Insurers’ use of certain criteria to separate hospital stays into inpatient or observation status remains widespread. Observation status ensures provider reimbursement for hospitalizations deemed necessary by clinical judgment but not qualifying as inpatient care. Admission under observation status impacts the patient’s financial burden, as well, with observation admissions typically associated with increased out-of-pocket costs.

Although hospitals have always faced decreased reimbursement for observation admissions (compared to inpatient admissions), new penalties attached to readmission for patients discharged from an inpatient stay raise the potential to impact hospitalist practice by incentivizing increased use of observation status for hospitalizations in order to avoid readmission penalties.

Have readmission penalties associated with inpatient admissions actually led to increased use of observation status by hospitalist groups?

SHM’s 2014 State of Hospital Medicine report provides insight into this question. In groups serving adults only, observation discharges accounted for 16.1% of all discharges (see Figure 1). If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

In groups serving adults only, observation discharges accounted for 16.1% of all discharges. If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

–Dr. Smith

The question of determining whether to bill episodes as inpatient or observation status was asked in the 2012 survey, as well, though by a different methodology: 20% of admissions were billed as observation status by hospitalist practices seeing adults only. Even with some observation admissions in 2012 being converted to inpatient status later in the hospital stay (a factor accounted for in the 2014 survey by changing the wording of the survey so that it asks about status at discharge), not much overall change in hospitalist group practice can be appreciated.

Does the overall observation status use rate tell the whole story?

When 2012 and 2014 survey data are separated by academic status, a clear change in practice over time can be seen. Academic HMGs experienced an increase in use of observation status, from 15.3% of admissions in 2012 to 19.4% of discharges in 2014 (or 22.8% in 2014, if same-day hospital stay responses are added to the observation data). In comparison, nonacademic hospitalist practices reported a decrease in observation status utilization, from 20.4% of admissions in 2012 to 15.6% of discharges in 2014 (or 19.2%, accounting for same-day discharges as observation status).

Academic HMGs, which frequently rely on housestaff for the finer points of patient care documentation, must consequently rely on documentation largely written by providers with less experience and incentive to optimize documentation for billing, compared to experienced hospitalists. It’s plausible to speculate that the benefits associated with compensation for inpatient status for hospitals, compared to the risks of financial penalty associated with billing under inpatient status, could be different for academic than for nonacademic hospitalist groups, due to the differences in the quality of documentation between the two practice types, and that academic HMGs, or the hospitals they work with, see the risks associated with inpatient status billing as high enough to change billing practices. Nonacademic hospitalist groups, on the other hand, may rely on the experience of their retained hospitalists to document justification for inpatient status more effectively, and may thus maximize the financial benefit of inpatient status utilization sufficiently to overcome associated financial risks.

In an ever-changing reimbursement and political advocacy landscape, future SHM surveys will be pivotal in assessing what happens with trends surrounding use of observation status for episodes of hospital care.

Dr. Smith is a hospitalist and assistant professor at Northwestern University in Chicago, Ill., and a member of SHM’s Practice Analysis Committee.

Insurers’ use of certain criteria to separate hospital stays into inpatient or observation status remains widespread. Observation status ensures provider reimbursement for hospitalizations deemed necessary by clinical judgment but not qualifying as inpatient care. Admission under observation status impacts the patient’s financial burden, as well, with observation admissions typically associated with increased out-of-pocket costs.

Although hospitals have always faced decreased reimbursement for observation admissions (compared to inpatient admissions), new penalties attached to readmission for patients discharged from an inpatient stay raise the potential to impact hospitalist practice by incentivizing increased use of observation status for hospitalizations in order to avoid readmission penalties.

Have readmission penalties associated with inpatient admissions actually led to increased use of observation status by hospitalist groups?

SHM’s 2014 State of Hospital Medicine report provides insight into this question. In groups serving adults only, observation discharges accounted for 16.1% of all discharges (see Figure 1). If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

In groups serving adults only, observation discharges accounted for 16.1% of all discharges. If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

–Dr. Smith

The question of determining whether to bill episodes as inpatient or observation status was asked in the 2012 survey, as well, though by a different methodology: 20% of admissions were billed as observation status by hospitalist practices seeing adults only. Even with some observation admissions in 2012 being converted to inpatient status later in the hospital stay (a factor accounted for in the 2014 survey by changing the wording of the survey so that it asks about status at discharge), not much overall change in hospitalist group practice can be appreciated.

Does the overall observation status use rate tell the whole story?

When 2012 and 2014 survey data are separated by academic status, a clear change in practice over time can be seen. Academic HMGs experienced an increase in use of observation status, from 15.3% of admissions in 2012 to 19.4% of discharges in 2014 (or 22.8% in 2014, if same-day hospital stay responses are added to the observation data). In comparison, nonacademic hospitalist practices reported a decrease in observation status utilization, from 20.4% of admissions in 2012 to 15.6% of discharges in 2014 (or 19.2%, accounting for same-day discharges as observation status).

Academic HMGs, which frequently rely on housestaff for the finer points of patient care documentation, must consequently rely on documentation largely written by providers with less experience and incentive to optimize documentation for billing, compared to experienced hospitalists. It’s plausible to speculate that the benefits associated with compensation for inpatient status for hospitals, compared to the risks of financial penalty associated with billing under inpatient status, could be different for academic than for nonacademic hospitalist groups, due to the differences in the quality of documentation between the two practice types, and that academic HMGs, or the hospitals they work with, see the risks associated with inpatient status billing as high enough to change billing practices. Nonacademic hospitalist groups, on the other hand, may rely on the experience of their retained hospitalists to document justification for inpatient status more effectively, and may thus maximize the financial benefit of inpatient status utilization sufficiently to overcome associated financial risks.

In an ever-changing reimbursement and political advocacy landscape, future SHM surveys will be pivotal in assessing what happens with trends surrounding use of observation status for episodes of hospital care.

Dr. Smith is a hospitalist and assistant professor at Northwestern University in Chicago, Ill., and a member of SHM’s Practice Analysis Committee.

Insurers’ use of certain criteria to separate hospital stays into inpatient or observation status remains widespread. Observation status ensures provider reimbursement for hospitalizations deemed necessary by clinical judgment but not qualifying as inpatient care. Admission under observation status impacts the patient’s financial burden, as well, with observation admissions typically associated with increased out-of-pocket costs.

Although hospitals have always faced decreased reimbursement for observation admissions (compared to inpatient admissions), new penalties attached to readmission for patients discharged from an inpatient stay raise the potential to impact hospitalist practice by incentivizing increased use of observation status for hospitalizations in order to avoid readmission penalties.

Have readmission penalties associated with inpatient admissions actually led to increased use of observation status by hospitalist groups?

SHM’s 2014 State of Hospital Medicine report provides insight into this question. In groups serving adults only, observation discharges accounted for 16.1% of all discharges (see Figure 1). If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

In groups serving adults only, observation discharges accounted for 16.1% of all discharges. If the survey’s reported same-day admission and discharge rate of 3.5%, collected separately this year, can be assumed to be largely reflective of observation status discharges, then the true percentage of discharges under observation status is likely closer to 19.6%.

–Dr. Smith

The question of determining whether to bill episodes as inpatient or observation status was asked in the 2012 survey, as well, though by a different methodology: 20% of admissions were billed as observation status by hospitalist practices seeing adults only. Even with some observation admissions in 2012 being converted to inpatient status later in the hospital stay (a factor accounted for in the 2014 survey by changing the wording of the survey so that it asks about status at discharge), not much overall change in hospitalist group practice can be appreciated.

Does the overall observation status use rate tell the whole story?

When 2012 and 2014 survey data are separated by academic status, a clear change in practice over time can be seen. Academic HMGs experienced an increase in use of observation status, from 15.3% of admissions in 2012 to 19.4% of discharges in 2014 (or 22.8% in 2014, if same-day hospital stay responses are added to the observation data). In comparison, nonacademic hospitalist practices reported a decrease in observation status utilization, from 20.4% of admissions in 2012 to 15.6% of discharges in 2014 (or 19.2%, accounting for same-day discharges as observation status).

Academic HMGs, which frequently rely on housestaff for the finer points of patient care documentation, must consequently rely on documentation largely written by providers with less experience and incentive to optimize documentation for billing, compared to experienced hospitalists. It’s plausible to speculate that the benefits associated with compensation for inpatient status for hospitals, compared to the risks of financial penalty associated with billing under inpatient status, could be different for academic than for nonacademic hospitalist groups, due to the differences in the quality of documentation between the two practice types, and that academic HMGs, or the hospitals they work with, see the risks associated with inpatient status billing as high enough to change billing practices. Nonacademic hospitalist groups, on the other hand, may rely on the experience of their retained hospitalists to document justification for inpatient status more effectively, and may thus maximize the financial benefit of inpatient status utilization sufficiently to overcome associated financial risks.

In an ever-changing reimbursement and political advocacy landscape, future SHM surveys will be pivotal in assessing what happens with trends surrounding use of observation status for episodes of hospital care.

Dr. Smith is a hospitalist and assistant professor at Northwestern University in Chicago, Ill., and a member of SHM’s Practice Analysis Committee.

Question: Charges of homicide have been successfully brought against doctors in the following situations except:

A. Withholding life-sustaining treatment.

B. Euthanasia.

C. Negligent treatment of a patient.

D. Overprescription of controlled substances.

Answer: A. Homicideis any act that causes the death of a human being with criminal intent and without legal justification. It comprises several crimes of varying severity, with murder being the most serious (requiring “malice aforethought”). Depending on the intent of the perpetrator and/or the presence of mitigating/aggravating circumstances, jurisdictions have subdivided homicide into categories such as first- and second-degree murder, voluntary and involuntary manslaughter, negligent homicide, and others.

Discontinuing futile medical treatment that ends with patient demise raises the specter of criminal prosecution for homicide. However, prosecution of doctors under such circumstances has failed. The seminal case is Barber v. Superior Court (147 Cal. App. 3d 1006 (1983)), in which the state of California brought murder charges against two doctors for discontinuing intravenous fluids and nutrition in a comatose patient.

The patient, a 55-year-old security guard, sustained a cardiopulmonary arrest following surgery for intestinal obstruction. Irreversible brain damage resulted, leaving him in a vegetative state. His family allegedly requested that life support measures and intravenous fluids be discontinued, to which the doctors complied, and the patient died 6 days later.

After a preliminary pretrial hearing, the magistrate dismissed the charges; but a trial court reinstated them. The court of appeals, however, viewed the defendant’s conduct in discontinuing intravenous fluids as an omission rather than an affirmative action, and found that a physician has no duty to continue treatment once it is proven to be ineffective.

The appeals court recognized that “a physician is authorized under the standards of medical practice to discontinue a form of therapy which in his medical judgment is useless. … If the treating physicians have determined that continued use of a respirator is useless, then they may decide to discontinue it without fear of civil or criminal liability.”

In rejecting the distinction between ordinary and extraordinary care, the court dismissed the prosecutor’s contention that unlike the respirator, fluids and nutrition represented ordinary care and therefore should never be withheld.

It concluded that “the petitioners’ omission to continue treatment under the circumstances, though intentional and with knowledge that the patient would die, was not an unlawful failure to perform a legal duty.” And because no criminal liability attaches for failure to act (i.e., an omission) unless there is a legal duty to act affirmatively, it issued a writ of prohibition restraining the lower court from taking any further action on the matter.

The U.S. Supreme Court has since validated the distinction between “letting die” and an affirmative action taken with the intention to cause death, such as the administration of a lethal injection. The former is ethical and legal, conforming to medical norms, while the latter amounts to murder (Vacco v. Quill (117 S. Ct. 2293 (1997)).

With these developments, physicians therefore need not worry about criminal prosecution for carrying out Barber-like noneuthanasia, end-of-life actions that result in the death of their patients.

On the other hand, those who act directly to end the life of a patient, even one who freely requests death, may face criminal prosecution.

The most notorious example is that of retired Michigan pathologist Dr. Jack Kevorkian, who was found guilty of the second-degree murder of Thomas Youk, a 52-year-old race-car driver with terminal Lou Gehrig’s disease. Dr. Kevorkian injected a lethal mixture of Seconal, Anectine, and potassium chloride to end the patient’s life.

At trial, Dr. Kevorkian dismissed his lawyer and served ineffectively in his own defense, never taking the witness stand. Found guilty by a jury and sentenced to 10-25 years in prison, he served just more than 8 years until 2007, when he was released for good behavior. Previous charges by the state of Michigan against Dr. Kevorkian for assisting in the suicide of some 130 patients had proven unsuccessful.

This case spawned a nationwide debate on physician-directed deaths, with a few states now legalizing physician-assisted suicide, although euthanasia remains illegal throughout the nation.

In general, the remedy sought in a medical wrongful death case lies in a malpractice civil lawsuit against the negligent doctor. Sometimes, the plaintiff may assert that there was gross negligence where the conduct was particularly blameworthy, and if proven, the jury may award punitive damages.

Rarely, however, does the level of misconduct rise to that of criminal negligence. Here, the burden of proof for a conviction requires evidence beyond reasonable doubt, rather than the lower “more probable than not” evidentiary standard required in a civil lawsuit.

However, in cases where the physician’s conduct has markedly deviated from the standard of care, doctors have been successfully prosecuted for their “criminal” conduct.

For example, in an English case, an anesthesiologist was convicted of manslaughter in the death of a patient undergoing surgery for a detached retina. During surgery, the patient’s ventilation was interrupted because of accidental disconnection of the endotracheal tube for 4 minutes, leading to a cardiac arrest. An alarm had apparently sounded but was not noticed. The injury would not have occurred had the doctor attended to the patient instead of being away from the operating room.

The tragic death of pop star Michael Jackson in 2009 is another example. Dr. Conrad Murray, a cardiologist who was Jackson’s personal physician, had used the surgical anesthetic propofol to treat Jackson’s insomnia in a bedroom setting without monitoring or resuscitation equipment. Concurrent use of the sedative lorazepam exacerbated the effect of propofol. The prosecution characterized Dr. Murray’s conduct as “egregious, unethical, and unconscionable,” which violated medical standards and amounted to criminal negligence. He was found guilty of involuntary manslaughter, and the state sentenced him to a 4-year prison term.

A new trend appears to be developing toward prosecuting doctors whose overprescription of controlled substances results in patient deaths.

According to a recent news report, New York for the first time convicted a doctor of manslaughter in the overdose deaths of patients from oxycodone and Xanax.¹ Some of the patients were reportedly prescribed as many as 500-800 pills over a 5-6 week period. Dr. Stan Li, an anesthesiologist and pain management specialist, allegedly saw up to 90 patients a day in his Queens, N.Y., weekend storefront clinic, charging them on a per-prescription basis. In his defense, Dr. Li claimed that he was simply trying to help suffering people who misused medications and who misled him (“tough patients and good liars”).

Meanwhile, a similar scenario played out in Oklahoma.² There, Dr. William Valuck, a pain management doctor, pleaded guilty to eight counts of second-degree murder in connection with several drug overdose deaths. He entered into a plea bargain with Oklahoma prosecutors and will serve 8 years in prison. Dr. Valuck had reportedly prescribed more controlled drugs than any other physician in the state of Oklahoma, which included hydrocodone, oxycodone, alprazolam, Valium, and Soma, sometimes as many as 600 pills at a time. He allegedly accepted only cash payment for the office visits, and review of his patient files revealed inadequate assessment of patient complaints or physical findings to justify the prescriptions.

Most physicians are unlikely to ever face the specter of criminal prosecution based on their medical performance. Only in the most egregious of circumstances have physicians been successfully prosecuted for homicide.

As requests for physicians to withhold or withdraw life-sustaining treatments grow, physicians may find themselves questioning what acts or omissions they may legally perform. Unless the legal landscape changes, however, it appears that the forgoing of life-sustaining treatments in the typical clinical context will not subject physicians to criminal prosecution.

References

1. “NY doctor convicted of manslaughter in 2 overdoses,” July 18, 2014 (http://bigstory.ap.org/article/ny-doctor-convicted-2-patients-overdose-deaths).

2. “Ex-doctor pleads guilty in overdose deaths,” Aug. 13, 2014 (www.usatoday.com/story/news/nation/2014/08/13/ex-doctor-guilty-deaths/14022735).

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at siang@hawaii.edu.

Question: Charges of homicide have been successfully brought against doctors in the following situations except:

A. Withholding life-sustaining treatment.

B. Euthanasia.

C. Negligent treatment of a patient.

D. Overprescription of controlled substances.

Answer: A. Homicideis any act that causes the death of a human being with criminal intent and without legal justification. It comprises several crimes of varying severity, with murder being the most serious (requiring “malice aforethought”). Depending on the intent of the perpetrator and/or the presence of mitigating/aggravating circumstances, jurisdictions have subdivided homicide into categories such as first- and second-degree murder, voluntary and involuntary manslaughter, negligent homicide, and others.

Discontinuing futile medical treatment that ends with patient demise raises the specter of criminal prosecution for homicide. However, prosecution of doctors under such circumstances has failed. The seminal case is Barber v. Superior Court (147 Cal. App. 3d 1006 (1983)), in which the state of California brought murder charges against two doctors for discontinuing intravenous fluids and nutrition in a comatose patient.

The patient, a 55-year-old security guard, sustained a cardiopulmonary arrest following surgery for intestinal obstruction. Irreversible brain damage resulted, leaving him in a vegetative state. His family allegedly requested that life support measures and intravenous fluids be discontinued, to which the doctors complied, and the patient died 6 days later.

After a preliminary pretrial hearing, the magistrate dismissed the charges; but a trial court reinstated them. The court of appeals, however, viewed the defendant’s conduct in discontinuing intravenous fluids as an omission rather than an affirmative action, and found that a physician has no duty to continue treatment once it is proven to be ineffective.

The appeals court recognized that “a physician is authorized under the standards of medical practice to discontinue a form of therapy which in his medical judgment is useless. … If the treating physicians have determined that continued use of a respirator is useless, then they may decide to discontinue it without fear of civil or criminal liability.”

In rejecting the distinction between ordinary and extraordinary care, the court dismissed the prosecutor’s contention that unlike the respirator, fluids and nutrition represented ordinary care and therefore should never be withheld.

It concluded that “the petitioners’ omission to continue treatment under the circumstances, though intentional and with knowledge that the patient would die, was not an unlawful failure to perform a legal duty.” And because no criminal liability attaches for failure to act (i.e., an omission) unless there is a legal duty to act affirmatively, it issued a writ of prohibition restraining the lower court from taking any further action on the matter.

The U.S. Supreme Court has since validated the distinction between “letting die” and an affirmative action taken with the intention to cause death, such as the administration of a lethal injection. The former is ethical and legal, conforming to medical norms, while the latter amounts to murder (Vacco v. Quill (117 S. Ct. 2293 (1997)).

With these developments, physicians therefore need not worry about criminal prosecution for carrying out Barber-like noneuthanasia, end-of-life actions that result in the death of their patients.

On the other hand, those who act directly to end the life of a patient, even one who freely requests death, may face criminal prosecution.

The most notorious example is that of retired Michigan pathologist Dr. Jack Kevorkian, who was found guilty of the second-degree murder of Thomas Youk, a 52-year-old race-car driver with terminal Lou Gehrig’s disease. Dr. Kevorkian injected a lethal mixture of Seconal, Anectine, and potassium chloride to end the patient’s life.

At trial, Dr. Kevorkian dismissed his lawyer and served ineffectively in his own defense, never taking the witness stand. Found guilty by a jury and sentenced to 10-25 years in prison, he served just more than 8 years until 2007, when he was released for good behavior. Previous charges by the state of Michigan against Dr. Kevorkian for assisting in the suicide of some 130 patients had proven unsuccessful.

This case spawned a nationwide debate on physician-directed deaths, with a few states now legalizing physician-assisted suicide, although euthanasia remains illegal throughout the nation.

In general, the remedy sought in a medical wrongful death case lies in a malpractice civil lawsuit against the negligent doctor. Sometimes, the plaintiff may assert that there was gross negligence where the conduct was particularly blameworthy, and if proven, the jury may award punitive damages.

Rarely, however, does the level of misconduct rise to that of criminal negligence. Here, the burden of proof for a conviction requires evidence beyond reasonable doubt, rather than the lower “more probable than not” evidentiary standard required in a civil lawsuit.

However, in cases where the physician’s conduct has markedly deviated from the standard of care, doctors have been successfully prosecuted for their “criminal” conduct.

For example, in an English case, an anesthesiologist was convicted of manslaughter in the death of a patient undergoing surgery for a detached retina. During surgery, the patient’s ventilation was interrupted because of accidental disconnection of the endotracheal tube for 4 minutes, leading to a cardiac arrest. An alarm had apparently sounded but was not noticed. The injury would not have occurred had the doctor attended to the patient instead of being away from the operating room.

The tragic death of pop star Michael Jackson in 2009 is another example. Dr. Conrad Murray, a cardiologist who was Jackson’s personal physician, had used the surgical anesthetic propofol to treat Jackson’s insomnia in a bedroom setting without monitoring or resuscitation equipment. Concurrent use of the sedative lorazepam exacerbated the effect of propofol. The prosecution characterized Dr. Murray’s conduct as “egregious, unethical, and unconscionable,” which violated medical standards and amounted to criminal negligence. He was found guilty of involuntary manslaughter, and the state sentenced him to a 4-year prison term.

A new trend appears to be developing toward prosecuting doctors whose overprescription of controlled substances results in patient deaths.

According to a recent news report, New York for the first time convicted a doctor of manslaughter in the overdose deaths of patients from oxycodone and Xanax.¹ Some of the patients were reportedly prescribed as many as 500-800 pills over a 5-6 week period. Dr. Stan Li, an anesthesiologist and pain management specialist, allegedly saw up to 90 patients a day in his Queens, N.Y., weekend storefront clinic, charging them on a per-prescription basis. In his defense, Dr. Li claimed that he was simply trying to help suffering people who misused medications and who misled him (“tough patients and good liars”).

Meanwhile, a similar scenario played out in Oklahoma.² There, Dr. William Valuck, a pain management doctor, pleaded guilty to eight counts of second-degree murder in connection with several drug overdose deaths. He entered into a plea bargain with Oklahoma prosecutors and will serve 8 years in prison. Dr. Valuck had reportedly prescribed more controlled drugs than any other physician in the state of Oklahoma, which included hydrocodone, oxycodone, alprazolam, Valium, and Soma, sometimes as many as 600 pills at a time. He allegedly accepted only cash payment for the office visits, and review of his patient files revealed inadequate assessment of patient complaints or physical findings to justify the prescriptions.

Most physicians are unlikely to ever face the specter of criminal prosecution based on their medical performance. Only in the most egregious of circumstances have physicians been successfully prosecuted for homicide.

As requests for physicians to withhold or withdraw life-sustaining treatments grow, physicians may find themselves questioning what acts or omissions they may legally perform. Unless the legal landscape changes, however, it appears that the forgoing of life-sustaining treatments in the typical clinical context will not subject physicians to criminal prosecution.

References

1. “NY doctor convicted of manslaughter in 2 overdoses,” July 18, 2014 (http://bigstory.ap.org/article/ny-doctor-convicted-2-patients-overdose-deaths).

2. “Ex-doctor pleads guilty in overdose deaths,” Aug. 13, 2014 (www.usatoday.com/story/news/nation/2014/08/13/ex-doctor-guilty-deaths/14022735).

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at siang@hawaii.edu.

Question: Charges of homicide have been successfully brought against doctors in the following situations except:

A. Withholding life-sustaining treatment.

B. Euthanasia.

C. Negligent treatment of a patient.

D. Overprescription of controlled substances.

Answer: A. Homicideis any act that causes the death of a human being with criminal intent and without legal justification. It comprises several crimes of varying severity, with murder being the most serious (requiring “malice aforethought”). Depending on the intent of the perpetrator and/or the presence of mitigating/aggravating circumstances, jurisdictions have subdivided homicide into categories such as first- and second-degree murder, voluntary and involuntary manslaughter, negligent homicide, and others.

Discontinuing futile medical treatment that ends with patient demise raises the specter of criminal prosecution for homicide. However, prosecution of doctors under such circumstances has failed. The seminal case is Barber v. Superior Court (147 Cal. App. 3d 1006 (1983)), in which the state of California brought murder charges against two doctors for discontinuing intravenous fluids and nutrition in a comatose patient.

The patient, a 55-year-old security guard, sustained a cardiopulmonary arrest following surgery for intestinal obstruction. Irreversible brain damage resulted, leaving him in a vegetative state. His family allegedly requested that life support measures and intravenous fluids be discontinued, to which the doctors complied, and the patient died 6 days later.

After a preliminary pretrial hearing, the magistrate dismissed the charges; but a trial court reinstated them. The court of appeals, however, viewed the defendant’s conduct in discontinuing intravenous fluids as an omission rather than an affirmative action, and found that a physician has no duty to continue treatment once it is proven to be ineffective.

The appeals court recognized that “a physician is authorized under the standards of medical practice to discontinue a form of therapy which in his medical judgment is useless. … If the treating physicians have determined that continued use of a respirator is useless, then they may decide to discontinue it without fear of civil or criminal liability.”

In rejecting the distinction between ordinary and extraordinary care, the court dismissed the prosecutor’s contention that unlike the respirator, fluids and nutrition represented ordinary care and therefore should never be withheld.

It concluded that “the petitioners’ omission to continue treatment under the circumstances, though intentional and with knowledge that the patient would die, was not an unlawful failure to perform a legal duty.” And because no criminal liability attaches for failure to act (i.e., an omission) unless there is a legal duty to act affirmatively, it issued a writ of prohibition restraining the lower court from taking any further action on the matter.

The U.S. Supreme Court has since validated the distinction between “letting die” and an affirmative action taken with the intention to cause death, such as the administration of a lethal injection. The former is ethical and legal, conforming to medical norms, while the latter amounts to murder (Vacco v. Quill (117 S. Ct. 2293 (1997)).

With these developments, physicians therefore need not worry about criminal prosecution for carrying out Barber-like noneuthanasia, end-of-life actions that result in the death of their patients.

On the other hand, those who act directly to end the life of a patient, even one who freely requests death, may face criminal prosecution.

The most notorious example is that of retired Michigan pathologist Dr. Jack Kevorkian, who was found guilty of the second-degree murder of Thomas Youk, a 52-year-old race-car driver with terminal Lou Gehrig’s disease. Dr. Kevorkian injected a lethal mixture of Seconal, Anectine, and potassium chloride to end the patient’s life.

At trial, Dr. Kevorkian dismissed his lawyer and served ineffectively in his own defense, never taking the witness stand. Found guilty by a jury and sentenced to 10-25 years in prison, he served just more than 8 years until 2007, when he was released for good behavior. Previous charges by the state of Michigan against Dr. Kevorkian for assisting in the suicide of some 130 patients had proven unsuccessful.

This case spawned a nationwide debate on physician-directed deaths, with a few states now legalizing physician-assisted suicide, although euthanasia remains illegal throughout the nation.

In general, the remedy sought in a medical wrongful death case lies in a malpractice civil lawsuit against the negligent doctor. Sometimes, the plaintiff may assert that there was gross negligence where the conduct was particularly blameworthy, and if proven, the jury may award punitive damages.

Rarely, however, does the level of misconduct rise to that of criminal negligence. Here, the burden of proof for a conviction requires evidence beyond reasonable doubt, rather than the lower “more probable than not” evidentiary standard required in a civil lawsuit.

However, in cases where the physician’s conduct has markedly deviated from the standard of care, doctors have been successfully prosecuted for their “criminal” conduct.

For example, in an English case, an anesthesiologist was convicted of manslaughter in the death of a patient undergoing surgery for a detached retina. During surgery, the patient’s ventilation was interrupted because of accidental disconnection of the endotracheal tube for 4 minutes, leading to a cardiac arrest. An alarm had apparently sounded but was not noticed. The injury would not have occurred had the doctor attended to the patient instead of being away from the operating room.

The tragic death of pop star Michael Jackson in 2009 is another example. Dr. Conrad Murray, a cardiologist who was Jackson’s personal physician, had used the surgical anesthetic propofol to treat Jackson’s insomnia in a bedroom setting without monitoring or resuscitation equipment. Concurrent use of the sedative lorazepam exacerbated the effect of propofol. The prosecution characterized Dr. Murray’s conduct as “egregious, unethical, and unconscionable,” which violated medical standards and amounted to criminal negligence. He was found guilty of involuntary manslaughter, and the state sentenced him to a 4-year prison term.

A new trend appears to be developing toward prosecuting doctors whose overprescription of controlled substances results in patient deaths.

According to a recent news report, New York for the first time convicted a doctor of manslaughter in the overdose deaths of patients from oxycodone and Xanax.¹ Some of the patients were reportedly prescribed as many as 500-800 pills over a 5-6 week period. Dr. Stan Li, an anesthesiologist and pain management specialist, allegedly saw up to 90 patients a day in his Queens, N.Y., weekend storefront clinic, charging them on a per-prescription basis. In his defense, Dr. Li claimed that he was simply trying to help suffering people who misused medications and who misled him (“tough patients and good liars”).

Meanwhile, a similar scenario played out in Oklahoma.² There, Dr. William Valuck, a pain management doctor, pleaded guilty to eight counts of second-degree murder in connection with several drug overdose deaths. He entered into a plea bargain with Oklahoma prosecutors and will serve 8 years in prison. Dr. Valuck had reportedly prescribed more controlled drugs than any other physician in the state of Oklahoma, which included hydrocodone, oxycodone, alprazolam, Valium, and Soma, sometimes as many as 600 pills at a time. He allegedly accepted only cash payment for the office visits, and review of his patient files revealed inadequate assessment of patient complaints or physical findings to justify the prescriptions.

Most physicians are unlikely to ever face the specter of criminal prosecution based on their medical performance. Only in the most egregious of circumstances have physicians been successfully prosecuted for homicide.

As requests for physicians to withhold or withdraw life-sustaining treatments grow, physicians may find themselves questioning what acts or omissions they may legally perform. Unless the legal landscape changes, however, it appears that the forgoing of life-sustaining treatments in the typical clinical context will not subject physicians to criminal prosecution.

References

1. “NY doctor convicted of manslaughter in 2 overdoses,” July 18, 2014 (http://bigstory.ap.org/article/ny-doctor-convicted-2-patients-overdose-deaths).

2. “Ex-doctor pleads guilty in overdose deaths,” Aug. 13, 2014 (www.usatoday.com/story/news/nation/2014/08/13/ex-doctor-guilty-deaths/14022735).

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii, and directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at siang@hawaii.edu.

Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?

Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.

Study design: Observational, retrospective, cohort study.

Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.

Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).

Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.

Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.

Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.

Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.

Citation: Chen LM, Wilk AS, Thumma JR, Birkmeyer JD, Banerjee M. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med. 2014;174(9):1470-1477.

Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?

Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.

Study design: Observational, retrospective, cohort study.

Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.

Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).

Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.

Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.

Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.

Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.

Citation: Chen LM, Wilk AS, Thumma JR, Birkmeyer JD, Banerjee M. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med. 2014;174(9):1470-1477.

Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?

Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.

Study design: Observational, retrospective, cohort study.

Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.

Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).

Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.

Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.

Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.

Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.

Citation: Chen LM, Wilk AS, Thumma JR, Birkmeyer JD, Banerjee M. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med. 2014;174(9):1470-1477.

Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?

Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.

Study design: Systematic review, network meta-analysis (NMA).

Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).

Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.

In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).

These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.

These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.

Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.

Citation: Rochwerg B, Alhazzani W, Sindi A, et al. Fluids in Sepsis and Septic Shock Group. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161(5):347-355.

Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?

Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.

Study design: Systematic review, network meta-analysis (NMA).

Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).

Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.

In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).

These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.

These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.

Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.

Citation: Rochwerg B, Alhazzani W, Sindi A, et al. Fluids in Sepsis and Septic Shock Group. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161(5):347-355.

Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?

Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.

Study design: Systematic review, network meta-analysis (NMA).

Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).

Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.

In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).

These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.

These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.

Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.

Citation: Rochwerg B, Alhazzani W, Sindi A, et al. Fluids in Sepsis and Septic Shock Group. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161(5):347-355.

Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?

Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.

Study design: Retrospective cohort study.

Setting: Fee-for-service Medicare beneficiaries.

Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.

Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.

The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.

Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.

Citation: Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014;174(8):1273-1280.

Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?

Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.

Study design: Retrospective cohort study.

Setting: Fee-for-service Medicare beneficiaries.

Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.

Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.

The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.

Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.

Citation: Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014;174(8):1273-1280.

Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?

Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.

Study design: Retrospective cohort study.

Setting: Fee-for-service Medicare beneficiaries.

Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.

Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.

The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.

Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.

Citation: Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014;174(8):1273-1280.

Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?

Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.

Study design: Retrospective, cohort study.

Setting: University-affiliated VA hospital involving all noncardiac surgical patients.

Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).

It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.

Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.

Citation: Kazaure HS, Martin M, Yoon JK, Wren SM. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward. JAMA Surg. 2014;149(9):914-918.

Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?

Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.

Study design: Retrospective, cohort study.

Setting: University-affiliated VA hospital involving all noncardiac surgical patients.

Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).

It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.

Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.

Citation: Kazaure HS, Martin M, Yoon JK, Wren SM. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward. JAMA Surg. 2014;149(9):914-918.

Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?

Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.

Study design: Retrospective, cohort study.

Setting: University-affiliated VA hospital involving all noncardiac surgical patients.

Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).

It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.

Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.

Citation: Kazaure HS, Martin M, Yoon JK, Wren SM. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward. JAMA Surg. 2014;149(9):914-918.

Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?

Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.

Study design: Meta-analysis.

Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.

Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.

Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).

Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.

Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.

Citation: Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585.

Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?

Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.

Study design: Meta-analysis.

Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.

Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.

Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).

Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.

Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.

Citation: Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585.

Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?

Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.

Study design: Meta-analysis.

Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.

Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.

Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).

Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.

Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.

Citation: Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585.

Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?

Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.

Study design: Randomized controlled trial.

Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.

Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.

Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.

Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.

Citation: Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65.

Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?

Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.

Study design: Randomized controlled trial.

Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.

Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.

Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.

Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.

Citation: Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65.

Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?

Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.

Study design: Randomized controlled trial.

Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.

Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.

Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.

Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.

Citation: Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65.

Clinical question: Why do providers continue to transfuse blood products outside of recommended guidelines, despite best practice alerts (BPAs)?

Background: There is evidence that a restrictive approach to blood transfusion versus a liberal approach is beneficial in reducing cost, morbidity, and mortality. It is unclear why providers continue to order transfusions outside of recommended guidelines in spite of interruptive prompts.

Study design: Retrospective cohort.

Setting: Academic, tertiary care medical care center in California.

Synopsis: Researchers reviewed 10,642 blood transfusion-triggered BPAs. The BPA led to abortion of only 2% of the transfusions in this study. From the predefined institutional accepted transfusion indication list, acute bleeding was the most common (34%), followed by protocol-driven behaviors in specialty services, i.e., stem cell transplant service.

“Other” accounted for 56% of the responses; of these, only 37% entered a free text comment elaborating on the reason to override. Symptomatic anemia was the most common indication cited for these blood transfusions, followed by peri-operative transfusion and anticipation of imminent discharge. The vast majority of providers who interacted with the BPA were resident physicians (55%).

The major limitation of this study is the substantial portion (>60%) of nonspecific “other” overrides.

Bottom line: Protocol-driven behaviors and subjective indications for transfusion, such as symptomatic anemia, are unlikely to be influenced by BPAs.

Citation: Chen JH, Fang DZ, Goodnough LT, Evans KH, Porter ML, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts [published online ahead of print July 7, 2014]. J Hosp Med.

Clinical question: Why do providers continue to transfuse blood products outside of recommended guidelines, despite best practice alerts (BPAs)?

Background: There is evidence that a restrictive approach to blood transfusion versus a liberal approach is beneficial in reducing cost, morbidity, and mortality. It is unclear why providers continue to order transfusions outside of recommended guidelines in spite of interruptive prompts.

Study design: Retrospective cohort.

Setting: Academic, tertiary care medical care center in California.

Synopsis: Researchers reviewed 10,642 blood transfusion-triggered BPAs. The BPA led to abortion of only 2% of the transfusions in this study. From the predefined institutional accepted transfusion indication list, acute bleeding was the most common (34%), followed by protocol-driven behaviors in specialty services, i.e., stem cell transplant service.

“Other” accounted for 56% of the responses; of these, only 37% entered a free text comment elaborating on the reason to override. Symptomatic anemia was the most common indication cited for these blood transfusions, followed by peri-operative transfusion and anticipation of imminent discharge. The vast majority of providers who interacted with the BPA were resident physicians (55%).

The major limitation of this study is the substantial portion (>60%) of nonspecific “other” overrides.

Bottom line: Protocol-driven behaviors and subjective indications for transfusion, such as symptomatic anemia, are unlikely to be influenced by BPAs.

Citation: Chen JH, Fang DZ, Goodnough LT, Evans KH, Porter ML, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts [published online ahead of print July 7, 2014]. J Hosp Med.

Clinical question: Why do providers continue to transfuse blood products outside of recommended guidelines, despite best practice alerts (BPAs)?

Background: There is evidence that a restrictive approach to blood transfusion versus a liberal approach is beneficial in reducing cost, morbidity, and mortality. It is unclear why providers continue to order transfusions outside of recommended guidelines in spite of interruptive prompts.

Study design: Retrospective cohort.

Setting: Academic, tertiary care medical care center in California.

Synopsis: Researchers reviewed 10,642 blood transfusion-triggered BPAs. The BPA led to abortion of only 2% of the transfusions in this study. From the predefined institutional accepted transfusion indication list, acute bleeding was the most common (34%), followed by protocol-driven behaviors in specialty services, i.e., stem cell transplant service.

“Other” accounted for 56% of the responses; of these, only 37% entered a free text comment elaborating on the reason to override. Symptomatic anemia was the most common indication cited for these blood transfusions, followed by peri-operative transfusion and anticipation of imminent discharge. The vast majority of providers who interacted with the BPA were resident physicians (55%).

The major limitation of this study is the substantial portion (>60%) of nonspecific “other” overrides.

Bottom line: Protocol-driven behaviors and subjective indications for transfusion, such as symptomatic anemia, are unlikely to be influenced by BPAs.

Citation: Chen JH, Fang DZ, Goodnough LT, Evans KH, Porter ML, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts [published online ahead of print July 7, 2014]. J Hosp Med.

Clinical question: Is there an association between peri-operative AF and long-term risk of ischemic stroke in patients undergoing any type of surgery?

Background: Peri-operative AF is usually viewed as a transient response to physiological stress, and the long-term risk of stroke after peri-operative AF is unclear. The incidence of peri-operative AF ranges widely, from 1% to 40%. Data are scarce regarding the long-term risk of stroke from peri-operative AF in patients undergoing various types of surgery.

Study design: Retrospective cohort.

Setting: Nonfederal California acute care hospitals.

Synopsis: The goal of this study was to evaluate the relationship between peri-operative AF and long-term post-operative ischemic stroke by measuring newly diagnosed AF during the index hospitalization among 1,729,360 adult patients who underwent inpatient cardiac and noncardiac surgeries between 2007 and 2010. The main outcome variable was ischemic stroke in any hospital discharge diagnosis, which was adjusted for age, sex, race, insurance status, and cardiovascular comorbidities (hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, and chronic obstructive pulmonary disease). Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke after surgery; cumulative stroke rates were stratified by the CHA2DS2VASc score.

Of 1.73 million eligible patients with diagnoses of ischemic strokes after discharge from the index hospitalization for surgery, 24,711 had new-onset peri-operative AF during the index hospitalization, and 13,952 experienced a stroke after discharge.

At one year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% in those with peri-operative AF and 0.83% in those without AF. At one year after noncardiac surgery, cumulative rates of stroke were 1.47% in those with peri-operative AF and 0.36% in those without AF.

In a Cox proportional hazards analysis accounting for potential confounders, peri-operative AF was associated with subsequent stroke after both cardiac and noncardiac surgery.

Bottom line: Among patients hospitalized for surgery, peri-operative AF was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.

Citation: Gialdini G, Nearing K, Bhave PD, et al. Perioperative atrial fibrillation and the long-term risk of ischemic stroke. JAMA. 2014;312(6):616-622.

Clinical question: Is there an association between peri-operative AF and long-term risk of ischemic stroke in patients undergoing any type of surgery?

Background: Peri-operative AF is usually viewed as a transient response to physiological stress, and the long-term risk of stroke after peri-operative AF is unclear. The incidence of peri-operative AF ranges widely, from 1% to 40%. Data are scarce regarding the long-term risk of stroke from peri-operative AF in patients undergoing various types of surgery.

Study design: Retrospective cohort.

Setting: Nonfederal California acute care hospitals.

Synopsis: The goal of this study was to evaluate the relationship between peri-operative AF and long-term post-operative ischemic stroke by measuring newly diagnosed AF during the index hospitalization among 1,729,360 adult patients who underwent inpatient cardiac and noncardiac surgeries between 2007 and 2010. The main outcome variable was ischemic stroke in any hospital discharge diagnosis, which was adjusted for age, sex, race, insurance status, and cardiovascular comorbidities (hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, and chronic obstructive pulmonary disease). Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke after surgery; cumulative stroke rates were stratified by the CHA2DS2VASc score.

Of 1.73 million eligible patients with diagnoses of ischemic strokes after discharge from the index hospitalization for surgery, 24,711 had new-onset peri-operative AF during the index hospitalization, and 13,952 experienced a stroke after discharge.

At one year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% in those with peri-operative AF and 0.83% in those without AF. At one year after noncardiac surgery, cumulative rates of stroke were 1.47% in those with peri-operative AF and 0.36% in those without AF.

In a Cox proportional hazards analysis accounting for potential confounders, peri-operative AF was associated with subsequent stroke after both cardiac and noncardiac surgery.

Bottom line: Among patients hospitalized for surgery, peri-operative AF was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.

Citation: Gialdini G, Nearing K, Bhave PD, et al. Perioperative atrial fibrillation and the long-term risk of ischemic stroke. JAMA. 2014;312(6):616-622.

Clinical question: Is there an association between peri-operative AF and long-term risk of ischemic stroke in patients undergoing any type of surgery?

Background: Peri-operative AF is usually viewed as a transient response to physiological stress, and the long-term risk of stroke after peri-operative AF is unclear. The incidence of peri-operative AF ranges widely, from 1% to 40%. Data are scarce regarding the long-term risk of stroke from peri-operative AF in patients undergoing various types of surgery.

Study design: Retrospective cohort.

Setting: Nonfederal California acute care hospitals.

Synopsis: The goal of this study was to evaluate the relationship between peri-operative AF and long-term post-operative ischemic stroke by measuring newly diagnosed AF during the index hospitalization among 1,729,360 adult patients who underwent inpatient cardiac and noncardiac surgeries between 2007 and 2010. The main outcome variable was ischemic stroke in any hospital discharge diagnosis, which was adjusted for age, sex, race, insurance status, and cardiovascular comorbidities (hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, and chronic obstructive pulmonary disease). Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke after surgery; cumulative stroke rates were stratified by the CHA2DS2VASc score.

Of 1.73 million eligible patients with diagnoses of ischemic strokes after discharge from the index hospitalization for surgery, 24,711 had new-onset peri-operative AF during the index hospitalization, and 13,952 experienced a stroke after discharge.

At one year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% in those with peri-operative AF and 0.83% in those without AF. At one year after noncardiac surgery, cumulative rates of stroke were 1.47% in those with peri-operative AF and 0.36% in those without AF.

In a Cox proportional hazards analysis accounting for potential confounders, peri-operative AF was associated with subsequent stroke after both cardiac and noncardiac surgery.

Bottom line: Among patients hospitalized for surgery, peri-operative AF was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.

Citation: Gialdini G, Nearing K, Bhave PD, et al. Perioperative atrial fibrillation and the long-term risk of ischemic stroke. JAMA. 2014;312(6):616-622.