Weekly EBM Update 11.16.18

Welcome to the EBM Weekly Update!

This week we chose one article highlighting an important shift in the epidemiology of mortality in the United States (attached above). The second is an opinion piece that finds itself where medicine, politics, policy abut. It is a response to the recent comments of the NRA directed at the medical community, written by Dr. Ester Choo here at OHSU.


Socioeconomic Differences in the Epidemiologic Transition From Heart Disease to Cancer as the Leading Cause of Death in the United States, 2003 to 2015: An Observational Study (Annals of Internal Medicine 11/2018)

Cardiovascular disease has long been known as the number one cause of mortality amongst women and men in the United States, with cancer coming in a close second. However, epidemiological data demonstrates a change in this pattern. Improved preventative cardiology with better control of risk factors such as smoking, hypertension, hyperlipidemia, and cholesterol in addition to improved management of acute coronary syndromes has greatly impacted mortality due to cardiovascular disease. While the CDC still lists cardiovascular disease as the leading cause of death based on 2015 data, due to the improvements listed above it is estimated that cancer will be the leading cause of death in the United States by 2020. The authors of this study evaluated socioeconomic and racial/ethnic factors influencing this epidemiological change.  The results indicated that cancer became the leading cause of death in 2015 amongst Asian Americans, Hispanics, and Non-Hispanic whites, in contrast to 2003, when heart disease was the leading cause of death. This shift was not evident for American Indians/Alaska Natives or blacks. Amongst the lowest-income counties, heart disease was the leading cause of death in 2015 across all racial groups. In the highest-income counties, Cancer was the leading cause of death amongst Hispanics, Asian Americans, and Non-Hispanic whites. Mortality was decreased for all racial groups except American Indians/Alaska Natives. Mortality rates decreased most across all racial groups in the highest income quintile. Blacks in the highest-income counties had cardiovascular mortality rates similar to Non-Hispanic whites in the lowest- income counties. 

Take home: An epidemiological shift appears to be occurring with cancer becoming the predominant cause of mortality amongst the United States population compared to heart disease. However, significant racial/ethnic and socioeconomic disparities remain, particularly in blacks, who had higher overall mortality than any other group, and American Indians/Alaska Natives- the one group with increased all-cause mortality over the study period, highlighting the need for improved advocacy, healthcare, and resource allocation for these populations. 

Link to article


Dr. Esther Choo: The NRA denies the reality of gun violence. Doctors like me know it all too well. ( NBC News 11/2018)

The second piece this week is not an original research piece, but rather is an article recently written by OHSU’s Dr. Esther Choo regarding the ongoing mass-shooting crisis. This is an excellent opinion piece highlighting recent events and the role and duty that we have as physicians in striving to provide a healthy, safe, and inclusive environment to all those around us. I encourage all to take a moment to read this well written- and well thought- article. 

Link to article

WIN OF THE WEEK: OHSU DOMINATES BEND ALE TRAIL 2K18

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A determined and mighty contingent of OHSU runners made the trek to Bend over the weekend and represented us proudly in the annual Bend Ale Trail. Dr. Claire Groth and Dr. Pat Liu placed in their respective categories!!! Give your congrats to all the runners and spectators when you see them around the hospital.

Give your regards to Francis! (a theatrical review of decision making capacity)

Watch out Broadway! Last week noon report took on a theatrical tone when Dr Francis Phan shook things up and added an element of role play.

While some our acting skills presented more as comedy, the content was that of pure drama. Inspired by a particularly challenging case of a woman with fluctuating goals of care in the setting of new Hungtington’s Disease and also brain metastases, Dr Phan's incentive for this role play session was to help our residents’ comfort and fluency with difficult capacity assessments.

To help us feel prepared going into our scripted interactions, Dr Phan provided his very own DMC (decision making capacity) mnemonic: Listen with “U-Ears” (TM)

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TAKE HOMES:

1) Decision making capacity assessments are hard, having a framework to fall back on can help. Use U-EARS!

2) Reach out for help, get additional input especially with higher stakes decisions

3) Establish SDMs (surrogate decision makers) early

*reference to the classic theater hit "Give My Regards to Broadway" from the 1904 hit musical, Little Johnny Jones

WIN OF THE WEEK: ACP WINNERS

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The OHSU IM program had a great showing at ACP last night 11/8 in Salem!

Presenting over 50 posters by over 40 residents (a new record!) our program placed in the following categories:

1st place Oral Presentation: Dr. Joel Burnett, “An Unnerving Situation”

3rd place Oral Presentation: Dr. Logan Jones, “This Case is Nuts”

2nd place Clinical Vignette Poster: Dr. Tyler Wells, “HIV: A Covert Risk Factor For Coronary Artery Disease”

3rd place Clinical Vignette Poster: Dr. Matt O’Donnell, “In The I-Odine Of The Thyroid Storm”

1st place, Clinical Research: Dr. Joaquin Chapa, “Interpreting The Effectiveness Of Cancer Screening From National Population Statistics: Is It Sound Practice?”

1st place, High Value Cost Conscious Care: Dr. Kaleb Keyserling, “Call Me Maybe? Improving Utilization Of Telemedicine In A VA Resident Clinic”, OHSU

Also, Dr. Jenna Petersen was the second author on the 2nd place Student Clinical Research poster: Christian Lindner, “Incidence And Outcome Of Bacteremia During Acute Graft-Versus-Host-Disease Involving The Gastrointestinal Tract Following Hematopoietic Stem Cell Transplant”

Please join us in congratulating all of the winners and celebrating their accomplishment!

Weekly EBM Update 11.9.018

Changes in Prevalence of Health Care–Associated Infections in U.S. Hospitals (NEJM 11/2018)

Healthcare associated infections are a common cause of morbidity and mortality. Additionally, a concern exists regarding increasing antimicrobial resistance in the form of multidrug resistant (MDR) organisms. As such, a large push to minimize hospital acquired infections such as catheter associated UTI’s (CAUTI’s), central line associated bloodstream infections (CLABSI), and ventilator associated pneumonia (VAP) has been seen across the country and are often reported as hospital performance measures or quality measures. The authors of the above study conducted an observational point prevalence study to investigate changes in healthcare associated infections from 2011 to 2015. The most common pathogens found (at frequencies of 10% or greater) included Clostridioides difficile, Staphylococcus Aureus (of which 45% of isolates were MRSA), and Escherichia Coli. There was no significant change in the rate of ventilator associated or healthcare associated pneumonia (the most common healthcare associated infection), C. Difficile associated diarrhea, or CLABSI between time periods. There was a significant decrease in CAUTI’s and surgical site infections. Patients admitted in 2015 had significantly less healthcare associated infections (3.2% vs. 4.0%), and after adjustment for age, time from admission to survey, presence of devices, and status of being in a large hospital, patients in 2015 were approximately 16% less likely to have a healthcare associated infection (RR 0.84, 95% CU 0.74-0.95).

Take home: Healthcare associated infections decreased in prevalence from 2011 to 2015. There was a reduction in UTI’s and surgical site infections, likely due to improved recognition and quality improvement measures aimed at prevention of these infections. Healthcare associated pneumonia and C. difficile infections did not decrease significantly over this time period. C. difficile, E. coli, and Staph Aureus (both MSSA and MRSA) remain the most common hospital acquired pathogens.

Read the article here

Acute Clinical Care for Transgender Patients A Review (JAMA IM 11/2018)

Transgender patients often have negative experiences with healthcare providers. The review included here cites the 2015 US transgender survey, which noted that 33% of transgender responders reported at least 1 negative experience with the healthcare system, and 23% reported avoiding medical care out of fear of mistreatment. From the standpoint of the provider, clinical care directed towards the needs of transgender patients is growing, but remains a small field. This integral review touches on topics from how to address transgender patients using appropriate terminology to the benefits and risks associated with hormone gender-affirming hormone therapy. It is an easy, and essential read for all healthcare providers in order to continue providing high quality care for all of our patients.

Take home: Read this review! Or at the very least, save it somewhere it can be accessed for future reference.

Read the article here

10/12 IM Residency Council Meeting Topics

The IMRC (Internal Medicine Residency Council) spent Friday 10/12 noon conference letting the residents know who IMRC is, what they've been doing, and asked what the residents have in mind for future IMRC projects. If you have an idea for IMRC, please reach out to one of our members or email us at IMRC@ohsu.edu.

Upcoming events (see email for details):
Habitat for Humanity Build- Saturday, November 17
Inaugural Tofurky Bowl (R1/R2 vs R3)- Sunday, November 18th, 7:30 pm, see email to sign up

Current Projects:
•Creating Hospitalist track
•Scheduling transparency
•DoM Happy Hours
•Increasing volunteer events
•Inaugural Tofurky Bowl
•new IMRESPDX documents – teaching, scheduling logistics, Step 3 FAQ
•Big sib/little sib

  • new administrative and educational documents in IMRESPDX

IMRC members:

R1: Mareli Coetzer, Kelly Jensen, Alice Kehaya, Cassie Mullen, Eric Schmidt, Derrick Tao, Yoni Taylor

R2: Joel Burnett, Justin Lewis, Eddie Maldonado, Ashray Maniar, Kelsi Manley, Matt O'Donnell, Francis Phan, Namisha Thapa

R3: Ambika Bhushan, Joaquin Chapa, Kim Chesteen, Whitney Elg-Salsman, Richie Hegarty, Pat Liu, Alina Plavsky, Riana Wurzburger