Established in 1927 by the American College of Physicians


18 January 2011 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in the January 18 issue of Annals of Internal Medicine, including two early release articles. The information is not intended to substitute for the full articles as sources of information. Attached is an embargoed PDF of the full Annals table of contents. All information regarding highlighted articles and those in the TOC are under strict embargo until 5:00 p.m. on Monday, January 17. Annals of Internal Medicine attribution is required for all coverage. For an embargoed copy of a study, contact Angela Collom at or 215-351-2653.

1. Storytelling May Help African Americans Control Blood Pressure

Controlling blood pressure is difficult because it requires strict adherence to a treatment plan that may include medication, dietary restrictions, and regular doctor visits. Social and cultural barriers may contribute to African American patients being far more likely than white patients to suffer from uncontrolled high blood pressure and resulting complications. While the medical community recognizes and has tried to bridge the racial gap in blood pressure control, there still is a lack of culturally relevant treatment interventions for minority patients. Emerging evidence suggests that storytelling may offer a unique opportunity to communicate evidence-based disease management choices in a culturally appropriate context. Researchers randomly assigned 299 African American patients with hypertension to receive either usual care or to view three videos that presented stories of real patients with hypertension. Among patients who had uncontrolled hypertension, those assigned to view the stories had better blood pressure control than those assigned to usual care.

2. For Heart Patients, High-volume Hospitals Provide Better Outcomes at Higher Cost

Congestive heart failure (CHF) is the most common reason for hospitalization among Medicare patients, but patient outcomes are consistently poor. One in 10 patients dies in the first 30 days after hospitalization. Of those who survive, one in four is readmitted to the hospital. The high clinical and financial burden of CHF has led to intense interest in both improving outcomes and decreasing the costs of care. Studies have shown that high patient volume results in better outcomes. But no previous studies have examined the effect of volume on costs. Researchers reviewed administrative data for 4,095 U.S. hospitals between 2006 and 2007 to examine the relationship between CHF patient volume with performance of the hospital in terms of CHF processes, outcomes (mortality and readmission), and costs of care. The researchers hypothesized that high-volume hospitals would have higher adherence to quality process measures, lower mortality and readmission rates, and lower costs of care, independent of other factors, such as the size of hospital or its teaching status. The researchers found that patients discharged from hospitals with higher CHF patient volume (high volume = 200 - 400 CHF cases) had an approximately 18 percent lower chance of dying than those discharged from lower-volume hospitals. However, patient costs were about $400 higher per hospitalization.

3. Advance Directive Laws May Unintentionally Compromise Clinical Care

Advance directive laws were created to protect patientsí rights to decline life-sustaining treatments. Physicians often use advance directives in conjunction with other forms of verbal or written communication of patientsí wishes to determine clinical care. In contrast, advance directive law takes a strict, legal-transactional approach, which may inadvertently compromise patient care. Researchers reviewed advance directive legal statutes for all 50 states and Washington, D.C. In addition, they reviewed 20 articles and 105 legal proceedings to identify unintended legal consequences that may prevent patients from communicating end-of-life preferences. The researchers found that advance directive legal restrictions have five issues that threaten their usefulness, especially to patients with low literacy levels. These are: using legal language that is difficult to understand; restricting patient choices regarding health surrogates; requiring multiple steps to make execution legal; having varying laws by state; and not taking into account religions, cultural, or social factors. The researchers recommend changes that would improve readability, allow oral advance directives, and eliminate witness or notary requirements.

Early Releases:

4. USPSTF Recommends Routine Osteoporosis Screening for All Women Over Age 65*

In an update to its 2002 recommendation, the U.S. Preventive Services Task Force (USPSTF) now recommends that all women ages 65 and older be routinely screened for osteoporosis. Younger women with increased risk factors for osteoporosis should be screened if their fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. White women are used as the benchmark because they have a markedly higher rate of osteoporosis and fractures than other ethnic groups. Other risk factors for osteoporosis include tobacco use, alcohol use, low body mass and parental history of fractures. The USPSTF did not indicate a specific age limit at which screening should no longer be offered because the risk for fractures continues to increase with age. The USPSTF found insufficient evidence to make a recommendation for screening men at this time.

* This is the first final recommendation statement to be published since the USPSTF implemented a new process in July 2010 in which all of its draft recommendation statements are posted for public comment on the USPSTF website prior to being issued in final form. The draft recommendation statement on screening for osteoporosis was posted for public comment from July 6 to August 3, 2010.

5. Evidence Supports Potential Use of Neurothrombectomy Devices for Treatment of Acute Ischemic Stroke

Stroke is the third leading cause of death in the United States, with most classified as ischemic in nature. Currently, approved pharmacologic treatments, including intravenous thrombolysis, have limited efficacy in treating patients with ischemic stroke. Neurothrombectomy devices are an emerging technology for the treatment of ischemic stroke. Currently, there are two devices approved by the FDA for patient use. These devices may offer advantages over pharmacologic agents, including more rapid achievement of recanalization, enhanced efficacy in treating large-vessel occlusions, and a potentially lower risk of hemorrhaging. Researchers reviewed 87 published articles to determine if evidence supports the use of neurothrombectomy devices in the treatment of acute ischemic stroke. While uncontrolled studies and case series suggest that neurothrombectomy devices hold promise as stroke therapy, further research is needed to determine their benefit over other treatment strategies, the relative risks and benefits of specific devices, and the types of patients most likely to benefit from its use.