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FOR THE PRESS

3 February 2009 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656, or visit www.annals.org. Past highlights are accessible as well.

1. A Comprehensive Approach to Hospital Discharge Can Reduce Re-hospitalization

One in five hospitalizations is complicated by a post-discharge event. Some of these events result in preventable ER visits or re-hospitalization. Despite this statistic, hospital discharge procedures have not been standardized. Researchers followed 749 hospitalized adults over 30 days to test the effects of an intervention designed to minimize hospital utilization after discharge. Approximately half of the patients received normal care, while the other half worked with a nurse discharge advocate. The nurse worked with the patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education. A clinical pharmacist called the patients soon after discharge to reinforce the discharge plan and review medications. The intervention resulted in a 30 percent reduction in hospital utilization, improved patient self-perceived preparation for discharge, and increased primary care physician follow up, even among participants who frequently used hospital services.

2. Not All Immunochemical Fecal Occult Blood Tests Equally Effective at Detecting Colorectal Cancer

Stool tests are less invasive and less expensive than colonoscopy for colorectal cancer screening. The traditional fecal occult blood test (FOBT) uses a chemical reaction on a paper card to find traces of blood that leak from pre-cancerous growths and cancer into the stool. While effective, these types of FOBTs have some limitations such as a high rate of false-positives. The new qualitative immunochemical FOBTs use specific antibodies against human blood components to detect traces of blood in the stool, and may yield fewer false-positive and false-negative results. To determine if efficacy was similar among the various qualitative immunochemical FOBTs, researchers compared screening results for six different tests against findings at colonoscopy. A large difference in diagnostic performance was found between tests. Sensitivity for detecting advanced adenomas ranged from 25 percent to 72 percent, and specificity ranged 70 percent and 97.

3. Study Supports U.S. Policy to Allocate Livers to Sickest Patients

In traditional practice, liver transplants are given to the sickest patients. However, some have proposed that outcomes might be better for patients if transplants were performed at earlier stages of chronic liver disease. Researchers randomly assigned 120 patients with Child-Pugh stage B alcoholic cirrhosis to either immediate listing for liver transplantation or standard medical care. The study showed that immediate listing for liver transplantation was not associated with improved patient survival. In addition, patients who received a liver transplant had an unexpectedly high rate of extrahepatic cancer. Patients who continued to consumer alcohol had a poor result regardless of treatment. Researchers concluded that immediate listing for transplantation is not a better strategy for patients with Child-Pugh stage B cirrhosis, especially when alcohol withdrawal is associated with recovery of liver function. The best strategy would be to consider liver transplantation on the basis of patient outcome and to actively screen patients for extrahepatic cancer before and after liver transplantation.

4. USPSTF Updates Skin Cancer Screening Recommendations: No New Evidence to Suggest Whole-body Examination Should Be Standard of Care

The U.S. Preventive Services Task Force (USPSTF) reviewed published studies about the accuracy of total-body skin examinations by primary care doctors. They also looked at the benefits of screening by doctors or by self-examination. The researchers found that primary care physicians are moderately accurate in diagnosing melanoma when presented with images of skin abnormalities. However, there was not enough evidence to assess the accuracy of real-life total-body skin examinations by doctors or patients themselves. The researchers conclude that there is not enough information to weigh the benefits and harms of using routine whole-body skin examination by a primary care physician or patient self-examination for the early detection of skin cancer in adults. Doctors and patients should consider the individual patientís risk factors and preferences when deciding whether to make total-body skin examination a regular part of preventive care.


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