Nearly two-thirds of low-risk pulmonary embolism patients are hospitalized after ED visit

Embargoed for release until 5:00 p.m. ET on Monday 29 January 2024  
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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.  
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1. Nearly two-thirds of low-risk pulmonary embolism patients are hospitalized after ED visit

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2442

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An analysis of more than 1.6 million emergency department (ED) visits for acute pulmonary embolism (PE) found that nearly two-thirds of ED visits still resulted in hospitalization for low-risk patients. This trend remained stable between 2012 and 2020, despite research indicating the safety of outpatient management. The analysis is published in Annals of Internal Medicine.

PE is a leading cause of cardiovascular mortality, and its clinical management among patients with more severe presentations often requires inpatient hospitalization for intravenous anticoagulation or other advanced therapies. However, in recent years, it has become increasingly clear that outpatient management for some low-risk patients with acute PE is a safe and feasible approach.

Researchers from Harvard Medical School and Beth Israel Deaconess Medical Center studied data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for 1,635,300 patient visits to evaluate whether the proportion of discharges from EDs for acute PE changed between 2012 and 2020 and which baseline characteristics were associated with ED discharge. The authors found that discharge rates remained constant over time. The authors could not identify any baseline characteristics related to an increased likelihood for discharge, including established risk stratification scores used to identify low risk patients. However, patients at teaching hospitals and those with private insurance were more likely to receive oral anticoagulation at discharge. According to the authors, these findings suggest that outpatient management of acute PE remains underutilized despite clinical evidence and guideline recommendations. They suggest further investigation of the root causes of ED triage decisions and dedicated interventions to improve appropriate use of outpatient management, such as dedicated post-discharge clinics.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Eric A. Secemsky, MD, MSc, please contact esecemsk@bidmc.harvard.edu.

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2. Measuring eGFR based on cystatin C levels may be a more accurate assessment of kidney function in older adults

Abstract: https://www.acpjournals.org/doi/10.7326/M23-1138        

Editorial : https://www.acpjournals.org/doi/10.7326/M24-0111        

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A study of more than 82,000 older adults receiving outpatient measurements of estimated glomerular filtration rate (eGFR) found that measuring eGFR based on creatinine and cystatin C levels (eGFRcr-cys) was more strongly associated with adverse outcomes than measuring eGFR with only creatinine levels (eGFRcr). The study is published in Annals of Internal Medicine.

Current guidelines define a GFR below 60 ml/min/1.73 m² for 3 months as chronic kidney disease, even in the absence of albuminuria.  eGFRcr is usually used in routine practice, rather than measured GFR to define and stage chronic kidney disease. An eGFRcr below 60 mL/min/1.73 m² is usually associated with adverse outcomes including kidney failure and all-cause mortality. However, this threshold is more common in older adults than in younger adults and less strongly associated with adverse outcomes in this population. This has created disagreement about the appropriateness of the threshold for these persons.

Researchers from Leiden University Medical Center, Karolinska Institute, Brigham and Women’s Hospital and Harvard Medical School, Tufts Medical Center and Tufts University School of Medicine, and New York University Grossman School of Medicine studied data from a Swedish cohort at or above age 65 years with simultaneous measurements of creatinine and cystatin C to evaluate associations in older adults between eGFRcr versus eGFRcr-cys and 8 outcomes. The authors found that eGFRcr-cys below 60 mL/min/1.73 m² had stronger associations with clinical outcomes including all-cause mortality, cardiovascular mortality, hospitalization, infection, stroke, heart failure, kidney failure with replacement therapy, and acute kidney injury than eGFRcr, even in the absence of albuminuria. The weaker associations with eGFRcr are likely explained because of limitations of creatinine as a filtration marker rather than the GFR threshold, since eGFRcr-cys is a more accurate reflection of measured GFR than eGFRcr. They note that these data indicate that CKD stage G3+ (GFR <60 mL/min/1.73 m²) at older age is associated with a wider range of outcomes than previously recognized. These data support the current GFR threshold of below 60 ml/min/1.73 m² for defining chronic kidney disease. While several clinical guidelines for evaluating and managing chronic kidney disease recommend measuring cystatin C, this practice is limited in most countries. The authors suggest that the broad range of risks associated with chronic kidney disease at older age is better appreciated when cystatin C is included in GFR estimation.

The authors of an accompanying editorial from the Cleveland Clinic Health System say the study demonstrates that creatinine and cystatin C have limitations as biomarkers and may lead to errors in estimation of measured GFR. Both biomarkers have non-GFR determinants that may detect pathophysiology unrelated to kidney function but associated with poor health outcomes. This may explain why eGFRcr and eGFRcr-cys have different associations with clinical outcomes.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Shoshana H. Ballew, PhD, please contact Gregory Williams at Gregory.Williams@nyulangone.org.

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3. Empathetic care from practitioners associated with better patient satisfaction

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2168        

URL goes live when the embargo lifts   

A review of 14 studies found that empathetic care is associated with improved patient satisfaction, a metric linked to important implications for patient outcomes. However, strong conclusions were limited by quality and applicability of evidence. The review is published in Annals of Internal Medicine.

Increased patient satisfaction is associated with improved survival after myocardial infarction; reduced hospital readmission; higher general quality of care; better patient safety; and other outcomes. It has also been reported to improve medication adherence. Hospital reimbursement is also often linked to patient satisfaction scores. Research on health care practitioner empathy—which is commonly taken to involve understanding, expressing understanding, and therapeutic action—may provide important insights for improving the metric of patient satisfaction.

Researchers from the University of Leicester reviewed 14 published randomized trials comprised of 80 health care practitioners and 1,986 patients across several locations, settings, and practitioner types to evaluate the effect of empathy on patient satisfaction. Based on all the studies reviewed, practitioner empathy was associated with a positive change in patient satisfaction; however, inadequate reporting hindered the ability to draw definitive conclusions about the precise effect size. The authors caution clinicians and policymakers against over measuring patient satisfaction when implementing this evidence as it may adversely affect practitioner well-being. They advise that future research should address barriers to implementation through better measurement and better reporting.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Jeremy Howick, PhD, please contact jh815@leicester.ac.uk.

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4. Review reveals potential uses and pitfalls for generative AI in the medical setting

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2772         

URL goes live when the embargo lifts   

A narrative review from authors at Stanford University provides important insights for clinicians considering using large language models (LLMs) like ChatGPT in their routine practice, including suggestions for usage and potential pitfalls with mitigation strategies. The review is published in Annals of Internal Medicine.

LLMs are AI models trained on vast text data to generate humanlike outputs and have been applied to various tasks in health care, such as answering medical examination questions, generating clinical reports, and taking notes. As these models gain traction, health care practitioners must learn their potential applications and the associated pitfalls of using them in a medical setting.

According to the review, LLMs can be used for administrative tasks, like summarizing medical notes and aiding documentation; tasks related to augmenting knowledge, like answering diagnostic questions and questions about medical management; tasks related to education, including writing recommendation letters and student-level text summaries; and tasks related to research including generating research ideas and writing drafts for grants. However, users should be cautious of potential pitfalls, including a lack of HIPAA adherence, inherent biases, lack of personalization, and possible ethical concerns related to text generation. To mitigate these risks, the authors suggest checks and balances that include always having a human being in the loop and using AI tools to augment work tasks rather than replace them. According to the authors, physicians and other health care professionals must weigh potential opportunities with these existing limitations as they seek to incorporate LLMs into their practice of medicine.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Roxana Daneshjou, MD, PhD, please contact roxanad@stanford.edu

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