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Hospitalist-neurosurgery comanagement, and more.


Hospitalist-neurosurgery comanagement lowers costs, doesn't change outcomes

A comanagement program between hospitalists and neurosurgeons lowered one hospital's costs, but didn't change patient satisfaction scores or outcomes, a recent study found.

Researchers conducted a retrospective, interrupted time-series analysis of data from adults admitted to the neurosurgery service of an academic hospital between June 2005 and December 2008. Researchers also collected data from a control group of adults admitted for major noncardiac surgery during the same time period. A hospitalist-neurosurgery comanagement service (CNS) was implemented at the hospital on July 1, 2007. Researchers collected data from administrative sources on length of stay, costs, inpatient mortality rate and 30-day readmission rate, and used surveys to assess patient and caregiver satisfaction. Results were published in the December 13/27, 2010 Archives of Internal Medicine.

During the study period, 7,596 patients were admitted to the neurosurgery service; about 55% (n=4,203) of these were admitted before the CNS was implemented and 44.7% (n=3,393) after. Of those admitted after CNS implementation, 29.1% (n=988) were comanaged. Hospital costs fell $1,439 per admission after CNS was implemented (adjusted cost ratio, 0.94; range, 0.88-1.00). There were no differences in patient mortality, readmissions or length of stay after CNS was implemented, nor any improvements in patient satisfaction (which was generally high to begin with). Nurses and other health care professionals reported strong perceived improvements in quality of care, especially regarding attention to medical issues during hospitalization (mean score of 2.9 on this measure before CNS vs. 4.8 after, P<0.001).

Although the findings on outcomes are similar to other studies on comanagement, the finding of cost savings is new, the authors noted. The data lacked specific information on which areas of practice (such as laboratory or radiology) were responsible for the cost reduction, however. The lack of an effect on mortality or readmission rates may be because hospitalist involvement doesn't affect the more powerful determinants of outcomes in these patients, they noted. On the whole, the study—while “well-performed”—doesn't provide definitive evidence to support or refute the value of comanagement, an editorialist wrote. “In the absence of solid evidence, I would argue that even the economic rationale for comanagement is poor because it really involves shifting work to lower-paid workers (internists), allowing surgeons to spend more time in the operating room, where they get paid more by a dysfunctional reimbursement system that disproportionately rewards procedural care over more cognitive services,” he wrote. He added that he worried about “the degradation of basic clinical inpatient skills of our subspecialty colleagues” and was concerned that, with the looming shortage of primary care internists, comanagement may exacerbate this shortage even more.

WHO issues guidelines on TB prevention in people with HIV in resource-constrained settings

The World Health Organization recently issued new guidelines on preventing tuberculosis (TB) in people with HIV infection in resource-constrained settings.

Although HIV-infected people are more likely to develop active TB, isoniazid preventive therapy (IPT), a cost-effective way to protect against TB, is often underused in this population, the WHO said. The guidelines' key recommendations, which update the WHO's 1998 policy on this topic, are as follows:

  • All HIV-infected children and adults, including pregnant women and those on antiretroviral treatment, should receive IPT.
  • IPT should be taken for six to 36 months, or for life in settings where HIV and TB are highly prevalent.
  • HIV-infected people with TB symptoms, such as cough, fever, weight loss or night sweats, should be further screened for active TB or other conditions so they can be treated appropriately.

The guidelines also noted that chest radiography is no longer required before starting IPT in HIV-infected patients, nor is a positive tuberculin skin test needed, although the latter can be helpful to target patients whom IPT would benefit. “The provision of IPT should not be viewed as an isolated intervention for people living with HIV. Rather, it should be part of a TB prevention package along with infection control for TB, [intensified case-finding] and provision of [antiretroviral therapy],” the guidelines stated. The guidelines were released in December 2010.

Score quantifies risk factors at admission for in-hospital bleeding

Researchers have developed a score to identify at admission those acutely ill patients at high risk of in-hospital bleeding, which may assist physicians in using venous thromboembolism (VTE) prophylaxis.

The researchers used data from 15,156 medical patients from the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) trial, a multinational, observational study that examined VTE prophylaxis patterns and clinical outcomes in hospitalized patients with acute illness. They estimated in-hospital bleeding incidence by Kaplan-Meier analysis, and used a multiple regression model analysis to identify risk factors at admission associated with bleeding. Results were published in the January Chest.

The cumulative bleeding incidence 14 days after admission was 3.2% (1.2% major bleeding and 2.1% nonmajor but clinically relevant bleeding). The most common sites of major bleeding were gastrointestinal, large hematoma and intracranial; gastrointestinal bleeding was also the most common site of nonmajor but clinically relevant bleeding. The strongest independent risk factors at admission for bleeding were active gastroduodenal ulcer (odds ratio [OR], 4.15; 95% CI, 2.21 to 7.77; P<0.001), bleeding in the three months prior to admission (OR, 3.64; 95% CI, 2.21 to 5.99; P<0.001) and platelet count of less than 50 × 109 cells/L (OR, 3.37; 95% CI 1.84 to 6.18; P<0.001). Other significant risk factors were age of 85 years or older versus younger than 40 years, hepatic failure (international normalized ratio >1.5), renal failure, ICU stay, central venous catheter use, rheumatic disease, cancer and male sex. Researchers developed a bleeding risk score based on these factors, for which the highest possible number of points is 33. They found that bleeding risk began to increase exponentially in patients with a risk score of 7.0 points or greater (about 10% of patients in the study).

The bleeding risk score, which can be determined via an online calculator, could be useful when deciding about the type of VTE prophylaxis to use (mechanical or pharmaceutical) in acutely ill patients, the authors said. Physicians should use caution when prescribing anticoagulant prophylaxis to patients with a risk score of 7.0 or higher, and determine management on a case-by-case basis, they added. Most patients will score below 7.0, however, and “our data indicate that physicians can be reassured that the bleeding risk in these patients is not significantly elevated by in-hospital provision of anticoagulant prophylaxis,” they wrote.

Guidelines detail MRSA treatments

The Infectious Diseases Society of America released its first set of guidelines on the treatment of methicillin-resistant Staphylococcus aureus (MRSA) in January.

The guidelines were developed by an expert panel of infectious disease specialists and cover MRSA infections associated with health care facilities (HA-MRSA) and those acquired in the community (CA-MRSA). The guidelines note that the “so-called CA-MRSA isolates” are genetically distinct from HA-MRSA and susceptible to many non-β-lactam antibiotics. Recommendations are provided on appropriate antibiotic and non-drug treatment of skin and soft-tissue infections, from simple abscesses seen in the outpatient setting to complicated infections in hospitalized patients.

The guidelines also discuss management of recurrent MRSA skin and soft-tissue infections, recommending education on personal hygiene for all patients, with decolonization and oral therapy reserved for patients in whom other measures are unsuccessful. Appropriate antibiotic and other therapy for MRSA bacteremia and infective endocarditis, MRSA pneumonia, and MRSA infections in bones, joints and the central nervous system are also covered in the guidelines, which appeared in the Feb. 1 Clinical Infectious Diseases. Local variations in epidemiology should be considered by physicians implementing the guidelines, the authors noted.

The guidelines provide advice on vancomycin therapy, including the limitations of vancomycin susceptibility testing. If testing indicates a vancomycin minimum inhibitory concentration (MIC) of 2 µg/mL or lower, the patient's clinical response should determine the continued use of vancomycin independent of the MIC. If the MIC is greater than 2 µg/mL (i.e., VISA or VRSA), an alternative drug should be used. The guidelines recommend dosing and monitoring vancomycin according to a previous consensus statement from the IDSA and other groups. The new guidelines have been endorsed by the Pediatric Infectious Diseases Society, the American College of Emergency Physicians and the American Academy of Pediatrics.

Guidelines revised to cover new pulmonary fungal infections

New guidance on the treatment of fungal infections in pulmonary and critical care patients was released by the American Thoracic Society (ATS) on Jan. 1. The clinical policy statement replaces ATS guidelines published in 1988, which primarily covered only fungal infections in patients with HIV. Since then, the incidence, diagnosis and clinical severity of pulmonary fungal infections have increased dramatically, according to the statement. The increase is attributable to growing numbers of patients with immune compromise due to malignancy or hematologic disease as well as HIV, in addition to the population of patients taking immunosuppressive drugs. New technologies have also made definitive diagnosis easier, the statement noted.

The statement offers advice on treating endemic mycoses, including histoplasmosis, sporotrichosis, blastomycosis and coccidioidomycosis. It covers the most common fungal infections in immune-compromised and critically ill patients, such as cryptococcosis, aspergillosis, candidiasis and Pneumocystis pneumonia. Finally, recommendations are offered on treating rare, emerging fungi: zygomycosis, hyalohyphomycosis, phaeohyphomycosis and infections related to Trichosporon.

The guidelines cover traditional antifungal agents, including amphotericin, itraconazole and fluconazole, but also newer pharmacologic options, such as novel lipid forms of amphotericin B and the echinocandins, a new class of antifungal agents that inhibit the formation of the cell walls of fungi. The statement was published in the Jan. 1 American Journal of Respiratory and Critical Care Medicine.

The new advice should guide physicians in treatment of fungal infections now, and may also be useful in responses to other fungal infections that emerge, the chair of the ATS working group that developed the statement said in a press release. The working group is also considering writing a separate statement focused entirely on the diagnosis of fungal infections, which would assess both old and new diagnostic tools.