#165 Things We Do For No Reason™ Part 2

August 12, 2019 | By Justin Berk

A high-value care episode on unnecessary inpatient practices featuring docusate, echocardiography, and sliding scale insulin

Discover common practices that persist in the hospital wards despite no proven benefit! We review how hospitals prescribe a “crapload” of docusate which only clogs up the medication list, how unnecessary echocardiograms are ordered enough times to make your head spin, and how basal insulin needs to slide back into your inpatient diabetes management instead of correctional insulin monotherapy. Join high-value care specialist Dr. Lenny Feldman (@DocLennyF, Hopkins) and tweetorialist Dr. Tony Breu (@tony_breu, Harvard) as they walk us through round 2 of “Things We Do For No Reason™.” 

SHM members can claim CME-MOC credit at https://www.shmlearningportal.org/curbsiders (CME goes live at 0900 ET on the episode’s release date). Note: The planners and faculty for this activity have no relevant relationships or conflicts to disclose.

Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits

Written and Produced by: Justin Berk, MD MPH MBA, Matthew Watto MD

Infographic: Justin Berk MD MPH MBA

Cover Art: Matthew Watto MD

Hosts: Stuart Brigham MD, Matthew Watto MD, and Paul Williams MD  

Editor: Matthew Watto MD, Emi Okamoto MD

Guest: Lenny Feldman MD, Tony Breu MD

Sponsor

The Society of Hospital Medicine / Journal of Hospital Medicine – Things We Do For No Reason™ series. Check out all the Things We Do For No Reason™ articles here: Master Index of TWDFNR articles .

Time Stamps

• 00:00 CME-MOC announcement https://www.shmlearningportal.org/curbsiders 
• 00:50 Intro, disclaimer, guest bios
• 05:20 Guest one-liners, picks of the week
• 14:32 Things We Do for No Reason^TM (TWDFNR) defined
• 18:06 A case of syncope; definition
• 19:58 Do all patients with syncope need an echo?
• 23:30 What’s the diagnostic yield of echo for syncope?
• 29:36 Workup for new onset syncope
• 33:54 Aortic stenosis murmur
• 35:55 Docusate. Mechanism of action. Why is it so popular? What’s the harm?
• 42:08 Docusate. What does the evidence say? What should we use instead
• 50:05 A case of Sliding scale insulin (SSI); a brief history of insulin therapy and monitoring; SSI monotherapy: Risks, benefits, alternatives
• 59:30 Metformin in the hospital
• 65:35 Starting insulin in the hospital
• 68:20 Plugs- Things We Do For No Reason^TM. Become an author.
• 72:10 Outro and post-credits scene

Things We Do For No Reason^TM Pearls

Echocardiography is unnecessary in unselected, low-risk patients presenting with syncope. Avoid echo if no history of heart disease, normal EKG, and no biomarker elevation (ROMEO Criteria).

Most all patients with moderate or severe aortic stenosis will have a murmur on exam.

Docusate has no high-quality evidence in preventing or treating constipation in the inpatient setting.

Polyethylene glycol, psyllium, and lactulose should be considered for treatment of chronic constipation.

Sliding scale insulin monotherapy does not prevent hyperglycemia. Basal insulin with or without short acting insulin is recommended by the ADA guidelines (Diabetes Care 2019 section 15.6 and 15.7).

DPP4 inhibitors and GLP1 agonists can be considered during inpatient stays in select patients.

Things We Do For No Reason™ Show Notes

The History of Things We Do For No Reason™ 

Started in 2012 at SHM Annual Meeting, “Things We Do For No Reason™” was a talk that covered 3 – 4 new topics each year that covered “the low hanging fruit of high value care.”  Topics include practices that have no evidence behind them, don’t help patients, and are things we should, for the most part, get rid of. These topics have now become a regular series in the Journal of Hospital Medicine.  The goal is for learners to become more skeptical and question norms rather than accept practices without evidence.

Echocardiography in Unselected Patients with Syncope

TWDFNR Article – Echo for Syncope

Definition of Syncope

The 2017 ACC/AHA Guidelines on Syncope define syncope as a symptom that presents with abrupt and transient loss of consciousness with loss of tone and rapid recovery. Of note, the presumed mechanism is cerebral hypoperfusion.

Why do people use transthoracic echocardiography (TTE) in syncope? 

Providers are typically looking for one of two things:

1) Structural heart disease – e.g. severe aortic stenosis, hypertrophic cardiomyopathy, atrial myxoma, pericardial effusion w/ tamponade, pulmonary arterial hypertension, signs of pulmonary embolism

2) Risk factors for ventricular arrhythmias – e.g. reduced ejection fraction which predisposes for ventricular tachycardia or ventricular fibrillation. 

How many people are getting TTE? 

Dr. Breu’s expert opinion: “Anecdotally, about half.”

The articles cited in the JHM TWDFNR article suggest a range of 30-90% of unselected patients presenting with syncope receiving an echocardiogram. In 2018, a recent study used the National Inpatient Sample Database demonstrated 6.8% of inpatients with syncope receive an echocardiogram in 2014 (though this is still an increase from 5.1% in 2001). [Satish et al. 2019].

Dr. Breu’s estimate: 40 – 60% of patients with the symptom of syncope will not have an underlying cause or diagnosis. 

How often are structural lesions the cause of syncope? 

Based on the studies cited in the Journal of Hospital Medicine review, approximately 3% of patients were found to have structural lesions, with much less (likely < 1%) having new aortic stenosis. Three studies demonstrated that echocardiogram had a yield of 0% among patients with a normal exam, no known cardiac disease (eg coronary artery disease or heart failure), and normal EKG. Three other studies suggested a yield of 2%-4% for echocardiogram in this “low risk” population of patients with syncope, and of the studies reporting echo findings, none had aortic stenosis identified.

Dr. Feldman’s expert opinion: Of the times when structural diagnoses were identified, there were often signs or concerns for aortic stenosis or pericardial effusion on history, exam, or EKG.

One article from 1991: No patient with moderate or severe aortic stenosis lacked a murmur. 70 of 74 patients with mild AS had a murmur.  Though there is often discussion that patients in a low-flow state may not produce a murmur, the sensitivity of murmur is exceedingly high in advanced aortic stenosis [Aronow & Kronzon ,1991].

What is the cost of making a diagnosis using echocardiogram? 

Echocardiography for unselected patients with syncope is low yield and expensive (approximately $1,000 – $2,000 per study). A cost-analysis performed (see TWDFNR article) suggested that the charged cost would likely be $60,000-$132,000 to make one underlying diagnosis using echocardiography. This does not account for possible costs associated with length of stay that may occur while waiting for an echocardiogram or with possible incidentalomas and added confusion to clinical decision-making.

What is the work-up for new-onset syncope without risk factors? 

Dr. Breu and Dr. Feldman recommend the following: history, exam and EKG. Consider proBNP and/or troponin (looking for cardiac disease), CBC (looking for anemia), and 24-hour telemetry. The 2017 ACC/AHA guidelines recommend orthostatic vital signs, history, exam and an EKG.

Recently released European Syncope Guidelines offer criteria to help stratify low-risk versus high-risk based on symptoms. (Example: passing out while eating = higher risk). There is also a Canadian Syncope Risk Score.

In a recent 2018 study, 5 criteria could help rule out cases with significant echocardiographic findings in older adults with a 99.5% sensitivity. The “ROMEO” criteria include: 1) history of congestive heart failure, 2) history of coronary artery disease, 3) abnormal EKG, 4) abnormal troponin, 5) elevated proBNP. If no criterion is met, the likelihood of clinically significant echocardiographic findings to explain syncope is very low [Probst et al. 2018].

Docusate for Inpatient Constipation

TWDFNR Article – Docusate for Constipation

Docusate likely acts as a detergent to keep water in the stool, and the increased retention of water can theoretically act as a surfactant to help passage of stool. There is little data for this medication. Despite this, the World Health Organization included this on its Essential Medicine List and it is also highlighted by a JAMA Patient Page.

How often is docusate prescribed?

One study from McGill University showed that docusate is the most frequently prescribed laxative (64% of doses) [Lee et al. 2016]. Patients averaged approximately 10 doses per admission (across 17,000 admissions) and 50% of those patients were discharged on docusate. The estimated cost of docusate was $60,000 per year, the majority of the cost being nursing hours needed for administration. In Toronto, 15% of all hospitalized patients receive docusate [Macmillan, 2016]. One-third of all new inpatient prescriptions of docusate were continued at discharge. 

What are the harms of docusate?

The greatest risk is that the patient at risk for constipation will have more effective constipation treatment withheld. Docusate also contributes to polypharmacy. The patient may take docusate over a more important medicine at home. Additionally, it requires significant nursing and pharmacy resources to give the medication rather than do other clinically significant tasks.

What is the quality of the data?

The data in support of docusate comes from seven studies with very small sample sizes (6 of the 7 studies had sample sizes less than 100, while the largest study included 170 patients).  In the first study, the investigators excluded 19 control patients because of placebo effect (i.e. improvement from patients on placebo) –see TWDFNR article. 

What should providers be using?

There are several reviews in the last few years. For chronic constipation, the American Journal of Gastroenterology published a review with Grade A evidence for polyethylene glycol (osmotic laxative) therapy and Grade B for psyllium (hydrophilic laxative) and lactulose (osmotic laxative) [Brant, 2005]. 

Other options also include stimulant laxatives such as senna and bisacodyl. Newer medications for opioid-induced constipation (e.g. methylnaltrexone) and others for IBS-C (e.g. linaclotide) are very expensive.  Mobilization and diet modification can also offer benefit [Mayo Clinic Proceedings – Barucha & Wald 2019].

 Studies show if you stay in bed, you become constipated [Iovino et al. 2013].

There is some positive evidence for chewing gum after surgery to reduce postoperative ileus [Cochrane Review 2015].

Reader Question: Should docusate be taken off hospital formularies?

Sliding Scale Insulin as Monotherapy

TWDFNR Article – Sliding Scale Insulin Monotherapy

Definitions

Inpatient hyperglycemia is typically defined as > 140. Most guidelines recommend insulin therapy if glucose is persistently > 180. 

Sliding scale insulin (correctional insulin) is short-acting insulin administered 3 – 4 times per day in reaction to hyperglycemia. It does not prevent hyperglycemia (since it is given in response) –see TWDFNR article. 

Why is this a prevalent practice? 

Inertia. In the early 1920s, Banting and Best discovered regular insulin. Capillary blood glucose (ie fingerstick) was not available until the 1970s. In the interim, serum glucose was labor intensive so surrogate markers were used (ie Urine!). Urine was therefore checked for glucose (if glucose is in the urine, then serum glucose >180). Fehling solution (ie copper sulfate) was mixed with urine and produced different colors based on the level of glucose in the urine. Different colored urine suggested different amounts of insulin treatment needed (see image below)

(Of note, Fehling solutions cannot be used with SGLT-2 inhibitors)

Some data about sliding-scale insulin monotherapy suggests that patients get more hyperglycemia than those not receiving insulin [Queale et al. 1997].

What can we do to reduce hyperglycemia? 

The most common recommended therapy is “basal-bolus”: long-acting insulin (e.g. insulin glargine) with short-acting insulin as well (RABBIT-2 trial).

Are there some patients that should only receive sliding scale insulin? 

Yes. For those where you are worried about hypoglycemia (i.e. patients with very brittle diabetes). Total amount of insulin correlates with likelihood of hypoglycemia events. 

Should we be discontinuing oral medications for inpatient patients with diabetes? 

There are some non-insulin therapies that have been tested in the hospital setting. Diabetes Care 2018 Guidelines: Once patient is stable, consider restarting oral medications (e.g. metformin, DPP4 inhibitors, etc).

Update: Since release of this episode the more recent 2019 Diabetes Care in the Hospital guidelines have been released.

Dr. Breu’s expert opinion: We hold metformin in the hospital too often. There is no reason to hold it if no acute kidney injury.  (If a patient has AKI, they would then have to accumulate metformin to have concern for metabolic lactic acidosis). Metformin can save significant insulin and help maintain euglycemia. 

One recent study in outpatients on metformin with low eGFR showed very low risk for lactic acidosis unless eGFR < 30 [Lazarus et al. 2018].

DPP4 inhibitors (sitagliptin) have been shown to safely help reduce insulin in the inpatient setting [Pasquel et al. 2017] as have GLP1 agonists (exenatide) [Fayfman et al. 2019]. DPP4i should not be given to patients with heart failure and GLP1a can cause some GI distress. 

There is good data to use basal insulin with correctional insulin [Umpierrez, 2013]. Consider this strategy if the patient is not eating consistently or if concern for hypoglycemia complications exists.

How much insulin should start? 

Dr. Breu expert opinion: For ease, start on 10 units basal insulin with correctional insulin.

Dr. Feldman expert opinion: Start with 0.3 – 0.5 units per kilogram to calculate Total Daily Insulin Dose (TDI), based on gestalt of insulin resistance and kidney function. This TDI can be split as basal and preprandial.

Goals

Listeners will identify three common practices that are commonly performed despite a lack of clinical evidence and understand the principles of high value care in clinical decision making processes.

Learning objectives

After listening to this episode listeners will…  

1. Identify which patients may benefit from transthoracic echocardiography when presenting with syncope
2. Acknowledge the lack of benefit from docusate and the superiority of other medical treatments for constipation
3. Determine appropriate insulin initiation for patients with diabetes and recognize the inferiority of sliding scale insulin monotherapy.
4. Continue to critically approach common medical practices that occur in hospital medicine.

Links*

1. Stranger Things (Netflix Series)
2. Revisionist History (Podcast) by Malcom Gladwell
3. Find Shadowing project: https://findshadowing.com/ by Ryan Gray MD- sign up!
4. Knowledge Project podcast by Shane Parrish with guest Jonathan Haidt
5. The Wrong Guy (film)
6. Baby 411 (book) by Dr. Ari Brown
7. Master Index with all the Choosing Wisely / TWDFNR articles 
8. Bharucha AE, Wald A. Chronic Constipation. Mayo Clinic Proc 2019

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

References

1. Madeira et al. Things We Do For No Reason: Echocardiogram in Unselected Patients with Syncope. J Hosp Medicine. 2017. [https://www.ncbi.nlm.nih.gov/pubmed/?term=29073313]
2. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the ACC/AHA Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017. [https://www.ncbi.nlm.nih.gov/pubmed/28286247]
3. Satish et al. Trends in use of echocardiography in hospitalized patients with syncope. Echocardiography. 2019.  [https://www.ncbi.nlm.nih.gov/pubmed/30479042]
4. Aronow WS et al. Prevalence and severity of valvular aortic stenosis determined by Doppler echocardiography and its association with echocardiographic and electrocardiographic left ventricular hypertrophy and physical signs of aortic stenosis in elderly patients. Am J Cardiol. 1991. [https://www.ncbi.nlm.nih.gov/pubmed/1826070]
5. Probst MA et al. Predictors of Clinically Significant Echocardiography Findings in Older Adults with Syncope: A Secondary Analysis. J Hosp Med. 2018. [https://www.ncbi.nlm.nih.gov/pubmed/30255862]
6. Fakheri RJ et al. Things We Do for No Reason: Prescribing Docusate for Constipation in Hospitalized Adults. J Hosp Med. 2019. [https://www.ncbi.nlm.nih.gov/pubmed/?term=30785419]
7. Lee TC et al. Pattern of Inpatient Laxative Use: Waste Not, Want Not. JAMA Internal Med. 2016. [https://www.ncbi.nlm.nih.gov/pubmed/27323235]
8. MacMillan TE et al. Missed opportunity to deprescribe: docusate for constipation in medical inpatients. Am J Med. 2016  [https://www.ncbi.nlm.nih.gov/pubmed/27154771]
9. Brandt et al. Systematic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005. [https://www.ncbi.nlm.nih.gov/pubmed/16008641]
10. Bharucha AE and Wald A. Chronic Constipation. Mayo Clin Proc. 2019. [https://www.ncbi.nlm.nih.gov/pubmed/31054770]
11. Iovono P et all. New Onset of Constipation during Long-Term Physical Inactivity: A Proof-of-Concept Study on the Immobility-Induced Bowel Changes. PLoS One. 2013. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748072/]
12. Bragg D et al. Chewing gum after surgery to help recovery of the digestive system. Clin Nutr. 2015. [https://www.ncbi.nlm.nih.gov/pubmed/?term=25819420]
13. Ambrus D and OConnor M. Things We Do For No Reason: Sliding-Scale Insulin as Monotherapy for Glycemic Control in Hospitalized Patients. J Hosp Med. 2019. [https://www.ncbi.nlm.nih.gov/pubmed/?term=30534639]
14. Queale et al. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med. 1997. [https://www.ncbi.nlm.nih.gov/pubmed/9066459]
15. Umpierrez GE et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007. [https://www.ncbi.nlm.nih.gov/pubmed/17513708] (RABBIT-2 trial)
16. American Diabetes Association. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018. [https://www.ncbi.nlm.nih.gov/pubmed/?term=29222385]
17. Lazarus et al. Association of Metformin Use With Risk of Lactic Acidosis Across the Range of Kidney Function: A Community-Based Cohort Study. JAMA Int Med. 2018. [https://www.ncbi.nlm.nih.gov/pubmed/29868840]
18. Pasquel et al. Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label, non-inferiority randomised trial. Lancet Diabetes Endocrinol. 2017. [https://www.ncbi.nlm.nih.gov/pubmed/27964837] 
19. Fayfmen et al. A Randomized Controlled Trial on the Safety and Efficacy of Exenatide Therapy for the Inpatient Management of General Medicine and Surgery Patients With Type 2 Diabetes. Diabetes Care. 2019. [https://www.ncbi.nlm.nih.gov/pubmed/30679302]
20. Umpierrez GE  et al. Randomized study comparing a Basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013. [https://www.ncbi.nlm.nih.gov/pubmed/?term=23435159]

Disclosures

Drs. Breu and Feldman report no relevant financial disclosures. The Curbsiders (Drs. Watto, Williams, Brigham and Berk) report no relevant financial disclosures. 

Citation

Feldman L, Breu T, Berk JL, Williams PW, Brigham SK, Watto MF. “#165 Things We Do For No Reason™Part 2”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list August 12, 2019.