Recent Research

Hospitalist care and post-discharge costs, very elderly patients and vitamin K thromboprophylaxis, and more.

Hospitalist care associated with higher costs after discharge

Though hospitalist care is associated with shorter length of stay and lower hospital costs, these are offset by more medical utilization and higher costs after discharge, a study found.

In an observational cohort study, researchers analyzed hospital admissions from January 2001 to November 2006 in a representative national sample of 5% of Medicare beneficiaries. Researchers looked at claims for hospital stays, outpatient facility use and physician services. They included only admissions for patients with an identified primary care physician (PCP) before admission, in order to better compare patients cared for by hospitalists versus PCPs. Admissions of patients cared for by both, or neither, were excluded. The main analysis included hospitals with at least 20 admissions cared for by hospitalists and 20 by PCPs during the study period, leaving a final cohort of 58,125 admissions at 454 hospitals. Outcomes of interest were length of stay, hospital charges, discharge location and physician visits, rehospitalization, emergency department visits, and Medicare spending in the 30 days after discharge. Results were published in the Aug. 2, 2011 Annals of Internal Medicine.

Among patients cared for by hospitalists, length of stay was 0.64 day less (5.17 days vs. 5.82 days; P<0.001). Hospital charges also were $282 lower ($15,019 vs. $15,301; P<0.001) than among those cared for by PCPs. Medicare costs 30 days after discharge were $332 higher for those seen by hospitalists ($3,279 vs. $2,947; P<0.001). Patients under hospitalist care also:

  • were less likely to be discharged to home (70.6% vs. 76%; odds ratio [OR], 0.82; 95% CI, 0.78 to 0.86),
  • were more likely to have emergency department visits within 30 days of discharge (20.7% vs. 17.8%; OR, 1.18; 95% CI, 1.12 to 1.24),
  • were more likely to be readmitted within 30 days post-discharge (19% vs. 17.4%; OR, 1.08; 95% CI, 1.02 to 1.14),
  • had fewer visits with their PCPs within 30 days post-discharge (0.62 visits vs. 0.79; P<0.001), and
  • had more nursing facility visits within 30 days post-discharge (0.58 vs. 0.52; P<0.001).

Study limitations included that only Medicare patients with an identified PCP and a medical diagnosis were included, thus results might not be generalizable to other kinds of patients. Still, the study's findings indicate that the apparent savings in hospital costs due to hospitalist care is in fact a shifting (and increase) of costs to the post-discharge period, the authors wrote. “If applied to the approximate 25% of Medicare admissions cared for by hospitalists, this represents more than $1.1 billion in additional Medicare costs annually,” they wrote. Hospitalists may be more susceptible to behaviors that promote cost shifting, they added, but current efforts toward bundling of payments should reduce incentives for these behaviors.

While the findings raise the question of whether hospitalists discharge their patients “more quickly but less appropriately,” such that they bounce back, the results should be interpreted cautiously as the study examined hospitalizations before the time when 30-day readmissions was a quality benchmark, as noted in the accompanying editorial.

As for why hospitalist care is associated with greater use of post-discharge services, it may be because hospitalists are under pressure to shorten length of stay and thus discharge sicker patients, or because they lack knowledge of outpatient services, the editorialists wrote. Ultimately, more studies that follow patients through their course of care are needed, they concluded.

Very elderly patients can benefit from well-managed vitamin K thromboprophylaxis

Adequate management of vitamin K agonist (VKA) therapy in trained centers allowed very old and frail patients to benefit from VKA thromboprophylaxis, an Italian study concluded.

To evaluate the quality of anticoagulation and the incidence of bleeding, Italian researchers performed a prospective observational study that enrolled from 27 centers 4,093 patients 80 years of age or older who were naive to VKA for thromboprophylaxis of atrial fibrillation (AF) or after venous thromboembolism (VTE).

Major end points of the study were:

  • first major bleeding, defined as fatal, intracranial (documented by imaging), ocular causing blindness, articular, or retroperitoneal bleeding;
  • when surgery or another invasive procedure was needed to stop bleeding;
  • when transfusion of more than 2 units of blood was required; or
  • when hemoglobin was reduced by more than 2 g/dL.

Follow-up was stopped after the first major bleed occurred, after the cessation of oral anticoagulation, or when a patient was no longer monitored by the participating center. Results were published in the Aug. 16, 2011 Circulation.

The follow-up was 9,603 patient-years; median age at the beginning of follow-up was 84 years (range, 80 to 102 years). During follow-up, 385 patients died (total mortality rate, 4.0 per 100 patient years). Of these, 26 (6.8%) died of hemorrhagic complications, 112 (29.1%) of cardiovascular disease, 34 (8.8%) of sudden death, 12 (3.1%) of stroke, 56 (14.5%) of cancer, and 145 (37.7%) of another disease unrelated to VKA treatment.

There were 179 major bleedings (rate, 1.87 per 100 patient-years), of which 53 (rate, 0.55 per 100 patient-years) were intracranial and 26 were fatal (rate, 0.27 per 100 patient-years). The rate of bleeding was higher in men than in women (relative risk [RR], 1.4; 95% CI, 1.12 to 1.72; P=0.002) and among patients 85 years of age or older compared with younger patients (RR, 1.3; 95% CI, 1.0 to 1.65; P=0.048).

The first three months of treatment were associated with a high risk of bleeding (RR, 2.4), as were renal failure, history of previous bleeding events, history of falling (a fivefold higher risk), and active cancer. Patients with prior gastroenterological bleedings were especially prone to recurrence (hazard ratio, 6.2).

The distribution of bleeding events in relation to indication for VKA treatment was higher among patients on VKA for VTE compared with patients on VKA for AF (RR, 1.4; 95% CI, 1.1 to 1.8; P=0.03).

The authors wrote, “In this large study on very old patients on VKA treatment, the rate of bleeding complications was low, suggesting that age in itself should not be considered a contraindication to treatment. Adequate management of VKA therapy through careful monitoring of patients in specifically trained centers allows very old and frail patients to benefit from VKA thromboprophylaxis.”

Clinical guideline issued on stable COPD diagnosis, management

Several collaborating medical societies, including the American College of Physicians (ACP), released guidelines recently on the diagnosis and management of stable chronic obstructive pulmonary disease (COPD).

The guideline, which updates and expands on a 2007 ACP guideline on this topic, was developed by a panel with members from ACP, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society, and represents an official, joint guideline from all four organizations. The panel helped develop key questions related to COPD diagnosis and management and evaluated related evidence reviews and tables to arrive at its recommendations, which were approved by unanimous vote. The guideline was published in the Aug. 2, 2011 Annals of Internal Medicine.

The guideline recommendations are as follows:

  • Spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms (strong recommendation, moderate-quality evidence) but should not be used to screen for airflow obstruction in individuals without respiratory symptoms (strong recommendation, moderate-quality evidence).
  • For stable COPD patients with respiratory symptoms and FEV1 between 60% and 80% predicted, treatment with inhaled bronchodilators may be used (weak recommendation, low-quality evidence).
  • For stable COPD patients with respiratory symptoms and FEV1 less than 60% predicted, treatment with inhaled bronchodilators is recommended (strong recommendation, moderate-quality evidence).
  • Clinicians should prescribe monotherapy using either long-acting inhaled anticholinergics or long-acting inhaled β-agonists for symptomatic patients with COPD and FEV1 less than 60% predicted (strong recommendation, moderate-quality evidence), and should base the choice of specific monotherapy on patient preference, cost, and adverse effect profile.
  • Clinicians may administer combination inhaled therapies (long-acting inhaled anticholinergics, long-acting inhaled β-agonists, or inhaled corticosteroids) for symptomatic patients with stable COPD and FEV1 less than 60% predicted (weak recommendation, moderate-quality evidence).
  • Clinicians should prescribe pulmonary rehabilitation for symptomatic patients with an FEV1 less than 50% predicted (strong recommendation, moderate-quality evidence) and may consider pulmonary rehabilitation for symptomatic or exercise-limited patients with an FEV1 more than 50% predicted (weak recommendation, moderate-quality evidence).
  • Clinicians should prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia (PaO2 ≤ 55 mm Hg or SpO2 ≤ 88%) (strong recommendation, moderate-quality evidence).

Commonly used delirium assessment tool may lack sensitivity in daily practice

The Confusion Assessment Method for the ICU (CAM-ICU), a commonly used tool to assess delirium, may lack sensitivity in daily practice as compared to clinical trials, a recent study suggests.

Although the CAM-ICU has high sensitivity and specificity when administered by research nurses, its performance in day-to-day practice is unknown. Researchers in the Netherlands performed a prospective multicenter study at 10 ICUs to see how well the test would identify delirium in a real-life setting. Each ICU was visited twice by teams of delirium experts, including psychiatrists, geriatricians, and neurologists, who classified participating patients as awake and not delirious, delirious, or comatose. The experts' assessments, considered the gold standard, were compared with bedside nurses' assessments using the CAM-ICU. Across all ICUs, the average time from initial implementation of the CAM-ICU to study participation was two years. The study results appeared in the Aug. 1, 2011 American Journal of Respiratory and Critical Care Medicine.

A total of 282 patients were assessed by 15 delirium experts between April 2009 and April 2010. Of these, 101 (36%) were classified as comatose by the experts or by the nurses and were excluded from further analysis. In the remaining 181 patients, the CAM-ICU had a sensitivity of 47% (95% CI, 35% to 58%), a specificity of 98% (95% CI, 93% to 100%), a positive predictive value of 95% (95% CI, 80% to 99%) and a negative predictive value of 72% (95% CI, 64% to 79%). The test had a positive likelihood ratio of 24.7 (95% CI, 6.1 to 1.00) and a negative likelihood ratio of 0.5 (95% CI, 0.4 to 0.8). The CAM-ICU had the lowest sensitivity in patients with hypoactive delirium (31% [95% CI, 17% to 48%]) and the highest sensitivity in patients with hyperactive delirium (100% [95% CI, 56% to 100%]). The CAM-ICU performed better in ICUs that used it daily than in those that did not.

The authors pointed out that experts' assessments were based on patients' conditions at a particular moment in time and could not consider fluctuations in symptoms, and that CAM-ICU assessment and experts' assessments could not always be performed sequentially, among other limitations. However, they concluded that the low sensitivity of the CAM-ICU in their study highlights a potential problem with its use in clinical practice for delirium assessment in critically ill patients. The test's sensitivity may be improved by using it every day and by combining its results with nurses' other clinical observations, the authors suggested.

Blood tests after MI associated with hospital-acquired anemia

Greater blood loss from phlebotomy is associated with higher risk of anemia in patients hospitalized for myocardial infarction (MI), a recent study found.

The retrospective study included more than 17,000 patients treated at 57 hospitals for acute MI between 2000 and 2008. None of the patients were anemic at hospital admission, and their diagnostic blood loss was calculated by multiplying the number and types of blood tubes drawn by the standard volume for each tube type. The study's results were published in the Oct. 10, 2011 Archives of Internal Medicine.

Overall, 20% of the patients developed moderate to severe anemia (defined as a hemoglobin level <11 g/dL). The anemic patients had significantly higher mean phlebotomy volume (173.8 mL vs. 83.5 mL; P<0.001). Over 12% of the patients had more than 300 mL drawn during hospitalization. For every 50 mL of blood drawn, patients' risk of moderate to severe anemia increased by 18%, and the association remained significant after multivariable adjustment.

The study also found significant variation among hospitals in how much blood was taken from patients, with averages for anemic patients ranging from 119.1 to 246.0 mL at different hospitals. The quantity of blood drawn was fairly constant over the course of hospitalization, so that patients with longer lengths of stay had greater blood loss. Combined, these findings indicate that many of the blood draws may result from routine processes of care, rather than diagnostic or therapeutic interventions, according to the study authors.

Limitations included using estimates for the amount of blood in each tube. Also, the findings of this study could be generalizable to other seriously ill medical patients, the authors said, although they cautioned that confounding could not be excluded in this observational, retrospective study, so future randomized trials should test whether reducing phlebotomy blood loss decreases anemia and improves outcomes. The authors did acknowledge they were unable to assess the impact of hemodilution, but they felt it was an unlikely cause of hospital-acquired anemia given that a large drop in hemoglobin was required to develop anemia. They offered some suggestions for reducing blood loss, including using pediatric phlebotomy tubes, or if those are not compatible with a hospital's equipment, putting less blood in standard tubes.

Observation unit reduced costs for chest pain patients

In a study of emergency department patients with chest pain, observation care and a stress cardiac magnetic resonance imaging exam in place of traditional admission reduced costs with no effect on outcomes.

The trial included 109 patients seen in one emergency department with intermediate-risk chest pain, but not definite acute coronary syndrome. They were randomized either to usual care (n=57) or an observation unit (n=52) where they received cardiac marker tests at 4 and 8 hours and stress cardiac magnetic resonance (MR) imaging. The results were published in the August 2011 JACC: Cardiovascular Imaging.

From randomization through one-year follow up, 6% of the observation group and 9% of the inpatients had experienced a major cardiac event (P=0.72). One patient in each group had an event after discharge. Cardiac-related hospital admissions were significantly lower in the observation unit group compared with the inpatient care group (12% vs. 35% respectively, P=0.01). The observation group had significantly lower cardiac-related costs in that year ($3,101 vs. $4,742, including $29 vs. $152 after discharge). There was no “rebound” increase after discharge, as would be seen if testing or treatment were being deferred from the index visit.

Study authors concluded that observation unit care with MR appeared to be as safe as inpatient care, but at lower cost. Inpatients had higher rates of return cardiac-related ED visits, rehospitalizations and cardiac catheterizations. The authors speculated that the lower catheterization rate may be due to observation patients being more stringently selected for revascularization during their first visit. The patients also may have felt more reassured and therefore less likely to return to the hospital.

Physician behavior may also have been affected. Observation patients' recent MR exam could reduce future testing, while inpatients established relationships with subspecialists who may perform more tests and procedures, the authors said.

Hospitalist-led ACE units show positive results

Two recent trials of acute care for the elderly (ACE) services included hospitalists and found potential benefits to these alternative models of geriatric care.

At the University of Colorado, researchers implemented an ACE service that included a hospitalist attending, daily interdisciplinary rounds, standardized geriatric assessments, a geriatrics curriculum for residents and students, and a focus on mitigating harm and discharge planning. The service was implemented in July 2007, and three months after its initiation, performance was compared to usual care, using 122 ACE patients and 95 usual care patients.

The primary outcome was recognition of patients' abnormal functional status, on which the ACE service outperformed usual care (65% vs. 32%, P<0.0001). The ACE service also recognized more abnormal cognitive status (57% vs. 36%, P=0.02) and used more do not resuscitate (DNR) orders (39% vs. 26%, P=0.04). No differences between the groups were seen in use of physical restraints or sleep aids, falls, discharge location, length of stay, cost and 30-day readmissions.

The authors concluded that a hospitalist ACE service could possibly improve care processes without increasing cost, and be a solution to geriatrician shortages. They noted that their model could be implemented without a dedicated unit, and called for further research into the potential benefits of the model. The results were published in the July/August 2011 Journal of Hospital Medicine.

The other ACE unit trial, conducted at Mt. Sinai Hospital and also published in the July/August 2011 JHM, was specifically designed not to be unit-based. Mobile ACE teams (consisting of a geriatrician-hospitalist, a geriatric medicine fellow, a social worker and a nurse coordinator) were created in the hospital in 2007. About 1,000 patients cared for by the MACE team during its first two years were included in the study. Controls included 450 patients treated by the traditional ACE service before implementation of the MACE, and more than 9,000 geriatric patients treated by general medical services.

Compared to the traditional ACE unit, the MACE service had significantly lower mean length of stay (LOS) and total cost (5.8 vs. 7.9 days, P<0.001 and $10,315 vs. $12,187, P=0.002). During its first year of operation, the MACE's patients' results were not significantly different from propensity-matched controls, except for the 90-day readmission rate, which was higher. In the second year (when the hospitalist model was fully implemented), LOS and cost were lower (5.6 vs. 7.2 days, P<0.001 and $10,693 vs. $15,636, P<0.001), but there were no significant differences for in-hospital mortality or readmission rate (which was higher than the national average).

Researchers concluded that a MACE model, which carries only the added cost of the nurse coordinator, could save health care expenditures without major investment by hospitals.

Mortality with later hip fracture surgery linked to medical reasons for delay

Late hip fracture surgery carries a higher mortality risk than early surgery, but mostly because of underlying medical reasons for the delay and not the delay itself, according to a recent study.

Researchers in Spain performed a prospective cohort study at a university hospital's hip fracture unit to determine how delayed surgery for hip fracture affected outcomes. A total of 2,250 consecutive elderly patients with hip fracture were included. The study's main outcome measures were time to surgery, reasons for delayed surgery, adjusted in-hospital mortality, and complication risk. The results appeared in the Aug. 16, 2011 Annals of Internal Medicine.

All study patients were admitted to the hospital's hip fracture unit between August 2003 and September 2008. All were 65 years of age or older (mean age, 83.6 years), and the median time to hip surgery was 72 hours. Fifty-six patients (2.5%) had surgery immediately, 311 (13.8%) had surgery within 24 hours of admission, and 1,459 patients (64.9%) had surgery more than 48 hours after admission.

The most common reasons for delaying surgery longer than 48 hours were lack of operating rooms (60.7%) and acute medical problems (33.1%). Of the acute medical problems, half were related to the need to interrupt antiplatelet therapy. Ninety-eight patients died (4.35%), while 1,031 (45.9%) had at least one postsurgical in-hospital medical complication. In patients who were clinically unstable on admission, these rates were 13.7% and 74.2%, respectively.

Longer time to surgery was associated with higher mortality rates and higher rates of medical complications. When the authors adjusted for age, dementia, chronic comorbidities and functionality, they found that these associations no longer persisted for delays of 120 hours or less but did persist for delays longer than 120 hours. However, when the authors adjusted for acute medical conditions as a cause of the delay, the risks were attenuated (P=0.06 for time effect on mortality; P=0.031 for time effect on medical complications) and delays to surgery greater than 120 hours were not associated with medical complications other than a marginal association with a higher risk of urinary tract infection (OR 1.54, 95% CI, 0.99 to 2.44).

The authors noted that reasons for clinical unsuitability for surgery varied, that all patients in their study received daily geriatric care, and that no patients were followed after discharge. They also pointed out that the most common reason for delayed surgery was lack of an operating room, highlighting the need for organizational improvements. However, they concluded that the association between late surgery for hip fracture and higher morbidity and mortality is mostly caused by medical reasons rather than by the delay itself. Very long delays in surgery continued to be associated with worse outcomes regardless of the reason for the delays.

An accompanying editorial noted that hip fracture patients are usually “medically complex,” that “medical reasons for delaying surgery are the rule rather than the exception,” and that clinicians should not delay surgery based on the current study's results. Citing a study from 2004, the editorialist noted that prolonged delays are associated with increased pain and hospital costs.