Patient Care

Background

Heart failure (HF) is the No. 1 cause of both hospitalization and readmission among Americans 65 years and older.1 Hospitalizations in the HF population are associated with poor patient outcomes (30% mortality in the following year) and high costs, accounting for approximately 70% of the $32 billion spent on HF care annually in the United States.¹ In 2009, the Centers for Medicare & Medicaid Services (CMS) introduced the 30-day, risk-standardized, all-cause readmission for HF as an indicator of quality and efficiency of care, which has since been incorporated into Medicare’s value-based purchasing program.²

HF is a complex syndrome that is associated with multiple comorbidities. Appropriate to these issues, management is multifaceted and involves care across the spectrum of disease:

• Diagnosing and treating underlying causes;
• Minimizing exacerbants;
• Optimizing management of comorbidities;
• Addressing psychosocial and environmental issues beyond the hospital; and
• Confronting end-of-life care.

In order to address this continuum of disease management, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) simultaneously released a new Guideline for the Management of HF in June in the Journal of the American College of Cardiology and Circulation.^3,4 This update was developed in collaboration with the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and the International Society for Heart and Lung Transplantation. The goals of the document are to improve quality of care, optimize patient outcomes, and advance the efficient use of healthcare resources. The guideline includes important recommendations for overall care, but particularly for hospital-based care and transitions of care that are largely the purview of hospitalists.

Guideline Update

The 2013 guideline is the third revision of the original guideline that was released in 2000. Despite being a complete rewrite of the 2009 HF guideline, the updated document contains relatively few changes to the recommendations that are Class I (should be performed) and III (no benefit or harm). The most significant randomized controlled trials in HF patients that have been published since the 2009 guideline include EMPHASIS-HF5 and MADIT-CRT/RAFT, which expand indications for aldosterone antagonists (AA) and cardiac resyncronization therapy (CRT), respectively, to patients with mild symptoms.^5,6,7 Additionally, the WARCEF trial was published, which failed to demonstrate a significant difference in death, ischemic stroke, or intracerebral hemorrhage between treatment with warfarin or aspirin in patients with HF and reduced left ventricular ejection fraction (LVEF) in sinus rhythm.⁸

The most notable updates from the 2009 guideline include (* = Class I and III indications):

• The definition of HF has been revised to include: 1) HF with reduced ejection fraction (HFrEF; LVEF ≤40%), 2) HF failure with preserved ejection fraction (HFpEF; LVEF ≥50%), 3) HFpEF, borderline (LVEF 41-49%), and 4) HFpEF, improved (LVEF >40%).
• In the hospitalized patient, measurement of brain natriuretic peptide (BNP) or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis.*
• AA should be used in patients with New York Heart Association (NYHA) functional Class II-IV and LVEF ≤35% unless contraindicated (creatinine ≤2.5 mg/dL in men, ≤2.0 mg/dL in women, and potassium <5.0 mEq/L).*
• CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block with a QRS duration of ³150 ms, and NYHA functional Class II-IV on guideline-directed medical therapy (GDMT).*
• Anticoagulation should not be used in patients with chronic HFrEF without atrial fibrillation, prior thromboembolic event, or cardioembolic source.*
• Transitions of care and GDMT can be improved by employing the following: 1) use of performance-improvement systems to identify HF patients, 2) development of multidisciplinary HF disease-management programs for patients at high risk of readmission, and 3) placing phone calls to the patient within three days of discharge and scheduling a follow-up visit within seven to 14 days.

Analysis

Overall, the new guideline provides a thorough reassessment and expert analysis on the diagnosis and management of HF for both inpatient and outpatient care. The authors introduce the phrase “guideline-directed medical therapy” (GDMT) to emphasize the smaller set of recommendations that constitute optimal medical therapy for HF patients. This designation, encompassing primarily Class I recommendations, helps providers rapidly determine the optimal treatment course for an individual patient. The mainstay of GDMT in HFrEF patients remains angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB) when ACE-I-intolerant, beta-blockers, and, in select patients, AA, hydralazine-nitrates, and diuretics.

A major shift in focus is seen in the new guideline with a greater emphasis on improved patient-centered outcomes across the spectrum of the disease. HF requires a continuum of care, from screening and genetic testing of family members of patients with idiopathic cardiomyopathy to conversations about palliative care and hospice. To this end, the authors highlight quality of life, shared decision-making, care coordination, transitions of care, and appropriateness of palliative care in a chronic disease state.

Further, the guideline expands upon previous recommendations for compliance with performance and quality metrics. Quality of care and adherence to performance measures of HF patients are becoming increasingly recognized, particularly in the hospital setting. The guideline offers recommendations for transitions of care in the hospitalized patient, which utilize systems of care coordination to ensure an evidence-based plan of care that includes the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up, and appropriate dietary and physical activities.

HM Takeaways

HF is one of the most common, most challenging diseases managed by hospitalists. The 2013 ACCF/AHA Guideline for the Management of HF, while providing a comprehensive summary of evidence with recommendations for the totality of care for these patients throughout the course of the disease, places heavy emphasis on management during hospitalization and transitions. This includes repositioning of performance measures involving GDMT to better ensure optimal use of proven therapies in HFrEF, evidence-based steps to reduce readmissions, and greater recognition of the role of palliative care for patients with advanced disease.

Drs. McIlvennan and Allen are cardiologists in the Department of Medicine at the University of Colorado School of Medicine in Denver. Dr. Allen also works in the Colorado Health Outcomes Program.

References available at the-hospitalist.org.

Background

Heart failure (HF) is the No. 1 cause of both hospitalization and readmission among Americans 65 years and older.1 Hospitalizations in the HF population are associated with poor patient outcomes (30% mortality in the following year) and high costs, accounting for approximately 70% of the $32 billion spent on HF care annually in the United States.¹ In 2009, the Centers for Medicare & Medicaid Services (CMS) introduced the 30-day, risk-standardized, all-cause readmission for HF as an indicator of quality and efficiency of care, which has since been incorporated into Medicare’s value-based purchasing program.²

HF is a complex syndrome that is associated with multiple comorbidities. Appropriate to these issues, management is multifaceted and involves care across the spectrum of disease:

• Diagnosing and treating underlying causes;
• Minimizing exacerbants;
• Optimizing management of comorbidities;
• Addressing psychosocial and environmental issues beyond the hospital; and
• Confronting end-of-life care.

In order to address this continuum of disease management, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) simultaneously released a new Guideline for the Management of HF in June in the Journal of the American College of Cardiology and Circulation.^3,4 This update was developed in collaboration with the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and the International Society for Heart and Lung Transplantation. The goals of the document are to improve quality of care, optimize patient outcomes, and advance the efficient use of healthcare resources. The guideline includes important recommendations for overall care, but particularly for hospital-based care and transitions of care that are largely the purview of hospitalists.

Guideline Update

The 2013 guideline is the third revision of the original guideline that was released in 2000. Despite being a complete rewrite of the 2009 HF guideline, the updated document contains relatively few changes to the recommendations that are Class I (should be performed) and III (no benefit or harm). The most significant randomized controlled trials in HF patients that have been published since the 2009 guideline include EMPHASIS-HF5 and MADIT-CRT/RAFT, which expand indications for aldosterone antagonists (AA) and cardiac resyncronization therapy (CRT), respectively, to patients with mild symptoms.^5,6,7 Additionally, the WARCEF trial was published, which failed to demonstrate a significant difference in death, ischemic stroke, or intracerebral hemorrhage between treatment with warfarin or aspirin in patients with HF and reduced left ventricular ejection fraction (LVEF) in sinus rhythm.⁸

The most notable updates from the 2009 guideline include (* = Class I and III indications):

• The definition of HF has been revised to include: 1) HF with reduced ejection fraction (HFrEF; LVEF ≤40%), 2) HF failure with preserved ejection fraction (HFpEF; LVEF ≥50%), 3) HFpEF, borderline (LVEF 41-49%), and 4) HFpEF, improved (LVEF >40%).
• In the hospitalized patient, measurement of brain natriuretic peptide (BNP) or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis.*
• AA should be used in patients with New York Heart Association (NYHA) functional Class II-IV and LVEF ≤35% unless contraindicated (creatinine ≤2.5 mg/dL in men, ≤2.0 mg/dL in women, and potassium <5.0 mEq/L).*
• CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block with a QRS duration of ³150 ms, and NYHA functional Class II-IV on guideline-directed medical therapy (GDMT).*
• Anticoagulation should not be used in patients with chronic HFrEF without atrial fibrillation, prior thromboembolic event, or cardioembolic source.*
• Transitions of care and GDMT can be improved by employing the following: 1) use of performance-improvement systems to identify HF patients, 2) development of multidisciplinary HF disease-management programs for patients at high risk of readmission, and 3) placing phone calls to the patient within three days of discharge and scheduling a follow-up visit within seven to 14 days.

Analysis

Overall, the new guideline provides a thorough reassessment and expert analysis on the diagnosis and management of HF for both inpatient and outpatient care. The authors introduce the phrase “guideline-directed medical therapy” (GDMT) to emphasize the smaller set of recommendations that constitute optimal medical therapy for HF patients. This designation, encompassing primarily Class I recommendations, helps providers rapidly determine the optimal treatment course for an individual patient. The mainstay of GDMT in HFrEF patients remains angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB) when ACE-I-intolerant, beta-blockers, and, in select patients, AA, hydralazine-nitrates, and diuretics.

A major shift in focus is seen in the new guideline with a greater emphasis on improved patient-centered outcomes across the spectrum of the disease. HF requires a continuum of care, from screening and genetic testing of family members of patients with idiopathic cardiomyopathy to conversations about palliative care and hospice. To this end, the authors highlight quality of life, shared decision-making, care coordination, transitions of care, and appropriateness of palliative care in a chronic disease state.

Further, the guideline expands upon previous recommendations for compliance with performance and quality metrics. Quality of care and adherence to performance measures of HF patients are becoming increasingly recognized, particularly in the hospital setting. The guideline offers recommendations for transitions of care in the hospitalized patient, which utilize systems of care coordination to ensure an evidence-based plan of care that includes the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up, and appropriate dietary and physical activities.

HM Takeaways

HF is one of the most common, most challenging diseases managed by hospitalists. The 2013 ACCF/AHA Guideline for the Management of HF, while providing a comprehensive summary of evidence with recommendations for the totality of care for these patients throughout the course of the disease, places heavy emphasis on management during hospitalization and transitions. This includes repositioning of performance measures involving GDMT to better ensure optimal use of proven therapies in HFrEF, evidence-based steps to reduce readmissions, and greater recognition of the role of palliative care for patients with advanced disease.

Drs. McIlvennan and Allen are cardiologists in the Department of Medicine at the University of Colorado School of Medicine in Denver. Dr. Allen also works in the Colorado Health Outcomes Program.

References available at the-hospitalist.org.

Background

Heart failure (HF) is the No. 1 cause of both hospitalization and readmission among Americans 65 years and older.1 Hospitalizations in the HF population are associated with poor patient outcomes (30% mortality in the following year) and high costs, accounting for approximately 70% of the $32 billion spent on HF care annually in the United States.¹ In 2009, the Centers for Medicare & Medicaid Services (CMS) introduced the 30-day, risk-standardized, all-cause readmission for HF as an indicator of quality and efficiency of care, which has since been incorporated into Medicare’s value-based purchasing program.²

HF is a complex syndrome that is associated with multiple comorbidities. Appropriate to these issues, management is multifaceted and involves care across the spectrum of disease:

• Diagnosing and treating underlying causes;
• Minimizing exacerbants;
• Optimizing management of comorbidities;
• Addressing psychosocial and environmental issues beyond the hospital; and
• Confronting end-of-life care.

In order to address this continuum of disease management, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) simultaneously released a new Guideline for the Management of HF in June in the Journal of the American College of Cardiology and Circulation.^3,4 This update was developed in collaboration with the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and the International Society for Heart and Lung Transplantation. The goals of the document are to improve quality of care, optimize patient outcomes, and advance the efficient use of healthcare resources. The guideline includes important recommendations for overall care, but particularly for hospital-based care and transitions of care that are largely the purview of hospitalists.

Guideline Update

The 2013 guideline is the third revision of the original guideline that was released in 2000. Despite being a complete rewrite of the 2009 HF guideline, the updated document contains relatively few changes to the recommendations that are Class I (should be performed) and III (no benefit or harm). The most significant randomized controlled trials in HF patients that have been published since the 2009 guideline include EMPHASIS-HF5 and MADIT-CRT/RAFT, which expand indications for aldosterone antagonists (AA) and cardiac resyncronization therapy (CRT), respectively, to patients with mild symptoms.^5,6,7 Additionally, the WARCEF trial was published, which failed to demonstrate a significant difference in death, ischemic stroke, or intracerebral hemorrhage between treatment with warfarin or aspirin in patients with HF and reduced left ventricular ejection fraction (LVEF) in sinus rhythm.⁸

The most notable updates from the 2009 guideline include (* = Class I and III indications):

• The definition of HF has been revised to include: 1) HF with reduced ejection fraction (HFrEF; LVEF ≤40%), 2) HF failure with preserved ejection fraction (HFpEF; LVEF ≥50%), 3) HFpEF, borderline (LVEF 41-49%), and 4) HFpEF, improved (LVEF >40%).
• In the hospitalized patient, measurement of brain natriuretic peptide (BNP) or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis.*
• AA should be used in patients with New York Heart Association (NYHA) functional Class II-IV and LVEF ≤35% unless contraindicated (creatinine ≤2.5 mg/dL in men, ≤2.0 mg/dL in women, and potassium <5.0 mEq/L).*
• CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block with a QRS duration of ³150 ms, and NYHA functional Class II-IV on guideline-directed medical therapy (GDMT).*
• Anticoagulation should not be used in patients with chronic HFrEF without atrial fibrillation, prior thromboembolic event, or cardioembolic source.*
• Transitions of care and GDMT can be improved by employing the following: 1) use of performance-improvement systems to identify HF patients, 2) development of multidisciplinary HF disease-management programs for patients at high risk of readmission, and 3) placing phone calls to the patient within three days of discharge and scheduling a follow-up visit within seven to 14 days.

Analysis

Overall, the new guideline provides a thorough reassessment and expert analysis on the diagnosis and management of HF for both inpatient and outpatient care. The authors introduce the phrase “guideline-directed medical therapy” (GDMT) to emphasize the smaller set of recommendations that constitute optimal medical therapy for HF patients. This designation, encompassing primarily Class I recommendations, helps providers rapidly determine the optimal treatment course for an individual patient. The mainstay of GDMT in HFrEF patients remains angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB) when ACE-I-intolerant, beta-blockers, and, in select patients, AA, hydralazine-nitrates, and diuretics.

A major shift in focus is seen in the new guideline with a greater emphasis on improved patient-centered outcomes across the spectrum of the disease. HF requires a continuum of care, from screening and genetic testing of family members of patients with idiopathic cardiomyopathy to conversations about palliative care and hospice. To this end, the authors highlight quality of life, shared decision-making, care coordination, transitions of care, and appropriateness of palliative care in a chronic disease state.

Further, the guideline expands upon previous recommendations for compliance with performance and quality metrics. Quality of care and adherence to performance measures of HF patients are becoming increasingly recognized, particularly in the hospital setting. The guideline offers recommendations for transitions of care in the hospitalized patient, which utilize systems of care coordination to ensure an evidence-based plan of care that includes the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up, and appropriate dietary and physical activities.

HM Takeaways

HF is one of the most common, most challenging diseases managed by hospitalists. The 2013 ACCF/AHA Guideline for the Management of HF, while providing a comprehensive summary of evidence with recommendations for the totality of care for these patients throughout the course of the disease, places heavy emphasis on management during hospitalization and transitions. This includes repositioning of performance measures involving GDMT to better ensure optimal use of proven therapies in HFrEF, evidence-based steps to reduce readmissions, and greater recognition of the role of palliative care for patients with advanced disease.

Drs. McIlvennan and Allen are cardiologists in the Department of Medicine at the University of Colorado School of Medicine in Denver. Dr. Allen also works in the Colorado Health Outcomes Program.

References available at the-hospitalist.org.

Clinical question: What are the characteristics of children who died in children’s hospitals while receiving palliative care (PC) compared to those who did not?

Background: Approximately 44,000 children die annually in hospitals in the U.S. Since the American Academy of Pediatrics (AAP) released a statement in August 2000 that presented an integrated model for providing PC to children with life-threatening conditions, pediatric PC programs have increased steadily in number. Children who receive PC services are commonly afflicted by genetic/congenital disorders, neuromuscular disorders, and cancer diagnoses. Although it is estimated that 6,320 people under the age of 24 received PC services in 2010, little data exist comparing pediatric inpatients receiving PC and those who do not.

Study design: Multicenter retrospective cohort study.

Setting: More than 40 freestanding children’s hospitals.

Synopsis: Using the Pediatric Health Information System (PHIS) database, which collects administrative and clinical data from more than 40 freestanding children’s hospitals belonging to the Children’s Hospital Association, researchers analyzed the characteristics of children under the age of 18 who died in the hospital more than five days after admission from 2001 to 2011. They extracted demographic data and categorized patients using major diagnostic categories (MDC) based on major organ system or etiology of disease. Identification of patients receiving PC services was by ICD-9 codes, and utilization of medications and procedures was identified by clinical transaction codes (CTC) and ICD-9 codes. The unit billing the last hospital day determined location of death.

Of the 24,342 children studied, only 3.8% received PC services based on coding. Patients less likely to receive PC services included black children (2.3%), those with circulatory diseases (2.8%), and those with neonatal diseases (1.9%). Children who did receive PC services had a significantly lower median length of stay (17 vs. 21 days), average daily charges ($9,348 vs. $11,806), received significantly fewer interventions (mechanical ventilation, invasive monitoring, surgical procedures), and died less frequently in an ICU setting (60% vs. 88%). PC services disproportionately altered the care of children with lymphatic/hematopoietic diseases, significantly decreasing use of mechanical ventilation (75% to 22%) and death in an ICU setting (66% to 21%).

Bottom line: Provision of PC services to children dying in children’s hospitals remains low. It is even lower for children with certain racial backgrounds and disease processes. When provided, PC services reduce length of stay, average daily charges, invasive procedures, and death in an ICU setting.

Citation: Keele L, Keenan HT, Sheetz J. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132(1):72-78.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What are the characteristics of children who died in children’s hospitals while receiving palliative care (PC) compared to those who did not?

Background: Approximately 44,000 children die annually in hospitals in the U.S. Since the American Academy of Pediatrics (AAP) released a statement in August 2000 that presented an integrated model for providing PC to children with life-threatening conditions, pediatric PC programs have increased steadily in number. Children who receive PC services are commonly afflicted by genetic/congenital disorders, neuromuscular disorders, and cancer diagnoses. Although it is estimated that 6,320 people under the age of 24 received PC services in 2010, little data exist comparing pediatric inpatients receiving PC and those who do not.

Study design: Multicenter retrospective cohort study.

Setting: More than 40 freestanding children’s hospitals.

Synopsis: Using the Pediatric Health Information System (PHIS) database, which collects administrative and clinical data from more than 40 freestanding children’s hospitals belonging to the Children’s Hospital Association, researchers analyzed the characteristics of children under the age of 18 who died in the hospital more than five days after admission from 2001 to 2011. They extracted demographic data and categorized patients using major diagnostic categories (MDC) based on major organ system or etiology of disease. Identification of patients receiving PC services was by ICD-9 codes, and utilization of medications and procedures was identified by clinical transaction codes (CTC) and ICD-9 codes. The unit billing the last hospital day determined location of death.

Of the 24,342 children studied, only 3.8% received PC services based on coding. Patients less likely to receive PC services included black children (2.3%), those with circulatory diseases (2.8%), and those with neonatal diseases (1.9%). Children who did receive PC services had a significantly lower median length of stay (17 vs. 21 days), average daily charges ($9,348 vs. $11,806), received significantly fewer interventions (mechanical ventilation, invasive monitoring, surgical procedures), and died less frequently in an ICU setting (60% vs. 88%). PC services disproportionately altered the care of children with lymphatic/hematopoietic diseases, significantly decreasing use of mechanical ventilation (75% to 22%) and death in an ICU setting (66% to 21%).

Bottom line: Provision of PC services to children dying in children’s hospitals remains low. It is even lower for children with certain racial backgrounds and disease processes. When provided, PC services reduce length of stay, average daily charges, invasive procedures, and death in an ICU setting.

Citation: Keele L, Keenan HT, Sheetz J. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132(1):72-78.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What are the characteristics of children who died in children’s hospitals while receiving palliative care (PC) compared to those who did not?

Background: Approximately 44,000 children die annually in hospitals in the U.S. Since the American Academy of Pediatrics (AAP) released a statement in August 2000 that presented an integrated model for providing PC to children with life-threatening conditions, pediatric PC programs have increased steadily in number. Children who receive PC services are commonly afflicted by genetic/congenital disorders, neuromuscular disorders, and cancer diagnoses. Although it is estimated that 6,320 people under the age of 24 received PC services in 2010, little data exist comparing pediatric inpatients receiving PC and those who do not.

Study design: Multicenter retrospective cohort study.

Setting: More than 40 freestanding children’s hospitals.

Synopsis: Using the Pediatric Health Information System (PHIS) database, which collects administrative and clinical data from more than 40 freestanding children’s hospitals belonging to the Children’s Hospital Association, researchers analyzed the characteristics of children under the age of 18 who died in the hospital more than five days after admission from 2001 to 2011. They extracted demographic data and categorized patients using major diagnostic categories (MDC) based on major organ system or etiology of disease. Identification of patients receiving PC services was by ICD-9 codes, and utilization of medications and procedures was identified by clinical transaction codes (CTC) and ICD-9 codes. The unit billing the last hospital day determined location of death.

Of the 24,342 children studied, only 3.8% received PC services based on coding. Patients less likely to receive PC services included black children (2.3%), those with circulatory diseases (2.8%), and those with neonatal diseases (1.9%). Children who did receive PC services had a significantly lower median length of stay (17 vs. 21 days), average daily charges ($9,348 vs. $11,806), received significantly fewer interventions (mechanical ventilation, invasive monitoring, surgical procedures), and died less frequently in an ICU setting (60% vs. 88%). PC services disproportionately altered the care of children with lymphatic/hematopoietic diseases, significantly decreasing use of mechanical ventilation (75% to 22%) and death in an ICU setting (66% to 21%).

Bottom line: Provision of PC services to children dying in children’s hospitals remains low. It is even lower for children with certain racial backgrounds and disease processes. When provided, PC services reduce length of stay, average daily charges, invasive procedures, and death in an ICU setting.

Citation: Keele L, Keenan HT, Sheetz J. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132(1):72-78.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Early treatment with intravenous tPA for acute stroke
2. Perioperative morbidity, mortality for current smokers
3. Statins associated with musculoskeletal conditions
4. Antithrombotic medications in patients with history of stroke
5. Extended prophylaxis with aspirin for patients after total hip arthroplasty
6. Prognosis for symptomatic subsegmental pulmonary embolism
7. Video-based educational workshops for academic hospitalists
8. Increased mortality for elective surgeries on Fridays, weekends
9. Basal plus correction insulin regimen and Type 2 diabetes
10. Capnography to diagnose diabetic ketoacidosis in the ED
11. How publicly reported mortality rates correlate with hospitals’ overall mortality
12. Cost savings and preventable acute-care visits for Medicare patients

Early tPA in Acute Stroke Is Associated with Better Short-Term Outcomes in Routine Clinical Practice

Clinical question: Does early treatment with intravenous (IV) tissue plasminogen activator (tPA) result in better outcomes among patients with acute ischemic stroke in routine clinical practice?

Background: IV tPA for acute ischemic stroke is beneficial if given in the first 4.5 hours after symptom onset. However, pooled data from clinical trials have been limited in characterizing the extent to which onset-to-treatment (OTT) with IV tPA influences outcomes and how effective tPA is in routine clinical practice.

Study design: Data analysis from a stroke registry.

Setting: One thousand three hundred ninety-five U.S. hospitals participating in the Get with the Guidelines—Stroke Program.

Synopsis: Data were analyzed from 58,353 tPA-treated patients within 4.5 hours of symptom onset. Clinical outcomes were compared among patients treated in the 0-90-, 91-180-, and 181-270-minute OTT windows. Patient factors strongly associated with shorter OTT were greater stroke severity (odds ratio [OR] 2.8; 95% confidence interval [CI], 2.5-3.1 per five-point increase), arrival by ambulance (OR 5.9; 95% CI, 4.5-7.3), and arrival during regular hours (OR 4.6; 95% CI, 3.8-5.4). Faster OTT, in 15-minute increments, was associated with reduced in-hospital mortality (OR 0.96; 95% CI, 0.95-0.98; P<.001), reduced symptomatic intracranial hemorrhage (OR 0.96; 95% CI, 0.95-0.98; P<.001), increased achievement of independent ambulation at discharge (OR 1.04; 95% CI, 1.03-1.05; P<.001), and increased discharge to home (OR 1.03; 95% CI, 1.02-1.04; P<.001).

Data collected were dependent on the accuracy and completeness of the chart abstraction, and only short-term outcomes were reported. Although no post-discharge outcomes were reported, previous studies have shown that functional status at discharge strongly correlates with three-month disability outcomes.

Bottom line: In routine clinical practice, earlier tPA for acute ischemic strokes results in better short-term clinical outcomes.

Citation: Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309:2480-2488.

Current Smokers Have Higher Perioperative Morbidity and Mortality Compared to Past Smokers

Clinical question: Is there an association between current and past smoking on outcomes among patients having major surgery?

Background: Smoking is associated with adverse postoperative outcomes, but it is not known whether the associations are dose-dependent or limited to patients with smoking-related diseases. Smoking-related effects on postoperative events among patients having major surgery are also not well established.

Study design: Retrospective cohort study.

Setting: Four hundred forty-eight non-VA hospitals across the U.S., Canada, Lebanon, and the United Arab Emirates.

Synopsis: Data from 607,558 adult patients undergoing major surgery were obtained from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. After adjusting for confounders (cardiopulmonary diseases and cancer), the effects of current and past smoking (quit >1 year prior) on 30-day post-operative outcomes were measured.

There were 125,192 (21%) current smokers and 78,763 (13%) past smokers. Increased odds of post-op mortality were noted in current smokers only (odds ratio [OR] 1.17; 95% CI, 1.10-1.24). The adjusted odds ratios were higher for arterial and respiratory events among current smokers compared with past smokers (OR 1.65; 95% CI, 1.51-1.81 vs. OR 1.20; CI, 1.09-1.31 for arterial events, respectively) and (OR, 1.45; CI, 1.40-1.51 vs. OR, 1.13; CI, 1.08-1.18, for respiratory events, respectively). No significant effects on venous events were observed.

There was an increased adjusted odds of mortality for current smokers with <10 pack-years, while the effects on arterial and respiratory events increased incrementally with increased pack-years. Smoking was associated with adverse post-op outcomes regardless of smoking-related diseases. Variability in hospital quality or surgical strategies may have confounded the results.

Bottom line: Among patients undergoing major surgery, current but not past smoking was associated with higher mortality; smoking cessation for at least a year prior to surgery may decrease post-operative adverse events.

Citation: Musallam KM, Rosendaal FR, Zaatari G, et al. Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. JAMA Surg. 2013 Jun 19:1-8. doi: 10.1001/jamasurg.2013.2360 [Epub ahead of print].

Statins Associated with Several Musculoskeletal Conditions

Clinical question: Is statin use associated with musculoskeletal adverse events, including arthropathy and injury, in physically active individuals?

Background: Statin-induced musculoskeletal adverse events (AEs) include myalgias, muscle weakness, cramps, rhabdomyolysis, and tendinous disease. The full spectrum of AEs is unknown because randomized clinical trials have not been powered to detect uncommon AEs.

Study design: Retrospective cohort study with propensity score matching.

Setting: San Antonio military area.

Synopsis: A total of 46,249 patients aged 30 to 85 years who met study criteria were propensity-matched into 6,967 statin users and 6,967 nonusers. The occurrence of musculoskeletal conditions were categorized using ICD-9 codes: Msk1, all musculoskeletal diseases; Msk1a, arthropathies and related diseases; Msk1b, injury-related diseases; and Msk2, drug-associated musculoskeletal pain. Of these, statin users had a higher odds ratio (OR) for Msk1 (OR 1.19; 95% CI, 1.08-1.30), Msk1b (1.13; 1.05-1.21), and Msk2 (1.09; 1.02-1.18). Msk1b (arthropathies) had an OR of 1.07 (0.9-1.16, P=0.07). Simvastatin was used by 73.5% of patients, and years of simvastatin use was not a significant predictor of any of the outcome measures. Secondary and sensitivity analyses showed higher adjusted ORs for statin users in all groups. This study was limited by the use of ICD-9-CM codes for identification of baseline characteristics, and the musculoskeletal diagnosis groups used were not validated.

Bottom line: Statin use is associated with an increased likelihood of musculoskeletal conditions, arthropathies, injuries, and pain.

Citation: Mansi I, Frei CR, Pugh M, Makris U, Mortensen EM. Statins and musculoskeletal conditions, arthropathies, and injuries. JAMA Intern Med. 2013;173:1318-1326.

Evidence-Based Guidelines on Periprocedural Management of Antithrombotic Medications in Patients with History of Stroke

Clinical question: What is the evidence for the periprocedural management of antithrombotics in patients with ischemic cerebrovascular accidents (CVAs)?

Background: Evidence-based guidelines are needed to help clinicians determine the thromboembolic risk of temporary discontinuation of antithrombotic medications, the perioperative bleeding risks of continuing antithrombotic agents, whether bridging therapy should be used, and the appropriate timing of antithrombotic agent discontinuation.

Study design: Systematic literature review with practice recommendations.

Setting: American Academy of Neurology Guideline Development Subcommittee convened an expert panel to review and provide recommendations.

Synopsis: Researchers analyzed 133 literature reviews via MEDLINE and EMBASE. Aspirin in stroke patients:

• Should routinely be continued for dental procedures (Level A);
• Should probably be continued for invasive ocular anesthesia, cataract surgery, dermatologic procedures, transrectal ultrasound-guided prostate biopsy, spinal/epidural procedures, and carpal tunnel surgery (Level B); and
• Should possibly be continued for vitreoretinal surgery, electromyogram (EMG), transbronchial lung biopsy, colonoscopic polypectomy, upper endoscopy and biopsy/sphincterotomy, and abdominal ultrasound-guided biopsies (Level C).

Warfarin in stroke patients:

• Should routinely be continued for dental procedures (Level A); and
• Should possibly continued for dermatologic procedures (Level B) and EMG, prostate procedures, inguinal hemiorrhaphy, and endothermal ablation of great saphenous vein (Level C).
• There is a lack of evidence on warfarin for ophthalmologic procedures, with the exception of ocular anesthesia, where it probably does not increase clinically significant bleeding (Level B).

There was not enough evidence to support or refute a recommendation regarding heparin bridge therapy in reducing thromboembolism in chronically anticoagulated patients (Level B).

Bottom line: These are the most up-to-date guidelines for anticoagulant and antiplatelet agents in patients with transient ischemic attacks and strokes undergoing procedures, but further research is needed in many areas.

Citation: Armstrong MJ, Gronseth G Anderson DC, et al. Summary of evidence-based guideline: periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80:2065-2069.

Extended Prophylaxis with Aspirin Was Noninferior to Extended Prophylaxis with Low-Molecular-Weight Heparin

Clinical question: Is aspirin as effective as low-molecular-weight heparin (LMWH) for the extended prophylaxis of venous thromboembolism (VTE) after total hip arthroplasty (THA)?

Background: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common complications after THA. After initial prophylaxis, LMWH given for up to 30 days has been shown to reduce VTE compared with placebo. However, LMWH is costly and may increase the risk of minor bleeding. Aspirin is a potentially simple, low-cost alternative.

Study design: Randomized, placebo-controlled trial.

Setting: Twelve university-affiliated orthopedic hospitals in Canada.

Synopsis: Patients undergoing elective THA without hip fracture, metastatic cancer, or bleeding precluding anticoagulants were eligible. All patients received dalteparin for 10 days and were then randomized to aspirin 81 mg daily or to continue dalteparin. The primary outcome was symptomatic proximal DVT or PE during 90 days’ follow-up. The study was terminated early due to slow enrollment. At that time, 2,364 patients had been enrolled, and an analysis by an independent data safety and monitoring board determined that continuing the study was unlikely to alter the main findings. Extended prophylaxis with aspirin was noninferior to LMWH for the primary outcome, which occurred in 0.3% vs. 1.3%, respectively (95% CI, -0.5% to 2.5%, P<.001 for noninferiority). There were no significant differences in major or minor bleeding.

Though the early termination is a concern, the sample size was large and the results do not suggest inadequate power as a reason for lack of superiority for LMWH. Also, all patients received 10 days of LMWH, which indicates a period of LMWH after discharge will still be needed for most patients prior to initiating aspirin.

Bottom line: After initial LMWH prophylaxis for 10 days, extended prophylaxis with aspirin can be considered, particularly for patients for whom LMWH may not be feasible.

Citation: Anderson DR, Dunbar MJ, Bohm ER, et al. Aspirin versus low-molecular-weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial. Ann Intern Med. 2013;158:800-806.

Symptomatic Subsegmental Pulmonary Embolism (PE) Has a Prognosis Similar to Proximal PE

Clinical question: Is the prognosis of a symptomatic subsegmental pulmonary embolism (PE) similar to that of a more proximal PE?

Background: The use of multidetector computed tomography angiography (CTA) has allowed for better assessment of the pulmonary vasculature and increased detection of distal emboli. Prior studies have raised questions on the clinical importance of subsegmental PE but have been limited by small size or retrospective design.

Study design: Combined data from two prospective trials of management of suspected PE.

Setting: Twelve hospitals in the Netherlands and four tertiary-care emergency departments in Canada.

Synopsis: The study cohort consisted of 3,769 patients with suspected PE, of which 2,688 underwent CTA. Of patients diagnosed with PE, 15.5% had isolated subsegmental emboli. All patients were treated with anticoagulation. During three months of follow-up, the incidence of symptomatic recurrence for subsegmental PE was similar to patients with proximal PE (3.6% vs. 2.5%, respectively). The mortality rates for patients with subsegmental and proximal PE were also similar (10.3% vs. 6.3%, respectively).

The study may have been underpowered to detect small differences in event rates; however, there was no trend suggesting that subsegmental PE had better outcomes than more proximal PE. Also, the study did not specifically investigate whether any management strategy is preferred based on thrombus location on CTA.

Bottom line: Clinicians should continue to anticoagulate patients with subsegmental PE as the prognosis is similar to those with proximal PE.

Citation: Den Exter PL, van Es J, Klok FA, et al. Risk profile and clinical outcome of symptomatic subsegmental pulmonary embolism. Blood. 2013;122:1144-1149.

Video-Based Educational Workshop for Academic Hospitalists and House Staff May Improve Professionalism

Clinical question: Can video-based education promote professionalism among academic hospitalists and house staff?

Background: Unprofessional behavior by academic hospitalists and residents can negatively impact the learning environment and patient safety. This behavior increases throughout training, and faculty behavior can be influential. There is a paucity of educational materials to train hospitalists and house staff to recognize and ameliorate unprofessional behaviors.

Study design: Educational survey study.

Setting: University of Chicago, Northwestern University, and NorthShore University Health System teaching hospitals.

Synopsis: Three videos were developed displaying three types of unprofessional behavior: disparaging other physicians, “blocking” admissions, and misrepresenting tests to expedite their completion. There were 44 hospitalists and 244 house staff who received a 60-minute workshop in which they watched the videos using a viewing tool and discussed the videos in small groups.

For all three videos, more than three-quarters of both hospitalists and house staff felt the behavior was unprofessional or somewhat unprofessional. Hospitalists and house staff found the workshop useful and effective (65.9% and 77.1%, respectively) and would change their behavior as a result of the workshop (65.9% and 67.2%, respectively). Those who perceived the videos as “very realistic” were more likely to report intent to change behavior (93% vs. 53%, P=0.01).

This study is limited by its small sample size and possible selection bias. Those interested or concerned about unprofessional behavior may have been more likely to attend the workshop.

Bottom line: Video-based professionalism education is a feasible and well-received way to educate hospitalists and residents about unprofessional behavior and may even affect their future behavior.

Citation: Farnan JM, O’Leary KJ, Didwania A, et al. Promoting professionalism via a video-based educational workshop for academic hospitalists and housestaff. J Hosp Med. 2013;8:386-389.

Friday and Weekend Elective Surgeries Have Increased Mortality

Clinical question: How can the association between mortality and the day of elective surgical procedures be assessed?

Background: Several studies have described the “weekend effect” for both surgical and medical patients, with higher mortality and length of stay in patients admitted on the weekend compared to weekdays. Two potential explanations are poorer quality of care being delivered on the weekend or more severely ill patients being operated on or admitted on the weekend.

Study design: Retrospective analysis of national hospital administrative data.

Setting: All acute-care and specialist hospitals in England from 2008 to 2011.

Synopsis: There were 4,133,346 elective, inpatient surgical procedures studied. Friday surgeries had an adjusted odds ratio of death within 30 days and within two days of 1.44 [95% CI, 1.39-1.50] and 1.42 [95% CI, 1.26-1.60], respectively, when compared with Monday. Weekend surgeries had an adjusted odds ratio of death within 30 days and within two days of 1.82 [95% CI, 1.71-1.94] and 2.67 [95% CI, 2.30-3.09], respectively, when compared with Monday. There were significant trends toward higher mortality at the end of the workweek and weekends for four high-risk procedures: esophagus and/or stomach excision, colon and/or rectum excisions, coronary artery bypass graft, and lung excision. For lower-risk procedures, there was a significant increase in mortality for Friday surgeries but not weekend surgeries. As with all studies using administrative data, inherent selection biases could not be adjusted for Friday or weekend procedures.

Bottom line: Elective surgeries that occur on the weekend and later in the week have an increased risk of mortality, implying that the weekend effect is due to poorer quality of care during weekends, rather than higher-acuity patients presenting on weekends.

Citation: Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ. 2013;346:f2424.

Basal Plus Correction Insulin Regimen Is Effective in Hospitalized Patients with Type 2 Diabetes

Clinical question: Does a basal plus correction insulin regimen (as needed with meals) result in similar glycemic control and lower rates of hypoglycemia compared to a basal-bolus regimen?

Background: Basal bolus is the preferred insulin regimen for non-critically-ill hospitalized patients as per clinical guidelines. But use is limited due to the complexity of the regimen and the fear of inducing hypoglycemia. A less complex, easier-to-implement basal plus correction insulin regimen may be an effective alternative.

Study design: Multicenter, prospective, open-label, randomized study.

Setting: Six hospitals in the U.S.

Synopsis: A group of 375 medical and surgical patients with Type 2 diabetes treated with diet, oral anti-diabetic agents, or low-dose insulin (≤ 0.4 units/kg/day) were randomized to:

• Basal-bolus insulin regimen with glargine once daily and fixed doses of glusiline before meals;
• Basal plus correction insulin (“basal plus”) regimen with glargine once daily and glusiline sliding scale insulin (SSI) before meals; or
• Regular SSI alone.

After the first day of therapy, treatment with basal-bolus and basal-plus regimens resulted in similar improvements in daily blood glucose (BG) (P=0.16), and both were superior to SSI alone (P=0.04). Both regimens also resulted in less treatment failure (defined as mean daily BG of >240 mg/dl or >2 consecutive BG >240 mg/dl) than did treatment with SSI. Hypoglycemia (BG <70 mg/dl) occurred in 16%, 13%, and 3% of patients in the basal-bolus, basal-plus, and SSI groups, respectively (P=0.02). There were no between-group differences in the frequency of severe hypoglycemia (<40 mg/dl; P=0.76).

The study was not powered to evaluate hospital complications (infection, mortality, hospital stay, and readmissions) across groups.

Bottom line: The basal-plus regimen resulted in glycemic control similar to standard basal-bolus regimen and is an effective alternative for the initial management of hyperglycemia in general medical and surgical patients with Type 2 diabetes.

Citation: Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: Basal plus trial. Diabetes Care. 2013;36:2169-2174.

Capnography Can Help Diagnose Diabetic Ketoacidosis in the ED

Clinical question: Can capnography be used as a screening tool to identify patients with diabetic ketoacidosis (DKA)?

Background: Metabolic acidosis is a major criterion for diagnosing DKA. Previous studies have shown that end-tidal carbon dioxide (ETCO2) measurement by capnography can provide an accurate estimation of arterial carbon dioxide tension (PaCO2) and may be a noninvasive, fast, inexpensive measurement of acidosis in DKA. However, those studies were in pediatric patients and had small sample sizes.

Study design: Cross-sectional, prospective descriptive-analytic study.

Setting: The ED of Imam Reza Medical Research and Training Hospital, Tabriz, East Azarbaijan, Iran.

Synopsis: A total of 181 adult patients older than 18 with suspected DKA and blood sugar >250 mg/dl were included in the study. Simultaneous capnography and arterial blood gas (ABG) were obtained on all patients. Urine ketones, complete blood count, serum levels of potassium, urea, and creatinine were collected. Sixty-two patients were found to have DKA, while 119 had other conditions associated with metabolic acidosis. There was a significant linear relationship between pH and ETCO2 (P>0.0001, relative risk (R)=0.253), PaCO2 and ETCO2 (P>0.0001, R=0.572), and bicarbonate (HCO3) and ETCO2 (P>0.0001, R=0.730). ETCO2 values >24.5 mmHg had a sensitivity and specificity of 0.90 for ruling out DKA. No cutoff point could be determined for ruling in DKA.

The study was open to selection bias as patient collection was only done during the day, so eligible subjects may have been missed. Moreover, though the study suggests that capnography has a role in ruling out DKA, the exact cutoff value is unclear. Other studies found that higher values were needed to exclude diagnosis.

Bottom line: Using ETCO2 values >24.5 mmHg, capnography can help exclude the diagnosis of DKA in adult patients with elevated BG.

Citation: Soleimanour H, Taghizadieh A, Niafar M, Rahmani F, Golzari S, Esfanjani RM. Predictive value of capnography for diagnosis in patients with suspected diabetic ketoacidosis in the emergency department. West J Emerg Med. 2013. doi: 10.5811/westjem.2013.4.14296.

Publicly Reported Mortality Correlates with Overall Mortality

Clinical question: Are publicly reported mortality rates associated with a hospital’s overall medical and surgical mortality rate?

Background: Public reporting of mortality has become an important strategy in Medicare’s quality-improvement initiative. However, the mortality rate for only three conditions, acute myocardial infarction, congestive heart failure, and pneumonia are reported. It is unclear if these rates correlate to a hospital’s overall mortality rate.

Study design: Retrospective cohort.

Setting: National Medicare fee-for-service population.

Synopsis: Using 2008-2009 data from 2,322 acute-care hospitals with 6.7 million admissions, an aggregate mortality rate for the three publicly reported conditions, a standardized 30-day mortality rate for selected medical and surgical conditions, and an overall average composite mortality score was calculated for each hospital. Based on their mortality for the three publicly reported conditions, hospitals were grouped into quartiles from highest (top-performing hospitals) to lowest mortality (poor-performing hospitals).

Top-performing hospitals had a 3.6% (9.4%vs 13.0%; P<.001) lower mortality rate than poor-performing hospitals and an odds ratio >5 of being a top performer in overall mortality (OR 5.3; 95% CI, 4.3-6.5). They also had an 81% lower chance of being in the worst-performing quartile in overall mortality (OR 0.19; 95% CI, 0.14-0.27). Conversely, poor-performing hospitals had a 4.5 times higher risk of being in the lowest quartile in overall mortality. The study is limited by the use of administrative data, which limits the ability to adjust for severity of illness, overall health, and socioeconomic status of each hospital’s population.

Bottom line: A hospital’s mortality performance on the three publicly reported conditions may predict mortality rates across a wide range of medical and surgical conditions.

Citation: McCrum ML, Joynt KE, Orav EJ, Gawande AA, Jha AK. Mortality for publicly reported conditions and overall hospital mortality rates. JAMA Intern Med. 2013;173:1351-1357.

Cost Savings in Decreasing Preventable Acute-Care Visits Are Limited among High-Cost Medicare Utilizers

Clinical question: What role do preventable acute-care visits play in the overall costs of care for the highest Medicare utilizers?

Background: Some 10% of Medicare patients account for more than half the costs. Interventions targeted at decreasing acute-care costs (ED visits and inpatient hospitalizations) for this high-cost population are widespread, but it is unknown what impact they can have.

Study design: Retrospective cohort.

Setting: National Medicare fee-for-service population.

Synopsis: Standardized total costs were created for fee-for-service Medicare patients for 2009 and 2010 in order to identify high-cost and persistently high-cost patients. Algorithms were used to identify preventable ED visits and hospitalizations in both the high-cost and non-high-cost cohorts.

Of the more than 1 million patients in the sample Medicare population, as many as 113,341 were high-cost. As much as 73% of acute-care spending was attributable to this cohort. Overall, 10% of acute-care costs were felt to be preventable in the high-cost group, 13.5% in the persistently high-cost group, and 19% in the non-high-cost group for 2010. The most common reasons for preventable acute care in the high-cost cohort were heart failure, bacterial pneumonia, and chronic obstructive pulmonary disease. Catastrophic events (myocardial infarction, stroke, sepsis), cancer, and orthopedic procedures drove overall inpatient costs in the high-cost group.

Preventable costs were higher per capita in areas with higher numbers of primary-care and specialist physicians, but it’s unclear if this was a supply or demand issue. The study also used algorithms that possibly overestimate the amount of preventable acute care.

Bottom line: In the highest Medicare utilizers, cost savings aimed at preventable acute care may be limited and might be better targeted at efficiency during acute-care episodes.

Citation: Joynt KE, Gawande AA, Orav EJ, Jha AK. Contribution of preventable acute care spending to total spending for high-cost Medicare patients. JAMA. 2013;309:2572-2578.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Early treatment with intravenous tPA for acute stroke
2. Perioperative morbidity, mortality for current smokers
3. Statins associated with musculoskeletal conditions
4. Antithrombotic medications in patients with history of stroke
5. Extended prophylaxis with aspirin for patients after total hip arthroplasty
6. Prognosis for symptomatic subsegmental pulmonary embolism
7. Video-based educational workshops for academic hospitalists
8. Increased mortality for elective surgeries on Fridays, weekends
9. Basal plus correction insulin regimen and Type 2 diabetes
10. Capnography to diagnose diabetic ketoacidosis in the ED
11. How publicly reported mortality rates correlate with hospitals’ overall mortality
12. Cost savings and preventable acute-care visits for Medicare patients

Early tPA in Acute Stroke Is Associated with Better Short-Term Outcomes in Routine Clinical Practice

Clinical question: Does early treatment with intravenous (IV) tissue plasminogen activator (tPA) result in better outcomes among patients with acute ischemic stroke in routine clinical practice?

Background: IV tPA for acute ischemic stroke is beneficial if given in the first 4.5 hours after symptom onset. However, pooled data from clinical trials have been limited in characterizing the extent to which onset-to-treatment (OTT) with IV tPA influences outcomes and how effective tPA is in routine clinical practice.

Study design: Data analysis from a stroke registry.

Setting: One thousand three hundred ninety-five U.S. hospitals participating in the Get with the Guidelines—Stroke Program.

Synopsis: Data were analyzed from 58,353 tPA-treated patients within 4.5 hours of symptom onset. Clinical outcomes were compared among patients treated in the 0-90-, 91-180-, and 181-270-minute OTT windows. Patient factors strongly associated with shorter OTT were greater stroke severity (odds ratio [OR] 2.8; 95% confidence interval [CI], 2.5-3.1 per five-point increase), arrival by ambulance (OR 5.9; 95% CI, 4.5-7.3), and arrival during regular hours (OR 4.6; 95% CI, 3.8-5.4). Faster OTT, in 15-minute increments, was associated with reduced in-hospital mortality (OR 0.96; 95% CI, 0.95-0.98; P<.001), reduced symptomatic intracranial hemorrhage (OR 0.96; 95% CI, 0.95-0.98; P<.001), increased achievement of independent ambulation at discharge (OR 1.04; 95% CI, 1.03-1.05; P<.001), and increased discharge to home (OR 1.03; 95% CI, 1.02-1.04; P<.001).

Data collected were dependent on the accuracy and completeness of the chart abstraction, and only short-term outcomes were reported. Although no post-discharge outcomes were reported, previous studies have shown that functional status at discharge strongly correlates with three-month disability outcomes.

Bottom line: In routine clinical practice, earlier tPA for acute ischemic strokes results in better short-term clinical outcomes.

Citation: Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309:2480-2488.

Current Smokers Have Higher Perioperative Morbidity and Mortality Compared to Past Smokers

Clinical question: Is there an association between current and past smoking on outcomes among patients having major surgery?

Background: Smoking is associated with adverse postoperative outcomes, but it is not known whether the associations are dose-dependent or limited to patients with smoking-related diseases. Smoking-related effects on postoperative events among patients having major surgery are also not well established.

Study design: Retrospective cohort study.

Setting: Four hundred forty-eight non-VA hospitals across the U.S., Canada, Lebanon, and the United Arab Emirates.

Synopsis: Data from 607,558 adult patients undergoing major surgery were obtained from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. After adjusting for confounders (cardiopulmonary diseases and cancer), the effects of current and past smoking (quit >1 year prior) on 30-day post-operative outcomes were measured.

There were 125,192 (21%) current smokers and 78,763 (13%) past smokers. Increased odds of post-op mortality were noted in current smokers only (odds ratio [OR] 1.17; 95% CI, 1.10-1.24). The adjusted odds ratios were higher for arterial and respiratory events among current smokers compared with past smokers (OR 1.65; 95% CI, 1.51-1.81 vs. OR 1.20; CI, 1.09-1.31 for arterial events, respectively) and (OR, 1.45; CI, 1.40-1.51 vs. OR, 1.13; CI, 1.08-1.18, for respiratory events, respectively). No significant effects on venous events were observed.

There was an increased adjusted odds of mortality for current smokers with <10 pack-years, while the effects on arterial and respiratory events increased incrementally with increased pack-years. Smoking was associated with adverse post-op outcomes regardless of smoking-related diseases. Variability in hospital quality or surgical strategies may have confounded the results.

Bottom line: Among patients undergoing major surgery, current but not past smoking was associated with higher mortality; smoking cessation for at least a year prior to surgery may decrease post-operative adverse events.

Citation: Musallam KM, Rosendaal FR, Zaatari G, et al. Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. JAMA Surg. 2013 Jun 19:1-8. doi: 10.1001/jamasurg.2013.2360 [Epub ahead of print].

Statins Associated with Several Musculoskeletal Conditions

Clinical question: Is statin use associated with musculoskeletal adverse events, including arthropathy and injury, in physically active individuals?

Background: Statin-induced musculoskeletal adverse events (AEs) include myalgias, muscle weakness, cramps, rhabdomyolysis, and tendinous disease. The full spectrum of AEs is unknown because randomized clinical trials have not been powered to detect uncommon AEs.

Study design: Retrospective cohort study with propensity score matching.

Setting: San Antonio military area.

Synopsis: A total of 46,249 patients aged 30 to 85 years who met study criteria were propensity-matched into 6,967 statin users and 6,967 nonusers. The occurrence of musculoskeletal conditions were categorized using ICD-9 codes: Msk1, all musculoskeletal diseases; Msk1a, arthropathies and related diseases; Msk1b, injury-related diseases; and Msk2, drug-associated musculoskeletal pain. Of these, statin users had a higher odds ratio (OR) for Msk1 (OR 1.19; 95% CI, 1.08-1.30), Msk1b (1.13; 1.05-1.21), and Msk2 (1.09; 1.02-1.18). Msk1b (arthropathies) had an OR of 1.07 (0.9-1.16, P=0.07). Simvastatin was used by 73.5% of patients, and years of simvastatin use was not a significant predictor of any of the outcome measures. Secondary and sensitivity analyses showed higher adjusted ORs for statin users in all groups. This study was limited by the use of ICD-9-CM codes for identification of baseline characteristics, and the musculoskeletal diagnosis groups used were not validated.

Bottom line: Statin use is associated with an increased likelihood of musculoskeletal conditions, arthropathies, injuries, and pain.

Citation: Mansi I, Frei CR, Pugh M, Makris U, Mortensen EM. Statins and musculoskeletal conditions, arthropathies, and injuries. JAMA Intern Med. 2013;173:1318-1326.

Evidence-Based Guidelines on Periprocedural Management of Antithrombotic Medications in Patients with History of Stroke

Clinical question: What is the evidence for the periprocedural management of antithrombotics in patients with ischemic cerebrovascular accidents (CVAs)?

Background: Evidence-based guidelines are needed to help clinicians determine the thromboembolic risk of temporary discontinuation of antithrombotic medications, the perioperative bleeding risks of continuing antithrombotic agents, whether bridging therapy should be used, and the appropriate timing of antithrombotic agent discontinuation.

Study design: Systematic literature review with practice recommendations.

Setting: American Academy of Neurology Guideline Development Subcommittee convened an expert panel to review and provide recommendations.

Synopsis: Researchers analyzed 133 literature reviews via MEDLINE and EMBASE. Aspirin in stroke patients:

• Should routinely be continued for dental procedures (Level A);
• Should probably be continued for invasive ocular anesthesia, cataract surgery, dermatologic procedures, transrectal ultrasound-guided prostate biopsy, spinal/epidural procedures, and carpal tunnel surgery (Level B); and
• Should possibly be continued for vitreoretinal surgery, electromyogram (EMG), transbronchial lung biopsy, colonoscopic polypectomy, upper endoscopy and biopsy/sphincterotomy, and abdominal ultrasound-guided biopsies (Level C).

Warfarin in stroke patients:

• Should routinely be continued for dental procedures (Level A); and
• Should possibly continued for dermatologic procedures (Level B) and EMG, prostate procedures, inguinal hemiorrhaphy, and endothermal ablation of great saphenous vein (Level C).
• There is a lack of evidence on warfarin for ophthalmologic procedures, with the exception of ocular anesthesia, where it probably does not increase clinically significant bleeding (Level B).

There was not enough evidence to support or refute a recommendation regarding heparin bridge therapy in reducing thromboembolism in chronically anticoagulated patients (Level B).

Bottom line: These are the most up-to-date guidelines for anticoagulant and antiplatelet agents in patients with transient ischemic attacks and strokes undergoing procedures, but further research is needed in many areas.

Citation: Armstrong MJ, Gronseth G Anderson DC, et al. Summary of evidence-based guideline: periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80:2065-2069.

Extended Prophylaxis with Aspirin Was Noninferior to Extended Prophylaxis with Low-Molecular-Weight Heparin

Clinical question: Is aspirin as effective as low-molecular-weight heparin (LMWH) for the extended prophylaxis of venous thromboembolism (VTE) after total hip arthroplasty (THA)?

Background: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common complications after THA. After initial prophylaxis, LMWH given for up to 30 days has been shown to reduce VTE compared with placebo. However, LMWH is costly and may increase the risk of minor bleeding. Aspirin is a potentially simple, low-cost alternative.

Study design: Randomized, placebo-controlled trial.

Setting: Twelve university-affiliated orthopedic hospitals in Canada.

Synopsis: Patients undergoing elective THA without hip fracture, metastatic cancer, or bleeding precluding anticoagulants were eligible. All patients received dalteparin for 10 days and were then randomized to aspirin 81 mg daily or to continue dalteparin. The primary outcome was symptomatic proximal DVT or PE during 90 days’ follow-up. The study was terminated early due to slow enrollment. At that time, 2,364 patients had been enrolled, and an analysis by an independent data safety and monitoring board determined that continuing the study was unlikely to alter the main findings. Extended prophylaxis with aspirin was noninferior to LMWH for the primary outcome, which occurred in 0.3% vs. 1.3%, respectively (95% CI, -0.5% to 2.5%, P<.001 for noninferiority). There were no significant differences in major or minor bleeding.

Though the early termination is a concern, the sample size was large and the results do not suggest inadequate power as a reason for lack of superiority for LMWH. Also, all patients received 10 days of LMWH, which indicates a period of LMWH after discharge will still be needed for most patients prior to initiating aspirin.

Bottom line: After initial LMWH prophylaxis for 10 days, extended prophylaxis with aspirin can be considered, particularly for patients for whom LMWH may not be feasible.

Citation: Anderson DR, Dunbar MJ, Bohm ER, et al. Aspirin versus low-molecular-weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial. Ann Intern Med. 2013;158:800-806.

Symptomatic Subsegmental Pulmonary Embolism (PE) Has a Prognosis Similar to Proximal PE

Clinical question: Is the prognosis of a symptomatic subsegmental pulmonary embolism (PE) similar to that of a more proximal PE?

Background: The use of multidetector computed tomography angiography (CTA) has allowed for better assessment of the pulmonary vasculature and increased detection of distal emboli. Prior studies have raised questions on the clinical importance of subsegmental PE but have been limited by small size or retrospective design.

Study design: Combined data from two prospective trials of management of suspected PE.

Setting: Twelve hospitals in the Netherlands and four tertiary-care emergency departments in Canada.

Synopsis: The study cohort consisted of 3,769 patients with suspected PE, of which 2,688 underwent CTA. Of patients diagnosed with PE, 15.5% had isolated subsegmental emboli. All patients were treated with anticoagulation. During three months of follow-up, the incidence of symptomatic recurrence for subsegmental PE was similar to patients with proximal PE (3.6% vs. 2.5%, respectively). The mortality rates for patients with subsegmental and proximal PE were also similar (10.3% vs. 6.3%, respectively).

The study may have been underpowered to detect small differences in event rates; however, there was no trend suggesting that subsegmental PE had better outcomes than more proximal PE. Also, the study did not specifically investigate whether any management strategy is preferred based on thrombus location on CTA.

Bottom line: Clinicians should continue to anticoagulate patients with subsegmental PE as the prognosis is similar to those with proximal PE.

Citation: Den Exter PL, van Es J, Klok FA, et al. Risk profile and clinical outcome of symptomatic subsegmental pulmonary embolism. Blood. 2013;122:1144-1149.

Video-Based Educational Workshop for Academic Hospitalists and House Staff May Improve Professionalism

Clinical question: Can video-based education promote professionalism among academic hospitalists and house staff?

Background: Unprofessional behavior by academic hospitalists and residents can negatively impact the learning environment and patient safety. This behavior increases throughout training, and faculty behavior can be influential. There is a paucity of educational materials to train hospitalists and house staff to recognize and ameliorate unprofessional behaviors.

Study design: Educational survey study.

Setting: University of Chicago, Northwestern University, and NorthShore University Health System teaching hospitals.

Synopsis: Three videos were developed displaying three types of unprofessional behavior: disparaging other physicians, “blocking” admissions, and misrepresenting tests to expedite their completion. There were 44 hospitalists and 244 house staff who received a 60-minute workshop in which they watched the videos using a viewing tool and discussed the videos in small groups.

For all three videos, more than three-quarters of both hospitalists and house staff felt the behavior was unprofessional or somewhat unprofessional. Hospitalists and house staff found the workshop useful and effective (65.9% and 77.1%, respectively) and would change their behavior as a result of the workshop (65.9% and 67.2%, respectively). Those who perceived the videos as “very realistic” were more likely to report intent to change behavior (93% vs. 53%, P=0.01).

This study is limited by its small sample size and possible selection bias. Those interested or concerned about unprofessional behavior may have been more likely to attend the workshop.

Bottom line: Video-based professionalism education is a feasible and well-received way to educate hospitalists and residents about unprofessional behavior and may even affect their future behavior.

Citation: Farnan JM, O’Leary KJ, Didwania A, et al. Promoting professionalism via a video-based educational workshop for academic hospitalists and housestaff. J Hosp Med. 2013;8:386-389.

Friday and Weekend Elective Surgeries Have Increased Mortality

Clinical question: How can the association between mortality and the day of elective surgical procedures be assessed?

Background: Several studies have described the “weekend effect” for both surgical and medical patients, with higher mortality and length of stay in patients admitted on the weekend compared to weekdays. Two potential explanations are poorer quality of care being delivered on the weekend or more severely ill patients being operated on or admitted on the weekend.

Study design: Retrospective analysis of national hospital administrative data.

Setting: All acute-care and specialist hospitals in England from 2008 to 2011.

Synopsis: There were 4,133,346 elective, inpatient surgical procedures studied. Friday surgeries had an adjusted odds ratio of death within 30 days and within two days of 1.44 [95% CI, 1.39-1.50] and 1.42 [95% CI, 1.26-1.60], respectively, when compared with Monday. Weekend surgeries had an adjusted odds ratio of death within 30 days and within two days of 1.82 [95% CI, 1.71-1.94] and 2.67 [95% CI, 2.30-3.09], respectively, when compared with Monday. There were significant trends toward higher mortality at the end of the workweek and weekends for four high-risk procedures: esophagus and/or stomach excision, colon and/or rectum excisions, coronary artery bypass graft, and lung excision. For lower-risk procedures, there was a significant increase in mortality for Friday surgeries but not weekend surgeries. As with all studies using administrative data, inherent selection biases could not be adjusted for Friday or weekend procedures.

Bottom line: Elective surgeries that occur on the weekend and later in the week have an increased risk of mortality, implying that the weekend effect is due to poorer quality of care during weekends, rather than higher-acuity patients presenting on weekends.

Citation: Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ. 2013;346:f2424.

Basal Plus Correction Insulin Regimen Is Effective in Hospitalized Patients with Type 2 Diabetes

Clinical question: Does a basal plus correction insulin regimen (as needed with meals) result in similar glycemic control and lower rates of hypoglycemia compared to a basal-bolus regimen?

Background: Basal bolus is the preferred insulin regimen for non-critically-ill hospitalized patients as per clinical guidelines. But use is limited due to the complexity of the regimen and the fear of inducing hypoglycemia. A less complex, easier-to-implement basal plus correction insulin regimen may be an effective alternative.

Study design: Multicenter, prospective, open-label, randomized study.

Setting: Six hospitals in the U.S.

Synopsis: A group of 375 medical and surgical patients with Type 2 diabetes treated with diet, oral anti-diabetic agents, or low-dose insulin (≤ 0.4 units/kg/day) were randomized to:

• Basal-bolus insulin regimen with glargine once daily and fixed doses of glusiline before meals;
• Basal plus correction insulin (“basal plus”) regimen with glargine once daily and glusiline sliding scale insulin (SSI) before meals; or
• Regular SSI alone.

After the first day of therapy, treatment with basal-bolus and basal-plus regimens resulted in similar improvements in daily blood glucose (BG) (P=0.16), and both were superior to SSI alone (P=0.04). Both regimens also resulted in less treatment failure (defined as mean daily BG of >240 mg/dl or >2 consecutive BG >240 mg/dl) than did treatment with SSI. Hypoglycemia (BG <70 mg/dl) occurred in 16%, 13%, and 3% of patients in the basal-bolus, basal-plus, and SSI groups, respectively (P=0.02). There were no between-group differences in the frequency of severe hypoglycemia (<40 mg/dl; P=0.76).

The study was not powered to evaluate hospital complications (infection, mortality, hospital stay, and readmissions) across groups.

Bottom line: The basal-plus regimen resulted in glycemic control similar to standard basal-bolus regimen and is an effective alternative for the initial management of hyperglycemia in general medical and surgical patients with Type 2 diabetes.

Citation: Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: Basal plus trial. Diabetes Care. 2013;36:2169-2174.

Capnography Can Help Diagnose Diabetic Ketoacidosis in the ED

Clinical question: Can capnography be used as a screening tool to identify patients with diabetic ketoacidosis (DKA)?

Background: Metabolic acidosis is a major criterion for diagnosing DKA. Previous studies have shown that end-tidal carbon dioxide (ETCO2) measurement by capnography can provide an accurate estimation of arterial carbon dioxide tension (PaCO2) and may be a noninvasive, fast, inexpensive measurement of acidosis in DKA. However, those studies were in pediatric patients and had small sample sizes.

Study design: Cross-sectional, prospective descriptive-analytic study.

Setting: The ED of Imam Reza Medical Research and Training Hospital, Tabriz, East Azarbaijan, Iran.

Synopsis: A total of 181 adult patients older than 18 with suspected DKA and blood sugar >250 mg/dl were included in the study. Simultaneous capnography and arterial blood gas (ABG) were obtained on all patients. Urine ketones, complete blood count, serum levels of potassium, urea, and creatinine were collected. Sixty-two patients were found to have DKA, while 119 had other conditions associated with metabolic acidosis. There was a significant linear relationship between pH and ETCO2 (P>0.0001, relative risk (R)=0.253), PaCO2 and ETCO2 (P>0.0001, R=0.572), and bicarbonate (HCO3) and ETCO2 (P>0.0001, R=0.730). ETCO2 values >24.5 mmHg had a sensitivity and specificity of 0.90 for ruling out DKA. No cutoff point could be determined for ruling in DKA.

The study was open to selection bias as patient collection was only done during the day, so eligible subjects may have been missed. Moreover, though the study suggests that capnography has a role in ruling out DKA, the exact cutoff value is unclear. Other studies found that higher values were needed to exclude diagnosis.

Bottom line: Using ETCO2 values >24.5 mmHg, capnography can help exclude the diagnosis of DKA in adult patients with elevated BG.

Citation: Soleimanour H, Taghizadieh A, Niafar M, Rahmani F, Golzari S, Esfanjani RM. Predictive value of capnography for diagnosis in patients with suspected diabetic ketoacidosis in the emergency department. West J Emerg Med. 2013. doi: 10.5811/westjem.2013.4.14296.

Publicly Reported Mortality Correlates with Overall Mortality

Clinical question: Are publicly reported mortality rates associated with a hospital’s overall medical and surgical mortality rate?

Background: Public reporting of mortality has become an important strategy in Medicare’s quality-improvement initiative. However, the mortality rate for only three conditions, acute myocardial infarction, congestive heart failure, and pneumonia are reported. It is unclear if these rates correlate to a hospital’s overall mortality rate.

Study design: Retrospective cohort.

Setting: National Medicare fee-for-service population.

Synopsis: Using 2008-2009 data from 2,322 acute-care hospitals with 6.7 million admissions, an aggregate mortality rate for the three publicly reported conditions, a standardized 30-day mortality rate for selected medical and surgical conditions, and an overall average composite mortality score was calculated for each hospital. Based on their mortality for the three publicly reported conditions, hospitals were grouped into quartiles from highest (top-performing hospitals) to lowest mortality (poor-performing hospitals).

Top-performing hospitals had a 3.6% (9.4%vs 13.0%; P<.001) lower mortality rate than poor-performing hospitals and an odds ratio >5 of being a top performer in overall mortality (OR 5.3; 95% CI, 4.3-6.5). They also had an 81% lower chance of being in the worst-performing quartile in overall mortality (OR 0.19; 95% CI, 0.14-0.27). Conversely, poor-performing hospitals had a 4.5 times higher risk of being in the lowest quartile in overall mortality. The study is limited by the use of administrative data, which limits the ability to adjust for severity of illness, overall health, and socioeconomic status of each hospital’s population.

Bottom line: A hospital’s mortality performance on the three publicly reported conditions may predict mortality rates across a wide range of medical and surgical conditions.

Citation: McCrum ML, Joynt KE, Orav EJ, Gawande AA, Jha AK. Mortality for publicly reported conditions and overall hospital mortality rates. JAMA Intern Med. 2013;173:1351-1357.

Cost Savings in Decreasing Preventable Acute-Care Visits Are Limited among High-Cost Medicare Utilizers

Clinical question: What role do preventable acute-care visits play in the overall costs of care for the highest Medicare utilizers?

Background: Some 10% of Medicare patients account for more than half the costs. Interventions targeted at decreasing acute-care costs (ED visits and inpatient hospitalizations) for this high-cost population are widespread, but it is unknown what impact they can have.

Study design: Retrospective cohort.

Setting: National Medicare fee-for-service population.

Synopsis: Standardized total costs were created for fee-for-service Medicare patients for 2009 and 2010 in order to identify high-cost and persistently high-cost patients. Algorithms were used to identify preventable ED visits and hospitalizations in both the high-cost and non-high-cost cohorts.

Of the more than 1 million patients in the sample Medicare population, as many as 113,341 were high-cost. As much as 73% of acute-care spending was attributable to this cohort. Overall, 10% of acute-care costs were felt to be preventable in the high-cost group, 13.5% in the persistently high-cost group, and 19% in the non-high-cost group for 2010. The most common reasons for preventable acute care in the high-cost cohort were heart failure, bacterial pneumonia, and chronic obstructive pulmonary disease. Catastrophic events (myocardial infarction, stroke, sepsis), cancer, and orthopedic procedures drove overall inpatient costs in the high-cost group.

Preventable costs were higher per capita in areas with higher numbers of primary-care and specialist physicians, but it’s unclear if this was a supply or demand issue. The study also used algorithms that possibly overestimate the amount of preventable acute care.

Bottom line: In the highest Medicare utilizers, cost savings aimed at preventable acute care may be limited and might be better targeted at efficiency during acute-care episodes.

Citation: Joynt KE, Gawande AA, Orav EJ, Jha AK. Contribution of preventable acute care spending to total spending for high-cost Medicare patients. JAMA. 2013;309:2572-2578.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Early treatment with intravenous tPA for acute stroke
2. Perioperative morbidity, mortality for current smokers
3. Statins associated with musculoskeletal conditions
4. Antithrombotic medications in patients with history of stroke
5. Extended prophylaxis with aspirin for patients after total hip arthroplasty
6. Prognosis for symptomatic subsegmental pulmonary embolism
7. Video-based educational workshops for academic hospitalists
8. Increased mortality for elective surgeries on Fridays, weekends
9. Basal plus correction insulin regimen and Type 2 diabetes
10. Capnography to diagnose diabetic ketoacidosis in the ED
11. How publicly reported mortality rates correlate with hospitals’ overall mortality
12. Cost savings and preventable acute-care visits for Medicare patients

Early tPA in Acute Stroke Is Associated with Better Short-Term Outcomes in Routine Clinical Practice

Clinical question: Does early treatment with intravenous (IV) tissue plasminogen activator (tPA) result in better outcomes among patients with acute ischemic stroke in routine clinical practice?

Background: IV tPA for acute ischemic stroke is beneficial if given in the first 4.5 hours after symptom onset. However, pooled data from clinical trials have been limited in characterizing the extent to which onset-to-treatment (OTT) with IV tPA influences outcomes and how effective tPA is in routine clinical practice.

Study design: Data analysis from a stroke registry.

Setting: One thousand three hundred ninety-five U.S. hospitals participating in the Get with the Guidelines—Stroke Program.

Synopsis: Data were analyzed from 58,353 tPA-treated patients within 4.5 hours of symptom onset. Clinical outcomes were compared among patients treated in the 0-90-, 91-180-, and 181-270-minute OTT windows. Patient factors strongly associated with shorter OTT were greater stroke severity (odds ratio [OR] 2.8; 95% confidence interval [CI], 2.5-3.1 per five-point increase), arrival by ambulance (OR 5.9; 95% CI, 4.5-7.3), and arrival during regular hours (OR 4.6; 95% CI, 3.8-5.4). Faster OTT, in 15-minute increments, was associated with reduced in-hospital mortality (OR 0.96; 95% CI, 0.95-0.98; P<.001), reduced symptomatic intracranial hemorrhage (OR 0.96; 95% CI, 0.95-0.98; P<.001), increased achievement of independent ambulation at discharge (OR 1.04; 95% CI, 1.03-1.05; P<.001), and increased discharge to home (OR 1.03; 95% CI, 1.02-1.04; P<.001).

Data collected were dependent on the accuracy and completeness of the chart abstraction, and only short-term outcomes were reported. Although no post-discharge outcomes were reported, previous studies have shown that functional status at discharge strongly correlates with three-month disability outcomes.

Bottom line: In routine clinical practice, earlier tPA for acute ischemic strokes results in better short-term clinical outcomes.

Citation: Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309:2480-2488.

Current Smokers Have Higher Perioperative Morbidity and Mortality Compared to Past Smokers

Clinical question: Is there an association between current and past smoking on outcomes among patients having major surgery?

Background: Smoking is associated with adverse postoperative outcomes, but it is not known whether the associations are dose-dependent or limited to patients with smoking-related diseases. Smoking-related effects on postoperative events among patients having major surgery are also not well established.

Study design: Retrospective cohort study.

Setting: Four hundred forty-eight non-VA hospitals across the U.S., Canada, Lebanon, and the United Arab Emirates.

Synopsis: Data from 607,558 adult patients undergoing major surgery were obtained from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. After adjusting for confounders (cardiopulmonary diseases and cancer), the effects of current and past smoking (quit >1 year prior) on 30-day post-operative outcomes were measured.

There were 125,192 (21%) current smokers and 78,763 (13%) past smokers. Increased odds of post-op mortality were noted in current smokers only (odds ratio [OR] 1.17; 95% CI, 1.10-1.24). The adjusted odds ratios were higher for arterial and respiratory events among current smokers compared with past smokers (OR 1.65; 95% CI, 1.51-1.81 vs. OR 1.20; CI, 1.09-1.31 for arterial events, respectively) and (OR, 1.45; CI, 1.40-1.51 vs. OR, 1.13; CI, 1.08-1.18, for respiratory events, respectively). No significant effects on venous events were observed.

There was an increased adjusted odds of mortality for current smokers with <10 pack-years, while the effects on arterial and respiratory events increased incrementally with increased pack-years. Smoking was associated with adverse post-op outcomes regardless of smoking-related diseases. Variability in hospital quality or surgical strategies may have confounded the results.

Bottom line: Among patients undergoing major surgery, current but not past smoking was associated with higher mortality; smoking cessation for at least a year prior to surgery may decrease post-operative adverse events.

Citation: Musallam KM, Rosendaal FR, Zaatari G, et al. Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. JAMA Surg. 2013 Jun 19:1-8. doi: 10.1001/jamasurg.2013.2360 [Epub ahead of print].

Statins Associated with Several Musculoskeletal Conditions

Clinical question: Is statin use associated with musculoskeletal adverse events, including arthropathy and injury, in physically active individuals?

Background: Statin-induced musculoskeletal adverse events (AEs) include myalgias, muscle weakness, cramps, rhabdomyolysis, and tendinous disease. The full spectrum of AEs is unknown because randomized clinical trials have not been powered to detect uncommon AEs.

Study design: Retrospective cohort study with propensity score matching.

Setting: San Antonio military area.

Synopsis: A total of 46,249 patients aged 30 to 85 years who met study criteria were propensity-matched into 6,967 statin users and 6,967 nonusers. The occurrence of musculoskeletal conditions were categorized using ICD-9 codes: Msk1, all musculoskeletal diseases; Msk1a, arthropathies and related diseases; Msk1b, injury-related diseases; and Msk2, drug-associated musculoskeletal pain. Of these, statin users had a higher odds ratio (OR) for Msk1 (OR 1.19; 95% CI, 1.08-1.30), Msk1b (1.13; 1.05-1.21), and Msk2 (1.09; 1.02-1.18). Msk1b (arthropathies) had an OR of 1.07 (0.9-1.16, P=0.07). Simvastatin was used by 73.5% of patients, and years of simvastatin use was not a significant predictor of any of the outcome measures. Secondary and sensitivity analyses showed higher adjusted ORs for statin users in all groups. This study was limited by the use of ICD-9-CM codes for identification of baseline characteristics, and the musculoskeletal diagnosis groups used were not validated.

Bottom line: Statin use is associated with an increased likelihood of musculoskeletal conditions, arthropathies, injuries, and pain.

Citation: Mansi I, Frei CR, Pugh M, Makris U, Mortensen EM. Statins and musculoskeletal conditions, arthropathies, and injuries. JAMA Intern Med. 2013;173:1318-1326.

Evidence-Based Guidelines on Periprocedural Management of Antithrombotic Medications in Patients with History of Stroke

Clinical question: What is the evidence for the periprocedural management of antithrombotics in patients with ischemic cerebrovascular accidents (CVAs)?

Background: Evidence-based guidelines are needed to help clinicians determine the thromboembolic risk of temporary discontinuation of antithrombotic medications, the perioperative bleeding risks of continuing antithrombotic agents, whether bridging therapy should be used, and the appropriate timing of antithrombotic agent discontinuation.

Study design: Systematic literature review with practice recommendations.

Setting: American Academy of Neurology Guideline Development Subcommittee convened an expert panel to review and provide recommendations.

Synopsis: Researchers analyzed 133 literature reviews via MEDLINE and EMBASE. Aspirin in stroke patients:

• Should routinely be continued for dental procedures (Level A);
• Should probably be continued for invasive ocular anesthesia, cataract surgery, dermatologic procedures, transrectal ultrasound-guided prostate biopsy, spinal/epidural procedures, and carpal tunnel surgery (Level B); and
• Should possibly be continued for vitreoretinal surgery, electromyogram (EMG), transbronchial lung biopsy, colonoscopic polypectomy, upper endoscopy and biopsy/sphincterotomy, and abdominal ultrasound-guided biopsies (Level C).

Warfarin in stroke patients:

• Should routinely be continued for dental procedures (Level A); and
• Should possibly continued for dermatologic procedures (Level B) and EMG, prostate procedures, inguinal hemiorrhaphy, and endothermal ablation of great saphenous vein (Level C).
• There is a lack of evidence on warfarin for ophthalmologic procedures, with the exception of ocular anesthesia, where it probably does not increase clinically significant bleeding (Level B).

There was not enough evidence to support or refute a recommendation regarding heparin bridge therapy in reducing thromboembolism in chronically anticoagulated patients (Level B).

Bottom line: These are the most up-to-date guidelines for anticoagulant and antiplatelet agents in patients with transient ischemic attacks and strokes undergoing procedures, but further research is needed in many areas.

Citation: Armstrong MJ, Gronseth G Anderson DC, et al. Summary of evidence-based guideline: periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80:2065-2069.

Extended Prophylaxis with Aspirin Was Noninferior to Extended Prophylaxis with Low-Molecular-Weight Heparin

Clinical question: Is aspirin as effective as low-molecular-weight heparin (LMWH) for the extended prophylaxis of venous thromboembolism (VTE) after total hip arthroplasty (THA)?

Background: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common complications after THA. After initial prophylaxis, LMWH given for up to 30 days has been shown to reduce VTE compared with placebo. However, LMWH is costly and may increase the risk of minor bleeding. Aspirin is a potentially simple, low-cost alternative.

Study design: Randomized, placebo-controlled trial.

Setting: Twelve university-affiliated orthopedic hospitals in Canada.

Synopsis: Patients undergoing elective THA without hip fracture, metastatic cancer, or bleeding precluding anticoagulants were eligible. All patients received dalteparin for 10 days and were then randomized to aspirin 81 mg daily or to continue dalteparin. The primary outcome was symptomatic proximal DVT or PE during 90 days’ follow-up. The study was terminated early due to slow enrollment. At that time, 2,364 patients had been enrolled, and an analysis by an independent data safety and monitoring board determined that continuing the study was unlikely to alter the main findings. Extended prophylaxis with aspirin was noninferior to LMWH for the primary outcome, which occurred in 0.3% vs. 1.3%, respectively (95% CI, -0.5% to 2.5%, P<.001 for noninferiority). There were no significant differences in major or minor bleeding.

Though the early termination is a concern, the sample size was large and the results do not suggest inadequate power as a reason for lack of superiority for LMWH. Also, all patients received 10 days of LMWH, which indicates a period of LMWH after discharge will still be needed for most patients prior to initiating aspirin.

Bottom line: After initial LMWH prophylaxis for 10 days, extended prophylaxis with aspirin can be considered, particularly for patients for whom LMWH may not be feasible.

Citation: Anderson DR, Dunbar MJ, Bohm ER, et al. Aspirin versus low-molecular-weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial. Ann Intern Med. 2013;158:800-806.

Symptomatic Subsegmental Pulmonary Embolism (PE) Has a Prognosis Similar to Proximal PE

Clinical question: Is the prognosis of a symptomatic subsegmental pulmonary embolism (PE) similar to that of a more proximal PE?

Background: The use of multidetector computed tomography angiography (CTA) has allowed for better assessment of the pulmonary vasculature and increased detection of distal emboli. Prior studies have raised questions on the clinical importance of subsegmental PE but have been limited by small size or retrospective design.

Study design: Combined data from two prospective trials of management of suspected PE.

Setting: Twelve hospitals in the Netherlands and four tertiary-care emergency departments in Canada.

Synopsis: The study cohort consisted of 3,769 patients with suspected PE, of which 2,688 underwent CTA. Of patients diagnosed with PE, 15.5% had isolated subsegmental emboli. All patients were treated with anticoagulation. During three months of follow-up, the incidence of symptomatic recurrence for subsegmental PE was similar to patients with proximal PE (3.6% vs. 2.5%, respectively). The mortality rates for patients with subsegmental and proximal PE were also similar (10.3% vs. 6.3%, respectively).

The study may have been underpowered to detect small differences in event rates; however, there was no trend suggesting that subsegmental PE had better outcomes than more proximal PE. Also, the study did not specifically investigate whether any management strategy is preferred based on thrombus location on CTA.

Bottom line: Clinicians should continue to anticoagulate patients with subsegmental PE as the prognosis is similar to those with proximal PE.

Citation: Den Exter PL, van Es J, Klok FA, et al. Risk profile and clinical outcome of symptomatic subsegmental pulmonary embolism. Blood. 2013;122:1144-1149.

Video-Based Educational Workshop for Academic Hospitalists and House Staff May Improve Professionalism

Clinical question: Can video-based education promote professionalism among academic hospitalists and house staff?

Background: Unprofessional behavior by academic hospitalists and residents can negatively impact the learning environment and patient safety. This behavior increases throughout training, and faculty behavior can be influential. There is a paucity of educational materials to train hospitalists and house staff to recognize and ameliorate unprofessional behaviors.

Study design: Educational survey study.

Setting: University of Chicago, Northwestern University, and NorthShore University Health System teaching hospitals.

Synopsis: Three videos were developed displaying three types of unprofessional behavior: disparaging other physicians, “blocking” admissions, and misrepresenting tests to expedite their completion. There were 44 hospitalists and 244 house staff who received a 60-minute workshop in which they watched the videos using a viewing tool and discussed the videos in small groups.

For all three videos, more than three-quarters of both hospitalists and house staff felt the behavior was unprofessional or somewhat unprofessional. Hospitalists and house staff found the workshop useful and effective (65.9% and 77.1%, respectively) and would change their behavior as a result of the workshop (65.9% and 67.2%, respectively). Those who perceived the videos as “very realistic” were more likely to report intent to change behavior (93% vs. 53%, P=0.01).

This study is limited by its small sample size and possible selection bias. Those interested or concerned about unprofessional behavior may have been more likely to attend the workshop.

Bottom line: Video-based professionalism education is a feasible and well-received way to educate hospitalists and residents about unprofessional behavior and may even affect their future behavior.

Citation: Farnan JM, O’Leary KJ, Didwania A, et al. Promoting professionalism via a video-based educational workshop for academic hospitalists and housestaff. J Hosp Med. 2013;8:386-389.

Friday and Weekend Elective Surgeries Have Increased Mortality

Clinical question: How can the association between mortality and the day of elective surgical procedures be assessed?

Background: Several studies have described the “weekend effect” for both surgical and medical patients, with higher mortality and length of stay in patients admitted on the weekend compared to weekdays. Two potential explanations are poorer quality of care being delivered on the weekend or more severely ill patients being operated on or admitted on the weekend.

Study design: Retrospective analysis of national hospital administrative data.

Setting: All acute-care and specialist hospitals in England from 2008 to 2011.

Synopsis: There were 4,133,346 elective, inpatient surgical procedures studied. Friday surgeries had an adjusted odds ratio of death within 30 days and within two days of 1.44 [95% CI, 1.39-1.50] and 1.42 [95% CI, 1.26-1.60], respectively, when compared with Monday. Weekend surgeries had an adjusted odds ratio of death within 30 days and within two days of 1.82 [95% CI, 1.71-1.94] and 2.67 [95% CI, 2.30-3.09], respectively, when compared with Monday. There were significant trends toward higher mortality at the end of the workweek and weekends for four high-risk procedures: esophagus and/or stomach excision, colon and/or rectum excisions, coronary artery bypass graft, and lung excision. For lower-risk procedures, there was a significant increase in mortality for Friday surgeries but not weekend surgeries. As with all studies using administrative data, inherent selection biases could not be adjusted for Friday or weekend procedures.

Bottom line: Elective surgeries that occur on the weekend and later in the week have an increased risk of mortality, implying that the weekend effect is due to poorer quality of care during weekends, rather than higher-acuity patients presenting on weekends.

Citation: Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ. 2013;346:f2424.

Basal Plus Correction Insulin Regimen Is Effective in Hospitalized Patients with Type 2 Diabetes

Clinical question: Does a basal plus correction insulin regimen (as needed with meals) result in similar glycemic control and lower rates of hypoglycemia compared to a basal-bolus regimen?

Background: Basal bolus is the preferred insulin regimen for non-critically-ill hospitalized patients as per clinical guidelines. But use is limited due to the complexity of the regimen and the fear of inducing hypoglycemia. A less complex, easier-to-implement basal plus correction insulin regimen may be an effective alternative.

Study design: Multicenter, prospective, open-label, randomized study.

Setting: Six hospitals in the U.S.

Synopsis: A group of 375 medical and surgical patients with Type 2 diabetes treated with diet, oral anti-diabetic agents, or low-dose insulin (≤ 0.4 units/kg/day) were randomized to:

• Basal-bolus insulin regimen with glargine once daily and fixed doses of glusiline before meals;
• Basal plus correction insulin (“basal plus”) regimen with glargine once daily and glusiline sliding scale insulin (SSI) before meals; or
• Regular SSI alone.

After the first day of therapy, treatment with basal-bolus and basal-plus regimens resulted in similar improvements in daily blood glucose (BG) (P=0.16), and both were superior to SSI alone (P=0.04). Both regimens also resulted in less treatment failure (defined as mean daily BG of >240 mg/dl or >2 consecutive BG >240 mg/dl) than did treatment with SSI. Hypoglycemia (BG <70 mg/dl) occurred in 16%, 13%, and 3% of patients in the basal-bolus, basal-plus, and SSI groups, respectively (P=0.02). There were no between-group differences in the frequency of severe hypoglycemia (<40 mg/dl; P=0.76).

The study was not powered to evaluate hospital complications (infection, mortality, hospital stay, and readmissions) across groups.

Bottom line: The basal-plus regimen resulted in glycemic control similar to standard basal-bolus regimen and is an effective alternative for the initial management of hyperglycemia in general medical and surgical patients with Type 2 diabetes.

Citation: Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: Basal plus trial. Diabetes Care. 2013;36:2169-2174.

Capnography Can Help Diagnose Diabetic Ketoacidosis in the ED

Clinical question: Can capnography be used as a screening tool to identify patients with diabetic ketoacidosis (DKA)?

Background: Metabolic acidosis is a major criterion for diagnosing DKA. Previous studies have shown that end-tidal carbon dioxide (ETCO2) measurement by capnography can provide an accurate estimation of arterial carbon dioxide tension (PaCO2) and may be a noninvasive, fast, inexpensive measurement of acidosis in DKA. However, those studies were in pediatric patients and had small sample sizes.

Study design: Cross-sectional, prospective descriptive-analytic study.

Setting: The ED of Imam Reza Medical Research and Training Hospital, Tabriz, East Azarbaijan, Iran.

Synopsis: A total of 181 adult patients older than 18 with suspected DKA and blood sugar >250 mg/dl were included in the study. Simultaneous capnography and arterial blood gas (ABG) were obtained on all patients. Urine ketones, complete blood count, serum levels of potassium, urea, and creatinine were collected. Sixty-two patients were found to have DKA, while 119 had other conditions associated with metabolic acidosis. There was a significant linear relationship between pH and ETCO2 (P>0.0001, relative risk (R)=0.253), PaCO2 and ETCO2 (P>0.0001, R=0.572), and bicarbonate (HCO3) and ETCO2 (P>0.0001, R=0.730). ETCO2 values >24.5 mmHg had a sensitivity and specificity of 0.90 for ruling out DKA. No cutoff point could be determined for ruling in DKA.

The study was open to selection bias as patient collection was only done during the day, so eligible subjects may have been missed. Moreover, though the study suggests that capnography has a role in ruling out DKA, the exact cutoff value is unclear. Other studies found that higher values were needed to exclude diagnosis.

Bottom line: Using ETCO2 values >24.5 mmHg, capnography can help exclude the diagnosis of DKA in adult patients with elevated BG.

Citation: Soleimanour H, Taghizadieh A, Niafar M, Rahmani F, Golzari S, Esfanjani RM. Predictive value of capnography for diagnosis in patients with suspected diabetic ketoacidosis in the emergency department. West J Emerg Med. 2013. doi: 10.5811/westjem.2013.4.14296.

Publicly Reported Mortality Correlates with Overall Mortality

Clinical question: Are publicly reported mortality rates associated with a hospital’s overall medical and surgical mortality rate?

Background: Public reporting of mortality has become an important strategy in Medicare’s quality-improvement initiative. However, the mortality rate for only three conditions, acute myocardial infarction, congestive heart failure, and pneumonia are reported. It is unclear if these rates correlate to a hospital’s overall mortality rate.

Study design: Retrospective cohort.

Setting: National Medicare fee-for-service population.

Synopsis: Using 2008-2009 data from 2,322 acute-care hospitals with 6.7 million admissions, an aggregate mortality rate for the three publicly reported conditions, a standardized 30-day mortality rate for selected medical and surgical conditions, and an overall average composite mortality score was calculated for each hospital. Based on their mortality for the three publicly reported conditions, hospitals were grouped into quartiles from highest (top-performing hospitals) to lowest mortality (poor-performing hospitals).

Top-performing hospitals had a 3.6% (9.4%vs 13.0%; P<.001) lower mortality rate than poor-performing hospitals and an odds ratio >5 of being a top performer in overall mortality (OR 5.3; 95% CI, 4.3-6.5). They also had an 81% lower chance of being in the worst-performing quartile in overall mortality (OR 0.19; 95% CI, 0.14-0.27). Conversely, poor-performing hospitals had a 4.5 times higher risk of being in the lowest quartile in overall mortality. The study is limited by the use of administrative data, which limits the ability to adjust for severity of illness, overall health, and socioeconomic status of each hospital’s population.

Bottom line: A hospital’s mortality performance on the three publicly reported conditions may predict mortality rates across a wide range of medical and surgical conditions.

Citation: McCrum ML, Joynt KE, Orav EJ, Gawande AA, Jha AK. Mortality for publicly reported conditions and overall hospital mortality rates. JAMA Intern Med. 2013;173:1351-1357.

Cost Savings in Decreasing Preventable Acute-Care Visits Are Limited among High-Cost Medicare Utilizers

Clinical question: What role do preventable acute-care visits play in the overall costs of care for the highest Medicare utilizers?

Background: Some 10% of Medicare patients account for more than half the costs. Interventions targeted at decreasing acute-care costs (ED visits and inpatient hospitalizations) for this high-cost population are widespread, but it is unknown what impact they can have.

Study design: Retrospective cohort.

Setting: National Medicare fee-for-service population.

Synopsis: Standardized total costs were created for fee-for-service Medicare patients for 2009 and 2010 in order to identify high-cost and persistently high-cost patients. Algorithms were used to identify preventable ED visits and hospitalizations in both the high-cost and non-high-cost cohorts.

Of the more than 1 million patients in the sample Medicare population, as many as 113,341 were high-cost. As much as 73% of acute-care spending was attributable to this cohort. Overall, 10% of acute-care costs were felt to be preventable in the high-cost group, 13.5% in the persistently high-cost group, and 19% in the non-high-cost group for 2010. The most common reasons for preventable acute care in the high-cost cohort were heart failure, bacterial pneumonia, and chronic obstructive pulmonary disease. Catastrophic events (myocardial infarction, stroke, sepsis), cancer, and orthopedic procedures drove overall inpatient costs in the high-cost group.

Preventable costs were higher per capita in areas with higher numbers of primary-care and specialist physicians, but it’s unclear if this was a supply or demand issue. The study also used algorithms that possibly overestimate the amount of preventable acute care.

Bottom line: In the highest Medicare utilizers, cost savings aimed at preventable acute care may be limited and might be better targeted at efficiency during acute-care episodes.

Citation: Joynt KE, Gawande AA, Orav EJ, Jha AK. Contribution of preventable acute care spending to total spending for high-cost Medicare patients. JAMA. 2013;309:2572-2578.

The Centers for Medicare & Medicaid Services (CMS) recently issued a Final Rule for the Inpatient Prospective Payment System, which guides payment and programs associated with inpatient hospitalizations. In this year’s rule, CMS adjusted the criteria for inpatient admissions in an attempt to simplify and clarify the decision-making process.

The policy would allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Admissions based on this time-limited expectation will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change.

With observation stays, there are two major financial concerns for patients: whether the hospital stay is paid under Medicare Part A or Part B, and whether Medicare will pay for post-acute care in a skilled-nursing facility (SNF). Medicare Part A reimburses for inpatient admissions, with a one-time deductible for the benefit period. Outpatient services, such as observation care and physician services, are covered under Medicare Part B, which has copays and co-insurance that greatly increase the costs for beneficiaries. In addition, SNF coverage through Medicare Part A is determined by the three-day rule; a patient must be an inpatient for three days to qualify for coverage.

While the long-term impacts of this regulatory change to the admission criteria remain to be seen, SHM is concerned that the rule does not adequately address the broader problems associated with inpatient and observation status. As we note in our comments to CMS on the new rule:¹

Even with these changes, the central tension created by the bifurcation in admission status still remains.…Other policies and programs, such as the attempts to reduce admissions, may inadvertently add pressure to the admission decision.

Indeed, for beneficiaries, the barrier to SNF coverage remains. CMS takes care to note that, while time under emergency care and observation care count toward the two-midnight presumption for inpatient admission, it does not count toward the three-day rule for SNF coverage. This is particularly problematic; as advances in medicine allow for the treatment of higher-acuity and -severity conditions with observation stays or shorter inpatient stays, patients might not be getting the follow-up care they need. This puts them at risk for additional complications and, ultimately, readmissions to the hospital.

In an era of seeking value in the healthcare system, it seems like an opportunity lost to streamline and coordinate care across settings and to ensure that patients are getting the follow-up care they require. It is for this reason that hospitalists continue to push for passage of the Improving Access to Medicare Coverage Act, a bill sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio) that would count observation status as time toward the three-day requirement for SNF coverage.

A recent Office of Inspector General (OIG) report for the U.S. Department of Health and Human Services on observation status sums up the problem succinctly.2 The OIG states that “CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access and cost-sharing for SNF services.”²

SHM concurs.

Joshua Lapps is SHM’s government relations specialist.

References

1. Society of Hospital Medicine. SHM submits comments in response to FY2014 inpatient prospective payment system proposed rule. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34044. Accessed Sept. 9, 2013.
2. Office of Inspector General. Memorandum report: Hospitals’ use of observations stays and short inpatient stays for Medicare beneficiaries, OEI-02-12-00040. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/oei/reports/oei-02-12-00040.pdf. Accessed Sept. 9, 2013.

The Centers for Medicare & Medicaid Services (CMS) recently issued a Final Rule for the Inpatient Prospective Payment System, which guides payment and programs associated with inpatient hospitalizations. In this year’s rule, CMS adjusted the criteria for inpatient admissions in an attempt to simplify and clarify the decision-making process.

The policy would allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Admissions based on this time-limited expectation will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change.

With observation stays, there are two major financial concerns for patients: whether the hospital stay is paid under Medicare Part A or Part B, and whether Medicare will pay for post-acute care in a skilled-nursing facility (SNF). Medicare Part A reimburses for inpatient admissions, with a one-time deductible for the benefit period. Outpatient services, such as observation care and physician services, are covered under Medicare Part B, which has copays and co-insurance that greatly increase the costs for beneficiaries. In addition, SNF coverage through Medicare Part A is determined by the three-day rule; a patient must be an inpatient for three days to qualify for coverage.

While the long-term impacts of this regulatory change to the admission criteria remain to be seen, SHM is concerned that the rule does not adequately address the broader problems associated with inpatient and observation status. As we note in our comments to CMS on the new rule:¹

Even with these changes, the central tension created by the bifurcation in admission status still remains.…Other policies and programs, such as the attempts to reduce admissions, may inadvertently add pressure to the admission decision.

Indeed, for beneficiaries, the barrier to SNF coverage remains. CMS takes care to note that, while time under emergency care and observation care count toward the two-midnight presumption for inpatient admission, it does not count toward the three-day rule for SNF coverage. This is particularly problematic; as advances in medicine allow for the treatment of higher-acuity and -severity conditions with observation stays or shorter inpatient stays, patients might not be getting the follow-up care they need. This puts them at risk for additional complications and, ultimately, readmissions to the hospital.

In an era of seeking value in the healthcare system, it seems like an opportunity lost to streamline and coordinate care across settings and to ensure that patients are getting the follow-up care they require. It is for this reason that hospitalists continue to push for passage of the Improving Access to Medicare Coverage Act, a bill sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio) that would count observation status as time toward the three-day requirement for SNF coverage.

A recent Office of Inspector General (OIG) report for the U.S. Department of Health and Human Services on observation status sums up the problem succinctly.2 The OIG states that “CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access and cost-sharing for SNF services.”²

SHM concurs.

Joshua Lapps is SHM’s government relations specialist.

References

1. Society of Hospital Medicine. SHM submits comments in response to FY2014 inpatient prospective payment system proposed rule. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34044. Accessed Sept. 9, 2013.
2. Office of Inspector General. Memorandum report: Hospitals’ use of observations stays and short inpatient stays for Medicare beneficiaries, OEI-02-12-00040. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/oei/reports/oei-02-12-00040.pdf. Accessed Sept. 9, 2013.

The Centers for Medicare & Medicaid Services (CMS) recently issued a Final Rule for the Inpatient Prospective Payment System, which guides payment and programs associated with inpatient hospitalizations. In this year’s rule, CMS adjusted the criteria for inpatient admissions in an attempt to simplify and clarify the decision-making process.

The policy would allow physicians to admit a patient if they reasonably expect and document in the medical record that a beneficiary will need to stay in the hospital for more than two midnights. Admissions based on this time-limited expectation will be presumed to be appropriate for Medicare Part A payment. CMS cited concerns about the growing trend of longer observation stays to support this change.

With observation stays, there are two major financial concerns for patients: whether the hospital stay is paid under Medicare Part A or Part B, and whether Medicare will pay for post-acute care in a skilled-nursing facility (SNF). Medicare Part A reimburses for inpatient admissions, with a one-time deductible for the benefit period. Outpatient services, such as observation care and physician services, are covered under Medicare Part B, which has copays and co-insurance that greatly increase the costs for beneficiaries. In addition, SNF coverage through Medicare Part A is determined by the three-day rule; a patient must be an inpatient for three days to qualify for coverage.

While the long-term impacts of this regulatory change to the admission criteria remain to be seen, SHM is concerned that the rule does not adequately address the broader problems associated with inpatient and observation status. As we note in our comments to CMS on the new rule:¹

Even with these changes, the central tension created by the bifurcation in admission status still remains.…Other policies and programs, such as the attempts to reduce admissions, may inadvertently add pressure to the admission decision.

Indeed, for beneficiaries, the barrier to SNF coverage remains. CMS takes care to note that, while time under emergency care and observation care count toward the two-midnight presumption for inpatient admission, it does not count toward the three-day rule for SNF coverage. This is particularly problematic; as advances in medicine allow for the treatment of higher-acuity and -severity conditions with observation stays or shorter inpatient stays, patients might not be getting the follow-up care they need. This puts them at risk for additional complications and, ultimately, readmissions to the hospital.

In an era of seeking value in the healthcare system, it seems like an opportunity lost to streamline and coordinate care across settings and to ensure that patients are getting the follow-up care they require. It is for this reason that hospitalists continue to push for passage of the Improving Access to Medicare Coverage Act, a bill sponsored by Rep. Joe Courtney (D-Conn.), Rep. Tom Latham (R-Iowa), and Sen. Sherrod Brown (D-Ohio) that would count observation status as time toward the three-day requirement for SNF coverage.

A recent Office of Inspector General (OIG) report for the U.S. Department of Health and Human Services on observation status sums up the problem succinctly.2 The OIG states that “CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access and cost-sharing for SNF services.”²

SHM concurs.

Joshua Lapps is SHM’s government relations specialist.

References

1. Society of Hospital Medicine. SHM submits comments in response to FY2014 inpatient prospective payment system proposed rule. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=34044. Accessed Sept. 9, 2013.
2. Office of Inspector General. Memorandum report: Hospitals’ use of observations stays and short inpatient stays for Medicare beneficiaries, OEI-02-12-00040. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/oei/reports/oei-02-12-00040.pdf. Accessed Sept. 9, 2013.

In This Edition

9 Things: At a Glance

An occasional series providing specialty-specific advice for hospitalists from experts in the field.

1. Recognize the differential diagnosis for pain exacerbation in a chronic opioid therapy (COT) patient/chronic pain patient.
2. Know where the opioids are going.
3. Sometimes stopping pills, rather than adding them, can cure pain.
4. Take time to educate patients about methadone and its risk of mortality if not used as prescribed.
5. A little local anesthetic (and some steroid) goes a long way.
6. Addiction to opioids is not rare.
7. Safely changing opioid regimens requires good math and good judgment.
8. For a low-risk chronic pain patient on low-dose opioids, don’t change the regimen, even if the indication for opioids isn’t clear.
9. If a patient has pain all the time, they need to be on a medication that works all the time.

The differential diagnosis for pain exacerbation in a chronic opioid therapy (COT) patient/chronic pain patient is:

1. Worsening medical problem;
2. New medical problem;
3. Nonopioid problem (side effect);
4. Opioid problem (resistance/tolerance/side effect); and
5. Opioid-induced hyperalgesia.

The search for an etiology and treatment for chronic pain should not end, even if a patient is labeled with “chronic pain syndrome.” The patient could simply be chronically undiagnosed or on an incorrect therapy.

Know where the opioids are going.

Whether it’s auditing a prescription-monitoring program (PMP), checking a urine drug screen, or calling a pharmacist, try to ensure that chronic pain patients are taking the opioids as prescribed. A phone call to the primary opioid prescriber or chronic pain provider could save a busy hospitalist a lot of time.

Using PMP data can consume a lot of time. Typically, only prescribing providers can access PMPs, so delegating this responsibility to someone else is not possible. If your state PMP does not help, simply call the patient’s pharmacy and ask for the last three fill dates on an opioid prescription. This also works well in case the patient’s pharmacy doesn’t participate in a PMP or is delayed in uploading recent prescriber data. Many COT patients have an opioid treatment agreement with their prescriber and must use only one pharmacy to fill opioids.

In January 2013, the University of North Carolina Injury Prevention Center published an analysis of three years of North Carolina PMP data.1 Patients followed by providers who consistently used the state PMP were five times more likely to receive treatment for opioid dependence compared with patients of providers who never used the state PMP.¹

Why go through all this trouble if a chronic pain specialist is also doing it? It’s good documentation and good care, like monitoring levels of transplant meds or making sure hemoglobin A1Cs are up to date and trending toward goal. It may only take one misused or diverted opioid pill to result in a serious adverse event.

Sometimes stopping pills, rather than adding them, can cure pain.

Many chronic pain patients accumulate a patchwork of pills (e.g. benzodiazepines, opioids, muscle relaxants, and antidepressants). Many interpret noxious symptoms associated with the drug burden as “uncontrolled pain.” Two conditions that might afflict the pain sufferer who takes multiple medications are opioid-induced hyperalgesia (OIH) and medication-overuse headaches (MOH). They are uncommon but should be on a hospitalist’s differential for difficult-to-control chronic pain. Opioids commonly are implicated in causing MOH, a chronic headache occurring at least 15 days a month, four hours a day if untreated, and for at least three consecutive months. OIH is a nociceptive sensitization caused by opioids that can occur suddenly or insidiously.

If a drug isn’t absolutely necessary, stop it. If you and the patient start by agreeing to the shared goal of improving health, the conversation should go better. An axiom we learned from mentors at the University of Washington is: “There is no pain that cannot be made worse with inappropriate therapy.”

Take time to educate patients about methadone and its risk of mortality if not used as prescribed.

Methadone is less frequently prescribed than other opioids, yet it is more frequently associated with death from overdose. Though there is a risk of overdose and death with any opioid, managing methadone is more difficult. A desperate chronic pain patient may self-escalate their methadone without proper insight into the consequences.

Remember the logarithmic relationship methadone doses have with their morphine equivalency. The following highlights how deceiving the numbers are: 50 mg of methadone is about 100 mg of morphine-equivalent, but 100 mg of methadone is about 1,000 mg of morphine-equivalent, or 10 times as strong.

From 1999 to 2005, methadone-related deaths increased by 468%.² If the patient doesn’t seem to understand these risks, they are not a good candidate for methadone treatment.

A little local anesthetic (and some steroid) goes a long way.

Hospitalists should offer an assortment of diagnostic and therapeutic injections to chronic pain patients. First, be sure you’ve done your due diligence:

• What procedures do you have privileges to do?
• Do you need to be proctored first?
• How do your local specialists feel about you doing injections?

In light of these considerations, hospitalists should be able to train and be credentialed to offer such procedures as trigger-point injections, joint injections (knees, shoulders), or even a peripheral nerve injection (e.g. lateral femoral cutaneous nerve or ilioinguinal nerve injection). Some hospitalists might even want to learn ultrasound-guided sacroiliac joint injections for chronic unexplained back pain.

Offering an indicated and effective injection is a good nonopioid option. And local anesthetic injections can help hospitalists establish an elusive diagnosis. For example, many patients spend years getting worked up for head and neck pain when dry-needling with a small volume (1 cc) of local anesthetic into a neck muscle trigger point can break their pain generator, eliminating their pain.

Addiction to opioids is not rare.

The use, misuse, and diversion of opioids and all the associated complications have appropriately received considerable media attention. A seminal paper by Porter and Jick titled “Addiction Is Rare in Patients Treated with Narcotics” is one of many tipping points associated with the boom in opioid prescribing.³ Whether it’s a three-day supply of hydrocodone, 24 hours on a PCA, or an opioid rotation, any exposure to opioids can put a patient on the runway to addiction.

There are only 3,071 board-certified addiction specialists certified by the American Board of Addiction Medicine, so access to an addiction specialist might be difficult.⁴

Nonetheless, do not become complacent and just continue the opioid therapy in a difficult opioid-addicted patient. Express your concerns to the primary opioid prescriber, or help patients who don’t have an opioid prescriber get access and treatment. Otherwise, you have no choice but to taper the opioids.

Ideally, chronic pain management should be delivered in the outpatient arena where long-term monitoring can take place.

Safely changing opioid regimens requires good math and good judgment.

During training and practice, hospitalists become accustomed to rapidly analyze objective data, such as ABGs, ECGs, anion gaps, and vent settings. A hospitalist should become similarly efficient at calculating morphine equivalencies (cautiously with methadone and fentanyl), making dose reductions, and rotating opioids. The more comfortable you are with morphine equivalencies, the faster and safer you will be at rotating opioids. Whatever morphine-equivalence table you feel comfortable with is the one you should use consistently.

We see many providers who unwittingly take, for example, a patient who has become resistant to hydrocodone/acetaminophen 10/325 mg PO TID (30 mg of morphine) and convert them to oxycodone/acetaminophen 10/325 mg PO QID (60 mg of morphine—a doubling), when doubling could cause respiratory depression or a faster path to addiction and dependency.

But there are cases in which judgment should trump math, such as when converting from an IV to an oral regimen. We frequently see patients in the clinic requesting refills for more than 100 mg of hydromorphone because “that’s what I was on when I was hospitalized and on the pump.” If the IV-to-oral conversion leaves you prescribing high doses of oral opioids, plan for a rapid taper and a smooth handoff to the outpatient setting.

One strategy to decrease an error in math and judgment is to use IV PCAs as infrequently as possible if a patient isn’t post-operative and they are able to take oral meds. And never hesitate to consult with your inpatient pharmacist or a chronic pain specialist.

For a low-risk chronic pain patient on low-dose opioids, don’t change the regimen, even if the indication for opioids isn’t clear.

Although it is tempting to become an opioid prohibitionist, if a patient has been taking an opioid for years and is functioning, working, compliant, and has no risk factors for complications from COT, it is likely fine to continue their current regimen. Touch base with the primary opioid prescriber, and if you’re concerned, use some of the monitoring instruments described earlier (PMP, urine drug screen, opioid treatment agreement, pill counts).

If a patient has pain all the time, they need to be on a medication that works all the time.

A good pain history followed by a good neurological and mental health assessment is of incalculable value, especially because physicians often underestimate a patient’s pain intensity and its impact on a patient’s quality of life.^5,6 A patient’s pain intensity, quality of life, and function can be dramatically improved by starting a long-acting medication for “constant pain.”

If a patient hurts “24 hours a day” and cannot function on hydrocodone/acetaminophen 10/325 QID, it’s probably because they are constantly reacting to spikes in pain and using a “some of the time” medicine to treat “all the time” pain. Switching to a long-acting medication—and it doesn’t have to be an opioid—could improve control and decrease how much narcotic the patient needs.

If you choose a long-acting opioid (in this case, you could try morphine sulphate extended-release 15 mg BID and satisfy 50% of the hydrocodone need), then you could titrate slowly upwards to where the patient would not need hydrocodone. If the patient still had uncontrolled pain, then either morphine is the wrong compound for them or they are benefiting from the “nonanalgesic properties” of the opioids.

Give the patient the benefit of the doubt; because of genetic polymorphisms, a patient may need several opioid rotations before the right opioid compound is found.

Dr. Schultz is a hospitalist and assistant professor in the department of internal medicine at the University of Miami Miller School of Medicine. She is board-certified in hospice and palliative care and specializes in chronic pain management. Dr. Ajam is a hospitalist and a clinical assistant professor in the department of anesthesiology at Wake Forest University Baptist Medical Center and the Carolinas Pain Institute. He is board-certified in chronic pain management.

References

1. Garrettson M, Ringwalt C. An evaluation of the North Carolina controlled substances reporting system: part II impact evaluation, January 2013. PDMP Center of Excellence website. Available at: http://pdmpexcellence.org/sites/all/pdfs/NC_control_sub_eval_pt_2.pdf. Accessed Sept. 3, 2013.
2. Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005, national vital statistics reports; Vol. 56 No. 10. Hyattsville, Md.: National Center for Health Statistics; 2008.
3. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980;302(2):123.
4. American Society of Addiction Medicine; personal communication, 2013.
5. Mäntyselkä P, Kumpusalo E, Ahonen R, Takala J. Patients’ versus general practitioners’ assessments of pain intensity in primary care patients with non-cancer pain. Br J Gen Pract. 2001;51(473):995-997.
6. Petersen MA, Larsen H, Pedersen L, Sonne N, Groenvold M. Assessing health-related quality of life in palliative care: comparing patient and physician assessments. Eur J Cancer. 2006;42(8):1159-1166.

In This Edition

9 Things: At a Glance

An occasional series providing specialty-specific advice for hospitalists from experts in the field.

1. Recognize the differential diagnosis for pain exacerbation in a chronic opioid therapy (COT) patient/chronic pain patient.
2. Know where the opioids are going.
3. Sometimes stopping pills, rather than adding them, can cure pain.
4. Take time to educate patients about methadone and its risk of mortality if not used as prescribed.
5. A little local anesthetic (and some steroid) goes a long way.
6. Addiction to opioids is not rare.
7. Safely changing opioid regimens requires good math and good judgment.
8. For a low-risk chronic pain patient on low-dose opioids, don’t change the regimen, even if the indication for opioids isn’t clear.
9. If a patient has pain all the time, they need to be on a medication that works all the time.

The differential diagnosis for pain exacerbation in a chronic opioid therapy (COT) patient/chronic pain patient is:

1. Worsening medical problem;
2. New medical problem;
3. Nonopioid problem (side effect);
4. Opioid problem (resistance/tolerance/side effect); and
5. Opioid-induced hyperalgesia.

The search for an etiology and treatment for chronic pain should not end, even if a patient is labeled with “chronic pain syndrome.” The patient could simply be chronically undiagnosed or on an incorrect therapy.

Know where the opioids are going.

Whether it’s auditing a prescription-monitoring program (PMP), checking a urine drug screen, or calling a pharmacist, try to ensure that chronic pain patients are taking the opioids as prescribed. A phone call to the primary opioid prescriber or chronic pain provider could save a busy hospitalist a lot of time.

Using PMP data can consume a lot of time. Typically, only prescribing providers can access PMPs, so delegating this responsibility to someone else is not possible. If your state PMP does not help, simply call the patient’s pharmacy and ask for the last three fill dates on an opioid prescription. This also works well in case the patient’s pharmacy doesn’t participate in a PMP or is delayed in uploading recent prescriber data. Many COT patients have an opioid treatment agreement with their prescriber and must use only one pharmacy to fill opioids.

In January 2013, the University of North Carolina Injury Prevention Center published an analysis of three years of North Carolina PMP data.1 Patients followed by providers who consistently used the state PMP were five times more likely to receive treatment for opioid dependence compared with patients of providers who never used the state PMP.¹

Why go through all this trouble if a chronic pain specialist is also doing it? It’s good documentation and good care, like monitoring levels of transplant meds or making sure hemoglobin A1Cs are up to date and trending toward goal. It may only take one misused or diverted opioid pill to result in a serious adverse event.

Sometimes stopping pills, rather than adding them, can cure pain.

Many chronic pain patients accumulate a patchwork of pills (e.g. benzodiazepines, opioids, muscle relaxants, and antidepressants). Many interpret noxious symptoms associated with the drug burden as “uncontrolled pain.” Two conditions that might afflict the pain sufferer who takes multiple medications are opioid-induced hyperalgesia (OIH) and medication-overuse headaches (MOH). They are uncommon but should be on a hospitalist’s differential for difficult-to-control chronic pain. Opioids commonly are implicated in causing MOH, a chronic headache occurring at least 15 days a month, four hours a day if untreated, and for at least three consecutive months. OIH is a nociceptive sensitization caused by opioids that can occur suddenly or insidiously.

If a drug isn’t absolutely necessary, stop it. If you and the patient start by agreeing to the shared goal of improving health, the conversation should go better. An axiom we learned from mentors at the University of Washington is: “There is no pain that cannot be made worse with inappropriate therapy.”

Take time to educate patients about methadone and its risk of mortality if not used as prescribed.

Methadone is less frequently prescribed than other opioids, yet it is more frequently associated with death from overdose. Though there is a risk of overdose and death with any opioid, managing methadone is more difficult. A desperate chronic pain patient may self-escalate their methadone without proper insight into the consequences.

Remember the logarithmic relationship methadone doses have with their morphine equivalency. The following highlights how deceiving the numbers are: 50 mg of methadone is about 100 mg of morphine-equivalent, but 100 mg of methadone is about 1,000 mg of morphine-equivalent, or 10 times as strong.

From 1999 to 2005, methadone-related deaths increased by 468%.² If the patient doesn’t seem to understand these risks, they are not a good candidate for methadone treatment.

A little local anesthetic (and some steroid) goes a long way.

Hospitalists should offer an assortment of diagnostic and therapeutic injections to chronic pain patients. First, be sure you’ve done your due diligence:

• What procedures do you have privileges to do?
• Do you need to be proctored first?
• How do your local specialists feel about you doing injections?

In light of these considerations, hospitalists should be able to train and be credentialed to offer such procedures as trigger-point injections, joint injections (knees, shoulders), or even a peripheral nerve injection (e.g. lateral femoral cutaneous nerve or ilioinguinal nerve injection). Some hospitalists might even want to learn ultrasound-guided sacroiliac joint injections for chronic unexplained back pain.

Offering an indicated and effective injection is a good nonopioid option. And local anesthetic injections can help hospitalists establish an elusive diagnosis. For example, many patients spend years getting worked up for head and neck pain when dry-needling with a small volume (1 cc) of local anesthetic into a neck muscle trigger point can break their pain generator, eliminating their pain.

Addiction to opioids is not rare.

The use, misuse, and diversion of opioids and all the associated complications have appropriately received considerable media attention. A seminal paper by Porter and Jick titled “Addiction Is Rare in Patients Treated with Narcotics” is one of many tipping points associated with the boom in opioid prescribing.³ Whether it’s a three-day supply of hydrocodone, 24 hours on a PCA, or an opioid rotation, any exposure to opioids can put a patient on the runway to addiction.

There are only 3,071 board-certified addiction specialists certified by the American Board of Addiction Medicine, so access to an addiction specialist might be difficult.⁴

Nonetheless, do not become complacent and just continue the opioid therapy in a difficult opioid-addicted patient. Express your concerns to the primary opioid prescriber, or help patients who don’t have an opioid prescriber get access and treatment. Otherwise, you have no choice but to taper the opioids.

Ideally, chronic pain management should be delivered in the outpatient arena where long-term monitoring can take place.

Safely changing opioid regimens requires good math and good judgment.

During training and practice, hospitalists become accustomed to rapidly analyze objective data, such as ABGs, ECGs, anion gaps, and vent settings. A hospitalist should become similarly efficient at calculating morphine equivalencies (cautiously with methadone and fentanyl), making dose reductions, and rotating opioids. The more comfortable you are with morphine equivalencies, the faster and safer you will be at rotating opioids. Whatever morphine-equivalence table you feel comfortable with is the one you should use consistently.

We see many providers who unwittingly take, for example, a patient who has become resistant to hydrocodone/acetaminophen 10/325 mg PO TID (30 mg of morphine) and convert them to oxycodone/acetaminophen 10/325 mg PO QID (60 mg of morphine—a doubling), when doubling could cause respiratory depression or a faster path to addiction and dependency.

But there are cases in which judgment should trump math, such as when converting from an IV to an oral regimen. We frequently see patients in the clinic requesting refills for more than 100 mg of hydromorphone because “that’s what I was on when I was hospitalized and on the pump.” If the IV-to-oral conversion leaves you prescribing high doses of oral opioids, plan for a rapid taper and a smooth handoff to the outpatient setting.

One strategy to decrease an error in math and judgment is to use IV PCAs as infrequently as possible if a patient isn’t post-operative and they are able to take oral meds. And never hesitate to consult with your inpatient pharmacist or a chronic pain specialist.

For a low-risk chronic pain patient on low-dose opioids, don’t change the regimen, even if the indication for opioids isn’t clear.

Although it is tempting to become an opioid prohibitionist, if a patient has been taking an opioid for years and is functioning, working, compliant, and has no risk factors for complications from COT, it is likely fine to continue their current regimen. Touch base with the primary opioid prescriber, and if you’re concerned, use some of the monitoring instruments described earlier (PMP, urine drug screen, opioid treatment agreement, pill counts).

If a patient has pain all the time, they need to be on a medication that works all the time.

A good pain history followed by a good neurological and mental health assessment is of incalculable value, especially because physicians often underestimate a patient’s pain intensity and its impact on a patient’s quality of life.^5,6 A patient’s pain intensity, quality of life, and function can be dramatically improved by starting a long-acting medication for “constant pain.”

If a patient hurts “24 hours a day” and cannot function on hydrocodone/acetaminophen 10/325 QID, it’s probably because they are constantly reacting to spikes in pain and using a “some of the time” medicine to treat “all the time” pain. Switching to a long-acting medication—and it doesn’t have to be an opioid—could improve control and decrease how much narcotic the patient needs.

If you choose a long-acting opioid (in this case, you could try morphine sulphate extended-release 15 mg BID and satisfy 50% of the hydrocodone need), then you could titrate slowly upwards to where the patient would not need hydrocodone. If the patient still had uncontrolled pain, then either morphine is the wrong compound for them or they are benefiting from the “nonanalgesic properties” of the opioids.

Give the patient the benefit of the doubt; because of genetic polymorphisms, a patient may need several opioid rotations before the right opioid compound is found.

Dr. Schultz is a hospitalist and assistant professor in the department of internal medicine at the University of Miami Miller School of Medicine. She is board-certified in hospice and palliative care and specializes in chronic pain management. Dr. Ajam is a hospitalist and a clinical assistant professor in the department of anesthesiology at Wake Forest University Baptist Medical Center and the Carolinas Pain Institute. He is board-certified in chronic pain management.

References

1. Garrettson M, Ringwalt C. An evaluation of the North Carolina controlled substances reporting system: part II impact evaluation, January 2013. PDMP Center of Excellence website. Available at: http://pdmpexcellence.org/sites/all/pdfs/NC_control_sub_eval_pt_2.pdf. Accessed Sept. 3, 2013.
2. Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005, national vital statistics reports; Vol. 56 No. 10. Hyattsville, Md.: National Center for Health Statistics; 2008.
3. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980;302(2):123.
4. American Society of Addiction Medicine; personal communication, 2013.
5. Mäntyselkä P, Kumpusalo E, Ahonen R, Takala J. Patients’ versus general practitioners’ assessments of pain intensity in primary care patients with non-cancer pain. Br J Gen Pract. 2001;51(473):995-997.
6. Petersen MA, Larsen H, Pedersen L, Sonne N, Groenvold M. Assessing health-related quality of life in palliative care: comparing patient and physician assessments. Eur J Cancer. 2006;42(8):1159-1166.

In This Edition

9 Things: At a Glance

An occasional series providing specialty-specific advice for hospitalists from experts in the field.

1. Recognize the differential diagnosis for pain exacerbation in a chronic opioid therapy (COT) patient/chronic pain patient.
2. Know where the opioids are going.
3. Sometimes stopping pills, rather than adding them, can cure pain.
4. Take time to educate patients about methadone and its risk of mortality if not used as prescribed.
5. A little local anesthetic (and some steroid) goes a long way.
6. Addiction to opioids is not rare.
7. Safely changing opioid regimens requires good math and good judgment.
8. For a low-risk chronic pain patient on low-dose opioids, don’t change the regimen, even if the indication for opioids isn’t clear.
9. If a patient has pain all the time, they need to be on a medication that works all the time.

The differential diagnosis for pain exacerbation in a chronic opioid therapy (COT) patient/chronic pain patient is:

1. Worsening medical problem;
2. New medical problem;
3. Nonopioid problem (side effect);
4. Opioid problem (resistance/tolerance/side effect); and
5. Opioid-induced hyperalgesia.

The search for an etiology and treatment for chronic pain should not end, even if a patient is labeled with “chronic pain syndrome.” The patient could simply be chronically undiagnosed or on an incorrect therapy.

Know where the opioids are going.

Whether it’s auditing a prescription-monitoring program (PMP), checking a urine drug screen, or calling a pharmacist, try to ensure that chronic pain patients are taking the opioids as prescribed. A phone call to the primary opioid prescriber or chronic pain provider could save a busy hospitalist a lot of time.

Using PMP data can consume a lot of time. Typically, only prescribing providers can access PMPs, so delegating this responsibility to someone else is not possible. If your state PMP does not help, simply call the patient’s pharmacy and ask for the last three fill dates on an opioid prescription. This also works well in case the patient’s pharmacy doesn’t participate in a PMP or is delayed in uploading recent prescriber data. Many COT patients have an opioid treatment agreement with their prescriber and must use only one pharmacy to fill opioids.

In January 2013, the University of North Carolina Injury Prevention Center published an analysis of three years of North Carolina PMP data.1 Patients followed by providers who consistently used the state PMP were five times more likely to receive treatment for opioid dependence compared with patients of providers who never used the state PMP.¹

Why go through all this trouble if a chronic pain specialist is also doing it? It’s good documentation and good care, like monitoring levels of transplant meds or making sure hemoglobin A1Cs are up to date and trending toward goal. It may only take one misused or diverted opioid pill to result in a serious adverse event.

Sometimes stopping pills, rather than adding them, can cure pain.

Many chronic pain patients accumulate a patchwork of pills (e.g. benzodiazepines, opioids, muscle relaxants, and antidepressants). Many interpret noxious symptoms associated with the drug burden as “uncontrolled pain.” Two conditions that might afflict the pain sufferer who takes multiple medications are opioid-induced hyperalgesia (OIH) and medication-overuse headaches (MOH). They are uncommon but should be on a hospitalist’s differential for difficult-to-control chronic pain. Opioids commonly are implicated in causing MOH, a chronic headache occurring at least 15 days a month, four hours a day if untreated, and for at least three consecutive months. OIH is a nociceptive sensitization caused by opioids that can occur suddenly or insidiously.

If a drug isn’t absolutely necessary, stop it. If you and the patient start by agreeing to the shared goal of improving health, the conversation should go better. An axiom we learned from mentors at the University of Washington is: “There is no pain that cannot be made worse with inappropriate therapy.”

Take time to educate patients about methadone and its risk of mortality if not used as prescribed.

Methadone is less frequently prescribed than other opioids, yet it is more frequently associated with death from overdose. Though there is a risk of overdose and death with any opioid, managing methadone is more difficult. A desperate chronic pain patient may self-escalate their methadone without proper insight into the consequences.

Remember the logarithmic relationship methadone doses have with their morphine equivalency. The following highlights how deceiving the numbers are: 50 mg of methadone is about 100 mg of morphine-equivalent, but 100 mg of methadone is about 1,000 mg of morphine-equivalent, or 10 times as strong.

From 1999 to 2005, methadone-related deaths increased by 468%.² If the patient doesn’t seem to understand these risks, they are not a good candidate for methadone treatment.

A little local anesthetic (and some steroid) goes a long way.

Hospitalists should offer an assortment of diagnostic and therapeutic injections to chronic pain patients. First, be sure you’ve done your due diligence:

• What procedures do you have privileges to do?
• Do you need to be proctored first?
• How do your local specialists feel about you doing injections?

In light of these considerations, hospitalists should be able to train and be credentialed to offer such procedures as trigger-point injections, joint injections (knees, shoulders), or even a peripheral nerve injection (e.g. lateral femoral cutaneous nerve or ilioinguinal nerve injection). Some hospitalists might even want to learn ultrasound-guided sacroiliac joint injections for chronic unexplained back pain.

Offering an indicated and effective injection is a good nonopioid option. And local anesthetic injections can help hospitalists establish an elusive diagnosis. For example, many patients spend years getting worked up for head and neck pain when dry-needling with a small volume (1 cc) of local anesthetic into a neck muscle trigger point can break their pain generator, eliminating their pain.

Addiction to opioids is not rare.

The use, misuse, and diversion of opioids and all the associated complications have appropriately received considerable media attention. A seminal paper by Porter and Jick titled “Addiction Is Rare in Patients Treated with Narcotics” is one of many tipping points associated with the boom in opioid prescribing.³ Whether it’s a three-day supply of hydrocodone, 24 hours on a PCA, or an opioid rotation, any exposure to opioids can put a patient on the runway to addiction.

There are only 3,071 board-certified addiction specialists certified by the American Board of Addiction Medicine, so access to an addiction specialist might be difficult.⁴

Nonetheless, do not become complacent and just continue the opioid therapy in a difficult opioid-addicted patient. Express your concerns to the primary opioid prescriber, or help patients who don’t have an opioid prescriber get access and treatment. Otherwise, you have no choice but to taper the opioids.

Ideally, chronic pain management should be delivered in the outpatient arena where long-term monitoring can take place.

Safely changing opioid regimens requires good math and good judgment.

During training and practice, hospitalists become accustomed to rapidly analyze objective data, such as ABGs, ECGs, anion gaps, and vent settings. A hospitalist should become similarly efficient at calculating morphine equivalencies (cautiously with methadone and fentanyl), making dose reductions, and rotating opioids. The more comfortable you are with morphine equivalencies, the faster and safer you will be at rotating opioids. Whatever morphine-equivalence table you feel comfortable with is the one you should use consistently.

We see many providers who unwittingly take, for example, a patient who has become resistant to hydrocodone/acetaminophen 10/325 mg PO TID (30 mg of morphine) and convert them to oxycodone/acetaminophen 10/325 mg PO QID (60 mg of morphine—a doubling), when doubling could cause respiratory depression or a faster path to addiction and dependency.

But there are cases in which judgment should trump math, such as when converting from an IV to an oral regimen. We frequently see patients in the clinic requesting refills for more than 100 mg of hydromorphone because “that’s what I was on when I was hospitalized and on the pump.” If the IV-to-oral conversion leaves you prescribing high doses of oral opioids, plan for a rapid taper and a smooth handoff to the outpatient setting.

One strategy to decrease an error in math and judgment is to use IV PCAs as infrequently as possible if a patient isn’t post-operative and they are able to take oral meds. And never hesitate to consult with your inpatient pharmacist or a chronic pain specialist.

For a low-risk chronic pain patient on low-dose opioids, don’t change the regimen, even if the indication for opioids isn’t clear.

Although it is tempting to become an opioid prohibitionist, if a patient has been taking an opioid for years and is functioning, working, compliant, and has no risk factors for complications from COT, it is likely fine to continue their current regimen. Touch base with the primary opioid prescriber, and if you’re concerned, use some of the monitoring instruments described earlier (PMP, urine drug screen, opioid treatment agreement, pill counts).

If a patient has pain all the time, they need to be on a medication that works all the time.

A good pain history followed by a good neurological and mental health assessment is of incalculable value, especially because physicians often underestimate a patient’s pain intensity and its impact on a patient’s quality of life.^5,6 A patient’s pain intensity, quality of life, and function can be dramatically improved by starting a long-acting medication for “constant pain.”

If a patient hurts “24 hours a day” and cannot function on hydrocodone/acetaminophen 10/325 QID, it’s probably because they are constantly reacting to spikes in pain and using a “some of the time” medicine to treat “all the time” pain. Switching to a long-acting medication—and it doesn’t have to be an opioid—could improve control and decrease how much narcotic the patient needs.

If you choose a long-acting opioid (in this case, you could try morphine sulphate extended-release 15 mg BID and satisfy 50% of the hydrocodone need), then you could titrate slowly upwards to where the patient would not need hydrocodone. If the patient still had uncontrolled pain, then either morphine is the wrong compound for them or they are benefiting from the “nonanalgesic properties” of the opioids.

Give the patient the benefit of the doubt; because of genetic polymorphisms, a patient may need several opioid rotations before the right opioid compound is found.

Dr. Schultz is a hospitalist and assistant professor in the department of internal medicine at the University of Miami Miller School of Medicine. She is board-certified in hospice and palliative care and specializes in chronic pain management. Dr. Ajam is a hospitalist and a clinical assistant professor in the department of anesthesiology at Wake Forest University Baptist Medical Center and the Carolinas Pain Institute. He is board-certified in chronic pain management.

References

1. Garrettson M, Ringwalt C. An evaluation of the North Carolina controlled substances reporting system: part II impact evaluation, January 2013. PDMP Center of Excellence website. Available at: http://pdmpexcellence.org/sites/all/pdfs/NC_control_sub_eval_pt_2.pdf. Accessed Sept. 3, 2013.
2. Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for 2005, national vital statistics reports; Vol. 56 No. 10. Hyattsville, Md.: National Center for Health Statistics; 2008.
3. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980;302(2):123.
4. American Society of Addiction Medicine; personal communication, 2013.
5. Mäntyselkä P, Kumpusalo E, Ahonen R, Takala J. Patients’ versus general practitioners’ assessments of pain intensity in primary care patients with non-cancer pain. Br J Gen Pract. 2001;51(473):995-997.
6. Petersen MA, Larsen H, Pedersen L, Sonne N, Groenvold M. Assessing health-related quality of life in palliative care: comparing patient and physician assessments. Eur J Cancer. 2006;42(8):1159-1166.

In one recently publicized demonstration of data mining’s potential, Austin, Texas-based Seton Healthcare Family used software developed by IBM to pore over doctors’ notes and predict the risk of readmission among patients with congestive heart failure. Among the shortlist of biggest predictors, the analysis pointed to a lack of emotional support and a bulging jugular vein—factors that could be easily identified through inpatient screening but might otherwise be overlooked by staff.

Similarly, New York-Presbyterian Hospital used a system by Microsoft to help reduce the rates of blood clotting in patients through an objective analysis of such risk factors as cancer, smoking, and bed confinement.

In June, Deloitte and Utah-based Intermountain Healthcare announced the launch of OutcomesMiner, an analytics tool that uses electronic health records to ferret out important variations and associations among patient populations. Brett Davis, general manager of Deloitte Health Informatics, says understanding asthma patients who are in different age brackets, have different comorbidities, and are on different drugs, for example, can allow providers to better manage the population. Merely using ICD-9 codes often results in inaccurate patient classifications, he warns. Instead, capturing and analyzing data from medications and clinical encounters can be vital for properly defining an asthma patient and separating the signal from the noise.

In one recently publicized demonstration of data mining’s potential, Austin, Texas-based Seton Healthcare Family used software developed by IBM to pore over doctors’ notes and predict the risk of readmission among patients with congestive heart failure. Among the shortlist of biggest predictors, the analysis pointed to a lack of emotional support and a bulging jugular vein—factors that could be easily identified through inpatient screening but might otherwise be overlooked by staff.

Similarly, New York-Presbyterian Hospital used a system by Microsoft to help reduce the rates of blood clotting in patients through an objective analysis of such risk factors as cancer, smoking, and bed confinement.

In June, Deloitte and Utah-based Intermountain Healthcare announced the launch of OutcomesMiner, an analytics tool that uses electronic health records to ferret out important variations and associations among patient populations. Brett Davis, general manager of Deloitte Health Informatics, says understanding asthma patients who are in different age brackets, have different comorbidities, and are on different drugs, for example, can allow providers to better manage the population. Merely using ICD-9 codes often results in inaccurate patient classifications, he warns. Instead, capturing and analyzing data from medications and clinical encounters can be vital for properly defining an asthma patient and separating the signal from the noise.

In one recently publicized demonstration of data mining’s potential, Austin, Texas-based Seton Healthcare Family used software developed by IBM to pore over doctors’ notes and predict the risk of readmission among patients with congestive heart failure. Among the shortlist of biggest predictors, the analysis pointed to a lack of emotional support and a bulging jugular vein—factors that could be easily identified through inpatient screening but might otherwise be overlooked by staff.

Similarly, New York-Presbyterian Hospital used a system by Microsoft to help reduce the rates of blood clotting in patients through an objective analysis of such risk factors as cancer, smoking, and bed confinement.

In June, Deloitte and Utah-based Intermountain Healthcare announced the launch of OutcomesMiner, an analytics tool that uses electronic health records to ferret out important variations and associations among patient populations. Brett Davis, general manager of Deloitte Health Informatics, says understanding asthma patients who are in different age brackets, have different comorbidities, and are on different drugs, for example, can allow providers to better manage the population. Merely using ICD-9 codes often results in inaccurate patient classifications, he warns. Instead, capturing and analyzing data from medications and clinical encounters can be vital for properly defining an asthma patient and separating the signal from the noise.

One hospital wanted to reduce readmissions among patients with congestive heart failure. Another hoped to improve upon its sepsis mortality rates. A third sought to determine whether its doctors were providing cost-effective care for pneumonia patients. All of them adopted the same type of technology to help identify a solution.

As the healthcare industry tilts toward accountable care, pay for performance and an increasingly

cost-conscious mindset, hospitalists and other providers are tapping into a fast-growing analytical tool collectively known as data mining to help make sense of the growing mounds of information. Although no single technology can be considered a cure-all, HM leaders are so optimistic about data mining’s potential to address cost, outcome, and performance issues that some have labeled it a “game changer” for hospitalists.

Karim Godamunne, MD, MBA, SFHM, chief medical officer at North Fulton Hospital in Roswell, Ga., and a member of SHM’s Practice Management Committee, says he can’t overstate the importance of hospitalists’ involvement in physician data mining. “From my perspective, we’re looking to hospitalists to help drive this quality-utilization bandwagon, to be the real leaders in it,” he says. With the tremendous value that can be generated through understanding and using the information, “it’s good for your group and can be good to your hospital as a whole.”

So what is data mining? The technology fully emerged in the mid-1990s as a way to help scientists analyze large and often disparate bodies of data, present relevant information in new ways, and illuminate previously unknown relationships.¹ In the healthcare industry, early adopters realized that the insights gleaned from data mining could help inform their clinical decision-making; organizations used the new tools to help predict health insurance fraud and identify at-risk patients, for example.

Cynthia Burghard, research director of Accountable Care IT Strategies at IDC Health Insights in Framingham, Mass., says researchers in academic medical centers initially conducted most of the clinical analytical work. Within the past few years, however, the increasing availability of data has allowed more hospitals to begin analyzing chronic disease, readmissions, and other areas of concern. In addition, Burghard says, new tools based on natural language processing are giving hospitals better access to unstructured clinical data, such as notes written by doctors and nurses.

“What I’m seeing both in my surveys as well as in conversations with hospitals is that analytics is the top of the investment priority for both hospitals and health plans,” Burghard says. According to IDC estimates, total spending for clinical analytics in the U.S. reached $3.7 billion in 2012 and is expected to grow to $5.14 billion by 2016. Much of the growth, she notes, is being driven by healthcare reform. “If your mandate is to manage populations of patients, it behooves you to know who those patients are and what their illnesses are, and to monitor what you’re doing for them,” she says.

Practice Improvement

Accordingly, a major goal of all this data-mining technology is to change practice behavior in a way that achieves the triple aim of improving quality of care, controlling costs, and bettering patient outcomes.

A growing number of companies are releasing tools that can compile and analyze the separate bits of information captured from claims and billing systems, Medicare reporting requirements, internal benchmarks, and other sources. Unlike passive data sources, such as Medicare’s Hospital Compare website, more active analytics can help their users zoom down to the level of an individual doctor or patient, pan out to the level of a hospitalist group, or expand out even more for a broader comparison among peer institutions.

Some newer data-mining tools with names like CRIMSON, Truven, Iodine, and Imagine are billing themselves as hospitalist-friendly performance-improvement aids and giving individual providers the ability to access and analyze the data themselves. A few of these applications can even provide real-time data via mobile devices (see “Physician Performance Aids,”).

Thomas Frederickson, MD, MBA, SFHM, medical director of the HM service at Alegent Creighton Health in Omaha, Neb., and a member of SHM’s Practice Management Committee, sees the biggest potential of this data-mining technology in its ability to help drive practice consistency. “You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists,” he says. “And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.”

When Alegent Creighton Health was scrutinizing the care of its pneumonia patients, for example, officials could compare the number of chest X-rays per pneumonia patient by hospital or across the entire CRIMSON database. At a deeper level, the officials could see how often individual providers ordered the tests compared to their peers. For outliers, they could follow up to determine whether the variability was warranted.

As champions of process improvement, Dr. Frederickson says, hospitalists can make particularly good use of database analytics. “It’s part of the process of making hospitalists invaluable to their hospitals and their systems,” he says. “Part of that is building up expertise on process improvement and safety, and familiarity with these kinds of tools is one thing that will help us do that.”

North Fulton Hospital used CRIMSON to analyze how its doctors care for patients with sepsis and to establish new benchmarks. Dr. Godamunne says the tools allowed the hospital to track its doctors’ progress over time and identify potential problems. “If a patient with sepsis is staying too long, you can see who admitted the patient and see if, a few months ago, the same physician was having similar problems,” he says. Similarly, the hospital was able to track the top DRGs resulting in excess length of stay among patients, to identify potential bottlenecks in the care and discharge processes.

Some tools require only two-day training sessions for basic proficiency, though more advanced manipulations often require a bigger commitment, like the 12-week training session that Dr. Godamunne completed. That training included one hour of online learning and one hour of homework every week, and most of the cases highlighted during his coursework, he says, focused on hospitalists—another sign of the major role he believes HM will play in harnessing data to improve performance quality.

You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists. And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.

—Thomas Frederickson, MD, MBA, SFHM, medical director, hospital medicine service, Alegent Creighton Health, Omaha, Neb., SHM Practice Management Committee member

Slow—Construction Ahead

The best information is meaningful, individualized, and timely, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine and medical director of regional business development at Ochsner Health System in New Orleans. “If you get something back six months after you’ve delivered the care, you’ll have a limited opportunity to improve, versus if you get it back in a week or two, or ideally, in real time,” says Dr. Deitelzweig, chair of SHM’s Practice Management Committee.

In examining length of stay, Dr. Deitelzweig says doctors could use data mining to look at time-stamped elements of patient flow and the timeliness of provider response: how patients go through the ED, and when they receive written orders or lab results. “It could be really powerful, and right now it’s a little bit of a black hole,” he says.

Based on her conversations with hospital executives and leaders, however, Burghard cautions that some real-time mobile applications, although technologically impressive, may be less useful or necessary in practice. “If it’s performance measurement, why do you need that in real time? It’s not going to change your behavior in the moment,” she says. “What you may want to get is an alert that your patient, who is in the hospital, has had some sort of negative event.”

Data mining has other potential limitations. “There’s always going to be questions of attribution, and you need to have clinical knowledge of your location,” Dr. Godamunne says. And data mining is only as good as the data that have been documented, underscoring the importance of securing provider cooperation.

Dr. Frederickson says physician acceptance, in fact, might be one of the biggest obstacles—a major reason why he recommends introducing the technology slowly and explaining why and how it will be used. If introduced too quickly and without adequate explanation about what a hospital or health system hopes to accomplish, he says, “there certainly is the potential for suspicion.” The key, he says, is to emphasize that the tools provide a valuable mechanism for gleaning new insights into doctors’ practice patterns, “not something that’s going to be used against them.”

Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company's Crimson division, agrees that personally engaging physicians is essential for a good return on investment in analytical tools like his company’s suite of CRIMSON products. “If you can’t work with the physicians to get them to understand the data and actively use the data in their practice patterns, it becomes a bit meaningless,” he says.

We’re looking to hospitalists to help drive this quality utilization bandwagon, to be the real leaders in it.…It’s good for your group and can be good to your hospital as a whole.

—Karim Godamunne, MD, MBA, SFHM, chief medical officer, North Fulton Hospital, Roswell, Ga., SHM Practice Management Committee member

Roscoe sees big opportunities in prospectively examining information while a patient is still in the hospital and when a change of course by providers could avert a bad outcome. “Suggesting a set of interventions that they could do differently is really the value-add,” he says. But he cautions that those suggestions must be worded carefully to avoid alienating physicians.

“If doctors don’t feel like they’re being judged, they’ll engage with you,” Roscoe says.

Similar nuances can affect how users perceive the tools themselves. After hearing feedback from members that the words “data mining” didn’t conjure trust and confidence, the Advisory Board Company dropped the phrase altogether in favor of “data analytics,” “physician engagement,” and similar descriptors. “It’s simple things like that that can very quickly either turn a physician on or off,” Roscoe says.

Once users take the time to understand data-mining tools and how they can be properly harnessed, advocates say, the technology can lead to a host of unanticipated benefits. When a hospital bills the federal government for a Medicare patient, for example, it must submit an HCC code that describes the patient’s condition. By doing a better job of mining the data, Burghard says, a hospital can more accurately reflect that patient’s contdition. For example, if a hospital is treating a diabetic who comes in with a broken leg, the hospital could receive a lower payment rate if it does not properly identify and record both conditions.

And by using the tools prospectively, Burghard says, “I think there’s the opportunity to make a quantum leap from what we’re doing today. We usually just report on facts, and usually retrospectively. With some of the new technology that’s available, the healthcare industry can begin to do discovery analytics—you’re identifying insights, patterns, and relationships.”

Better integration of computerized physician order entry with data-mining ports, Dr. Godamunne predicts, will allow for much better attribution and finer parsing of the data. As the transparency increases, though, hospitalists will have to adapt to a new reality in which stronger analytical tools may point out individual outliers. And that level of detail, in turn, will require some hospitalists to justify why they’re different than their peers.

Even so, Roscoe says, he’s found that hospitalists are very open to using data to improve performance and that they make up a high percentage of CRIMSON users. “There isn’t a physician group that is in a better position to help drive this quality- and data-driven culture,” he says.

Bryn Nelson is a freelance medical writer in Seattle.

Physician Performance Aids

Company: The Advisory Board Company

Sample product: CRIMSON Continuum of Care

Claim: “Places credible, severity-adjusted performance profiles directly in the hands of physicians, enabling the hospital-physician collaboration needed to advance quality goals and secure cost savings.”

Number of users: More than 850 hospitals

Real-time data? No, but available as add-on service

To learn more: www.advisory.com/Technology/Crimson-Continuum-of-Care

Company: Panacea Developments

Sample product: Iodine

Claim: “An easy-to-use mobile system that analyzes a hospital’s sea of data for knowledge that physicians, case managers, and documentation specialists can act upon to improve length-of-stay, readmissions, and documentation.”

Number of users: More than 50 hospitals

Real-time data? Yes

To learn more: www.panaceadevelopments.com/iodine

Company: Truven Health

Sample product: CareDiscovery

Claim: “Provides powerful insights into a hospital’s or health system’s quality measures and resource utilization to support improvement with objective, fact-based information.”

Real-time data? No

Number of users: More than 3,000 users in 400 hospitals

To learn more: http://truvenhealth.com/products/carediscovery

Company: Ingenious Med

Sample product: Imagine

Claim: “A comprehensive analytics dashboard platform that provides actionable decision making data to optimize physician performance and revenue.”

Real-time data? Yes

Number of users: 25,000 total users (not separated by individual products)

To learn more: http://ingeniousmed.com/what-we-do/imagine

Reference

1. Yoo I, Alafaireet P, Marinov M, et al. Data mining in healthcare and biomedicine: a survey of the literature. J Med Syst. 2012;36:2431-2448.

One hospital wanted to reduce readmissions among patients with congestive heart failure. Another hoped to improve upon its sepsis mortality rates. A third sought to determine whether its doctors were providing cost-effective care for pneumonia patients. All of them adopted the same type of technology to help identify a solution.

As the healthcare industry tilts toward accountable care, pay for performance and an increasingly

cost-conscious mindset, hospitalists and other providers are tapping into a fast-growing analytical tool collectively known as data mining to help make sense of the growing mounds of information. Although no single technology can be considered a cure-all, HM leaders are so optimistic about data mining’s potential to address cost, outcome, and performance issues that some have labeled it a “game changer” for hospitalists.

Karim Godamunne, MD, MBA, SFHM, chief medical officer at North Fulton Hospital in Roswell, Ga., and a member of SHM’s Practice Management Committee, says he can’t overstate the importance of hospitalists’ involvement in physician data mining. “From my perspective, we’re looking to hospitalists to help drive this quality-utilization bandwagon, to be the real leaders in it,” he says. With the tremendous value that can be generated through understanding and using the information, “it’s good for your group and can be good to your hospital as a whole.”

So what is data mining? The technology fully emerged in the mid-1990s as a way to help scientists analyze large and often disparate bodies of data, present relevant information in new ways, and illuminate previously unknown relationships.¹ In the healthcare industry, early adopters realized that the insights gleaned from data mining could help inform their clinical decision-making; organizations used the new tools to help predict health insurance fraud and identify at-risk patients, for example.

Cynthia Burghard, research director of Accountable Care IT Strategies at IDC Health Insights in Framingham, Mass., says researchers in academic medical centers initially conducted most of the clinical analytical work. Within the past few years, however, the increasing availability of data has allowed more hospitals to begin analyzing chronic disease, readmissions, and other areas of concern. In addition, Burghard says, new tools based on natural language processing are giving hospitals better access to unstructured clinical data, such as notes written by doctors and nurses.

“What I’m seeing both in my surveys as well as in conversations with hospitals is that analytics is the top of the investment priority for both hospitals and health plans,” Burghard says. According to IDC estimates, total spending for clinical analytics in the U.S. reached $3.7 billion in 2012 and is expected to grow to $5.14 billion by 2016. Much of the growth, she notes, is being driven by healthcare reform. “If your mandate is to manage populations of patients, it behooves you to know who those patients are and what their illnesses are, and to monitor what you’re doing for them,” she says.

Practice Improvement

Accordingly, a major goal of all this data-mining technology is to change practice behavior in a way that achieves the triple aim of improving quality of care, controlling costs, and bettering patient outcomes.

A growing number of companies are releasing tools that can compile and analyze the separate bits of information captured from claims and billing systems, Medicare reporting requirements, internal benchmarks, and other sources. Unlike passive data sources, such as Medicare’s Hospital Compare website, more active analytics can help their users zoom down to the level of an individual doctor or patient, pan out to the level of a hospitalist group, or expand out even more for a broader comparison among peer institutions.

Some newer data-mining tools with names like CRIMSON, Truven, Iodine, and Imagine are billing themselves as hospitalist-friendly performance-improvement aids and giving individual providers the ability to access and analyze the data themselves. A few of these applications can even provide real-time data via mobile devices (see “Physician Performance Aids,”).

Thomas Frederickson, MD, MBA, SFHM, medical director of the HM service at Alegent Creighton Health in Omaha, Neb., and a member of SHM’s Practice Management Committee, sees the biggest potential of this data-mining technology in its ability to help drive practice consistency. “You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists,” he says. “And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.”

When Alegent Creighton Health was scrutinizing the care of its pneumonia patients, for example, officials could compare the number of chest X-rays per pneumonia patient by hospital or across the entire CRIMSON database. At a deeper level, the officials could see how often individual providers ordered the tests compared to their peers. For outliers, they could follow up to determine whether the variability was warranted.

As champions of process improvement, Dr. Frederickson says, hospitalists can make particularly good use of database analytics. “It’s part of the process of making hospitalists invaluable to their hospitals and their systems,” he says. “Part of that is building up expertise on process improvement and safety, and familiarity with these kinds of tools is one thing that will help us do that.”

North Fulton Hospital used CRIMSON to analyze how its doctors care for patients with sepsis and to establish new benchmarks. Dr. Godamunne says the tools allowed the hospital to track its doctors’ progress over time and identify potential problems. “If a patient with sepsis is staying too long, you can see who admitted the patient and see if, a few months ago, the same physician was having similar problems,” he says. Similarly, the hospital was able to track the top DRGs resulting in excess length of stay among patients, to identify potential bottlenecks in the care and discharge processes.

Some tools require only two-day training sessions for basic proficiency, though more advanced manipulations often require a bigger commitment, like the 12-week training session that Dr. Godamunne completed. That training included one hour of online learning and one hour of homework every week, and most of the cases highlighted during his coursework, he says, focused on hospitalists—another sign of the major role he believes HM will play in harnessing data to improve performance quality.

You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists. And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.

—Thomas Frederickson, MD, MBA, SFHM, medical director, hospital medicine service, Alegent Creighton Health, Omaha, Neb., SHM Practice Management Committee member

Slow—Construction Ahead

The best information is meaningful, individualized, and timely, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine and medical director of regional business development at Ochsner Health System in New Orleans. “If you get something back six months after you’ve delivered the care, you’ll have a limited opportunity to improve, versus if you get it back in a week or two, or ideally, in real time,” says Dr. Deitelzweig, chair of SHM’s Practice Management Committee.

In examining length of stay, Dr. Deitelzweig says doctors could use data mining to look at time-stamped elements of patient flow and the timeliness of provider response: how patients go through the ED, and when they receive written orders or lab results. “It could be really powerful, and right now it’s a little bit of a black hole,” he says.

Based on her conversations with hospital executives and leaders, however, Burghard cautions that some real-time mobile applications, although technologically impressive, may be less useful or necessary in practice. “If it’s performance measurement, why do you need that in real time? It’s not going to change your behavior in the moment,” she says. “What you may want to get is an alert that your patient, who is in the hospital, has had some sort of negative event.”

Data mining has other potential limitations. “There’s always going to be questions of attribution, and you need to have clinical knowledge of your location,” Dr. Godamunne says. And data mining is only as good as the data that have been documented, underscoring the importance of securing provider cooperation.

Dr. Frederickson says physician acceptance, in fact, might be one of the biggest obstacles—a major reason why he recommends introducing the technology slowly and explaining why and how it will be used. If introduced too quickly and without adequate explanation about what a hospital or health system hopes to accomplish, he says, “there certainly is the potential for suspicion.” The key, he says, is to emphasize that the tools provide a valuable mechanism for gleaning new insights into doctors’ practice patterns, “not something that’s going to be used against them.”

Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company's Crimson division, agrees that personally engaging physicians is essential for a good return on investment in analytical tools like his company’s suite of CRIMSON products. “If you can’t work with the physicians to get them to understand the data and actively use the data in their practice patterns, it becomes a bit meaningless,” he says.

We’re looking to hospitalists to help drive this quality utilization bandwagon, to be the real leaders in it.…It’s good for your group and can be good to your hospital as a whole.

—Karim Godamunne, MD, MBA, SFHM, chief medical officer, North Fulton Hospital, Roswell, Ga., SHM Practice Management Committee member

Roscoe sees big opportunities in prospectively examining information while a patient is still in the hospital and when a change of course by providers could avert a bad outcome. “Suggesting a set of interventions that they could do differently is really the value-add,” he says. But he cautions that those suggestions must be worded carefully to avoid alienating physicians.

“If doctors don’t feel like they’re being judged, they’ll engage with you,” Roscoe says.

Similar nuances can affect how users perceive the tools themselves. After hearing feedback from members that the words “data mining” didn’t conjure trust and confidence, the Advisory Board Company dropped the phrase altogether in favor of “data analytics,” “physician engagement,” and similar descriptors. “It’s simple things like that that can very quickly either turn a physician on or off,” Roscoe says.

Once users take the time to understand data-mining tools and how they can be properly harnessed, advocates say, the technology can lead to a host of unanticipated benefits. When a hospital bills the federal government for a Medicare patient, for example, it must submit an HCC code that describes the patient’s condition. By doing a better job of mining the data, Burghard says, a hospital can more accurately reflect that patient’s contdition. For example, if a hospital is treating a diabetic who comes in with a broken leg, the hospital could receive a lower payment rate if it does not properly identify and record both conditions.

And by using the tools prospectively, Burghard says, “I think there’s the opportunity to make a quantum leap from what we’re doing today. We usually just report on facts, and usually retrospectively. With some of the new technology that’s available, the healthcare industry can begin to do discovery analytics—you’re identifying insights, patterns, and relationships.”

Better integration of computerized physician order entry with data-mining ports, Dr. Godamunne predicts, will allow for much better attribution and finer parsing of the data. As the transparency increases, though, hospitalists will have to adapt to a new reality in which stronger analytical tools may point out individual outliers. And that level of detail, in turn, will require some hospitalists to justify why they’re different than their peers.

Even so, Roscoe says, he’s found that hospitalists are very open to using data to improve performance and that they make up a high percentage of CRIMSON users. “There isn’t a physician group that is in a better position to help drive this quality- and data-driven culture,” he says.

Bryn Nelson is a freelance medical writer in Seattle.

Physician Performance Aids

Company: The Advisory Board Company

Sample product: CRIMSON Continuum of Care

Claim: “Places credible, severity-adjusted performance profiles directly in the hands of physicians, enabling the hospital-physician collaboration needed to advance quality goals and secure cost savings.”

Number of users: More than 850 hospitals

Real-time data? No, but available as add-on service

To learn more: www.advisory.com/Technology/Crimson-Continuum-of-Care

Company: Panacea Developments

Sample product: Iodine

Claim: “An easy-to-use mobile system that analyzes a hospital’s sea of data for knowledge that physicians, case managers, and documentation specialists can act upon to improve length-of-stay, readmissions, and documentation.”

Number of users: More than 50 hospitals

Real-time data? Yes

To learn more: www.panaceadevelopments.com/iodine

Company: Truven Health

Sample product: CareDiscovery

Claim: “Provides powerful insights into a hospital’s or health system’s quality measures and resource utilization to support improvement with objective, fact-based information.”

Real-time data? No

Number of users: More than 3,000 users in 400 hospitals

To learn more: http://truvenhealth.com/products/carediscovery

Company: Ingenious Med

Sample product: Imagine

Claim: “A comprehensive analytics dashboard platform that provides actionable decision making data to optimize physician performance and revenue.”

Real-time data? Yes

Number of users: 25,000 total users (not separated by individual products)

To learn more: http://ingeniousmed.com/what-we-do/imagine

Reference

1. Yoo I, Alafaireet P, Marinov M, et al. Data mining in healthcare and biomedicine: a survey of the literature. J Med Syst. 2012;36:2431-2448.

One hospital wanted to reduce readmissions among patients with congestive heart failure. Another hoped to improve upon its sepsis mortality rates. A third sought to determine whether its doctors were providing cost-effective care for pneumonia patients. All of them adopted the same type of technology to help identify a solution.

As the healthcare industry tilts toward accountable care, pay for performance and an increasingly

cost-conscious mindset, hospitalists and other providers are tapping into a fast-growing analytical tool collectively known as data mining to help make sense of the growing mounds of information. Although no single technology can be considered a cure-all, HM leaders are so optimistic about data mining’s potential to address cost, outcome, and performance issues that some have labeled it a “game changer” for hospitalists.

Karim Godamunne, MD, MBA, SFHM, chief medical officer at North Fulton Hospital in Roswell, Ga., and a member of SHM’s Practice Management Committee, says he can’t overstate the importance of hospitalists’ involvement in physician data mining. “From my perspective, we’re looking to hospitalists to help drive this quality-utilization bandwagon, to be the real leaders in it,” he says. With the tremendous value that can be generated through understanding and using the information, “it’s good for your group and can be good to your hospital as a whole.”

So what is data mining? The technology fully emerged in the mid-1990s as a way to help scientists analyze large and often disparate bodies of data, present relevant information in new ways, and illuminate previously unknown relationships.¹ In the healthcare industry, early adopters realized that the insights gleaned from data mining could help inform their clinical decision-making; organizations used the new tools to help predict health insurance fraud and identify at-risk patients, for example.

Cynthia Burghard, research director of Accountable Care IT Strategies at IDC Health Insights in Framingham, Mass., says researchers in academic medical centers initially conducted most of the clinical analytical work. Within the past few years, however, the increasing availability of data has allowed more hospitals to begin analyzing chronic disease, readmissions, and other areas of concern. In addition, Burghard says, new tools based on natural language processing are giving hospitals better access to unstructured clinical data, such as notes written by doctors and nurses.

“What I’m seeing both in my surveys as well as in conversations with hospitals is that analytics is the top of the investment priority for both hospitals and health plans,” Burghard says. According to IDC estimates, total spending for clinical analytics in the U.S. reached $3.7 billion in 2012 and is expected to grow to $5.14 billion by 2016. Much of the growth, she notes, is being driven by healthcare reform. “If your mandate is to manage populations of patients, it behooves you to know who those patients are and what their illnesses are, and to monitor what you’re doing for them,” she says.

Practice Improvement

Accordingly, a major goal of all this data-mining technology is to change practice behavior in a way that achieves the triple aim of improving quality of care, controlling costs, and bettering patient outcomes.

A growing number of companies are releasing tools that can compile and analyze the separate bits of information captured from claims and billing systems, Medicare reporting requirements, internal benchmarks, and other sources. Unlike passive data sources, such as Medicare’s Hospital Compare website, more active analytics can help their users zoom down to the level of an individual doctor or patient, pan out to the level of a hospitalist group, or expand out even more for a broader comparison among peer institutions.

Some newer data-mining tools with names like CRIMSON, Truven, Iodine, and Imagine are billing themselves as hospitalist-friendly performance-improvement aids and giving individual providers the ability to access and analyze the data themselves. A few of these applications can even provide real-time data via mobile devices (see “Physician Performance Aids,”).

Thomas Frederickson, MD, MBA, SFHM, medical director of the HM service at Alegent Creighton Health in Omaha, Neb., and a member of SHM’s Practice Management Committee, sees the biggest potential of this data-mining technology in its ability to help drive practice consistency. “You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists,” he says. “And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.”

When Alegent Creighton Health was scrutinizing the care of its pneumonia patients, for example, officials could compare the number of chest X-rays per pneumonia patient by hospital or across the entire CRIMSON database. At a deeper level, the officials could see how often individual providers ordered the tests compared to their peers. For outliers, they could follow up to determine whether the variability was warranted.

As champions of process improvement, Dr. Frederickson says, hospitalists can make particularly good use of database analytics. “It’s part of the process of making hospitalists invaluable to their hospitals and their systems,” he says. “Part of that is building up expertise on process improvement and safety, and familiarity with these kinds of tools is one thing that will help us do that.”

North Fulton Hospital used CRIMSON to analyze how its doctors care for patients with sepsis and to establish new benchmarks. Dr. Godamunne says the tools allowed the hospital to track its doctors’ progress over time and identify potential problems. “If a patient with sepsis is staying too long, you can see who admitted the patient and see if, a few months ago, the same physician was having similar problems,” he says. Similarly, the hospital was able to track the top DRGs resulting in excess length of stay among patients, to identify potential bottlenecks in the care and discharge processes.

Some tools require only two-day training sessions for basic proficiency, though more advanced manipulations often require a bigger commitment, like the 12-week training session that Dr. Godamunne completed. That training included one hour of online learning and one hour of homework every week, and most of the cases highlighted during his coursework, he says, focused on hospitalists—another sign of the major role he believes HM will play in harnessing data to improve performance quality.

You can use the database to analyze practice patterns of large groups, or even individuals, and see where variability exists. And then, based on that, you can analyze why the variability exists and begin to address whether it’s variability that’s clinically indicated or not.

—Thomas Frederickson, MD, MBA, SFHM, medical director, hospital medicine service, Alegent Creighton Health, Omaha, Neb., SHM Practice Management Committee member

Slow—Construction Ahead

The best information is meaningful, individualized, and timely, says Steven Deitelzweig, MD, SFHM, system chairman for hospital medicine and medical director of regional business development at Ochsner Health System in New Orleans. “If you get something back six months after you’ve delivered the care, you’ll have a limited opportunity to improve, versus if you get it back in a week or two, or ideally, in real time,” says Dr. Deitelzweig, chair of SHM’s Practice Management Committee.

In examining length of stay, Dr. Deitelzweig says doctors could use data mining to look at time-stamped elements of patient flow and the timeliness of provider response: how patients go through the ED, and when they receive written orders or lab results. “It could be really powerful, and right now it’s a little bit of a black hole,” he says.

Based on her conversations with hospital executives and leaders, however, Burghard cautions that some real-time mobile applications, although technologically impressive, may be less useful or necessary in practice. “If it’s performance measurement, why do you need that in real time? It’s not going to change your behavior in the moment,” she says. “What you may want to get is an alert that your patient, who is in the hospital, has had some sort of negative event.”

Data mining has other potential limitations. “There’s always going to be questions of attribution, and you need to have clinical knowledge of your location,” Dr. Godamunne says. And data mining is only as good as the data that have been documented, underscoring the importance of securing provider cooperation.

Dr. Frederickson says physician acceptance, in fact, might be one of the biggest obstacles—a major reason why he recommends introducing the technology slowly and explaining why and how it will be used. If introduced too quickly and without adequate explanation about what a hospital or health system hopes to accomplish, he says, “there certainly is the potential for suspicion.” The key, he says, is to emphasize that the tools provide a valuable mechanism for gleaning new insights into doctors’ practice patterns, “not something that’s going to be used against them.”

Paul Roscoe, CEO of the Washington, D.C.-based Advisory Board Company's Crimson division, agrees that personally engaging physicians is essential for a good return on investment in analytical tools like his company’s suite of CRIMSON products. “If you can’t work with the physicians to get them to understand the data and actively use the data in their practice patterns, it becomes a bit meaningless,” he says.

We’re looking to hospitalists to help drive this quality utilization bandwagon, to be the real leaders in it.…It’s good for your group and can be good to your hospital as a whole.

—Karim Godamunne, MD, MBA, SFHM, chief medical officer, North Fulton Hospital, Roswell, Ga., SHM Practice Management Committee member

Roscoe sees big opportunities in prospectively examining information while a patient is still in the hospital and when a change of course by providers could avert a bad outcome. “Suggesting a set of interventions that they could do differently is really the value-add,” he says. But he cautions that those suggestions must be worded carefully to avoid alienating physicians.

“If doctors don’t feel like they’re being judged, they’ll engage with you,” Roscoe says.

Similar nuances can affect how users perceive the tools themselves. After hearing feedback from members that the words “data mining” didn’t conjure trust and confidence, the Advisory Board Company dropped the phrase altogether in favor of “data analytics,” “physician engagement,” and similar descriptors. “It’s simple things like that that can very quickly either turn a physician on or off,” Roscoe says.

Once users take the time to understand data-mining tools and how they can be properly harnessed, advocates say, the technology can lead to a host of unanticipated benefits. When a hospital bills the federal government for a Medicare patient, for example, it must submit an HCC code that describes the patient’s condition. By doing a better job of mining the data, Burghard says, a hospital can more accurately reflect that patient’s contdition. For example, if a hospital is treating a diabetic who comes in with a broken leg, the hospital could receive a lower payment rate if it does not properly identify and record both conditions.

And by using the tools prospectively, Burghard says, “I think there’s the opportunity to make a quantum leap from what we’re doing today. We usually just report on facts, and usually retrospectively. With some of the new technology that’s available, the healthcare industry can begin to do discovery analytics—you’re identifying insights, patterns, and relationships.”

Better integration of computerized physician order entry with data-mining ports, Dr. Godamunne predicts, will allow for much better attribution and finer parsing of the data. As the transparency increases, though, hospitalists will have to adapt to a new reality in which stronger analytical tools may point out individual outliers. And that level of detail, in turn, will require some hospitalists to justify why they’re different than their peers.

Even so, Roscoe says, he’s found that hospitalists are very open to using data to improve performance and that they make up a high percentage of CRIMSON users. “There isn’t a physician group that is in a better position to help drive this quality- and data-driven culture,” he says.

Bryn Nelson is a freelance medical writer in Seattle.

Physician Performance Aids

Company: The Advisory Board Company

Sample product: CRIMSON Continuum of Care

Claim: “Places credible, severity-adjusted performance profiles directly in the hands of physicians, enabling the hospital-physician collaboration needed to advance quality goals and secure cost savings.”

Number of users: More than 850 hospitals

Real-time data? No, but available as add-on service

To learn more: www.advisory.com/Technology/Crimson-Continuum-of-Care

Company: Panacea Developments

Sample product: Iodine

Claim: “An easy-to-use mobile system that analyzes a hospital’s sea of data for knowledge that physicians, case managers, and documentation specialists can act upon to improve length-of-stay, readmissions, and documentation.”

Number of users: More than 50 hospitals

Real-time data? Yes

To learn more: www.panaceadevelopments.com/iodine

Company: Truven Health

Sample product: CareDiscovery

Claim: “Provides powerful insights into a hospital’s or health system’s quality measures and resource utilization to support improvement with objective, fact-based information.”

Real-time data? No

Number of users: More than 3,000 users in 400 hospitals

To learn more: http://truvenhealth.com/products/carediscovery

Company: Ingenious Med

Sample product: Imagine

Claim: “A comprehensive analytics dashboard platform that provides actionable decision making data to optimize physician performance and revenue.”

Real-time data? Yes

Number of users: 25,000 total users (not separated by individual products)

To learn more: http://ingeniousmed.com/what-we-do/imagine

Reference

1. Yoo I, Alafaireet P, Marinov M, et al. Data mining in healthcare and biomedicine: a survey of the literature. J Med Syst. 2012;36:2431-2448.

Hospitalists and ED physicians at Newton Medical Center in New Jersey recently participated in an improvised, interactive learning experience with actors who portrayed problematic patients. “Developing Doctor-Patient Relations through Better Communication” is a curriculum to test and teach communication skills for doctors that was created by Anthony Orsini, MD, a neonatologist at Morristown Medical Center, Newton’s sister facility in the Atlantic Health System. Dr. Orsini founded the Breaking Bad News Foundation (www.bbnfoundation.org) more than a decade ago to help health professionals impart bad medical news to patients and families.

Physicians role-play with actors in such difficult scenarios as imparting a troubling diagnosis to a patient who does not want to hear it. This interaction is viewed remotely by instructors from the foundation and by peers, who then meet with the doctor to go over the videotaped encounter regarding its effectiveness, spoken messages, body language, and other communications.

The project to improve staff communication skills is enhancing teamwork between Newton’s hospitalists and emergency doctors, according to David Stuhlmiller, MD, the hospital’s director of emergency medicine.

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Hospitalists and ED physicians at Newton Medical Center in New Jersey recently participated in an improvised, interactive learning experience with actors who portrayed problematic patients. “Developing Doctor-Patient Relations through Better Communication” is a curriculum to test and teach communication skills for doctors that was created by Anthony Orsini, MD, a neonatologist at Morristown Medical Center, Newton’s sister facility in the Atlantic Health System. Dr. Orsini founded the Breaking Bad News Foundation (www.bbnfoundation.org) more than a decade ago to help health professionals impart bad medical news to patients and families.

Physicians role-play with actors in such difficult scenarios as imparting a troubling diagnosis to a patient who does not want to hear it. This interaction is viewed remotely by instructors from the foundation and by peers, who then meet with the doctor to go over the videotaped encounter regarding its effectiveness, spoken messages, body language, and other communications.

The project to improve staff communication skills is enhancing teamwork between Newton’s hospitalists and emergency doctors, according to David Stuhlmiller, MD, the hospital’s director of emergency medicine.

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Hospitalists and ED physicians at Newton Medical Center in New Jersey recently participated in an improvised, interactive learning experience with actors who portrayed problematic patients. “Developing Doctor-Patient Relations through Better Communication” is a curriculum to test and teach communication skills for doctors that was created by Anthony Orsini, MD, a neonatologist at Morristown Medical Center, Newton’s sister facility in the Atlantic Health System. Dr. Orsini founded the Breaking Bad News Foundation (www.bbnfoundation.org) more than a decade ago to help health professionals impart bad medical news to patients and families.

Physicians role-play with actors in such difficult scenarios as imparting a troubling diagnosis to a patient who does not want to hear it. This interaction is viewed remotely by instructors from the foundation and by peers, who then meet with the doctor to go over the videotaped encounter regarding its effectiveness, spoken messages, body language, and other communications.

The project to improve staff communication skills is enhancing teamwork between Newton’s hospitalists and emergency doctors, according to David Stuhlmiller, MD, the hospital’s director of emergency medicine.

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Dr. Hospitalist

In this age of cost containment and fiscal frugality, how do you handle high-census periods without jeopardizing patient care?

–Michael P. Mason, Tulsa, Okla.

Dr. Hospitalist responds:

Your group must first define the term “high census,” because workload is based on many factors. Seeing 20 patients a day in a large inner-city hospital is much different from seeing 20 patients in a suburban hospital in an affluent part of town. Also, seeing 20 patients geographically located on the same floor is much easier than 20 patients spread all over the hospital. Mid-level or nurse case-management support also makes a difference.

Once defined, there are many different ways to handle the high census; each hospitalist group must decide what works for them.

Many groups rely on their compensation structure to entice their physicians to see higher numbers of patients. The pay structure may be production-based and entice many of the group members to see more patients. Typically, for the member that does not want to see the large volumes, there are usually colleagues who are more than happy to cover the excess patients.

Some groups employ a hybrid system, with their compensation based on production and salary. Generally, bonuses or incentives are applied after meeting a specific relative value unit (RVU) threshold. These thresholds vary and usually are raised periodically based on the percentage of staff able to collect. Again, some group members may volunteer to see the excess patients for higher compensation. It is up to the group to develop mechanisms to measure the quality of care of these high producers and monitor for burnout.

Then there are groups that have no volume incentives and everyone is paid a salary. Many groups that utilize any of these compensation models have group members “on call” to come in when needed and see the excess patients. Many pay the on-call person some nominal amount just for being on call, or a per-patient or hourly rate if they have to come in. Others make it a mandatory part of the schedule without any additional compensation.

Many groups have integrated advanced-practice providers (nurse practitioners and physician assistants) into their systems. They can help hospitalists improve efficiency by seeing patients that are less ill or awaiting placement, or by performing such labor-intensive tasks as admissions and discharges.

HM groups should collaborate with the hospital’s chief financial officer. Like clinicians, most administrators recognize it is very difficult to deliver high-quality and efficient care when the numbers get high. It is in their best interest to help devise strategies and models that deliver quality care and the metrics needed to sustain support.

HM has become such a large specialty that there is no-one-size-fits-all solution to high censuses. In the end, you have to be comfortable with the system created by your group, work to help improve it, or seek a better fit.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

Dr. Hospitalist

In this age of cost containment and fiscal frugality, how do you handle high-census periods without jeopardizing patient care?

–Michael P. Mason, Tulsa, Okla.

Dr. Hospitalist responds:

Your group must first define the term “high census,” because workload is based on many factors. Seeing 20 patients a day in a large inner-city hospital is much different from seeing 20 patients in a suburban hospital in an affluent part of town. Also, seeing 20 patients geographically located on the same floor is much easier than 20 patients spread all over the hospital. Mid-level or nurse case-management support also makes a difference.

Once defined, there are many different ways to handle the high census; each hospitalist group must decide what works for them.

Many groups rely on their compensation structure to entice their physicians to see higher numbers of patients. The pay structure may be production-based and entice many of the group members to see more patients. Typically, for the member that does not want to see the large volumes, there are usually colleagues who are more than happy to cover the excess patients.

Some groups employ a hybrid system, with their compensation based on production and salary. Generally, bonuses or incentives are applied after meeting a specific relative value unit (RVU) threshold. These thresholds vary and usually are raised periodically based on the percentage of staff able to collect. Again, some group members may volunteer to see the excess patients for higher compensation. It is up to the group to develop mechanisms to measure the quality of care of these high producers and monitor for burnout.

Then there are groups that have no volume incentives and everyone is paid a salary. Many groups that utilize any of these compensation models have group members “on call” to come in when needed and see the excess patients. Many pay the on-call person some nominal amount just for being on call, or a per-patient or hourly rate if they have to come in. Others make it a mandatory part of the schedule without any additional compensation.

Many groups have integrated advanced-practice providers (nurse practitioners and physician assistants) into their systems. They can help hospitalists improve efficiency by seeing patients that are less ill or awaiting placement, or by performing such labor-intensive tasks as admissions and discharges.

HM groups should collaborate with the hospital’s chief financial officer. Like clinicians, most administrators recognize it is very difficult to deliver high-quality and efficient care when the numbers get high. It is in their best interest to help devise strategies and models that deliver quality care and the metrics needed to sustain support.

HM has become such a large specialty that there is no-one-size-fits-all solution to high censuses. In the end, you have to be comfortable with the system created by your group, work to help improve it, or seek a better fit.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

Dr. Hospitalist

In this age of cost containment and fiscal frugality, how do you handle high-census periods without jeopardizing patient care?

–Michael P. Mason, Tulsa, Okla.

Dr. Hospitalist responds:

Your group must first define the term “high census,” because workload is based on many factors. Seeing 20 patients a day in a large inner-city hospital is much different from seeing 20 patients in a suburban hospital in an affluent part of town. Also, seeing 20 patients geographically located on the same floor is much easier than 20 patients spread all over the hospital. Mid-level or nurse case-management support also makes a difference.

Once defined, there are many different ways to handle the high census; each hospitalist group must decide what works for them.

Many groups rely on their compensation structure to entice their physicians to see higher numbers of patients. The pay structure may be production-based and entice many of the group members to see more patients. Typically, for the member that does not want to see the large volumes, there are usually colleagues who are more than happy to cover the excess patients.

Some groups employ a hybrid system, with their compensation based on production and salary. Generally, bonuses or incentives are applied after meeting a specific relative value unit (RVU) threshold. These thresholds vary and usually are raised periodically based on the percentage of staff able to collect. Again, some group members may volunteer to see the excess patients for higher compensation. It is up to the group to develop mechanisms to measure the quality of care of these high producers and monitor for burnout.

Then there are groups that have no volume incentives and everyone is paid a salary. Many groups that utilize any of these compensation models have group members “on call” to come in when needed and see the excess patients. Many pay the on-call person some nominal amount just for being on call, or a per-patient or hourly rate if they have to come in. Others make it a mandatory part of the schedule without any additional compensation.

Many groups have integrated advanced-practice providers (nurse practitioners and physician assistants) into their systems. They can help hospitalists improve efficiency by seeing patients that are less ill or awaiting placement, or by performing such labor-intensive tasks as admissions and discharges.

HM groups should collaborate with the hospital’s chief financial officer. Like clinicians, most administrators recognize it is very difficult to deliver high-quality and efficient care when the numbers get high. It is in their best interest to help devise strategies and models that deliver quality care and the metrics needed to sustain support.

HM has become such a large specialty that there is no-one-size-fits-all solution to high censuses. In the end, you have to be comfortable with the system created by your group, work to help improve it, or seek a better fit.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Perioperative SSRI use associated with adverse surgical outcomes
2. Copper-surfaced rooms reduce health-care-acquired infections
3. Glucocorticoid therapy for five days not inferior to 14 days for COPD exacerbation
4. Patient preference for participation in medical decision-making may be associated with increased resource utilization
5. Early parenteral nutrition in critically ill adults does not significantly affect mortality or infection rates
6. Aggressive fluid and sodium restriction in acute decompensated heart failure did not improve outcomes
7. Lower rate of pacemaker, defibrillator device-pocket hematoma without anticoagulation interruption
8. Prophylactic penicillin decreased risk of recurrent leg cellulitis
9. Universal ICU decolonization reduced rates of mrsa clinical isolates and bloodstream infection
10. Intensive blood-pressure lowering in intracerebral hemorrhage did not reduce death or severe disability

Perioperative SSRI Use Associated with Adverse Surgical Outcomes

Clinical question: Does selective serotonin reuptake inhibitor (SSRI) use during hospitalization for surgery increase the risk of adverse perioperative outcomes?

Background: SSRIs commonly are prescribed but are associated with a small but higher risk for hemorrhage, arrhythmia, and sudden death. Single-site studies have described an association between SSRIs and adverse perioperative outcomes, but larger studies utilizing a broad range of surgical cases are lacking.

Study design: Retrospective cohort study.

Setting: Three hundred hospitals concentrated in the Southern U.S.

Synopsis: Using the “Perspective” database, this study examined 530,416 patients age >18 years undergoing major elective surgery, 72,540 (13.7%) of whom received an SSRI. Regression analysis showed patients receiving an SSRI had higher odds of mortality (OR 1.2, 95% CI [1.07-1.36]), higher odds of 30-day readmission (OR 1.22 [1.18-1.26]), and higher odds for bleeding (1.09 [1.04-1.15]). When the analysis was restricted to only patients with a diagnosis of depression, a higher risk of bleeding and readmission persisted.

This study reaffirms an association but does not establish a causal relationship between SSRI use and adverse perioperative outcomes. SSRI use may be a surrogate for other factors, including more severe mood disorders, poorer functional status, or chronic pain. Additionally, no information has been provided as to optimal duration of withholding SSRIs preoperatively. As such, it may be premature for hospitalists involved in perioperative care to modify recommendations based on this study.

Bottom line: Perioperative SSRI use is associated with an increased risk of bleeding and 30-day readmission.

Citation: Auerbach AD, Vittinghoff E, Maselli J, et al. Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery. JAMA Intern Med. 2013;173(12):1075-1081.

Copper-Surfaced Rooms Reduce Health-Care-Acquired Infections

Clinical question: Can copper alloy surfaces in ICU rooms lower rates of health-care-acquired infections (HAIs)?

Background: Environmental contamination is a potential source of HAIs. Copper has intrinsic broad-spectrum antimicrobial properties. This study tests the efficacy copper-surfaced items in hospital rooms have in preventing HAIs.

Study design: Randomized controlled trial.

Setting: Medical ICUs at Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center in Charleston, and the Memorial Sloan Kettering Cancer Center in New York City.

Synopsis: Six hundred fifty ICU patients were randomized to receive care either in rooms with copper surfacing on commonly handled patient care objects or in traditional rooms. Patients were screened for methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) on admission. The proportion of patients that developed either an HAI and/or MRSA or VRE colonization was significantly lower among patients in rooms with the copper-surfaced items (0.071 vs. 0.128; P=0.02). The rate of HAIs alone was also lower in the rooms with the copper (0.034 vs. 0.081; P=0.013).

A potential limitation to this study is that the rooms with copper items appeared different than traditional rooms, and therefore might have changed the behavior of health-care workers. Further, it is unclear how much copper surfacing would be necessary on general wards, where patients are more mobile. Still, HAIs are associated with longer lengths of stay and higher 30-day readmission rates, so these encouraging results warrant additional investigation into antimicrobial copper-alloy surfaces.

Bottom line: Copper-surfaced objects reduce HAI rates in ICU patients.

Citation: Salgado CD, Sepkowitz, KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.

Glucocorticoid Therapy for Five Days Not Inferior to 14 Days for COPD Exacerbation

Clinical question: Do short-course glucocorticoids work as well as conventional long courses for COPD exacerbation?

Background: International guidelines advocate a seven- to 14-day treatment course with glucocorticoids for COPD exacerbation, but the optimal duration of treatment is not known, and there are potential risks associated with glucocorticoid exposure.

Study design: Randomized, noninferiority, multicenter trial.

Setting: Five Swiss teaching hospitals.

Synopsis: Three hundred fourteen patients presenting to the ED with acute COPD exacerbation and without a history of asthma were randomized to receive treatment with 40 mg prednisone daily for either five or 14 days in a placebo-controlled, double-blinded fashion. There was no significant difference in the primary endpoint of re-exacerbation within six months. Patients in the five-day glucocorticoid group compared with the 14-day group were exposed to significantly less glucocorticoid.

Bottom line: Treatment for five days with glucocorticoids was not inferior to 14 days for acute COPD exacerbations with regard to re-exacerbations within six months and resulted in less glucocorticoid exposure overall.

Citation: Leuppi JF, Schuetz P, Bingisser R, et al. Short-term vs. conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE Randomized Clinical Trial. JAMA. 2013;390(21):2223-2231.

Patient Preference for Participation in Medical Decision-Making May Be Associated with Increased Resource Utilization

Clinical question: Do patient preferences for participation in medical decision-making affect health-care utilization?

Background: Patient participation in medical decision-making has been associated with improved patient satisfaction and health outcomes. There is little evidence to support theories that patient preferences might decrease or increase health-care utilization.

Study design: Survey study in academic research setting.

Setting: University of Chicago Medical Center.

Synopsis: More than 21,700 patients admitted to a general internal-medicine service completed a survey that included questions regarding preferences about receiving medical information and participation in medical decision-making. Survey data were linked with administrative data, including length of stay and total hospitalization costs.

Most patients (96.3%) expressed interest in receiving information about their illness and treatment options, but the majority of patients (71.1%) also expressed a preference to leave medical decision-making to their physician. Patients who preferred to participate in medical decision-making had significantly longer hospital LOS and higher total hospitalization cost.

Bottom line: Participation in medical decision-making significantly increased LOS and total costs.

Citation: Tak HJ, Ruhnke GW, Meltzer DO. Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients. JAMA Intern Med. 2013;173(13):1195-1205. doi: 10.1001/jamainternmed.2013.6048.

Early Parenteral Nutrition in Critically Ill Adults Does Not Significantly Affect Mortality or Infection Rates

Clinical question: Does providing early parenteral nutrition to critically ill adults with short-term relative contraindications to early enteral nutrition affect outcomes?

Background: The appropriate use of parenteral nutrition in critically ill adults is controversial. A systematic review found that critically ill patients randomized to receive early parenteral nutrition had significantly lower mortality but increased infection rates compared with standard care. A large-scale randomized trial was necessary to confirm the results.

Study design: Multicenter, randomized, single-blinded, controlled trial.

Setting: ICUs in 31 tertiary-care and community hospitals in Australia and New Zealand.

Synopsis: Researchers randomized 1,372 critically ill adults with relative contraindications to early enteral nutrition upon admission to the ICU to receive early parenteral nutrition or standard care. Early parenteral nutrition was started an average of 44 minutes after randomization. Clinicians defined standard care, with most patients remaining unfed for 2.8 days after randomization. Results were analyzed by intention-to-treat analysis, and loss to follow-up was 1%.

There was no significant difference in the primary outcome of 60-day mortality. Early parenteral nutrition patients received significantly fewer days of invasive ventilation, but did not have shorter ICU or hospital stays. Early parenteral nutrition patients experienced significantly less muscle-wasting and fat loss. There was no significant difference in new infection rates.

Bottom line: Early parenteral nutrition in critically ill adults resulted in significantly fewer days of invasive mechanical ventilation but did not cause a significant difference in length of stay, infection rates, or 60-day mortality.

Citation: Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition. JAMA. 2013;309(20): 2130-2138.

Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure Did Not Improve Outcomes

Clinical question: Does aggressive fluid and sodium restriction in acute decompensated heart failure (ADHF) result in increased weight loss, improved clinical stability, or decreased 30-day readmission rate?

Background: Fluid and sodium restriction are standard nonpharmacologic measures used in the management of ADHF in hospitalized patients, despite an absence of data to support their efficacy.

Study design: Randomized, controlled clinical trial with blinded outcome assessments.

Setting: A public teaching hospital in Brazil.

Synopsis: Seventy-five patients hospitalized with ADHF were randomized to receive aggressive fluid (800 mL/day) and sodium restriction (800 mg/day) or liberal intake (at least 2.5 L/day fluid, 3 to 5 g/day sodium). There were no significant between-group differences in diuretic administration. The primary outcomes of weight loss and clinical stability at three days were not significantly different between the groups. The heart-failure-specific readmission rate at 30 days was not significantly different between the groups. The aggressive restriction group had significantly worse thirst.

The study is limited by the small fraction of patients enrolled (9.2% of 813 screened) and homogenous population. Additional confirmatory trials likely are needed to change the standard of care, but this study demonstrated that aggressive fluid and sodium restriction does not benefit hospitalized patients with ADHF.

Bottom line: Aggressive fluid and sodium restriction in hospitalized patients with ADHF does not result in improved short-term weight loss, clinical stability, or decreased 30-day readmission rate, but it does cause significantly worse thirst.

Citation: Aliti GB, Rabelo ER, Clausell N, et al. Aggressive fluid and sodium restriction in acute decompensated heart failure. JAMA Intern Med. 2013;173(12):1058-1064.

Lower Rate of Pacemaker, Defibrillator Device-Pocket Hematoma without Anticoagulation Interruption

Clinical question: Is it safer to place a pacemaker or implantable cardioverter-defibrillator (ICD) while on therapeutic warfarin versus bridging with heparin/low-molecular-weight heparin (LMWH)?

Background: Current guidelines recommend bridging with heparin or LMWH for patients at high risk for thromboembolic events around the time of pacemaker or ICD placement, but it is associated with significant risk of device-pocket hematoma. Some centers place pacemakers and ICDs without interruption of warfarin. However, there are limited data to support the safety of this approach.

Study design: Multicenter, single-blinded, randomized, controlled trial.

Setting: Seventeen centers in Canada and one center in Brazil.

Synopsis: Patients with a predicted annual risk of 5% of thromboembolism were randomized to continue anticoagulation with warfarin (median INR 2.3) or to bridge therapy with heparin or LMWH; they then evaluated the incidence of clinically significant hematoma requiring prolonged hospitalization, interruption of anticoagulation therapy, or further surgical intervention. After reviewing the data on 668 patients, the Data and Safety Monitoring Board recommended termination of the study given a significantly lower rate of device-pocket hematoma in the warfarin group (3.5%) compared with the bridge group (16%) with RR 0.19 (95% CI 0.10-0.36, P<0.001). Otherwise, major surgical and thromboembolic complications were rare and not significantly different in both groups.

Bottom line: Continued warfarin therapy was associated with significantly reduced incidence of device-pocket hematoma compared with bridge with heparin or LMWH.

Citation: Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084-2093.

Prophylactic Penicillin Decreased Risk of Recurrent Leg Cellulitis

Clinical question: Does prophylactic, low-dose penicillin prevent recurrent cellulitis in patients with a history of two or more episodes of cellulitis?

Background: Some guidelines recommend prophylactic antibiotics for recurrent leg cellulitis, but there is no large randomized trial to support this practice, and clinical opinion is mixed.

Study design: Double-blinded, randomized, controlled trial.

Setting: Twenty-eight hospitals in the United Kingdom and Ireland.

Synopsis: Researchers randomized 274 patients with recurrent episodes of leg cellulitis (at least two episodes within the previous three years) to low-dose penicillin (250 mg) or placebo for 12 months and followed them for more than three years. During the prophylactic period, the penicillin group had a 45% reduction in the risk of a repeat cellulitis as compared to placebo (22% vs. 37%), equivalent to a number needed to treat to prevent a first recurrent cellulitis of five. The number of repeat episodes of cellulitis was lower overall in penicillin compared with the placebo group (119 vs. 164, P=0.02), although no significant difference was noted during the three-year follow-up period.

Factors associated with prophylaxis failure included three or more previous episodes of cellulitis, body mass index of 33 kg/m² or higher, and the presence of edema. No significant difference in adverse events was noted between the groups. Complete follow-up data was not available for participants during the follow-up period. Further study is needed to assess the long-term adverse effects and the duration of prophylaxis needed.

Bottom line: Prophylactic penicillin was effective in preventing recurrent leg cellulitis without increasing adverse effects, but its protective effect gradually declined once discontinued.

Citation: Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J Med. 2013;368(18):1695-1703.

Universal ICU Decolonization Reduced Rates of MRSA Clinical Isolates and Bloodstream Infection

Clinical question: What is the most effective decolonization strategy for reducing methicillin-resistant Staphylococcus aureus (MRSA) and other pathogens in ICUs?

Background: Studies have shown that daily chlorhexidine bathing of all patients in ICUs reduced MRSA acquisition and bloodstream infection from all pathogens. However, this universal strategy has not been compared to MRSA screening and contact precautions alone, or to targeted decolonization of MRSA carriers.

Study design: Cluster-randomized comparative-effectiveness trial.

Setting: Adult ICUs in 43 Hospital Corporation of America (HCA) hospitals in 16 states.

Synopsis: All adult ICUs in a given hospital were randomized to one of three infection prevention strategies: Group 1 continued MRSA screening and isolation; Group 2 performed screening, isolation, and decolonization of MRSA carriers; and Group 3 implemented universal decolonization with intranasal mupirocin and daily bathing with chlorhexidine-impregnated cloths but no screening.

Forty-three hospitals, including 74 ICUs and 74,256 patients, underwent randomization. Significant reductions in the primary outcome of ICU-attributable MRSA clinical isolates (excluding MRSA screening tests) and the secondary outcome of bloodstream infection due to any pathogen were demonstrated across the three groups. One bloodstream infection was prevented for every 54 patients who underwent decolonization. Formal cost-effectiveness analysis was not performed.

Bottom line: In the ICU, universal decolonization was more effective than screening and isolation or targeted decolonization in the reduction of clinical MRSA isolates and bloodstream infection due to any pathogen, although monitoring for emerging resistance is necessary.

Citation: Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.

Intensive Blood-Pressure Lowering in Intracerebral Hemorrhage Did Not Reduce Death or Severe Disability

Clinical question: What is the efficacy and safety of early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage?

Background: After intracerebral hemorrhage, blood pressure often becomes elevated and is a predictor of outcome. It is not known whether rapid lowering of blood pressure would improve outcome.

Study design: International, multicenter, prospective, randomized, open-treatment, blinded end-point trial.

Setting: One hundred forty-four hospitals in 21 countries.

Synopsis: Researchers randomly assigned 2,839 patients with intracerebral hemorrhage in the previous six hours to intensive blood-pressure lowering with target systolic blood pressure of <140 mmHg within one hour, or guideline-recommended treatment with target systolic blood pressure of <180 mmHg. The mean systolic blood pressure achieved was 150 mmHg in the intensive-treatment group and 164 mmHg in the standard-treatment group.

There was no significant difference between the two groups in the primary outcome of death or major disability. A pre-specified ordinal analysis of modified Rankin score (score of 0 indicates no symptoms; a score of 5 indicates severe disability) did show significantly lower modified Rankin scores with intensive treatment. There was no difference between the two groups in the rate of serious adverse events.

Bottom line: Early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage did not reduce death or major disability, although there may be improved functional outcomes with intensive blood-pressure lowering.

Citation: Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Perioperative SSRI use associated with adverse surgical outcomes
2. Copper-surfaced rooms reduce health-care-acquired infections
3. Glucocorticoid therapy for five days not inferior to 14 days for COPD exacerbation
4. Patient preference for participation in medical decision-making may be associated with increased resource utilization
5. Early parenteral nutrition in critically ill adults does not significantly affect mortality or infection rates
6. Aggressive fluid and sodium restriction in acute decompensated heart failure did not improve outcomes
7. Lower rate of pacemaker, defibrillator device-pocket hematoma without anticoagulation interruption
8. Prophylactic penicillin decreased risk of recurrent leg cellulitis
9. Universal ICU decolonization reduced rates of mrsa clinical isolates and bloodstream infection
10. Intensive blood-pressure lowering in intracerebral hemorrhage did not reduce death or severe disability

Perioperative SSRI Use Associated with Adverse Surgical Outcomes

Clinical question: Does selective serotonin reuptake inhibitor (SSRI) use during hospitalization for surgery increase the risk of adverse perioperative outcomes?

Background: SSRIs commonly are prescribed but are associated with a small but higher risk for hemorrhage, arrhythmia, and sudden death. Single-site studies have described an association between SSRIs and adverse perioperative outcomes, but larger studies utilizing a broad range of surgical cases are lacking.

Study design: Retrospective cohort study.

Setting: Three hundred hospitals concentrated in the Southern U.S.

Synopsis: Using the “Perspective” database, this study examined 530,416 patients age >18 years undergoing major elective surgery, 72,540 (13.7%) of whom received an SSRI. Regression analysis showed patients receiving an SSRI had higher odds of mortality (OR 1.2, 95% CI [1.07-1.36]), higher odds of 30-day readmission (OR 1.22 [1.18-1.26]), and higher odds for bleeding (1.09 [1.04-1.15]). When the analysis was restricted to only patients with a diagnosis of depression, a higher risk of bleeding and readmission persisted.

This study reaffirms an association but does not establish a causal relationship between SSRI use and adverse perioperative outcomes. SSRI use may be a surrogate for other factors, including more severe mood disorders, poorer functional status, or chronic pain. Additionally, no information has been provided as to optimal duration of withholding SSRIs preoperatively. As such, it may be premature for hospitalists involved in perioperative care to modify recommendations based on this study.

Bottom line: Perioperative SSRI use is associated with an increased risk of bleeding and 30-day readmission.

Citation: Auerbach AD, Vittinghoff E, Maselli J, et al. Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery. JAMA Intern Med. 2013;173(12):1075-1081.

Copper-Surfaced Rooms Reduce Health-Care-Acquired Infections

Clinical question: Can copper alloy surfaces in ICU rooms lower rates of health-care-acquired infections (HAIs)?

Background: Environmental contamination is a potential source of HAIs. Copper has intrinsic broad-spectrum antimicrobial properties. This study tests the efficacy copper-surfaced items in hospital rooms have in preventing HAIs.

Study design: Randomized controlled trial.

Setting: Medical ICUs at Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center in Charleston, and the Memorial Sloan Kettering Cancer Center in New York City.

Synopsis: Six hundred fifty ICU patients were randomized to receive care either in rooms with copper surfacing on commonly handled patient care objects or in traditional rooms. Patients were screened for methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) on admission. The proportion of patients that developed either an HAI and/or MRSA or VRE colonization was significantly lower among patients in rooms with the copper-surfaced items (0.071 vs. 0.128; P=0.02). The rate of HAIs alone was also lower in the rooms with the copper (0.034 vs. 0.081; P=0.013).

A potential limitation to this study is that the rooms with copper items appeared different than traditional rooms, and therefore might have changed the behavior of health-care workers. Further, it is unclear how much copper surfacing would be necessary on general wards, where patients are more mobile. Still, HAIs are associated with longer lengths of stay and higher 30-day readmission rates, so these encouraging results warrant additional investigation into antimicrobial copper-alloy surfaces.

Bottom line: Copper-surfaced objects reduce HAI rates in ICU patients.

Citation: Salgado CD, Sepkowitz, KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.

Glucocorticoid Therapy for Five Days Not Inferior to 14 Days for COPD Exacerbation

Clinical question: Do short-course glucocorticoids work as well as conventional long courses for COPD exacerbation?

Background: International guidelines advocate a seven- to 14-day treatment course with glucocorticoids for COPD exacerbation, but the optimal duration of treatment is not known, and there are potential risks associated with glucocorticoid exposure.

Study design: Randomized, noninferiority, multicenter trial.

Setting: Five Swiss teaching hospitals.

Synopsis: Three hundred fourteen patients presenting to the ED with acute COPD exacerbation and without a history of asthma were randomized to receive treatment with 40 mg prednisone daily for either five or 14 days in a placebo-controlled, double-blinded fashion. There was no significant difference in the primary endpoint of re-exacerbation within six months. Patients in the five-day glucocorticoid group compared with the 14-day group were exposed to significantly less glucocorticoid.

Bottom line: Treatment for five days with glucocorticoids was not inferior to 14 days for acute COPD exacerbations with regard to re-exacerbations within six months and resulted in less glucocorticoid exposure overall.

Citation: Leuppi JF, Schuetz P, Bingisser R, et al. Short-term vs. conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE Randomized Clinical Trial. JAMA. 2013;390(21):2223-2231.

Patient Preference for Participation in Medical Decision-Making May Be Associated with Increased Resource Utilization

Clinical question: Do patient preferences for participation in medical decision-making affect health-care utilization?

Background: Patient participation in medical decision-making has been associated with improved patient satisfaction and health outcomes. There is little evidence to support theories that patient preferences might decrease or increase health-care utilization.

Study design: Survey study in academic research setting.

Setting: University of Chicago Medical Center.

Synopsis: More than 21,700 patients admitted to a general internal-medicine service completed a survey that included questions regarding preferences about receiving medical information and participation in medical decision-making. Survey data were linked with administrative data, including length of stay and total hospitalization costs.

Most patients (96.3%) expressed interest in receiving information about their illness and treatment options, but the majority of patients (71.1%) also expressed a preference to leave medical decision-making to their physician. Patients who preferred to participate in medical decision-making had significantly longer hospital LOS and higher total hospitalization cost.

Bottom line: Participation in medical decision-making significantly increased LOS and total costs.

Citation: Tak HJ, Ruhnke GW, Meltzer DO. Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients. JAMA Intern Med. 2013;173(13):1195-1205. doi: 10.1001/jamainternmed.2013.6048.

Early Parenteral Nutrition in Critically Ill Adults Does Not Significantly Affect Mortality or Infection Rates

Clinical question: Does providing early parenteral nutrition to critically ill adults with short-term relative contraindications to early enteral nutrition affect outcomes?

Background: The appropriate use of parenteral nutrition in critically ill adults is controversial. A systematic review found that critically ill patients randomized to receive early parenteral nutrition had significantly lower mortality but increased infection rates compared with standard care. A large-scale randomized trial was necessary to confirm the results.

Study design: Multicenter, randomized, single-blinded, controlled trial.

Setting: ICUs in 31 tertiary-care and community hospitals in Australia and New Zealand.

Synopsis: Researchers randomized 1,372 critically ill adults with relative contraindications to early enteral nutrition upon admission to the ICU to receive early parenteral nutrition or standard care. Early parenteral nutrition was started an average of 44 minutes after randomization. Clinicians defined standard care, with most patients remaining unfed for 2.8 days after randomization. Results were analyzed by intention-to-treat analysis, and loss to follow-up was 1%.

There was no significant difference in the primary outcome of 60-day mortality. Early parenteral nutrition patients received significantly fewer days of invasive ventilation, but did not have shorter ICU or hospital stays. Early parenteral nutrition patients experienced significantly less muscle-wasting and fat loss. There was no significant difference in new infection rates.

Bottom line: Early parenteral nutrition in critically ill adults resulted in significantly fewer days of invasive mechanical ventilation but did not cause a significant difference in length of stay, infection rates, or 60-day mortality.

Citation: Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition. JAMA. 2013;309(20): 2130-2138.

Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure Did Not Improve Outcomes

Clinical question: Does aggressive fluid and sodium restriction in acute decompensated heart failure (ADHF) result in increased weight loss, improved clinical stability, or decreased 30-day readmission rate?

Background: Fluid and sodium restriction are standard nonpharmacologic measures used in the management of ADHF in hospitalized patients, despite an absence of data to support their efficacy.

Study design: Randomized, controlled clinical trial with blinded outcome assessments.

Setting: A public teaching hospital in Brazil.

Synopsis: Seventy-five patients hospitalized with ADHF were randomized to receive aggressive fluid (800 mL/day) and sodium restriction (800 mg/day) or liberal intake (at least 2.5 L/day fluid, 3 to 5 g/day sodium). There were no significant between-group differences in diuretic administration. The primary outcomes of weight loss and clinical stability at three days were not significantly different between the groups. The heart-failure-specific readmission rate at 30 days was not significantly different between the groups. The aggressive restriction group had significantly worse thirst.

The study is limited by the small fraction of patients enrolled (9.2% of 813 screened) and homogenous population. Additional confirmatory trials likely are needed to change the standard of care, but this study demonstrated that aggressive fluid and sodium restriction does not benefit hospitalized patients with ADHF.

Bottom line: Aggressive fluid and sodium restriction in hospitalized patients with ADHF does not result in improved short-term weight loss, clinical stability, or decreased 30-day readmission rate, but it does cause significantly worse thirst.

Citation: Aliti GB, Rabelo ER, Clausell N, et al. Aggressive fluid and sodium restriction in acute decompensated heart failure. JAMA Intern Med. 2013;173(12):1058-1064.

Lower Rate of Pacemaker, Defibrillator Device-Pocket Hematoma without Anticoagulation Interruption

Clinical question: Is it safer to place a pacemaker or implantable cardioverter-defibrillator (ICD) while on therapeutic warfarin versus bridging with heparin/low-molecular-weight heparin (LMWH)?

Background: Current guidelines recommend bridging with heparin or LMWH for patients at high risk for thromboembolic events around the time of pacemaker or ICD placement, but it is associated with significant risk of device-pocket hematoma. Some centers place pacemakers and ICDs without interruption of warfarin. However, there are limited data to support the safety of this approach.

Study design: Multicenter, single-blinded, randomized, controlled trial.

Setting: Seventeen centers in Canada and one center in Brazil.

Synopsis: Patients with a predicted annual risk of 5% of thromboembolism were randomized to continue anticoagulation with warfarin (median INR 2.3) or to bridge therapy with heparin or LMWH; they then evaluated the incidence of clinically significant hematoma requiring prolonged hospitalization, interruption of anticoagulation therapy, or further surgical intervention. After reviewing the data on 668 patients, the Data and Safety Monitoring Board recommended termination of the study given a significantly lower rate of device-pocket hematoma in the warfarin group (3.5%) compared with the bridge group (16%) with RR 0.19 (95% CI 0.10-0.36, P<0.001). Otherwise, major surgical and thromboembolic complications were rare and not significantly different in both groups.

Bottom line: Continued warfarin therapy was associated with significantly reduced incidence of device-pocket hematoma compared with bridge with heparin or LMWH.

Citation: Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084-2093.

Prophylactic Penicillin Decreased Risk of Recurrent Leg Cellulitis

Clinical question: Does prophylactic, low-dose penicillin prevent recurrent cellulitis in patients with a history of two or more episodes of cellulitis?

Background: Some guidelines recommend prophylactic antibiotics for recurrent leg cellulitis, but there is no large randomized trial to support this practice, and clinical opinion is mixed.

Study design: Double-blinded, randomized, controlled trial.

Setting: Twenty-eight hospitals in the United Kingdom and Ireland.

Synopsis: Researchers randomized 274 patients with recurrent episodes of leg cellulitis (at least two episodes within the previous three years) to low-dose penicillin (250 mg) or placebo for 12 months and followed them for more than three years. During the prophylactic period, the penicillin group had a 45% reduction in the risk of a repeat cellulitis as compared to placebo (22% vs. 37%), equivalent to a number needed to treat to prevent a first recurrent cellulitis of five. The number of repeat episodes of cellulitis was lower overall in penicillin compared with the placebo group (119 vs. 164, P=0.02), although no significant difference was noted during the three-year follow-up period.

Factors associated with prophylaxis failure included three or more previous episodes of cellulitis, body mass index of 33 kg/m² or higher, and the presence of edema. No significant difference in adverse events was noted between the groups. Complete follow-up data was not available for participants during the follow-up period. Further study is needed to assess the long-term adverse effects and the duration of prophylaxis needed.

Bottom line: Prophylactic penicillin was effective in preventing recurrent leg cellulitis without increasing adverse effects, but its protective effect gradually declined once discontinued.

Citation: Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J Med. 2013;368(18):1695-1703.

Universal ICU Decolonization Reduced Rates of MRSA Clinical Isolates and Bloodstream Infection

Clinical question: What is the most effective decolonization strategy for reducing methicillin-resistant Staphylococcus aureus (MRSA) and other pathogens in ICUs?

Background: Studies have shown that daily chlorhexidine bathing of all patients in ICUs reduced MRSA acquisition and bloodstream infection from all pathogens. However, this universal strategy has not been compared to MRSA screening and contact precautions alone, or to targeted decolonization of MRSA carriers.

Study design: Cluster-randomized comparative-effectiveness trial.

Setting: Adult ICUs in 43 Hospital Corporation of America (HCA) hospitals in 16 states.

Synopsis: All adult ICUs in a given hospital were randomized to one of three infection prevention strategies: Group 1 continued MRSA screening and isolation; Group 2 performed screening, isolation, and decolonization of MRSA carriers; and Group 3 implemented universal decolonization with intranasal mupirocin and daily bathing with chlorhexidine-impregnated cloths but no screening.

Forty-three hospitals, including 74 ICUs and 74,256 patients, underwent randomization. Significant reductions in the primary outcome of ICU-attributable MRSA clinical isolates (excluding MRSA screening tests) and the secondary outcome of bloodstream infection due to any pathogen were demonstrated across the three groups. One bloodstream infection was prevented for every 54 patients who underwent decolonization. Formal cost-effectiveness analysis was not performed.

Bottom line: In the ICU, universal decolonization was more effective than screening and isolation or targeted decolonization in the reduction of clinical MRSA isolates and bloodstream infection due to any pathogen, although monitoring for emerging resistance is necessary.

Citation: Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.

Intensive Blood-Pressure Lowering in Intracerebral Hemorrhage Did Not Reduce Death or Severe Disability

Clinical question: What is the efficacy and safety of early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage?

Background: After intracerebral hemorrhage, blood pressure often becomes elevated and is a predictor of outcome. It is not known whether rapid lowering of blood pressure would improve outcome.

Study design: International, multicenter, prospective, randomized, open-treatment, blinded end-point trial.

Setting: One hundred forty-four hospitals in 21 countries.

Synopsis: Researchers randomly assigned 2,839 patients with intracerebral hemorrhage in the previous six hours to intensive blood-pressure lowering with target systolic blood pressure of <140 mmHg within one hour, or guideline-recommended treatment with target systolic blood pressure of <180 mmHg. The mean systolic blood pressure achieved was 150 mmHg in the intensive-treatment group and 164 mmHg in the standard-treatment group.

There was no significant difference between the two groups in the primary outcome of death or major disability. A pre-specified ordinal analysis of modified Rankin score (score of 0 indicates no symptoms; a score of 5 indicates severe disability) did show significantly lower modified Rankin scores with intensive treatment. There was no difference between the two groups in the rate of serious adverse events.

Bottom line: Early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage did not reduce death or major disability, although there may be improved functional outcomes with intensive blood-pressure lowering.

Citation: Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Perioperative SSRI use associated with adverse surgical outcomes
2. Copper-surfaced rooms reduce health-care-acquired infections
3. Glucocorticoid therapy for five days not inferior to 14 days for COPD exacerbation
4. Patient preference for participation in medical decision-making may be associated with increased resource utilization
5. Early parenteral nutrition in critically ill adults does not significantly affect mortality or infection rates
6. Aggressive fluid and sodium restriction in acute decompensated heart failure did not improve outcomes
7. Lower rate of pacemaker, defibrillator device-pocket hematoma without anticoagulation interruption
8. Prophylactic penicillin decreased risk of recurrent leg cellulitis
9. Universal ICU decolonization reduced rates of mrsa clinical isolates and bloodstream infection
10. Intensive blood-pressure lowering in intracerebral hemorrhage did not reduce death or severe disability

Perioperative SSRI Use Associated with Adverse Surgical Outcomes

Clinical question: Does selective serotonin reuptake inhibitor (SSRI) use during hospitalization for surgery increase the risk of adverse perioperative outcomes?

Background: SSRIs commonly are prescribed but are associated with a small but higher risk for hemorrhage, arrhythmia, and sudden death. Single-site studies have described an association between SSRIs and adverse perioperative outcomes, but larger studies utilizing a broad range of surgical cases are lacking.

Study design: Retrospective cohort study.

Setting: Three hundred hospitals concentrated in the Southern U.S.

Synopsis: Using the “Perspective” database, this study examined 530,416 patients age >18 years undergoing major elective surgery, 72,540 (13.7%) of whom received an SSRI. Regression analysis showed patients receiving an SSRI had higher odds of mortality (OR 1.2, 95% CI [1.07-1.36]), higher odds of 30-day readmission (OR 1.22 [1.18-1.26]), and higher odds for bleeding (1.09 [1.04-1.15]). When the analysis was restricted to only patients with a diagnosis of depression, a higher risk of bleeding and readmission persisted.

This study reaffirms an association but does not establish a causal relationship between SSRI use and adverse perioperative outcomes. SSRI use may be a surrogate for other factors, including more severe mood disorders, poorer functional status, or chronic pain. Additionally, no information has been provided as to optimal duration of withholding SSRIs preoperatively. As such, it may be premature for hospitalists involved in perioperative care to modify recommendations based on this study.

Bottom line: Perioperative SSRI use is associated with an increased risk of bleeding and 30-day readmission.

Citation: Auerbach AD, Vittinghoff E, Maselli J, et al. Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery. JAMA Intern Med. 2013;173(12):1075-1081.

Copper-Surfaced Rooms Reduce Health-Care-Acquired Infections

Clinical question: Can copper alloy surfaces in ICU rooms lower rates of health-care-acquired infections (HAIs)?

Background: Environmental contamination is a potential source of HAIs. Copper has intrinsic broad-spectrum antimicrobial properties. This study tests the efficacy copper-surfaced items in hospital rooms have in preventing HAIs.

Study design: Randomized controlled trial.

Setting: Medical ICUs at Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center in Charleston, and the Memorial Sloan Kettering Cancer Center in New York City.

Synopsis: Six hundred fifty ICU patients were randomized to receive care either in rooms with copper surfacing on commonly handled patient care objects or in traditional rooms. Patients were screened for methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) on admission. The proportion of patients that developed either an HAI and/or MRSA or VRE colonization was significantly lower among patients in rooms with the copper-surfaced items (0.071 vs. 0.128; P=0.02). The rate of HAIs alone was also lower in the rooms with the copper (0.034 vs. 0.081; P=0.013).

A potential limitation to this study is that the rooms with copper items appeared different than traditional rooms, and therefore might have changed the behavior of health-care workers. Further, it is unclear how much copper surfacing would be necessary on general wards, where patients are more mobile. Still, HAIs are associated with longer lengths of stay and higher 30-day readmission rates, so these encouraging results warrant additional investigation into antimicrobial copper-alloy surfaces.

Bottom line: Copper-surfaced objects reduce HAI rates in ICU patients.

Citation: Salgado CD, Sepkowitz, KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486.

Glucocorticoid Therapy for Five Days Not Inferior to 14 Days for COPD Exacerbation

Clinical question: Do short-course glucocorticoids work as well as conventional long courses for COPD exacerbation?

Background: International guidelines advocate a seven- to 14-day treatment course with glucocorticoids for COPD exacerbation, but the optimal duration of treatment is not known, and there are potential risks associated with glucocorticoid exposure.

Study design: Randomized, noninferiority, multicenter trial.

Setting: Five Swiss teaching hospitals.

Synopsis: Three hundred fourteen patients presenting to the ED with acute COPD exacerbation and without a history of asthma were randomized to receive treatment with 40 mg prednisone daily for either five or 14 days in a placebo-controlled, double-blinded fashion. There was no significant difference in the primary endpoint of re-exacerbation within six months. Patients in the five-day glucocorticoid group compared with the 14-day group were exposed to significantly less glucocorticoid.

Bottom line: Treatment for five days with glucocorticoids was not inferior to 14 days for acute COPD exacerbations with regard to re-exacerbations within six months and resulted in less glucocorticoid exposure overall.

Citation: Leuppi JF, Schuetz P, Bingisser R, et al. Short-term vs. conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE Randomized Clinical Trial. JAMA. 2013;390(21):2223-2231.

Patient Preference for Participation in Medical Decision-Making May Be Associated with Increased Resource Utilization

Clinical question: Do patient preferences for participation in medical decision-making affect health-care utilization?

Background: Patient participation in medical decision-making has been associated with improved patient satisfaction and health outcomes. There is little evidence to support theories that patient preferences might decrease or increase health-care utilization.

Study design: Survey study in academic research setting.

Setting: University of Chicago Medical Center.

Synopsis: More than 21,700 patients admitted to a general internal-medicine service completed a survey that included questions regarding preferences about receiving medical information and participation in medical decision-making. Survey data were linked with administrative data, including length of stay and total hospitalization costs.

Most patients (96.3%) expressed interest in receiving information about their illness and treatment options, but the majority of patients (71.1%) also expressed a preference to leave medical decision-making to their physician. Patients who preferred to participate in medical decision-making had significantly longer hospital LOS and higher total hospitalization cost.

Bottom line: Participation in medical decision-making significantly increased LOS and total costs.

Citation: Tak HJ, Ruhnke GW, Meltzer DO. Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients. JAMA Intern Med. 2013;173(13):1195-1205. doi: 10.1001/jamainternmed.2013.6048.

Early Parenteral Nutrition in Critically Ill Adults Does Not Significantly Affect Mortality or Infection Rates

Clinical question: Does providing early parenteral nutrition to critically ill adults with short-term relative contraindications to early enteral nutrition affect outcomes?

Background: The appropriate use of parenteral nutrition in critically ill adults is controversial. A systematic review found that critically ill patients randomized to receive early parenteral nutrition had significantly lower mortality but increased infection rates compared with standard care. A large-scale randomized trial was necessary to confirm the results.

Study design: Multicenter, randomized, single-blinded, controlled trial.

Setting: ICUs in 31 tertiary-care and community hospitals in Australia and New Zealand.

Synopsis: Researchers randomized 1,372 critically ill adults with relative contraindications to early enteral nutrition upon admission to the ICU to receive early parenteral nutrition or standard care. Early parenteral nutrition was started an average of 44 minutes after randomization. Clinicians defined standard care, with most patients remaining unfed for 2.8 days after randomization. Results were analyzed by intention-to-treat analysis, and loss to follow-up was 1%.

There was no significant difference in the primary outcome of 60-day mortality. Early parenteral nutrition patients received significantly fewer days of invasive ventilation, but did not have shorter ICU or hospital stays. Early parenteral nutrition patients experienced significantly less muscle-wasting and fat loss. There was no significant difference in new infection rates.

Bottom line: Early parenteral nutrition in critically ill adults resulted in significantly fewer days of invasive mechanical ventilation but did not cause a significant difference in length of stay, infection rates, or 60-day mortality.

Citation: Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition. JAMA. 2013;309(20): 2130-2138.

Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure Did Not Improve Outcomes

Clinical question: Does aggressive fluid and sodium restriction in acute decompensated heart failure (ADHF) result in increased weight loss, improved clinical stability, or decreased 30-day readmission rate?

Background: Fluid and sodium restriction are standard nonpharmacologic measures used in the management of ADHF in hospitalized patients, despite an absence of data to support their efficacy.

Study design: Randomized, controlled clinical trial with blinded outcome assessments.

Setting: A public teaching hospital in Brazil.

Synopsis: Seventy-five patients hospitalized with ADHF were randomized to receive aggressive fluid (800 mL/day) and sodium restriction (800 mg/day) or liberal intake (at least 2.5 L/day fluid, 3 to 5 g/day sodium). There were no significant between-group differences in diuretic administration. The primary outcomes of weight loss and clinical stability at three days were not significantly different between the groups. The heart-failure-specific readmission rate at 30 days was not significantly different between the groups. The aggressive restriction group had significantly worse thirst.

The study is limited by the small fraction of patients enrolled (9.2% of 813 screened) and homogenous population. Additional confirmatory trials likely are needed to change the standard of care, but this study demonstrated that aggressive fluid and sodium restriction does not benefit hospitalized patients with ADHF.

Bottom line: Aggressive fluid and sodium restriction in hospitalized patients with ADHF does not result in improved short-term weight loss, clinical stability, or decreased 30-day readmission rate, but it does cause significantly worse thirst.

Citation: Aliti GB, Rabelo ER, Clausell N, et al. Aggressive fluid and sodium restriction in acute decompensated heart failure. JAMA Intern Med. 2013;173(12):1058-1064.

Lower Rate of Pacemaker, Defibrillator Device-Pocket Hematoma without Anticoagulation Interruption

Clinical question: Is it safer to place a pacemaker or implantable cardioverter-defibrillator (ICD) while on therapeutic warfarin versus bridging with heparin/low-molecular-weight heparin (LMWH)?

Background: Current guidelines recommend bridging with heparin or LMWH for patients at high risk for thromboembolic events around the time of pacemaker or ICD placement, but it is associated with significant risk of device-pocket hematoma. Some centers place pacemakers and ICDs without interruption of warfarin. However, there are limited data to support the safety of this approach.

Study design: Multicenter, single-blinded, randomized, controlled trial.

Setting: Seventeen centers in Canada and one center in Brazil.

Synopsis: Patients with a predicted annual risk of 5% of thromboembolism were randomized to continue anticoagulation with warfarin (median INR 2.3) or to bridge therapy with heparin or LMWH; they then evaluated the incidence of clinically significant hematoma requiring prolonged hospitalization, interruption of anticoagulation therapy, or further surgical intervention. After reviewing the data on 668 patients, the Data and Safety Monitoring Board recommended termination of the study given a significantly lower rate of device-pocket hematoma in the warfarin group (3.5%) compared with the bridge group (16%) with RR 0.19 (95% CI 0.10-0.36, P<0.001). Otherwise, major surgical and thromboembolic complications were rare and not significantly different in both groups.

Bottom line: Continued warfarin therapy was associated with significantly reduced incidence of device-pocket hematoma compared with bridge with heparin or LMWH.

Citation: Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084-2093.

Prophylactic Penicillin Decreased Risk of Recurrent Leg Cellulitis

Clinical question: Does prophylactic, low-dose penicillin prevent recurrent cellulitis in patients with a history of two or more episodes of cellulitis?

Background: Some guidelines recommend prophylactic antibiotics for recurrent leg cellulitis, but there is no large randomized trial to support this practice, and clinical opinion is mixed.

Study design: Double-blinded, randomized, controlled trial.

Setting: Twenty-eight hospitals in the United Kingdom and Ireland.

Synopsis: Researchers randomized 274 patients with recurrent episodes of leg cellulitis (at least two episodes within the previous three years) to low-dose penicillin (250 mg) or placebo for 12 months and followed them for more than three years. During the prophylactic period, the penicillin group had a 45% reduction in the risk of a repeat cellulitis as compared to placebo (22% vs. 37%), equivalent to a number needed to treat to prevent a first recurrent cellulitis of five. The number of repeat episodes of cellulitis was lower overall in penicillin compared with the placebo group (119 vs. 164, P=0.02), although no significant difference was noted during the three-year follow-up period.

Factors associated with prophylaxis failure included three or more previous episodes of cellulitis, body mass index of 33 kg/m² or higher, and the presence of edema. No significant difference in adverse events was noted between the groups. Complete follow-up data was not available for participants during the follow-up period. Further study is needed to assess the long-term adverse effects and the duration of prophylaxis needed.

Bottom line: Prophylactic penicillin was effective in preventing recurrent leg cellulitis without increasing adverse effects, but its protective effect gradually declined once discontinued.

Citation: Thomas KS, Crook AM, Nunn AJ, et al. Penicillin to prevent recurrent leg cellulitis. N Engl J Med. 2013;368(18):1695-1703.

Universal ICU Decolonization Reduced Rates of MRSA Clinical Isolates and Bloodstream Infection

Clinical question: What is the most effective decolonization strategy for reducing methicillin-resistant Staphylococcus aureus (MRSA) and other pathogens in ICUs?

Background: Studies have shown that daily chlorhexidine bathing of all patients in ICUs reduced MRSA acquisition and bloodstream infection from all pathogens. However, this universal strategy has not been compared to MRSA screening and contact precautions alone, or to targeted decolonization of MRSA carriers.

Study design: Cluster-randomized comparative-effectiveness trial.

Setting: Adult ICUs in 43 Hospital Corporation of America (HCA) hospitals in 16 states.

Synopsis: All adult ICUs in a given hospital were randomized to one of three infection prevention strategies: Group 1 continued MRSA screening and isolation; Group 2 performed screening, isolation, and decolonization of MRSA carriers; and Group 3 implemented universal decolonization with intranasal mupirocin and daily bathing with chlorhexidine-impregnated cloths but no screening.

Forty-three hospitals, including 74 ICUs and 74,256 patients, underwent randomization. Significant reductions in the primary outcome of ICU-attributable MRSA clinical isolates (excluding MRSA screening tests) and the secondary outcome of bloodstream infection due to any pathogen were demonstrated across the three groups. One bloodstream infection was prevented for every 54 patients who underwent decolonization. Formal cost-effectiveness analysis was not performed.

Bottom line: In the ICU, universal decolonization was more effective than screening and isolation or targeted decolonization in the reduction of clinical MRSA isolates and bloodstream infection due to any pathogen, although monitoring for emerging resistance is necessary.

Citation: Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.

Intensive Blood-Pressure Lowering in Intracerebral Hemorrhage Did Not Reduce Death or Severe Disability

Clinical question: What is the efficacy and safety of early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage?

Background: After intracerebral hemorrhage, blood pressure often becomes elevated and is a predictor of outcome. It is not known whether rapid lowering of blood pressure would improve outcome.

Study design: International, multicenter, prospective, randomized, open-treatment, blinded end-point trial.

Setting: One hundred forty-four hospitals in 21 countries.

Synopsis: Researchers randomly assigned 2,839 patients with intracerebral hemorrhage in the previous six hours to intensive blood-pressure lowering with target systolic blood pressure of <140 mmHg within one hour, or guideline-recommended treatment with target systolic blood pressure of <180 mmHg. The mean systolic blood pressure achieved was 150 mmHg in the intensive-treatment group and 164 mmHg in the standard-treatment group.

There was no significant difference between the two groups in the primary outcome of death or major disability. A pre-specified ordinal analysis of modified Rankin score (score of 0 indicates no symptoms; a score of 5 indicates severe disability) did show significantly lower modified Rankin scores with intensive treatment. There was no difference between the two groups in the rate of serious adverse events.

Bottom line: Early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage did not reduce death or major disability, although there may be improved functional outcomes with intensive blood-pressure lowering.

Citation: Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365.