Remote Patient Monitoring | ACP

Patients with chronic medical conditions may benefit from remote patient monitoring. Learn how you can implement remote monitoring of your patients here.

ORCHA’s Assessment Process

Baseline AssessmentThe ORCHA Assessment Development Team have translated the DHAF evaluation criteria into a set of 350 objective questions that trained ORCHA Assessors are looking to answer. Questions are scored, earning the app positive points or negative points depending on the nature of the question and the response. Each Review Domain (set of questions) produces a Domain score. These Review Domain scores are then combined to create an overall DHAF percentage score.

About the Digital Health Assessment Framework (DHAF)

Seeking a common framework for assessing apps.

Library of Digital Health Apps for Patients

Are you keeping up with your patients’ interests in using digital health apps to monitor and manage chronic conditions and health? Recent surveys show 35-40% of adults use phone or tablet apps to manage their health.

Telehealthcare Guidance and Resources | Business Resources | ACP

ACP supports physicians use of telehealth to provide care to their patients from anywhere. Learn if it will work for your practice and the regulations here.

The Importance of Value Based Care

Success Story: Strategies to Reduce Inappropriate Antibiotic Prescribing

Success Story: Building a Team-based Care Approach

Internal Medicine’s Role in Practice Transformation

Engaging Patients and Families in Practice Transformations

To My Doctor on the Day of My Death

Annals Video Summary - Computer-Aided Diagnosis for Leaving Colorectal Polyps In Situ

Association Between the SaFETy Score and Self-reported Firearm Violence Among Young Adults Presenting to Emergency Departments in Three Cities: A Cross-Sectional Study

Effectiveness of Integrating Suicide Care in Primary Care: Secondary Analysis of a Stepped-Wedge, Cluster Randomized Implementation Trial: Annals of Internal Medicine: Vol 177, No 11

Background: Primary care encounters are common among patients at risk for suicide. Objective: To evaluate the effectiveness of implementing population-based suicide care (SC) in primary care for suicide attempt prevention. Design: Secondary analysis of a stepped-wedge, cluster randomized implementation trial. (ClinicalTrials.gov: NCT02675777) Setting: 19 primary care practices within a large health care system in Washington State, randomly assigned launch dates. Patients: Adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018. Intervention: Practice facilitators, electronic medical record (EMR) clinical decision support, and performance monitoring supported implementation of depression screening, suicide risk assessment, and safety planning. Measurements: Clinical practice and patient measures relied on EMR and insurance claims data to compare usual care (UC) and SC periods. Primary outcomes included documented safety planning after population-based screening and suicide risk assessment and suicide attempts or deaths (with self-harm intent) within 90 days of a visit. Mixed-effects logistic models regressed binary outcome indicators on UC versus SC, adjusted for randomization stratification and calendar time, accounting for repeated outcomes from the same site. Monthly outcome rates (percentage per 10 000 patients) were estimated by applying marginal standardization. Results: During UC, 255 789 patients made 953 402 primary care visits and 228 255 patients made 615 511 visits during the SC period. The rate of safety planning was higher in the SC group than in the UC group (38.3 vs. 32.8 per 10 000 patients; rate difference, 5.5 [95% CI, 2.3 to 8.7]). Suicide attempts within 90 days were lower in the SC group than in the UC group (4.5 vs. 6.0 per 10 000 patients; rate difference, −1.5 [CI, −2.6 to −0.4]). Limitation: Suicide care was implemented in combination with care for depression and substance use. Conclusion: Implementation of population-based SC concurrent with a substance use program resulted in a 25% reduction in the suicide attempt rate in the 90 days after primary care visits. Primary Funding Source: National Institute of Mental Health.

Shifting Trends in the Indication of Glucagon-like Peptide-1 Receptor Agonist Prescriptions: A Nationwide Analysis

WCNSF

The Effect of Denosumab on Risk for Emergently Treated Hypocalcemia by Stage of Chronic Kidney Disease: A Target Trial Emulation: Annals of Internal Medicine: Vol 178, No 1

Background: There is a paucity of data on treatment of osteoporosis in patients with advanced chronic kidney disease (CKD). Objective: To assess the risk for emergently treated hypocalcemia with denosumab by stage of CKD and presence of CKD–mineral and bone disorder (CKD-MBD). Design: Target trial emulation. Setting: Medicare fee-for-service data with prescription drug coverage, 2012 to 2020. Participants: Female patients aged 65 years or older initiating denosumab, oral bisphosphonates, or intravenous (IV) bisphosphonates for osteoporosis. Measurements: Hospital and emergency department admissions (that is, emergent care) for hypocalcemia were assessed in the first 12 treatment weeks. Inverse probability of treatment weighted cumulative incidence and weighted risk differences (RDs) were calculated. Results: A total of 361 453 patients treated with denosumab, 829 044 treated with oral bisphosphonates, and 160 413 treated with IV bisphosphonates were identified. Risk for emergently treated hypocalcemia with denosumab versus oral bisphosphonates increased with worsening CKD stage (P < 0.001), with greatest risk among dialysis-dependent (DD) patients (3.01% vs. 0.00%; RD, 3.01% [95% CI, 2.27% to 3.77%]) and non–dialysis-dependent (NDD) patients with CKD stages 4 and 5 (0.57% vs. 0.03%; RD, 0.54% [CI, 0.41% to 0.68%]). Among patients with stages 4 and 5 CKD (NDD + DD), denosumab had a greater risk for emergently treated hypocalcemia versus oral bisphosphonates in those with CKD-MBD (1.53% vs. 0.02%; RD, 1.51% [CI, 1.21% to 1.78%]) than in those without CKD-MBD (0.22% vs. 0.03%; RD, 0.19% [CI, 0.08% to 0.31%]). Denosumab also showed increased risk compared with IV bisphosphonates. Limitation: Generalizability to men and non-Medicare populations. Conclusion: Risk for emergently treated hypocalcemia with denosumab increased with worsening CKD stage and was highest in DD patients and those with CKD-MBD. Primary Funding Source: U.S. Food and Drug Administration.

Epidemiology of Homebound Population Among Beneficiaries of a Large National Medicare Advantage Plan

Background: Interest in home-based care is increasing among Medicare Advantage (MA) plans. The epidemiology of homebound MA beneficiaries is unknown. Objective: To determine the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national MA plan. Design: Cross-sectional. Setting: National MA plan. Participants: Humana MA beneficiaries in 2022 (n = 2 435 519). Measurements: Homebound status was assessed via in-home assessment using previously defined categories: homebound (never or rarely left home in the past month), semihomebound (left home with assistance, had difficulty, or needed help leaving home), and not homebound. Demographic, clinical, health service use, and mortality outcomes were compared by homebound status. Results: In 2022, the overall prevalence of homebound beneficiaries was 22.0% (8.4% of beneficiaries were homebound, and 13.6% were semihomebound). In adjusted models, female sex (odds ratio [OR], 1.36 [95% CI, 1.35 to 1.37), low-income status or dual eligibility for Medicare and Medicaid (OR, 1.56 [CI, 1.55 to 1.57]), dementia (OR, 2.36 [CI, 2.33 to 2.39]), and moderate to severe frailty (OR, 4.32 [CI, 4.19 to 4.45]) were predictive of homebound status. In multivariable logistic regression, homebound status was associated with increased odds of any emergency department visit (OR, 1.14 [ CI, 1.14 to 1.15]), any inpatient hospital admission (OR, 1.44 [CI, 1.42 to 1.46]), any skilled-nursing facility admission (OR, 2.18 [CI, 2.13 to 2.23]), and death (OR, 2.55 [CI, 2.52 to 2.58]). Limitation: The study period overlapped the tail end of the COVID-19 pandemic, and data were derived from a single national MA plan, which limits generalizability. Conclusion: Overall homebound prevalence in a national MA plan was 22.0% and was independently associated with increased health service use and mortality. Study findings can inform strategic initiatives to identify and manage care for homebound beneficiaries. Primary Funding Source: Humana, under a collaborative research agreement with Johns Hopkins University.

Benefits and Risks Associated With Statin Therapy for Primary Prevention in Old and Very Old Adults: Real-World Evidence From a Target Trial Emulation Study: Annals of Internal Medicine: Vol 177, No 6

Background: There is little consensus on using statins for primary prevention of cardiovascular diseases (CVDs) and all-cause mortality in adults aged 75 years or older due to the underrepresentation of this population in randomized controlled trials. Objective: To investigate the benefits and risks of using statins for primary prevention in old (aged 75 to 84 years) and very old (aged ≥85 years) adults. Design: Sequential target trial emulation comparing matched cohorts initiating versus not initiating statin therapy. Setting: Territory-wide public electronic medical records in Hong Kong. Participants: Persons aged 75 years or older who met indications for statin initiation from January 2008 to December 2015 were included. Participants with preexisting diagnosed CVDs at baseline, such as coronary heart disease (CHD), were excluded from the analysis. Among 69 981 eligible persons aged 75 to 84 years and 14 555 persons aged 85 years or older, 41 884 and 9457 had history of CHD equivalents (for example, diabetes) in the respective age groups. Intervention: Initiation of statin therapy. Measurements: Incidence of major CVDs (stroke, myocardial infarction, or heart failure), all-cause mortality, and major adverse events (myopathies and liver dysfunction). Results: Of 42 680 matched person-trials aged 75 to 84 years and 5390 matched person-trials aged 85 years or older (average follow-up, 5.3 years), 9676 and 1600 of them developed CVDs in each age group, respectively. Risk reduction for overall CVD incidence was found for initiating statin therapy in adults aged 75 to 84 years (5-year standardized risk reduction, 1.20% [95% CI, 0.57% to 1.82%] in the intention-to-treat [ITT] analysis; 5.00% [CI, 1.11% to 8.89%] in the per protocol [PP] analysis) and in those aged 85 years or older (ITT: 4.44% [CI, 1.40% to 7.48%]; PP: 12.50% [CI, 4.33% to 20.66%]). No significantly increased risks for myopathies and liver dysfunction were found in both age groups. Limitation: Unmeasured confounders, such as lifestyle factors of diet and physical activity, may exist. Conclusion: Reduction for CVDs after statin therapy were seen in patients aged 75 years or older without increasing risks for severe adverse effects. Of note, the benefits and safety of statin therapy were consistently found in adults aged 85 years or older. Primary Funding Source: Health Bureau, the Government of Hong Kong Special Administrative Region, China, and National Natural Science Foundation of China.

Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations: A Retrospective Cohort Study: Annals of Internal Medicine: Vol 177, No 9

Background: Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care. Objective: To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations. Design: Retrospective cohort study. Setting: Medicare. Participants: Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019. Measurements: Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes. Results: The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non–dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF. Limitation: Generalizability to other payers. Conclusion: Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF. Primary Funding Source: National Institute on Aging.

Article, podcast highlight the importance of celebrating women in medicine

New ACP paper reviews performance measures for pain management

Self-guided sleep intervention reduced sedative use, improved quality rest

MKSAP Quiz: Slow, labored gait in a patient with MS

Urinary metal levels associated with risk for cardiovascular disease

Oral drugs for acute migraines compared head to head

And the winner is …

Update your registration on National Voter Registration Day

ACP recognizes National Physician Suicide Awareness Day on Sept. 17

Poststroke patients with cognitive impairment at increased risk for recurrent stroke, death

Stroke risk may be lower than expected in patients diagnosed with AF while admitted | ACP Hospitalist

Elevated troponin level at sepsis diagnosis did not predict in-hospital mortality | ACP Hospitalist

Correction to ‘Choices in C. diff Care’ | ACP Hospitalist

Bacterial infection unlikely in almost a third who got extended-spectrum antibiotics in ED | ACP Hospitalist

Take action on anaphylaxis | ACP Hospitalist

Take a quiz about the April 9 issue! | ACP Hospitalist

Poor communication involved in almost a quarter of patient safety incidents | ACP Hospitalist

Optimal medical therapy for HFrEF associated with lower 30-day readmissions | ACP Hospitalist

Intervention reduced antibiotic overuse for skin and soft-tissue infections | ACP Hospitalist

Choices in C. diff care | ACP Hospitalist

Intercostal Retraction With Pleural Effusion | Annals of Internal Medicine: Clinical Cases

An 80-year-old man presented to our hospital with a cough for 2 weeks and a 2-day history of fever. On physical examination, a localized intercostal retraction was observed in his right lower thorax. The most intriguing point in this case is that when a localized intercostal retraction on inspiration is found, clinicians should consider pleural effusion.

Ophthalmoplegia and Tumor Lysis Syndrome: An Uncommon Presentation of Posttransplant Lymphoproliferative Disorder | Annals of Internal Medicine: Clinical Cases

A 55-year-old man presented with 1 month of fatigue, nausea, vomiting, and weight loss, and blurry vision in his left eye. He has a history of type 1 diabetes mellitus after allogenic kidney and pancreas transplantation 15 years prior. He was found to have tumor lysis syndrome (TLS), total left-sided ophthalmoplegia and ptosis, and left cavernous, abdomen, and pelvic masses. Biopsy revealed an Epstein-Barr virus–negative diffuse large B-cell lymphoma, a type of posttransplant lymphoproliferative disorder (PTLD). It is essential to consider PTLD in transplant patients who present with TLS and compressive neurologic deficits.

Cushing Syndrome Secondary to Ectopic ACTH Production in Pregnancy: A Case Report | Annals of Internal Medicine: Clinical Cases

Ectopic adrenocorticotropic hormone production is an extremely rare cause of Cushing syndrome in pregnancy and is associated with significant morbidity. A 37-year-old multiparous woman at 32 weeks’ gestation presented with hypertension, anasarca, hypokalemia, and fetal distress requiring an urgent cesarean section. Her adrenocorticotropic hormone and cortisol levels were elevated, and high-dose dexamethasone failed to suppress them, suggesting ectopic adrenocorticotropic hormone production. Multimodality imaging did not identify a source, and she had urgent bilateral adrenalectomy for refractory severe hypercortisolism. Ectopic Cushing syndrome in pregnancy requires a high index of suspicion for diagnostic testing and prompt treatment to minimize maternal and fetal complications.

Spontaneous Hemopericardium: A Lesson on Risk-Benefit Profile of Contemporary Oral Anticoagulant Therapy Prompted by an Uncommon Occurrence | Annals of Internal Medicine: Clinical Cases

Anticoagulation therapy is of paramount importance in atrial fibrillation (AF) because of the substantial risk for stroke associated with high morbidity and mortality. The current therapeutic options include vitamin K antagonists and novel oral anticoagulant agents. Despite meticulous therapy selection, the risk for bleeding remains with all forms of anticoagulation and has infrequently been reported in the form of hemopericardium. We highlight a patient case of an 84-year-old man with a history of permanent atrial fibrillation on warfarin who presented with shortness of breath and was found to have a massive hemopericardium.

Sarcomatoid Carcinoma of the Colon in a 46-Year-Old: A Rare Disease With Limited Literature | Annals of Internal Medicine: Clinical Cases

Sarcomatoid carcinoma (SCA) is an extremely aggressive, rare malignancy composed of mixed epithelial and mesenchymal components. Fewer than 10 cases of SCA of primary colonic origin have been reported in the literature. SCA has a poor prognosis. Currently, there is limited consensus regarding treatment recommendations. We review the current literature and present the case of a 46-year-old man with stage 3c sigmoid sarcomatoid carcinoma who presented with 3 months of abdominal distension, weight loss, and abdominal mass. The patient had a sigmoid colectomy with adjuvant chemotherapy and is currently alive at 8 months.

Ivermectin-Clorsulon Overdose in Attempting Coronavirus Disease 2019 Prophylaxis: A Case Report | Annals of Internal Medicine: Clinical Cases

With aims of coronavirus disease 2019 (COVID-19) prophylaxis, a 60-year-old woman ingested a formulation of ivermectin and clorsulon, intended for veterinarian use, that contained 30 times the U.S. Food and Drug Administration–approved dose of ivermectin (5.4 mg/kg). She developed altered mental status requiring intubation. Symptoms were similar to other cases of supratherapeutic ivermectin ingestion. Misinformation propagated about COVID-19 prophylaxis and treatment has led to adverse effects both from misuse of medications and disregard of proven options.

A Case of Multiple Skin Lesions After LipodissolveTM Injection | Annals of Internal Medicine: Clinical Cases

Mycobacterium abscessus (M. abscessus) is a rapidly growing nontuberculous mycobacterium commonly found in soil and water. It can cause localized infection when inoculated during surgical or cosmetic procedures. We describe a case of a patient who developed multiple skin nodules resulting from injection of LipodissolveTM for cosmetic purposes. We highlight the following points: M. abscessus can have inducible resistance to macrolides and may require novel agents for treatment; outbreaks can occur when injectables contaminated with M. abscessus are inoculated into the skin; and local health departments and the U.S. Food and Drug Administration should be contacted for outbreak investigation.

Aplasia Cutis Congenita in the Setting of Maternal Cystic Fibrosis | Annals of Internal Medicine: Clinical Cases

Aplasia cutis congenita is a rare scalp defect. An affected neonate was delivered after in utero exposure beginning in the midtrimester to elexacaftor/tezacaftor/ivacaftor for maternal cystic fibrosis management. Although aplasia cutis congenita has many potential etiologies, maternal cystic fibrosis transmembrane regulator modulator therapy has not been implicated.

Cardiogenic Shock Secondary to Giant Cell Arteritis | Annals of Internal Medicine: Clinical Cases

This paper reports a case of type 1 nonatherothrombotic myocardial infarction caused by giant cell arteritis vasculitis.

Hypoglossal Nerve Paralysis Caused by Diffuse Idiopathic Skeletal Hyperostosis | Annals of Internal Medicine: Clinical Cases

Diffuse idiopathic skeletal hyperostosis (DISH) is a rare disease characterized by bony overgrowth of the spine. If severe enough, it can lead to dysphagia from many different mechanisms. These most commonly include mechanical obstruction, inflammation, or vocal cord paralysis. In our patient case, DISH caused paralysis of the hypoglossal nerve, which contributed to his dysphagia. Paralysis of the hypoglossal nerve as a result of DISH has not yet been reported in the literature.