3 vertebral body, the pain is mild, managed with a NSAID, and there is no evidence of cord compression; consequently, radiation treatment is not needed for palliation.
- Patients with lung cancer and poor performance status do not benefit from chemotherapy and should undergo a palliative care assessment.