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Better Reporting Needed to Accurately Estimate Medical Error as Cause of Death in U.S.
Clinical question: What is the contribution of hospital-based medical errors to national mortality in the U.S. compared to other causes listed by the Centers for Disease Control and Prevention (CDC)?
Background: Medical error can contribute to patient mortality. Currently, the annual list of the most common causes of death in the U.S. is compiled by the CDC using the International Classification of Diseases (ICD) codes on death certificates. Deaths caused by errors are unmeasured because medical errors are not included in the death certificate.
Study design: Analysis of existing literature on medical errors.
Setting: U.S. hospitals.
Synopsis: Findings of four studies on U.S. death rates from medical errors published between 2000 and 2008 were synthesized and extrapolated to the total number of U.S. hospital admissions in 2013. This resulted in a mean rate of death from medical errors of 251,454 per year, which is much higher than the annual incidence of 44,000–98,000 deaths published in the 1999 Institute of Medicine report. Comparing these data to the CDC ranking makes medical errors the third-leading cause of death in the U.S.
Although the accuracy of this result is limited to inpatient deaths and as the authors extrapolated the data from other studies, the number is still staggering and highlights the need for systematic measurement of the problem. One simple solution for this could be to have an extra field on the death certificate asking whether a preventable complication stemming from the patient’s medical care contributed to the death.
Bottom line: Medical error as the estimated third-leading cause of the death in the U.S. remains under-recognized, underappreciated, and highly unmeasured.
Citation: Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.
Short Take
Isolating C. Difficile Carriers Decreases Hospital-Acquired C. Difficile Infections
In a nonblinded time-series analysis, screening all patients for asymptomatic C. diff carrier status and isolating carriers reduced rates of hospital-acquired C. diff, preventing 62.4% of expected cases.
Citation: Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C difficile infections: a quasi-experimental controlled study. JAMA Inter Med. 2016;176(6):796¬-804.
Clinical question: What is the contribution of hospital-based medical errors to national mortality in the U.S. compared to other causes listed by the Centers for Disease Control and Prevention (CDC)?
Background: Medical error can contribute to patient mortality. Currently, the annual list of the most common causes of death in the U.S. is compiled by the CDC using the International Classification of Diseases (ICD) codes on death certificates. Deaths caused by errors are unmeasured because medical errors are not included in the death certificate.
Study design: Analysis of existing literature on medical errors.
Setting: U.S. hospitals.
Synopsis: Findings of four studies on U.S. death rates from medical errors published between 2000 and 2008 were synthesized and extrapolated to the total number of U.S. hospital admissions in 2013. This resulted in a mean rate of death from medical errors of 251,454 per year, which is much higher than the annual incidence of 44,000–98,000 deaths published in the 1999 Institute of Medicine report. Comparing these data to the CDC ranking makes medical errors the third-leading cause of death in the U.S.
Although the accuracy of this result is limited to inpatient deaths and as the authors extrapolated the data from other studies, the number is still staggering and highlights the need for systematic measurement of the problem. One simple solution for this could be to have an extra field on the death certificate asking whether a preventable complication stemming from the patient’s medical care contributed to the death.
Bottom line: Medical error as the estimated third-leading cause of the death in the U.S. remains under-recognized, underappreciated, and highly unmeasured.
Citation: Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.
Short Take
Isolating C. Difficile Carriers Decreases Hospital-Acquired C. Difficile Infections
In a nonblinded time-series analysis, screening all patients for asymptomatic C. diff carrier status and isolating carriers reduced rates of hospital-acquired C. diff, preventing 62.4% of expected cases.
Citation: Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C difficile infections: a quasi-experimental controlled study. JAMA Inter Med. 2016;176(6):796¬-804.
Clinical question: What is the contribution of hospital-based medical errors to national mortality in the U.S. compared to other causes listed by the Centers for Disease Control and Prevention (CDC)?
Background: Medical error can contribute to patient mortality. Currently, the annual list of the most common causes of death in the U.S. is compiled by the CDC using the International Classification of Diseases (ICD) codes on death certificates. Deaths caused by errors are unmeasured because medical errors are not included in the death certificate.
Study design: Analysis of existing literature on medical errors.
Setting: U.S. hospitals.
Synopsis: Findings of four studies on U.S. death rates from medical errors published between 2000 and 2008 were synthesized and extrapolated to the total number of U.S. hospital admissions in 2013. This resulted in a mean rate of death from medical errors of 251,454 per year, which is much higher than the annual incidence of 44,000–98,000 deaths published in the 1999 Institute of Medicine report. Comparing these data to the CDC ranking makes medical errors the third-leading cause of death in the U.S.
Although the accuracy of this result is limited to inpatient deaths and as the authors extrapolated the data from other studies, the number is still staggering and highlights the need for systematic measurement of the problem. One simple solution for this could be to have an extra field on the death certificate asking whether a preventable complication stemming from the patient’s medical care contributed to the death.
Bottom line: Medical error as the estimated third-leading cause of the death in the U.S. remains under-recognized, underappreciated, and highly unmeasured.
Citation: Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.
Short Take
Isolating C. Difficile Carriers Decreases Hospital-Acquired C. Difficile Infections
In a nonblinded time-series analysis, screening all patients for asymptomatic C. diff carrier status and isolating carriers reduced rates of hospital-acquired C. diff, preventing 62.4% of expected cases.
Citation: Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C difficile infections: a quasi-experimental controlled study. JAMA Inter Med. 2016;176(6):796¬-804.
Hospital Admission, Stroke Clinic Follow-up Improve Outcomes for Patients with Transient Ischemic Attack, Minor Ischemic Stroke
Clinical question: How do guideline-based care and outcomes of patients with transient ischemic attack (TIA) and minor ischemic stroke differ among patients admitted to the hospital and discharged from the ED, as well as in those referred versus not referred to stroke prevention clinics following discharge?
Background: Previous research demonstrated that urgent outpatient management strategies for patients with TIA and minor ischemic stroke are superior to standard outpatient care. However, there is less known about how outpatient stroke care compares to inpatient care in terms of outcomes, rapid risk factor identification/modification, and initiation of antithrombotic therapy.
Study design: Retrospective cohort study.
Setting: EDs of acute-care hospitals in Ontario, Canada.
Synopsis: Using the Ontario Stroke Registry, 8,540 patients seen in the ED with TIA or minor ischemic stroke were identified. The use of guideline-based interventions was highest in admitted patients, followed by patients discharged from the ED with stroke clinic follow-up, followed by patients discharged without follow-up. There was no significant difference in one-year mortality between admitted and discharged patients when adjusted for age, sex, and comorbid conditions (adjusted hazard ratio, 1.11; 95% CI, 0.92–1.34). However, stroke clinic referral was associated with a lower risk of one-year mortality compared with those discharged without follow-up (adjusted hazard ratio, 0.49; 95% CI, 0.38–0.64).
Limitations of this study include that it was carried out only in Ontario, where there is a universal healthcare system, which may limit the generalizability of the findings. Additionally, patient information was limited to what was available through the registry, which may mean there were other unmeasurable differences among groups.
Bottom line: Admitted patients with TIA or minor ischemic stroke are more likely to receive guideline-based therapy, and among patients discharged from the ED, referral to stroke clinic improves outcomes, including one-year mortality.
Citation: Kapral MK, Hall R, Fang J, et al. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582-1589.
Clinical question: How do guideline-based care and outcomes of patients with transient ischemic attack (TIA) and minor ischemic stroke differ among patients admitted to the hospital and discharged from the ED, as well as in those referred versus not referred to stroke prevention clinics following discharge?
Background: Previous research demonstrated that urgent outpatient management strategies for patients with TIA and minor ischemic stroke are superior to standard outpatient care. However, there is less known about how outpatient stroke care compares to inpatient care in terms of outcomes, rapid risk factor identification/modification, and initiation of antithrombotic therapy.
Study design: Retrospective cohort study.
Setting: EDs of acute-care hospitals in Ontario, Canada.
Synopsis: Using the Ontario Stroke Registry, 8,540 patients seen in the ED with TIA or minor ischemic stroke were identified. The use of guideline-based interventions was highest in admitted patients, followed by patients discharged from the ED with stroke clinic follow-up, followed by patients discharged without follow-up. There was no significant difference in one-year mortality between admitted and discharged patients when adjusted for age, sex, and comorbid conditions (adjusted hazard ratio, 1.11; 95% CI, 0.92–1.34). However, stroke clinic referral was associated with a lower risk of one-year mortality compared with those discharged without follow-up (adjusted hazard ratio, 0.49; 95% CI, 0.38–0.64).
Limitations of this study include that it was carried out only in Ontario, where there is a universal healthcare system, which may limit the generalizability of the findings. Additionally, patient information was limited to what was available through the registry, which may mean there were other unmeasurable differences among groups.
Bottom line: Admitted patients with TIA or minor ischemic stroke are more likely to receive guideline-based therapy, and among patients discharged from the ED, referral to stroke clinic improves outcomes, including one-year mortality.
Citation: Kapral MK, Hall R, Fang J, et al. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582-1589.
Clinical question: How do guideline-based care and outcomes of patients with transient ischemic attack (TIA) and minor ischemic stroke differ among patients admitted to the hospital and discharged from the ED, as well as in those referred versus not referred to stroke prevention clinics following discharge?
Background: Previous research demonstrated that urgent outpatient management strategies for patients with TIA and minor ischemic stroke are superior to standard outpatient care. However, there is less known about how outpatient stroke care compares to inpatient care in terms of outcomes, rapid risk factor identification/modification, and initiation of antithrombotic therapy.
Study design: Retrospective cohort study.
Setting: EDs of acute-care hospitals in Ontario, Canada.
Synopsis: Using the Ontario Stroke Registry, 8,540 patients seen in the ED with TIA or minor ischemic stroke were identified. The use of guideline-based interventions was highest in admitted patients, followed by patients discharged from the ED with stroke clinic follow-up, followed by patients discharged without follow-up. There was no significant difference in one-year mortality between admitted and discharged patients when adjusted for age, sex, and comorbid conditions (adjusted hazard ratio, 1.11; 95% CI, 0.92–1.34). However, stroke clinic referral was associated with a lower risk of one-year mortality compared with those discharged without follow-up (adjusted hazard ratio, 0.49; 95% CI, 0.38–0.64).
Limitations of this study include that it was carried out only in Ontario, where there is a universal healthcare system, which may limit the generalizability of the findings. Additionally, patient information was limited to what was available through the registry, which may mean there were other unmeasurable differences among groups.
Bottom line: Admitted patients with TIA or minor ischemic stroke are more likely to receive guideline-based therapy, and among patients discharged from the ED, referral to stroke clinic improves outcomes, including one-year mortality.
Citation: Kapral MK, Hall R, Fang J, et al. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582-1589.
Left Atrial Appendage Closure Noninferior to Warfain for Cardioembolic Event Prophylaxis in Nonvalvular Afibrillation
Clinical question: Is mechanical, left atrial appendage (LAA) closure as effective as warfarin therapy in preventing cardioembolic events in patients with nonvalvular atrial fibrillation (Afib)?
Background: Anticoagulation with warfarin has long been the standard therapy for prevention of thromboembolic complications of nonvalvular Afib; however, its use is limited by the need for monitoring and lifelong adherence, as well as its many dietary and medication interactions. Prior studies investigating the efficacy of a deployable device intended to close the LAA have shown noninferiority of the device when compared with standard warfarin anticoagulation. This study evaluated LAA closure device efficacy after a 3.8-year interval.
Study design: Randomized, unblinded controlled trial.
Setting: Fifty-nine centers in the U.S. and Europe.
Synopsis: Authors randomized 707 participants 18 years or older with nonvalvular Afib and CHADS2 score ≥1 in a 2:1 fashion to the intervention and warfarin therapy groups. The primary outcome was a composite endpoint including stroke, systemic embolism, and cardiovascular or unexplained death. The event rate in the device group was 2.3 per 100 patient-years, compared with 3.8 in the warfarin group. Rate ratio was 0.60, meeting noninferiority criteria. Primary safety events were not statistically different.
Although the authors concluded that LAA device closure was noninferior to warfarin therapy, it should be noted that there was a high dropout rate, especially in the warfarin group, motivated either by a desire to try a novel oral anticoagulant or the perception that warfarin therapy was not beneficial. It should also be noted that device placement involved not only a percutaneous procedure, but also 45 days of aspirin and warfarin therapy initially to promote endothelization, followed by six months of clopidogrel.
Bottom line: Percutaneous device closure of the LAA appears to be noninferior to warfarin therapy in the prevention of cardioembolic events over a period of several years, and might be superior.
Clinical question: Is mechanical, left atrial appendage (LAA) closure as effective as warfarin therapy in preventing cardioembolic events in patients with nonvalvular atrial fibrillation (Afib)?
Background: Anticoagulation with warfarin has long been the standard therapy for prevention of thromboembolic complications of nonvalvular Afib; however, its use is limited by the need for monitoring and lifelong adherence, as well as its many dietary and medication interactions. Prior studies investigating the efficacy of a deployable device intended to close the LAA have shown noninferiority of the device when compared with standard warfarin anticoagulation. This study evaluated LAA closure device efficacy after a 3.8-year interval.
Study design: Randomized, unblinded controlled trial.
Setting: Fifty-nine centers in the U.S. and Europe.
Synopsis: Authors randomized 707 participants 18 years or older with nonvalvular Afib and CHADS2 score ≥1 in a 2:1 fashion to the intervention and warfarin therapy groups. The primary outcome was a composite endpoint including stroke, systemic embolism, and cardiovascular or unexplained death. The event rate in the device group was 2.3 per 100 patient-years, compared with 3.8 in the warfarin group. Rate ratio was 0.60, meeting noninferiority criteria. Primary safety events were not statistically different.
Although the authors concluded that LAA device closure was noninferior to warfarin therapy, it should be noted that there was a high dropout rate, especially in the warfarin group, motivated either by a desire to try a novel oral anticoagulant or the perception that warfarin therapy was not beneficial. It should also be noted that device placement involved not only a percutaneous procedure, but also 45 days of aspirin and warfarin therapy initially to promote endothelization, followed by six months of clopidogrel.
Bottom line: Percutaneous device closure of the LAA appears to be noninferior to warfarin therapy in the prevention of cardioembolic events over a period of several years, and might be superior.
Clinical question: Is mechanical, left atrial appendage (LAA) closure as effective as warfarin therapy in preventing cardioembolic events in patients with nonvalvular atrial fibrillation (Afib)?
Background: Anticoagulation with warfarin has long been the standard therapy for prevention of thromboembolic complications of nonvalvular Afib; however, its use is limited by the need for monitoring and lifelong adherence, as well as its many dietary and medication interactions. Prior studies investigating the efficacy of a deployable device intended to close the LAA have shown noninferiority of the device when compared with standard warfarin anticoagulation. This study evaluated LAA closure device efficacy after a 3.8-year interval.
Study design: Randomized, unblinded controlled trial.
Setting: Fifty-nine centers in the U.S. and Europe.
Synopsis: Authors randomized 707 participants 18 years or older with nonvalvular Afib and CHADS2 score ≥1 in a 2:1 fashion to the intervention and warfarin therapy groups. The primary outcome was a composite endpoint including stroke, systemic embolism, and cardiovascular or unexplained death. The event rate in the device group was 2.3 per 100 patient-years, compared with 3.8 in the warfarin group. Rate ratio was 0.60, meeting noninferiority criteria. Primary safety events were not statistically different.
Although the authors concluded that LAA device closure was noninferior to warfarin therapy, it should be noted that there was a high dropout rate, especially in the warfarin group, motivated either by a desire to try a novel oral anticoagulant or the perception that warfarin therapy was not beneficial. It should also be noted that device placement involved not only a percutaneous procedure, but also 45 days of aspirin and warfarin therapy initially to promote endothelization, followed by six months of clopidogrel.
Bottom line: Percutaneous device closure of the LAA appears to be noninferior to warfarin therapy in the prevention of cardioembolic events over a period of several years, and might be superior.
Tramadol Associated with Increased Rate of Hypoglycemia
Clinical question: Does tramadol increase rates of hospitalization from hypoglycemia compared to other opioids?
Background: As tramadol use has increased in the general population, there have been multiple reports of hypoglycemia after initiation of the painkiller, including in patients with no other known risk factors, such as diabetes mellitus.
Study design: Case control study.
Setting: United Kingdom.
Synopsis: Using the United Kingdom’s Clinical Practice Research Datalink, a cohort of 334,034 patients was identified, including 1,105 hospitalized for hypoglycemia. To compare incidence of hypoglycemia in patients taking tramadol versus nontramadol opioids, patients newly treated with tramadol for noncancer pain were compared with those treated with codeine.
Use of tramadol was associated with increase in hospitalization for treatment of hypoglycemia compared with codeine. Specifically, tramadol use had an odds ratio (OR) of 1.52 (95% confidence interval, 1.09-2.10). The risk of hypoglycemia was higher in the first 30 days of use, with an OR of 2.61 (95% confidence interval, 1.61-4.23).
Since tramadol prescribing has increased over the past 10 years, clinicians should be mindful of the potential association between tramadol and severe hypoglycemia requiring hospitalization. Although the details of the pathophysiology leading to this outcome remain unclear, evidence of a causal relationship is mounting. The association with hypoglycemia was seen particularly in the first 30 days of therapy. The incidence of less severe hypoglycemia not requiring hospitalization remains unknown.
Bottom line: Tramadol use is associated with increased rates of hypoglycemia requiring hospitalization.
Clinical question: Does tramadol increase rates of hospitalization from hypoglycemia compared to other opioids?
Background: As tramadol use has increased in the general population, there have been multiple reports of hypoglycemia after initiation of the painkiller, including in patients with no other known risk factors, such as diabetes mellitus.
Study design: Case control study.
Setting: United Kingdom.
Synopsis: Using the United Kingdom’s Clinical Practice Research Datalink, a cohort of 334,034 patients was identified, including 1,105 hospitalized for hypoglycemia. To compare incidence of hypoglycemia in patients taking tramadol versus nontramadol opioids, patients newly treated with tramadol for noncancer pain were compared with those treated with codeine.
Use of tramadol was associated with increase in hospitalization for treatment of hypoglycemia compared with codeine. Specifically, tramadol use had an odds ratio (OR) of 1.52 (95% confidence interval, 1.09-2.10). The risk of hypoglycemia was higher in the first 30 days of use, with an OR of 2.61 (95% confidence interval, 1.61-4.23).
Since tramadol prescribing has increased over the past 10 years, clinicians should be mindful of the potential association between tramadol and severe hypoglycemia requiring hospitalization. Although the details of the pathophysiology leading to this outcome remain unclear, evidence of a causal relationship is mounting. The association with hypoglycemia was seen particularly in the first 30 days of therapy. The incidence of less severe hypoglycemia not requiring hospitalization remains unknown.
Bottom line: Tramadol use is associated with increased rates of hypoglycemia requiring hospitalization.
Clinical question: Does tramadol increase rates of hospitalization from hypoglycemia compared to other opioids?
Background: As tramadol use has increased in the general population, there have been multiple reports of hypoglycemia after initiation of the painkiller, including in patients with no other known risk factors, such as diabetes mellitus.
Study design: Case control study.
Setting: United Kingdom.
Synopsis: Using the United Kingdom’s Clinical Practice Research Datalink, a cohort of 334,034 patients was identified, including 1,105 hospitalized for hypoglycemia. To compare incidence of hypoglycemia in patients taking tramadol versus nontramadol opioids, patients newly treated with tramadol for noncancer pain were compared with those treated with codeine.
Use of tramadol was associated with increase in hospitalization for treatment of hypoglycemia compared with codeine. Specifically, tramadol use had an odds ratio (OR) of 1.52 (95% confidence interval, 1.09-2.10). The risk of hypoglycemia was higher in the first 30 days of use, with an OR of 2.61 (95% confidence interval, 1.61-4.23).
Since tramadol prescribing has increased over the past 10 years, clinicians should be mindful of the potential association between tramadol and severe hypoglycemia requiring hospitalization. Although the details of the pathophysiology leading to this outcome remain unclear, evidence of a causal relationship is mounting. The association with hypoglycemia was seen particularly in the first 30 days of therapy. The incidence of less severe hypoglycemia not requiring hospitalization remains unknown.
Bottom line: Tramadol use is associated with increased rates of hypoglycemia requiring hospitalization.
Longer Surgeries Associated with Increased VTE Risk
Clinical question: Does duration of surgical procedure influence venous thromboembolism (VTE) risk?
Background: The relationship between surgical procedure length and VTE risk has not been vigorously assessed, although it has been postulated that longer procedures are associated with increased VTE risk. Improved understanding of this relationship may be beneficial to surgeons deciding on VTE prophylaxis strategies or determining whether to perform coupled procedures.
Study design: Retrospective cohort study.
Setting: Data collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).
Synopsis: Study authors divided 1,432,855 surgical cases during which general anesthesia was administered for a specified duration into five quintiles based on length of operative time, defined as the period during which a patient was under general anesthesia. The primary outcome was the development of a VTE within 30 days of the procedure, defined as deep venous thrombosis (DVT), pulmonary embolism (PE), or both. Logistic regression analyses were performed to assess the relationship between procedure length and VTE occurrence.
The middle quintile of procedures carried a VTE rate of 0.86%. There was a significant association between procedure duration and VTE risk when the first and second quintiles, and fourth and fifth quintiles, were compared to the middle quintile. The association was present across all surgical subspecialties.
Bottom line: Longer duration of surgical procedures is associated with increased VTE risk.
Clinical question: Does duration of surgical procedure influence venous thromboembolism (VTE) risk?
Background: The relationship between surgical procedure length and VTE risk has not been vigorously assessed, although it has been postulated that longer procedures are associated with increased VTE risk. Improved understanding of this relationship may be beneficial to surgeons deciding on VTE prophylaxis strategies or determining whether to perform coupled procedures.
Study design: Retrospective cohort study.
Setting: Data collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).
Synopsis: Study authors divided 1,432,855 surgical cases during which general anesthesia was administered for a specified duration into five quintiles based on length of operative time, defined as the period during which a patient was under general anesthesia. The primary outcome was the development of a VTE within 30 days of the procedure, defined as deep venous thrombosis (DVT), pulmonary embolism (PE), or both. Logistic regression analyses were performed to assess the relationship between procedure length and VTE occurrence.
The middle quintile of procedures carried a VTE rate of 0.86%. There was a significant association between procedure duration and VTE risk when the first and second quintiles, and fourth and fifth quintiles, were compared to the middle quintile. The association was present across all surgical subspecialties.
Bottom line: Longer duration of surgical procedures is associated with increased VTE risk.
Clinical question: Does duration of surgical procedure influence venous thromboembolism (VTE) risk?
Background: The relationship between surgical procedure length and VTE risk has not been vigorously assessed, although it has been postulated that longer procedures are associated with increased VTE risk. Improved understanding of this relationship may be beneficial to surgeons deciding on VTE prophylaxis strategies or determining whether to perform coupled procedures.
Study design: Retrospective cohort study.
Setting: Data collected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).
Synopsis: Study authors divided 1,432,855 surgical cases during which general anesthesia was administered for a specified duration into five quintiles based on length of operative time, defined as the period during which a patient was under general anesthesia. The primary outcome was the development of a VTE within 30 days of the procedure, defined as deep venous thrombosis (DVT), pulmonary embolism (PE), or both. Logistic regression analyses were performed to assess the relationship between procedure length and VTE occurrence.
The middle quintile of procedures carried a VTE rate of 0.86%. There was a significant association between procedure duration and VTE risk when the first and second quintiles, and fourth and fifth quintiles, were compared to the middle quintile. The association was present across all surgical subspecialties.
Bottom line: Longer duration of surgical procedures is associated with increased VTE risk.
Mortality, Readmission Rates Unchanged by Duty Hour Reforms
Clinical question: Did the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms change mortality rates or readmission rates at teaching hospitals?
Background: The 2011 ACGME duty hour reforms maintained the 80-hour weekly work limit for medical residents, decreased the number of continuous hours to 16 hours from 30 hours for interns, and decreased the number of continuous hours for residents to 24 hours, with an additional four hours allowed for transitions of care. These changes have raised concerns about increased handoffs and potential changes in patient safety.
Study design: Observational study of Medicare admissions before and after duty hour reforms.
Setting: Short-term, acute-care hospitals.
Synopsis: Investigators compared 4,325,854 inpatient Medicare admissions from the two years prior to duty hour reforms with 2,058,419 admissions the year after the reforms. For each time period, the 30-day mortality and 30-day readmission rates were assessed; outcomes from more intensive teaching hospitals were compared with the outcomes from less intensive teaching hospitals. Teaching intensity was assessed according to the resident-to-bed ratio, a measure that has been used in prior research.
No significant differences were found in the primary outcomes of 30-day all-location mortality or 30-day all-cause readmissions.
When looking at specific diagnoses, only stroke was found to have a higher risk of readmission in the post-reform period (OR 1.06, 95% CI 1.01-1.13).
Although 2011 duty hour reforms represented a large, national structural change in resident education, no significant positive or negative effect was found on these important patient safety measures, consistent with what has been found in prior reviews.
Bottom line: The 2011 ACGME duty hour reforms showed no significant changes in mortality or readmissions when comparing hospitals with intensive teaching roles to those with fewer trainees.
Clinical question: Did the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms change mortality rates or readmission rates at teaching hospitals?
Background: The 2011 ACGME duty hour reforms maintained the 80-hour weekly work limit for medical residents, decreased the number of continuous hours to 16 hours from 30 hours for interns, and decreased the number of continuous hours for residents to 24 hours, with an additional four hours allowed for transitions of care. These changes have raised concerns about increased handoffs and potential changes in patient safety.
Study design: Observational study of Medicare admissions before and after duty hour reforms.
Setting: Short-term, acute-care hospitals.
Synopsis: Investigators compared 4,325,854 inpatient Medicare admissions from the two years prior to duty hour reforms with 2,058,419 admissions the year after the reforms. For each time period, the 30-day mortality and 30-day readmission rates were assessed; outcomes from more intensive teaching hospitals were compared with the outcomes from less intensive teaching hospitals. Teaching intensity was assessed according to the resident-to-bed ratio, a measure that has been used in prior research.
No significant differences were found in the primary outcomes of 30-day all-location mortality or 30-day all-cause readmissions.
When looking at specific diagnoses, only stroke was found to have a higher risk of readmission in the post-reform period (OR 1.06, 95% CI 1.01-1.13).
Although 2011 duty hour reforms represented a large, national structural change in resident education, no significant positive or negative effect was found on these important patient safety measures, consistent with what has been found in prior reviews.
Bottom line: The 2011 ACGME duty hour reforms showed no significant changes in mortality or readmissions when comparing hospitals with intensive teaching roles to those with fewer trainees.
Clinical question: Did the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms change mortality rates or readmission rates at teaching hospitals?
Background: The 2011 ACGME duty hour reforms maintained the 80-hour weekly work limit for medical residents, decreased the number of continuous hours to 16 hours from 30 hours for interns, and decreased the number of continuous hours for residents to 24 hours, with an additional four hours allowed for transitions of care. These changes have raised concerns about increased handoffs and potential changes in patient safety.
Study design: Observational study of Medicare admissions before and after duty hour reforms.
Setting: Short-term, acute-care hospitals.
Synopsis: Investigators compared 4,325,854 inpatient Medicare admissions from the two years prior to duty hour reforms with 2,058,419 admissions the year after the reforms. For each time period, the 30-day mortality and 30-day readmission rates were assessed; outcomes from more intensive teaching hospitals were compared with the outcomes from less intensive teaching hospitals. Teaching intensity was assessed according to the resident-to-bed ratio, a measure that has been used in prior research.
No significant differences were found in the primary outcomes of 30-day all-location mortality or 30-day all-cause readmissions.
When looking at specific diagnoses, only stroke was found to have a higher risk of readmission in the post-reform period (OR 1.06, 95% CI 1.01-1.13).
Although 2011 duty hour reforms represented a large, national structural change in resident education, no significant positive or negative effect was found on these important patient safety measures, consistent with what has been found in prior reviews.
Bottom line: The 2011 ACGME duty hour reforms showed no significant changes in mortality or readmissions when comparing hospitals with intensive teaching roles to those with fewer trainees.
Emergency Department Utilization May Be Lower for Attending-Only Physician Visits versus Supervised Visits
Clinical question: Does supervised learning in the ED lead to higher rates of resource utilization?
Background: Care at academic medical centers might be more expensive than nonteaching hospitals because of the increased testing and resource utilization that occurs among learners. Although there is a growing emphasis in training programs on cost-conscious care, little data has looked at resource use as an outcome.
Study design: Cross-sectional study of the National Hospital Ambulatory Medical Care Survey in 2010.
Setting: Probability sample of American EDs and ED visits.
Synopsis: Using the 2010 National Hospital Ambulatory Medical Care Survey ED sub-file, a probability sample of 29,182 ED visits was obtained—25,808 attending-only visits and 3,374 supervised visits.
Supervised visits were more likely to lead to hospital admissions (21% versus 14%), advanced imaging (28% vs. 21%), and a longer median ED stay, but not with more blood testing than attending-only ED visits. EDs were placed into three categories: “nonteaching”; “minor teaching,” where trainees are involved in fewer than 50% of visits; and “major teaching,” where trainees are involved in more than 50% of visits. Study results showed no increase in resource utilization in major teaching EDs, except for an increase in ED length of stay.
Although there was an attempt to adjust for biased selection and complexity, there is a risk that biased selection of “teaching cases” in minor teaching EDs could explain some of the higher resource use for these cases. This study does not imply causation; however, it suggests that further studies might be warranted to evaluate the relationship between learners and resource utilization.
Bottom line: Supervised visits were associated with increased hospital admissions, advanced imaging, and longer ED length of stay (LOS), but other than LOS, this relationship did not persist in major teaching EDs.
Clinical question: Does supervised learning in the ED lead to higher rates of resource utilization?
Background: Care at academic medical centers might be more expensive than nonteaching hospitals because of the increased testing and resource utilization that occurs among learners. Although there is a growing emphasis in training programs on cost-conscious care, little data has looked at resource use as an outcome.
Study design: Cross-sectional study of the National Hospital Ambulatory Medical Care Survey in 2010.
Setting: Probability sample of American EDs and ED visits.
Synopsis: Using the 2010 National Hospital Ambulatory Medical Care Survey ED sub-file, a probability sample of 29,182 ED visits was obtained—25,808 attending-only visits and 3,374 supervised visits.
Supervised visits were more likely to lead to hospital admissions (21% versus 14%), advanced imaging (28% vs. 21%), and a longer median ED stay, but not with more blood testing than attending-only ED visits. EDs were placed into three categories: “nonteaching”; “minor teaching,” where trainees are involved in fewer than 50% of visits; and “major teaching,” where trainees are involved in more than 50% of visits. Study results showed no increase in resource utilization in major teaching EDs, except for an increase in ED length of stay.
Although there was an attempt to adjust for biased selection and complexity, there is a risk that biased selection of “teaching cases” in minor teaching EDs could explain some of the higher resource use for these cases. This study does not imply causation; however, it suggests that further studies might be warranted to evaluate the relationship between learners and resource utilization.
Bottom line: Supervised visits were associated with increased hospital admissions, advanced imaging, and longer ED length of stay (LOS), but other than LOS, this relationship did not persist in major teaching EDs.
Clinical question: Does supervised learning in the ED lead to higher rates of resource utilization?
Background: Care at academic medical centers might be more expensive than nonteaching hospitals because of the increased testing and resource utilization that occurs among learners. Although there is a growing emphasis in training programs on cost-conscious care, little data has looked at resource use as an outcome.
Study design: Cross-sectional study of the National Hospital Ambulatory Medical Care Survey in 2010.
Setting: Probability sample of American EDs and ED visits.
Synopsis: Using the 2010 National Hospital Ambulatory Medical Care Survey ED sub-file, a probability sample of 29,182 ED visits was obtained—25,808 attending-only visits and 3,374 supervised visits.
Supervised visits were more likely to lead to hospital admissions (21% versus 14%), advanced imaging (28% vs. 21%), and a longer median ED stay, but not with more blood testing than attending-only ED visits. EDs were placed into three categories: “nonteaching”; “minor teaching,” where trainees are involved in fewer than 50% of visits; and “major teaching,” where trainees are involved in more than 50% of visits. Study results showed no increase in resource utilization in major teaching EDs, except for an increase in ED length of stay.
Although there was an attempt to adjust for biased selection and complexity, there is a risk that biased selection of “teaching cases” in minor teaching EDs could explain some of the higher resource use for these cases. This study does not imply causation; however, it suggests that further studies might be warranted to evaluate the relationship between learners and resource utilization.
Bottom line: Supervised visits were associated with increased hospital admissions, advanced imaging, and longer ED length of stay (LOS), but other than LOS, this relationship did not persist in major teaching EDs.
Physician Spending Habits During Residency Training Can Persist for Years
Clinical question: For primary care physicians (PCPs), does residency training area affect the pattern of physician spending after training is complete?
Background: Regional and system-level variations in the intensity of medical services provided are common in the U.S. Residency training practice patterns could explain these variations. This study examines the relationship between spending patterns in the region of residency training and individual physician practice spending patterns after training.
Study design: Secondary, multilevel, multivariable analysis of 2011 Medicare claims data.
Setting: Random, nationally representative sample of family and internal medicine physicians completing residency between 1992 and 2010, with Medicare patient panels of 40 or more patients.
Synopsis: Investigators randomly selected 2,851 PCPs who completed residency training from 1992-2010, providing care to 491,948 Medicare beneficiaries. Practice locations and residency training were matched with the Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups.
Physicians practicing in high-spending regions who trained in high-spending regions spent $1,926 more per Medicare beneficiary than those trained in low-spending regions. In average-spending regions, physicians who trained in high-spending regions spent an average of $897 higher than those who trained in low-spending regions. No differences were found in low-spending regions.
This association varied significantly according to years in practice. For physicians in the first seven years of practice, patient expenditures in the highest-spending training HRR were 29% greater than those in the lowest-spending training HRR. After 16 years of practice, this variation disappeared.
Although this study does not establish causality, there may be opportunities to control spending with focused interventions in residency.
Bottom line: Spending patterns vary even within HRRs; however, this study’s findings suggest that physicians’ practice patterns are developed in residency training and that training in high-spending regions likely leads to increased expenditures. Focusing on cost-conscious care during residency training could be a significant option for curtailing healthcare costs in the future.
Clinical question: For primary care physicians (PCPs), does residency training area affect the pattern of physician spending after training is complete?
Background: Regional and system-level variations in the intensity of medical services provided are common in the U.S. Residency training practice patterns could explain these variations. This study examines the relationship between spending patterns in the region of residency training and individual physician practice spending patterns after training.
Study design: Secondary, multilevel, multivariable analysis of 2011 Medicare claims data.
Setting: Random, nationally representative sample of family and internal medicine physicians completing residency between 1992 and 2010, with Medicare patient panels of 40 or more patients.
Synopsis: Investigators randomly selected 2,851 PCPs who completed residency training from 1992-2010, providing care to 491,948 Medicare beneficiaries. Practice locations and residency training were matched with the Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups.
Physicians practicing in high-spending regions who trained in high-spending regions spent $1,926 more per Medicare beneficiary than those trained in low-spending regions. In average-spending regions, physicians who trained in high-spending regions spent an average of $897 higher than those who trained in low-spending regions. No differences were found in low-spending regions.
This association varied significantly according to years in practice. For physicians in the first seven years of practice, patient expenditures in the highest-spending training HRR were 29% greater than those in the lowest-spending training HRR. After 16 years of practice, this variation disappeared.
Although this study does not establish causality, there may be opportunities to control spending with focused interventions in residency.
Bottom line: Spending patterns vary even within HRRs; however, this study’s findings suggest that physicians’ practice patterns are developed in residency training and that training in high-spending regions likely leads to increased expenditures. Focusing on cost-conscious care during residency training could be a significant option for curtailing healthcare costs in the future.
Clinical question: For primary care physicians (PCPs), does residency training area affect the pattern of physician spending after training is complete?
Background: Regional and system-level variations in the intensity of medical services provided are common in the U.S. Residency training practice patterns could explain these variations. This study examines the relationship between spending patterns in the region of residency training and individual physician practice spending patterns after training.
Study design: Secondary, multilevel, multivariable analysis of 2011 Medicare claims data.
Setting: Random, nationally representative sample of family and internal medicine physicians completing residency between 1992 and 2010, with Medicare patient panels of 40 or more patients.
Synopsis: Investigators randomly selected 2,851 PCPs who completed residency training from 1992-2010, providing care to 491,948 Medicare beneficiaries. Practice locations and residency training were matched with the Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups.
Physicians practicing in high-spending regions who trained in high-spending regions spent $1,926 more per Medicare beneficiary than those trained in low-spending regions. In average-spending regions, physicians who trained in high-spending regions spent an average of $897 higher than those who trained in low-spending regions. No differences were found in low-spending regions.
This association varied significantly according to years in practice. For physicians in the first seven years of practice, patient expenditures in the highest-spending training HRR were 29% greater than those in the lowest-spending training HRR. After 16 years of practice, this variation disappeared.
Although this study does not establish causality, there may be opportunities to control spending with focused interventions in residency.
Bottom line: Spending patterns vary even within HRRs; however, this study’s findings suggest that physicians’ practice patterns are developed in residency training and that training in high-spending regions likely leads to increased expenditures. Focusing on cost-conscious care during residency training could be a significant option for curtailing healthcare costs in the future.
Malpractice Reform Does Not Change Physician Practice Patterns
Clinical question: Do malpractice reform policies shift physician practice patterns toward lower utilization of healthcare resources?
Background: Physician-reported fears of lawsuits lead to defensive medicine practices, which contribute to high healthcare costs. It is unclear whether malpractice reform legislation reduces these costly physician practice patterns. The ED is a high-risk environment that may promote defensive medicine practices and is the focus of recent malpractice reform legislation in Texas, Georgia, and South Carolina.
Study design: Case-control.
Setting: EDs in Texas, Georgia, South Carolina, and adjacent states.
Synopsis: Using a 5% random sample of Medicare claims from 1997-2011, the investigators evaluated the impact of recent malpractice reform legislation on intensity of practice by ED physicians, as defined by rates of use of advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]), hospital admission, and average charges. ED claims from the three reform states (Texas, Ga., and S.C.) were compared to neighboring (control) states.
Adjusted analysis of 3,868,110 ED visits from 1,166 eligible hospitals demonstrated no significant reductions in CT/MRI utilization, rates of hospital admission, or (in two of the three reform states) average per-visit ED charges attributable to policy reforms.
Bottom line: Broadly protective malpractice reform had minimal impact on emergency physicians’ intensity of practice, as measured by rates of advanced imaging use, hospital admission, and average charges. Such “pro-physician” legal reforms may be inadequate in isolation to significantly reduce costs.
Clinical question: Do malpractice reform policies shift physician practice patterns toward lower utilization of healthcare resources?
Background: Physician-reported fears of lawsuits lead to defensive medicine practices, which contribute to high healthcare costs. It is unclear whether malpractice reform legislation reduces these costly physician practice patterns. The ED is a high-risk environment that may promote defensive medicine practices and is the focus of recent malpractice reform legislation in Texas, Georgia, and South Carolina.
Study design: Case-control.
Setting: EDs in Texas, Georgia, South Carolina, and adjacent states.
Synopsis: Using a 5% random sample of Medicare claims from 1997-2011, the investigators evaluated the impact of recent malpractice reform legislation on intensity of practice by ED physicians, as defined by rates of use of advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]), hospital admission, and average charges. ED claims from the three reform states (Texas, Ga., and S.C.) were compared to neighboring (control) states.
Adjusted analysis of 3,868,110 ED visits from 1,166 eligible hospitals demonstrated no significant reductions in CT/MRI utilization, rates of hospital admission, or (in two of the three reform states) average per-visit ED charges attributable to policy reforms.
Bottom line: Broadly protective malpractice reform had minimal impact on emergency physicians’ intensity of practice, as measured by rates of advanced imaging use, hospital admission, and average charges. Such “pro-physician” legal reforms may be inadequate in isolation to significantly reduce costs.
Clinical question: Do malpractice reform policies shift physician practice patterns toward lower utilization of healthcare resources?
Background: Physician-reported fears of lawsuits lead to defensive medicine practices, which contribute to high healthcare costs. It is unclear whether malpractice reform legislation reduces these costly physician practice patterns. The ED is a high-risk environment that may promote defensive medicine practices and is the focus of recent malpractice reform legislation in Texas, Georgia, and South Carolina.
Study design: Case-control.
Setting: EDs in Texas, Georgia, South Carolina, and adjacent states.
Synopsis: Using a 5% random sample of Medicare claims from 1997-2011, the investigators evaluated the impact of recent malpractice reform legislation on intensity of practice by ED physicians, as defined by rates of use of advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]), hospital admission, and average charges. ED claims from the three reform states (Texas, Ga., and S.C.) were compared to neighboring (control) states.
Adjusted analysis of 3,868,110 ED visits from 1,166 eligible hospitals demonstrated no significant reductions in CT/MRI utilization, rates of hospital admission, or (in two of the three reform states) average per-visit ED charges attributable to policy reforms.
Bottom line: Broadly protective malpractice reform had minimal impact on emergency physicians’ intensity of practice, as measured by rates of advanced imaging use, hospital admission, and average charges. Such “pro-physician” legal reforms may be inadequate in isolation to significantly reduce costs.
Updated Guidelines for Management of Non-ST-Elevation Acute Coronary Syndrome
Clinical question: What is the recommended approach for management of non-ST-elevation acute coronary syndrome (NSTE-ACS)?
Background: This is the first comprehensive update from the American Heart Association/American College of Cardiology (AHA/ACC) on NSTE-ACS since 2007 and follows a focused update published in 2012.
Synopsis: This guideline provides recommendations for acute and long-term care of patients with NSTE-ACS.
Cardiac-specific troponin assays (troponin I or T) are the mainstay for ACS diagnosis. When contemporary troponin assays are used for diagnosis, other biomarkers (CK-MB, myoglobin) are not useful.
Initial hospital care for all patients with NSTE-ACS should include early initiation of beta-blockers (within the first 24 hours), high-intensity statin therapy, P2Y12 inhibitor (clopidogrel or ticagrelor) plus aspirin, and parenteral anticoagulation.
An early invasive strategy (diagnostic angiography within 24 hours with intent to perform revascularization based on coronary anatomy) is preferred to an ischemia-guided strategy, particularly in high-risk NSTE-ACS patients (Global Registry of Acute Coronary Events [GRACE] score >140).
“Ischemia-guided” strategy replaces the term “conservative management strategy,” and its focus on aggressive medical therapy is an option in selected low-risk patient populations (e.g. thrombolysis in myocardial infarction [TIMI] risk score 0 or 1, GRACE score <109, low-risk troponin-negative females). Patients managed with an ischemia-guided strategy should undergo pre-discharge noninvasive stress testing for further risk stratification.
Regardless of angiography strategy (invasive vs. ischemia-guided), post-discharge dual antiplatelet therapy (clopidogrel or ticagrelor) is recommended for up to 12 months in all patients with NSTE-ACS. Prasugrel is an appropriate P2Y12 inhibitor option for patients following percutaneous coronary intervention with stent placement.
All patients with NSTE-ACS should be referred to an outpatient comprehensive cardiovascular rehabilitation program.
Clinical question: What is the recommended approach for management of non-ST-elevation acute coronary syndrome (NSTE-ACS)?
Background: This is the first comprehensive update from the American Heart Association/American College of Cardiology (AHA/ACC) on NSTE-ACS since 2007 and follows a focused update published in 2012.
Synopsis: This guideline provides recommendations for acute and long-term care of patients with NSTE-ACS.
Cardiac-specific troponin assays (troponin I or T) are the mainstay for ACS diagnosis. When contemporary troponin assays are used for diagnosis, other biomarkers (CK-MB, myoglobin) are not useful.
Initial hospital care for all patients with NSTE-ACS should include early initiation of beta-blockers (within the first 24 hours), high-intensity statin therapy, P2Y12 inhibitor (clopidogrel or ticagrelor) plus aspirin, and parenteral anticoagulation.
An early invasive strategy (diagnostic angiography within 24 hours with intent to perform revascularization based on coronary anatomy) is preferred to an ischemia-guided strategy, particularly in high-risk NSTE-ACS patients (Global Registry of Acute Coronary Events [GRACE] score >140).
“Ischemia-guided” strategy replaces the term “conservative management strategy,” and its focus on aggressive medical therapy is an option in selected low-risk patient populations (e.g. thrombolysis in myocardial infarction [TIMI] risk score 0 or 1, GRACE score <109, low-risk troponin-negative females). Patients managed with an ischemia-guided strategy should undergo pre-discharge noninvasive stress testing for further risk stratification.
Regardless of angiography strategy (invasive vs. ischemia-guided), post-discharge dual antiplatelet therapy (clopidogrel or ticagrelor) is recommended for up to 12 months in all patients with NSTE-ACS. Prasugrel is an appropriate P2Y12 inhibitor option for patients following percutaneous coronary intervention with stent placement.
All patients with NSTE-ACS should be referred to an outpatient comprehensive cardiovascular rehabilitation program.
Clinical question: What is the recommended approach for management of non-ST-elevation acute coronary syndrome (NSTE-ACS)?
Background: This is the first comprehensive update from the American Heart Association/American College of Cardiology (AHA/ACC) on NSTE-ACS since 2007 and follows a focused update published in 2012.
Synopsis: This guideline provides recommendations for acute and long-term care of patients with NSTE-ACS.
Cardiac-specific troponin assays (troponin I or T) are the mainstay for ACS diagnosis. When contemporary troponin assays are used for diagnosis, other biomarkers (CK-MB, myoglobin) are not useful.
Initial hospital care for all patients with NSTE-ACS should include early initiation of beta-blockers (within the first 24 hours), high-intensity statin therapy, P2Y12 inhibitor (clopidogrel or ticagrelor) plus aspirin, and parenteral anticoagulation.
An early invasive strategy (diagnostic angiography within 24 hours with intent to perform revascularization based on coronary anatomy) is preferred to an ischemia-guided strategy, particularly in high-risk NSTE-ACS patients (Global Registry of Acute Coronary Events [GRACE] score >140).
“Ischemia-guided” strategy replaces the term “conservative management strategy,” and its focus on aggressive medical therapy is an option in selected low-risk patient populations (e.g. thrombolysis in myocardial infarction [TIMI] risk score 0 or 1, GRACE score <109, low-risk troponin-negative females). Patients managed with an ischemia-guided strategy should undergo pre-discharge noninvasive stress testing for further risk stratification.
Regardless of angiography strategy (invasive vs. ischemia-guided), post-discharge dual antiplatelet therapy (clopidogrel or ticagrelor) is recommended for up to 12 months in all patients with NSTE-ACS. Prasugrel is an appropriate P2Y12 inhibitor option for patients following percutaneous coronary intervention with stent placement.
All patients with NSTE-ACS should be referred to an outpatient comprehensive cardiovascular rehabilitation program.