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News From The Annals Of Internal Medicine: March 5, 2013

A special supplement on patient safety strategies will be published with the March 5 issue. In addition to the 10 articles included in the supplement, Annals of Internal Medicine also will publish a special five-page graphic narrative on the topic of medical errors.

1. Screening with Colonoscopy May Reduce Risk for Late-stage Cancer By 70 Percent

Screening with sigmoidoscopy yields similar results in cancer of the left colon, but not the right

Using colonoscopy to screen average-risk adults for colorectal cancer (CRC) reduces the risk for diagnosis of late-stage CRC by about 70 percent for both the right- and left-sided disease. Previous trials and observational studies have shown that screening with fecal occult blood tests (FOBT) and sigmoidoscopy reduce the risk for CRC incidence and death, but evidence of the effectiveness of screening colonoscopy has been limited. Researchers reviewed health records for 1,012 average-risk adults between the ages of 55 and 85 to examine the association between screening colonoscopy and incident late-state CRC risk. Case patients (n = 474), or those with advanced CRC at the time of diagnosis, were compared to 538 control patients. Those screened with colonoscopy had a significant overall reduction in the risk for late-stage colorectal cancer diagnosis. The authors simultaneously examined the association between screening sigmoidoscopy and late-state CRC risk. They found that screening sigmoidoscopy was associated with a reduction in risk similar to that of colonoscopy for left-sided late-stage CRC, but showed a modest, statistically nonsignificant effect on risk for right-sided colon cancer, which accounts for about 50 percent of new CRC cases in the United States. Link to this article: http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-5-201303050-00001.

2. Mailings Linked to Electronic Health Records Double Colorectal Cancer Screening Adherence Rates

Sending automated mailings linked to electronic health records (EHR) led to twice as many persons adhering to colorectal cancer (CRC) screening recommendations compared to usual care. CRC is the second leading cause of cancer death in the United States. Screening has been proven to reduce morbidity and mortality, but fewer than 60 percent of Americans aged 50 (the recommended age range for screening) report being current for screening. According to the authors, interventions to increase adherence to recommendations for CRC screening are needed. The researchers sought to determine if interventions using EHR, automated mailings, and stepped increases in support could improve CRC screening adherence over two years. They randomly assigned 4,675 adult Group Health patients aged 50 to 73 years who were not current on CRC screening to one of four interventions: usual care; EHR-linked mailings that included a letter, a pamphlet, and a fecal occult blood testing kit (“automated”); automated plus telephone assistance (“assisted”), or automated and assisted plus nurse navigation to testing completion or refusal (“navigated”). These same interventions were repeated in year two. Compared with usual care, patients in the automated group, where letters, pamphlets, and fecal occult blood tests were mailed, completed recommended screening twice as often, for less cost. Patients in the assisted and navigated groups had additional but smaller incremental improvements in adherence. Link to this article: http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-5-201303050-00002.

3. Atrial Fibrillation Associated with Higher Risk for Cognitive Impairment, Dementia

Atrial fibrillation is associated with a higher risk for cognitive impairment and dementia, with or without stroke. AF is the most common arrhythmia in the United States, affecting more than 2.7 million Americans in 2010. Three known risk factors for AF – heart failure, diabetes, and hypertension – are also risk factors for cognitive impairment. Mild cognitive impairment may affect long-term memory, but does not adversely affect daily living. However, dementia is associated with memory and other cognitive impairments that may have a substantial impact on patients, families, and the health care system. For this reason, finding and addressing major risk factors is imperative. Researchers reviewed 21 published studies to assess the association between AF and cognitive impairment. The studies revealed a strong association between AF and cognitive impairment or dementia independent of stroke. The authors suggest that these findings should inspire future research that carefully distinguishes types of dementia. Investigators also should consider cognitive function as a new outcome to be assessed in studies about treatments for AF. Link to this article: http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-5-201303050-00007.

*Special Section/Supplement

4. Comics Offer an Innovative Way to Enhance Medical Training

Comics, or graphic narratives, may be an effective way to share important medical experiences with physicians in training. The graphic narrative, “Missed It” is being published in Annals of Internal Medicine to illustrate how creative learning tools can enhance medical training by adding an emotional and visual component. “Missed It” tells the story of a medical resident dealing with a seemingly routine case of COPD in the emergency room. The five-page story unfolds in a dramatic and emotionally compelling fashion. According to the author, graphic narratives are not always silly or frivolous, as some may say. They can be used to tell incredibly moving stories about serious topics. Link to this article: http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-5-201303050-00013.

5. Special Supplement Focuses on Top 10 Strategies to Improve Patient Safety Now

Between 44,000 and 80,000 patients die each year in the United states from diagnostic errors. Another 68,000 patients die of bed sores, and many thousands of patients die from teamwork and communication errors or failure to receive evidence-based interventions. Patient safety is a significant public health issue that requires strategic intervention. In 2000, the Agency for Healthcare Research and Quality (AHRQ) commissioned a report analyzing and rating nearly 80 different patient safety strategies (PSSs). Since the report was issued, clinicians, researchers, and policymakers gained a greater understanding of the epidemiology of errors and preventable harms. The burden is larger than previously thought. In a major effort to help health care systems protect the safety of patients, the AHRQ developed a report identifying the top 10 patient safety strategies ready for immediate use. If widely implemented, these 10 strategies have the potential to vastly improve patient safety and save lives, according to the report. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices assess the evidence for 41 patient safety strategies and strongly encourages that 10 be adopted now. The strategies can help prevent harmful events such as medication errors, bed sores, and healthcare-associated infections. Ten of the 41 strategies are being published in a special supplement to Annals of Internal Medicine at http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-5-201303050-00010.


American College of Physicians