Sheena Mathew, MD

 

Clinical question: Are there differences in mortality and health care resource utilization in patients treated by hospitalists, primary care physicians, or other generalists?

Background: Most hospitalized patients now are being cared for by hospitalists rather than their primary care physicians (PCP). Covering generalists, who lack a prior relationship with the patient, also care for hospitalized patients when their PCP is unavailable. Although past studies have found some differences in outcomes in patients when care was provided by hospitalists vs. PCPs, those studies have grouped covering generalists with PCPs, which could affect the data.

Study design: Retrospective study.

Setting: Medicare admissions to acute care hospitals in all 50 states from January 2013 to December 2013.

Synopsis: Researchers analyzed data from 560,651 patients admitted with the 20 most common diagnoses looking for differences in health care utilization, length of stay, mortality, and discharge disposition depending on the type of provider: PCP, hospitalist, or other covering generalist. PCPs and other generalists consulted specialists more often than hospitalists. Length of stay was shorter in the hospitalist group. PCPs discharged patients to home more often than the other groups (68.5%, compared with 64% for hospitalists and 62% for other generalists). Readmission rates at 7 days were the same between hospitalists and PCPs but were higher in the other generalist group. PCPs also had lower 30-day mortality, compared with hospitalists (8.6% vs. 10.8%), while other generalists had higher mortality at 11%. Limitations include the use of administrative data and including only Medicare patients.

Bottom line: Inpatient care by PCP decreases mortality and increases likelihood of discharging home compared to care by hospitalists or other generalists.

Citation: Stevens JP et al. Comparison of hospital resource use and outcomes among hospitalists, primary care physicians, and other generalists. JAMA Intern Med. 2017 Dec 1;177(12):1781-7.

Dr. Mathew is assistant professor of medicine, division of hospital medicine, University of Virginia.

 

Clinical question: Are there differences in mortality and health care resource utilization in patients treated by hospitalists, primary care physicians, or other generalists?

Background: Most hospitalized patients now are being cared for by hospitalists rather than their primary care physicians (PCP). Covering generalists, who lack a prior relationship with the patient, also care for hospitalized patients when their PCP is unavailable. Although past studies have found some differences in outcomes in patients when care was provided by hospitalists vs. PCPs, those studies have grouped covering generalists with PCPs, which could affect the data.

Study design: Retrospective study.

Setting: Medicare admissions to acute care hospitals in all 50 states from January 2013 to December 2013.

Synopsis: Researchers analyzed data from 560,651 patients admitted with the 20 most common diagnoses looking for differences in health care utilization, length of stay, mortality, and discharge disposition depending on the type of provider: PCP, hospitalist, or other covering generalist. PCPs and other generalists consulted specialists more often than hospitalists. Length of stay was shorter in the hospitalist group. PCPs discharged patients to home more often than the other groups (68.5%, compared with 64% for hospitalists and 62% for other generalists). Readmission rates at 7 days were the same between hospitalists and PCPs but were higher in the other generalist group. PCPs also had lower 30-day mortality, compared with hospitalists (8.6% vs. 10.8%), while other generalists had higher mortality at 11%. Limitations include the use of administrative data and including only Medicare patients.

Bottom line: Inpatient care by PCP decreases mortality and increases likelihood of discharging home compared to care by hospitalists or other generalists.

Citation: Stevens JP et al. Comparison of hospital resource use and outcomes among hospitalists, primary care physicians, and other generalists. JAMA Intern Med. 2017 Dec 1;177(12):1781-7.

Dr. Mathew is assistant professor of medicine, division of hospital medicine, University of Virginia.

 

Clinical question: Are there differences in mortality and health care resource utilization in patients treated by hospitalists, primary care physicians, or other generalists?

Background: Most hospitalized patients now are being cared for by hospitalists rather than their primary care physicians (PCP). Covering generalists, who lack a prior relationship with the patient, also care for hospitalized patients when their PCP is unavailable. Although past studies have found some differences in outcomes in patients when care was provided by hospitalists vs. PCPs, those studies have grouped covering generalists with PCPs, which could affect the data.

Study design: Retrospective study.

Setting: Medicare admissions to acute care hospitals in all 50 states from January 2013 to December 2013.

Synopsis: Researchers analyzed data from 560,651 patients admitted with the 20 most common diagnoses looking for differences in health care utilization, length of stay, mortality, and discharge disposition depending on the type of provider: PCP, hospitalist, or other covering generalist. PCPs and other generalists consulted specialists more often than hospitalists. Length of stay was shorter in the hospitalist group. PCPs discharged patients to home more often than the other groups (68.5%, compared with 64% for hospitalists and 62% for other generalists). Readmission rates at 7 days were the same between hospitalists and PCPs but were higher in the other generalist group. PCPs also had lower 30-day mortality, compared with hospitalists (8.6% vs. 10.8%), while other generalists had higher mortality at 11%. Limitations include the use of administrative data and including only Medicare patients.

Bottom line: Inpatient care by PCP decreases mortality and increases likelihood of discharging home compared to care by hospitalists or other generalists.

Citation: Stevens JP et al. Comparison of hospital resource use and outcomes among hospitalists, primary care physicians, and other generalists. JAMA Intern Med. 2017 Dec 1;177(12):1781-7.

Dr. Mathew is assistant professor of medicine, division of hospital medicine, University of Virginia.

 

Clinical question: What is the most effective analgesic combination, opioid vs. nonopioid, for treating acute extremity pain in the emergency department?

Background: Patients often are prescribed opioids for acute pain in the ED while awaiting work-up. With the current opioid epidemic in the United States, it is important to examine the appropriate use of opioids and look for alternative medications for acute pain.

Study design: Randomized, controlled trial.

Setting: Two urban New York City emergency departments from July 2015 to August 2016.

Synopsis: 411 patients aged 21-65 years were randomized to four groups for treatment of acute extremity pain. Each received one oral analgesic combination: ibuprofen 400 mg and acetaminophen 1,000 mg; oxycodone 5 mg and acetaminophen 325 mg; hydrocodone 5 mg and acetaminophen 300 mg; or codeine 30 mg and acetaminophen 300 mg. Their pain was scored on presentation using a standard 0-10 numerical rating scale (NRS) and then at 2 hours after medication. The primary outcome was difference in NRS among groups. All patients had improvement in pain scores. Pain score improved by 4.4 in the oxycodone group, 4.3 in the ibuprofen group, 3.5 in the hydrocodone group, and 3.9 in the codeine group. There were no statistically significant differences among groups. Limitations to the study included short follow-up time, no reported data on adverse effects, and lack of uniform acetaminophen doses in each group.

Bottom line: There was no statistically significant difference in pain control among patients given a combination of acetaminophen and ibuprofen vs. three different opioids with acetaminophen when treating acute extremity pain in the ED.

Citation: Chang AK et al. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017 Nov 7;318(17):1661-7.

Dr. Mathew is assistant professor of medicine, division of hospital medicine, University of Virginia.

 

Clinical question: What is the most effective analgesic combination, opioid vs. nonopioid, for treating acute extremity pain in the emergency department?

Background: Patients often are prescribed opioids for acute pain in the ED while awaiting work-up. With the current opioid epidemic in the United States, it is important to examine the appropriate use of opioids and look for alternative medications for acute pain.

Study design: Randomized, controlled trial.

Setting: Two urban New York City emergency departments from July 2015 to August 2016.

Synopsis: 411 patients aged 21-65 years were randomized to four groups for treatment of acute extremity pain. Each received one oral analgesic combination: ibuprofen 400 mg and acetaminophen 1,000 mg; oxycodone 5 mg and acetaminophen 325 mg; hydrocodone 5 mg and acetaminophen 300 mg; or codeine 30 mg and acetaminophen 300 mg. Their pain was scored on presentation using a standard 0-10 numerical rating scale (NRS) and then at 2 hours after medication. The primary outcome was difference in NRS among groups. All patients had improvement in pain scores. Pain score improved by 4.4 in the oxycodone group, 4.3 in the ibuprofen group, 3.5 in the hydrocodone group, and 3.9 in the codeine group. There were no statistically significant differences among groups. Limitations to the study included short follow-up time, no reported data on adverse effects, and lack of uniform acetaminophen doses in each group.

Bottom line: There was no statistically significant difference in pain control among patients given a combination of acetaminophen and ibuprofen vs. three different opioids with acetaminophen when treating acute extremity pain in the ED.

Citation: Chang AK et al. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017 Nov 7;318(17):1661-7.

Dr. Mathew is assistant professor of medicine, division of hospital medicine, University of Virginia.

 

Clinical question: What is the most effective analgesic combination, opioid vs. nonopioid, for treating acute extremity pain in the emergency department?

Background: Patients often are prescribed opioids for acute pain in the ED while awaiting work-up. With the current opioid epidemic in the United States, it is important to examine the appropriate use of opioids and look for alternative medications for acute pain.

Study design: Randomized, controlled trial.

Setting: Two urban New York City emergency departments from July 2015 to August 2016.

Synopsis: 411 patients aged 21-65 years were randomized to four groups for treatment of acute extremity pain. Each received one oral analgesic combination: ibuprofen 400 mg and acetaminophen 1,000 mg; oxycodone 5 mg and acetaminophen 325 mg; hydrocodone 5 mg and acetaminophen 300 mg; or codeine 30 mg and acetaminophen 300 mg. Their pain was scored on presentation using a standard 0-10 numerical rating scale (NRS) and then at 2 hours after medication. The primary outcome was difference in NRS among groups. All patients had improvement in pain scores. Pain score improved by 4.4 in the oxycodone group, 4.3 in the ibuprofen group, 3.5 in the hydrocodone group, and 3.9 in the codeine group. There were no statistically significant differences among groups. Limitations to the study included short follow-up time, no reported data on adverse effects, and lack of uniform acetaminophen doses in each group.

Bottom line: There was no statistically significant difference in pain control among patients given a combination of acetaminophen and ibuprofen vs. three different opioids with acetaminophen when treating acute extremity pain in the ED.

Citation: Chang AK et al. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017 Nov 7;318(17):1661-7.

Dr. Mathew is assistant professor of medicine, division of hospital medicine, University of Virginia.