Clinical Corner: Inpatient Glycemic Control

Clinical Corner

Today’s Internal Medicine Morbidity and Mortality Conference focused on a patient with type 1 diabetes who had difficulty with glycemic control during hospitalization. Here are several articles for background information:

  • Inpatient glycemic control: Best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Qaseem A, Chou R, Humphrey LL, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Am J Med Qual. 2014 Mar-Apr;29(2):95-8. PMID: 23709472. Full text (free to UCD-AMC affiliates).

 

  • Management of hyperglycemia in hospitalized patients in non-critical care setting: An Endocrine Society clinical practice guideline. Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, Seley JJ, Van den Berghe G; Endocrine Society. J Clin Endocrinol Metab. 2012 Jan;97(1):16-38. PMID: 22223765. Full text (free to UCD-AMC affiliates).

 

  • Hospital management of hyperglycemia. Lleva RR, Inzucchi SE. Curr Opin Endocrinol Diabetes Obes. 2011 Apr;18(2):110-8. PMID: 21358407. Full text (free to UCD-AMC affiliates).

 

  • Intensive insulin therapy in hospitalized patients: A systematic review. Kansagara D, Fu R, Freeman M, Wolf F, Helfand M. Ann Intern Med. 2011 Feb 15;154(4):268-82. PMID: 21320942. Full text (free to UCD-AMC affiliates).

 

Three studies were presented at the end of conference as teaching points:

  • Patient communication during handovers between emergency medicine and internal medicine residents. Fischer M, Hemphill RR, Rimler E, Marshall S, Brownfield E, Shayne P, Di Francesco L, Santen SA. J Grad Med Educ. 2012 Dec;4(4):533-7. PMID: 24294436. Free full text.

 

  • Exploring emergency physician-hospitalist handoff interactions: Development of the Handoff Communication Assessment. Apker J, Mallak LA, Applegate EB 3rd, Gibson SC, Ham JJ, Johnson NA, Street RL Jr. Ann Emerg Med. 2010 Feb;55(2):161-70. PMID: 19944486. Full text (free to UCD-AMC affiliates).

 

  • Chart biopsy: An emerging medical practice enabled by electronic health records and its impacts on emergency department-inpatient admission handoffs. Hilligoss B, Zheng K. J Am Med Inform Assoc. 2013 Mar-Apr;20(2):260-7. PMID: 22962194. Free full text.

 

Kristen DeSanto, MSLS, MS, RD, AHIP

Clinical Librarian

kristen.desanto@ucdenver.edu • 303-724-2121

Clinical Corner: Seizure/Epilepsy Videos

Clinical Corner

Cameron Ludt, DO (Neurology PGY-3) gave a presentation at Internal Medicine noon conference last Friday on epilepsy and seizure disorders. A highlight of the presentation was the showing of several videos recorded on the epilepsy monitoring unit, so that students and residents could see firsthand what different types of seizures looked like.

To see even more seizure/epilepsy videos, the Health Sciences Library subscribes to the Neurology Video Textbook (2013), by Jonathan Howard from NYU School of Medicine. Here are the steps to browse and view videos:

Neurology TOC

  • Scroll down the page to view all available videos.

Please contact me for further questions or if you have problems accessing the book.

Kristen DeSanto, MSLS, MS, RD, AHIP

Clinical Librarian

kristen.desanto@ucdenver.edu • 303-724-2121

Clinical Corner: High-Value, Cost-Conscious Care

Clinical Corner

Steven Weinberger MD, of the American College of Physicians (ACP), gave a presentation on Friday, July 31 at internal medicine conference on the topic of high-value, cost-conscious care. The ACP High Value Care initiative has two aims:

  1. Helping physicians to provide the best possible patient care.
  2. Simultaneously reducing unnecessary costs to the healthcare system.

Here are resources to learn more about this topic:


Choosing Wisely®

www.choosingwisely.org

Choosing Wisely® is an initiative of the ABIM (American Board of Internal Medicine) Foundation, which explores ways to avoid unnecessary medical interventions. The website contains recommendations from over 70 medical specialty societies and health care organizations.


ACP High Value Care

hvc.acponline.org

The ACP High Value Care site contains guidelines and clinical recommendations that address the benefits, harms, and costs of various interventions. There are also curriculum and public policy recommendations, and resources for consumers.


Ann Intern Med. 2013 Jan 1;158(1):55-9.

Design and use of performance measures to decrease low-value services and achieve cost-conscious care.

Baker DW, Qaseem A, Reynolds PP, Gardner LA, Schneider EC; American College of Physicians Performance Measurement Committee.

Abstract

Improving quality of care while decreasing the cost of health care is a national priority. The American College of Physicians recently launched its High-Value Care Initiative to help physicians and patients understand the benefits, harms, and costs of interventions and to determine whether services provide good value. Public and private payers continue to measure underuse of high-value services(for example, preventive services, medications for chronic disease),but they are now widely using performance measures to assess use of low-value interventions (such as imaging for patients with uncomplicated low back pain) and using the results for public reporting and pay-for-performance. This paper gives an overview of performance measures that target low-value services to help physicians understand the strengths and limitations of these measures, provides specific examples of measures that assess use of low-value services, and discusses how these measures can be used in clinical practice and policy.


Ann Intern Med. 2012 Aug 21;157(4):284-6.

Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine–American College of Physicians Curriculum.

Smith CD; Alliance for Academic Internal Medicine–American College of Physicians High Value; Cost-Conscious Care Curriculum Development Committee.

Abstract

Health care expenditures are projected to reach nearly 20% of the U.S. gross domestic product by 2020. Up to $765 billion of this spending has been identified as potentially avoidable; many of the avoidable costs have been attributed to unnecessary services. Postgraduate trainees have historically received little specific training in the stewardship of health care resources and minimal feedback on resource utilization and its effect on the cost of care. This article describes a new curriculum that was developed collaboratively by the Alliance for Academic Internal Medicine and the American College of Physicians to address this training gap. The curriculum introduces a simple, stepwise framework for delivering high-value care and focuses on teaching trainees to incorporate high-value, cost-conscious care principles into their clinical practice. It consists of ten 1-hour, case-based, interactive sessions designed to be flexibly incorporated into the existing conference structure of a residency training program.


Ann Intern Med. 2012 Jan 17;156(2):147-9.

Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care.

Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, LeBlond R, Moyer D, Wiese JG, Weinberger S.

Abstract

Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests-meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.


Ann Intern Med. 2011 Sep 20;155(6):386-8.

Providing high-value, cost-conscious care: a critical seventh general competency for physicians.

Weinberger SE.

Abstract

There is general agreement that the U.S. economy cannot sustain the staggering economic burden imposed by the current and projected costs of health care. Whereas governmental approaches are focused primarily on decreasing spending for medical care, it is the responsibility of the medical profession to become cost-conscious and decrease unnecessary care that does not benefit patients but represents a substantial percentage of health care costs. At present, the 6 general competencies of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) that drive residency training place relatively little emphasis on residents’ understanding of the need for stewardship of resources or for practicing in a cost-conscious fashion. Given the importance in today’s health care system, the author proposes that cost-consciousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a new, seventh general competency. This will hopefully provide the necessary impetus to change the culture of the training environment and the practice patterns of both residents and their supervising faculty.


Ann Intern Med. 2011 Feb 1;154(3):174-80.

High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions.

Owens DK, Qaseem A, Chou R, Shekelle P; Clinical Guidelines Committee of the American College of Physicians.

Abstract

Health care costs in the United States are increasing unsustainably, and further efforts to control costs are inevitable and essential. Efforts to control expenditures should focus on the value, in addition to the costs, of health care interventions. Whether an intervention provides high value depends on assessing whether its health benefits justify its costs. High-cost interventions may provide good value because they are highly beneficial; conversely, low-cost interventions may have little or no value if they provide little benefit. Thus, the challenge becomes determining how to slow the rate of increase in costs while preserving high-value, high-quality care. A first step is to decrease or eliminate care that provides no benefit and may even be harmful. A second step is to provide medical interventions that provide good value: medical benefits that are commensurate with their costs. This article discusses 3 key concepts for understanding how to assess the value of health care interventions. First, assessing the benefits, harms, and costs of an intervention is essential to understand whether it provides good value. Second, assessing the cost of an intervention should include not only the cost of the intervention itself but also any downstream costs that occur because the intervention was performed. Third, the incremental cost-effectiveness ratio estimates the additional cost required to obtain additional health benefits and provides a key measure of the value of a health care intervention.


Kristen DeSanto, MSLS, MS, RD, AHIP

Clinical Librarian

kristen.desanto@ucdenver.edu • 303-724-2121

Clinical Corner – Joanna Briggs Institute database

by Kristen DeSanto, Clinical Librarian

The Joanna Briggs Institute (JBI) database provides evidence-based resources specifically for nurses to guide patient care practices. It contains over 3000 records across seven different publication types, including evidence summaries, best practice information sheets, and systematic reviews. The records are also tagged with subject area nodes, including acute care, chronic disease, and infection control.

The Health Sciences Library subscribes to JBI through Ovid, so if you access JBI from the library website you will be taken to an Ovid search page. From there you must enter a search term before you can see a list of JBI records related to that term. If you prefer to browse a list of records by subject area node and/or publication type, there is a separate landing page that you can bookmark: http://tinyurl.com/jbi-mbpb. As you can see in the screenshot below, there are two ways you can browse a list of records:

  • Under the heading “Search JBI EBP Database” you can select one or more publication types and one or more subject area nodes from the drop-down lists, then click the search button.
  • Under the heading “Browse by Subject Area Nodes” you can click on a subject and see a list of all records tagged with that subject.

JBI EBP Resources on Ovid

If you have questions, please contact me at kristen.desanto@ucdenver.edu or 303-724-2121.

Find evidence based full text information quickly using Trip Database

Trip Database is an evidence based search filter for research articles, evidence based synopses, DynaMed (an evidence based clinical information tool), and non-evidence based image, video, and news resources. It provides an efficient first stop for searching for evidence based information.

Trip Full Text and Dynamed

Trip has enabled full text linking to the University of Colorado Anschutz Medical Campus’ journal subscriptions and to PubMed Central’s (PMC) free full text collection.

To set up full text linking, first sign up for an account (your account will facilitate full text linkage, saving searches, and convenient return to prior search topics via the timeline.)

Trip Full Text 1a

Once you have signed in, alter your profile (via the ‘Setting’ button) by selecting the “University of Colorado Anschutz Medical Campus Health Sciences Library option from the Your Institution menu.

Trip Full Text 2

Trip now offers the following resources with its one-stop searching interface:

  • DynaMed integration: Click on the DynaMed tab and you’ll see the results. Access to the actual content is only available for those with subscription access – the Health Sciences Library provides a subscription.  To utilize this resource through Trip when off-campus, go to the Clinical Tools list, click on Dynamed, and log in as prompted (use your employee or student ID.  Hospital staff should put an H in front of their 5 digit ID number).  Users may need to repeat this process if  your login times out while browsing Trip results.
  • Case Reports: Working with BioMedCentral’s Cases Database we’re really pleased to see this interesting collection added to the site.
  • Developing World Filter: Working with a slightly modified filter from a Norwegian Cochrane site we have created a specific and sensitive filter to quickly and easily find evidence suitable for low and middle income countries. This is a great tool for evidence based decision making for Global Health projects.

To see these changes, click here.

If you’d like to work with a Health Sciences Librarian to use Trip more efficiently, feel free to set up a consultation.  We’re happy to meet in your office to provide the training and consultation you need to efficiently tackle any project!

[Lynne M. Fox, Education Librarian]

Clinical Corner: High Altitude Pulmonary Edema (HAPE)

Clinical CornerWith a location like Colorado, we encounter a fair number of cases involving altitude sickness.  HAPE or High Altitude Pulmonary Edema is one of the more severe types.  How do you find the right articles when looking at the journal literature?  The closest Medical Subject Heading for this condition is Altitude Sickness.  The search “Altitude Sickness”[MeSH] retrieves at least 2740 citations in PubMed.  Synonym keywords you might include for better coverage for your search:  Altitude Sickness (2805), Altitude Sicknesses (1), Mountain Sickness (1184), Mountain Sicknesses (1) and you might have other phrases or wording that you might decide to use as well.  If you want to focus on particular type of altitude sickness you might need to use keywords and phrases like:  HAPE (329) or “high altitude pulmonary edema” (500) or “high altitude pulmonary oedema” (114).  This table gives you an idea of how including different synonym phrases can affect the quality of your search retrieval.

Description Search Strategy Results
Just the MeSH term “Altitude Sickness”[MeSH] 2740
MeSH with MeSH as keyword phrase and entry term synonyms “Altitude Sickness”[MeSH] OR “Altitude Sickness” OR “Altitude Sicknesses” OR “Mountain Sickness” OR “Mountain Sicknesses” 3044
MeSH with MeSH as keyword phrase and entry term synonyms and other identified synonyms (there could still be more) “Altitude Sickness”[MeSH] OR “Altitude Sickness” OR “Altitude Sicknesses” OR “Mountain Sickness” OR “Mountain Sicknesses” OR HAPE OR “high altitude pulmonary edema” OR “high altitude pulmonary oedema” 3274
Just keyword phrases for HAPE HAPE OR “high altitude pulmonary edema” OR “high altitude pulmonary oedema” 665

You can use PubMed’s Clinical Queries to limit any of the above searches to articles about Therapy, Etiology, Prognosis, Clinical Prediction Guides or Diagnosis with a Broad/Sensitive or Narrow/Specific focus.   I’ll use the last example with just the keyword phrases for HAPE – Therapy B 163 | N 26, Etiology B 223 | N 15, Prognosis B 72 | N 5, Clinical Prediction Guides B 137 | N 5 or Diagnosis B 172 |N 4.

If you are looking for resources that may help explain this condition to a patient, MedlinePlus has several topics that may help.

Please feel free to comment on the post or contact me if you have clinical pearls, questions or great resource suggestions that we should consider for this column in HSLNews.

John.Jones@ucdenver.edu OR 303-724-2117

Clinical Corner: Clinical Pearls & Clinical Information

Clinical CornerHere’s a quick post to introduce a new column/category of the Health Sciences Library News blog.  As we have opportunities to interact with and learn from our clinical faculty and staff, we’ll turn that information around and put it out there to our broader clinical audience.  Researchers and educators might find it of interest as well.  In general, anything that builds synergy and collaboration is probably a good thing.

We already have one posting in Clinical Corner about our new subscription to JAMAevidence, which can help you around all evidence-based medicine searching, article critiques and teaching.  Any time you want to see the postings in the Clinical Corner, all you need to do is choose the Clinical Corner category from the Categories drop down menu and there you’ll have it.

Anyway, don’t hesitate to comment on the post or contact me if you have clinical pearls, questions or great resource suggestions that we should consider for this new part of the HSLNews.

John.Jones@ucdenver.edu OR 303-724-2117