In the News

Antiviral agents for influenza, prognostic scores and stroke, and more.

Updated recommendations issued on antiviral agents for influenza

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) released updated recommendations in January for antiviral treatment in patients with confirmed or suspected influenza.

The recommendations address use of antiviral agents for influenza prevention and treatment and include the following changes from previous recommendations:

  • Early antiviral treatment is recommended for patients with suspected influenza or clinically or laboratory-confirmed influenza who have severe, complicated, or progressive illness or require hospitalization, and for outpatients with confirmed or suspected influenza at higher risk for complications because of their age or underlying medical conditions.
  • Antiviral treatment has the greatest benefit when started within 48 hours of illness onset. However, antiviral treatment may still be beneficial when administered later than 48 hours in patients with severe, complicated, or progressive illness and in hospitalized patients.
  • Oseltamivir and zanamivir are recommended because almost all currently circulating influenza virus strains are sensitive to them.
  • Amantadine and rimantadine should not be used because of high resistance among circulating influenza A viruses.
  • Oseltamivir may be used for treatment or chemoprophylaxis in infants younger than 1 year when indicated.
  • Antiviral treatment within 48 hours of illness onset may be considered on the basis of clinical judgment for any outpatient with confirmed or suspected influenza but no known risk factors for severe illness.

The recommendations were published Jan. 21 in the CDC's Morbidity and Mortality Weekly Report.

Hospital mortality drops with Keystone ICU project in Michigan

The Michigan Keystone ICU project, a statewide quality improvement initiative, was associated with lower hospital mortality compared to surrounding Midwestern states, a study found.

Previous research has shown that the Michigan Keystone ICU project reduced catheter-related bloodstream infection rates and ventilator-associated pneumonia in the ICU through its promotion of evidence-based practices, improved communication and a culture of safety. This retrospective study used Medicare claims data to evaluate whether the initiative was associated with fewer deaths and lower length of stay for older adults in ICUs in Michigan compared to other Midwestern states. The study period spanned October 2001 to December 2006, representing a start date two years before the project was initiated to 22 months after its implementation. It included hospital admissions for patients age 65 years and older in 95 Michigan hospitals (238,937 total admissions) compared with 364 hospitals in the surrounding Midwest region (1,091,547 admissions).

The trajectory of mortality differed significantly between the study and comparison groups once the initiative was implemented (Wald test X2=8.73, P=0.033). Mortality reductions were greater for the study group than the comparison group at 1 to 12 months after project implementation (odds ratio [OR], 0.83, 95% CI, 0.79 to 0.87 vs. OR, 0.88, 95% CI, 0.85 to 0.90; P=0.041) and 13 to 22 months after implementation (OR, 0.76, 95% CI, 0.72 to 0.81 vs. OR, 0.84, 95% CI, 0.81 to 0.86; P=0.007). Length of stay did not differ significantly between the groups during or after implementation. Results were published Jan. 31 by BMJ.

The study results may be conservative, since all Michigan hospitals were included in the study group although only 77% actually participated and contributed data to the Keystone ICU project, the authors noted. Improvement in mortality increased over the two post-implementation periods, suggesting the full benefit of the program took time to be realized, and/or that other quality initiatives at Michigan hospitals during this time may have boosted the effect, they wrote. Overall, the findings suggest that large-scale, robust and successful quality improvement initiatives can reduce adverse events, improve quality of care, and save lives, they concluded.

Prognostic scores don't reliably predict minor stroke recurrence

Leading prognostic scores don't reliably predict risk for early recurrence after a minor stroke, a study has indicated.

Researchers used data from the Oxford Vascular Study, a prospective, population-based study of all incident and recurrent strokes in Oxfordshire, United Kingdom, to examine the prognostic value of three stroke scores for early recurrence after minor stroke: the ABCD2 score, the Essen Stroke Risk Score (ESRS) and the Stroke Prognosis Instrument II (SPI-II). Strokes were considered minor if they scored 5 or lower on the National Institutes of Health Stroke Scale. The study was published in the March 1 Stroke.

A total of 1,247 first events occurred from April 1, 2002 to March 31, 2007. Of these, 488 were transient ischemic attacks, 520 were minor strokes and 239 were major strokes. Patients were a mean age of 73 years (range, 24 to 98 years) when the first event occurred. One hundred forty-two recurrent strokes occurred within 90 days of the first event, 81 within 7 days and 111 within 30 days. Only the ABCD2 score was predictive of recurrence 7 and 90 days after minor stroke, but its predictive value was modest (area under the receiver operator curve, 0.64, 95% CI, 0.53 to 0.74, P=0.03 and 0.62, 95% CI, 0.54 to 0.70, P=0.004, respectively). The Essen Stroke Risk Score and the Stroke Prognosis Instrument II did not predict 7-day or 90-day risk. The authors examined the risk factors included in the ABCD2 score and found that only two, blood pressure above 140/90 mm Hg and large artery disease, predicted 90-day recurrence risk (hazard ratio, 2.75, 95% CI, 1.18 to 6.38, P=0.02 and 2.21, 95% CI, 1.00 to 4.88, P=0.05, respectively).

The authors noted that their estimates of stroke risk may have been imprecise because some patients with minor stroke don't seek medical care, and that relatively few outcomes were used to validate the scores for recurrence. They concluded that while the ABCD2 score is highly predictive of recurrent stroke after a TIA in the acute phase, it is less predictive after minor stroke, and neither the ESRS nor the SPI-II predict 90-day recurrence. “More reliable early risk prediction after minor stroke is required,” they wrote.

Majority of asthma, COPD inpatients misuse inhalers

While inhaler misuse is common among hospitalized patients with asthma or chronic obstructive pulmonary disease (COPD), patients can be easily taught to use the devices correctly, a study found.

In a cross-sectional, pre-post intervention study from September 2007 to March 2009, research staff at two facilities reviewed admission logs to identify 146 eligible patients hospitalized with COPD or asthma; 100 were enrolled in the study. Participants completed a survey that inquired about age, sex, ethnicity, race and smoking history. Health literacy was measured using the Short Test of Functional Health Literacy in Adults (S-TOFHLA), and vision and lung function were also assessed. Inhaler technique was assessed by using detailed checklists; misuse of metered-dose inhalers (MDIs) or Diskus® was defined as fewer than 75% of steps correct for each device. A subset of 42 intervention patients was instructed on the correct use of inhalers using the “teach to goal” (TTG) method. Results were published in the June Journal of General Internal Medicine.

Sixty patients had asthma and 40 had COPD. Rates of inhaler misuse were similar for patients with COPD and asthma; overall, misuse was common at 86% for those using MDIs and 71% of those using Diskus® devices. COPD patients were twice as likely to have insufficient vision as asthma patients (43% vs. 20%, P=0.02), and patients with insufficient vision (worse than 20/50 in both eyes) were more likely to misuse Diskus® devices (95% vs. 61%, P=0.004) but not MDIs. COPD patients were three times as likely to have less than adequate health literacy (<23/36 on the Short Test of Functional Health Literacy in Adults [S-TOFHLA]) compared with asthma patients (61% vs. 19%, P=0.001); literacy was not associated with inhaler misuse. After one round of instruction, most intervention patients achieved mastery at using inhalers; after two rounds, 100% achieved mastery. There was no difference between asthma and COPD patients in ability to learn inhaler technique.

The study is unique in that it examines inhaler use for both rescue (MDIs) and controller medications (MDI and Diskus® devices) in patients hospitalized with COPD or asthma, the authors noted. An unexpected finding was that more than 25% of participants had insufficient vision; the majority of these did not have corrective lenses with them, and the rest either had inadequate lenses or no corrective lenses, they wrote. Insufficient vision may be a barrier to chronic disease management, including inhaler use, since patient education often comprises written materials with smaller font sizes, the authors noted. While it is encouraging that the TTG intervention succeeded, it must be noted that there was no control group to this intervention, and the intervention was provided by trained researchers rather than lay clinicians, they wrote. Different approaches to assessing and improving inhaler technique should be targeted for future comparative effectiveness studies, the authors concluded.

Failure to follow up on inpatient test results is common

A significant percentage of tests performed in the hospital are not followed up, according to a systematic review.

The review included 12 studies, eight of which were conducted in the U.S., all of which quantified the proportion of diagnostic tests not followed up for inpatients. The review found wide variation. For admitted patients, estimates of missed follow up ranged from 1% to 22.9% (as a proportion of inpatients) and from 20.04% to 61.9% when reported per test type.

There was even greater variation in follow-up on tests performed in the emergency department, with estimates ranging from 1% to 75% of tests not followed up, or 0% to 16.5% as a proportion of patients. Several studies observed serious negative outcomes resulting from the failure to follow up, including missed cancer diagnoses. The review was published in the February issue of BMJ Quality and Safety.

The review authors noted particular problems with critical test results, which were apparently lost to follow-up due to communication breakdowns, including noncompliance with guidelines calling for results to be phoned to practitioners. Patients who moved across health care settings, for example from inpatient to outpatient, also posed challenges for follow-up. This finding highlights the “need for systems, policies and practices which facilitate communication of information across different settings,” the study authors said.

The review also looked at the role of various medical records systems, but found no evidence of any association between the type of record system used and follow-up of test results. Electronic, paper, and mixed electronic/paper systems all had high rates of missed results. Electronic systems that can be accessed by clinicians in and out of the hospital and those that include a function for clinicians to endorse results may be helpful, but they would require further study, and should be combined with other strategies, the authors wrote.