Bottom line: Among Medicare patients hospitalized for heart failure, AMI, or pneumonia, 30-day readmissions were frequent throughout the entire period, and readmission diagnoses or timing did not vary by patient age, sex, or race.
Citation: Dharmarajan K, Hsich AF, Lin Z, et al. Diagnosis and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
Workload Might Impact Patient Safety and Quality of Care
Clinical question: Do hospitalists’ workloads affect patient quality of care and safety?
Background: Preventable medical errors contribute to a large number of patient deaths each year. It is unclear if a hospitalist’s clinical workload affects rates of medical errors or patient harm.
Study design: Cross-sectional cohort study.
Setting: Hospitalists enrolled in online physician community QuantiaMD.com.
Synopsis: There has been limited research evaluating the correlation between physician workload and patient safety. An online survey compared the responses of 506 out of 890 enrolled physicians on the impact of average patient census and several outcome measures of quality of care. Some 40% reported that their patient census exceeded their personal safe workload at least once a month. They also reported that less time for patient evaluations led to fewer discussions with patients and family members, more unnecessary medical work-ups, and lower patient satisfaction.
A limitation of this study is that this electronic survey had the potential for selection bias. It also only measured perceptions of safety and quality, and only used standard daytime shifts (excluding night, cross-cover, weekend, and holiday shifts), which might have been associated with significantly different conclusions.
Bottom line: Increase in workload has a negative perceived impact on patient safety and quality of care for attending hospitalists.
Citation: Michtalik HJ, Yeh HC, Pronovost P, et. al. Impact of attending physician workload on patient care: a survey of hospitalists. JAMA Intern Med. 2013;173(5):375-377.
Permanent Atrial Fibrillation Best Controlled by Diltiazem
Clinical question: Is there a difference between beta-blockers and calcium channel blockers for ventricular rate control and arrhythmia-related symptoms in patients with permanent atrial fibrillation?
Background: Rate control with beta-blockers or calcium channel blockers is recommended for the initial therapy of atrial fibrillation. However, studies comparing those drug classes or drugs within them are lacking.
Study design: Prospective, randomized, investigator-blind crossover study.
Setting: Majority of patients from an atrial fibrillation outpatient clinic at Baerum Hospital in Norway.
Synopsis: The RATe Control in Atrial Fibrillation (RATAF) study included 60 participants with permanent atrial fibrillation. The goal of the study was to compare the efficacy of diltiazem at 360 mg/day, verapamil at 240 mg/day, metoprolol at 100 mg/day, and carvedilol at 25mg/day on ventricular heart rate and related symptoms in atrial fibrillation. Patients had a mean age of 71, atrial fibrillation for more than three months, and mean heart rate of 96 beats/minute. Exclusion criteria included the presence of congestive heart failure or ischemic heart disease with the need for other medications that could compromise the study.
From this study, diltiazem was shown to have the greatest effect in lowering heart rate, and those patients taking this medication had decreased symptoms related to atrial fibrillation. Hospitalists should not rely solely on this study for their treatment choice in all atrial fibrillation patients, but in certain populations, they should consider diltiazem as their first-line drug.
Bottom line: Diltiazem was shown to have the greatest reduction in heart rate and symptoms related to permanent atrial fibrillation.
Citation: Ulimoen SR, Enger S, Carlson J, et al. Comparison of four single-drug regimens on ventricular rate and arrhythmia-related symptoms in patients with permanent atrial fibrillation. Am J Cardiol. 2013:111(2):225-230.