In the News

New hospitals and patient satisfaction, NSAIDs and adverse events, and more.

New hospital with amenities didn't improve patient satisfaction scores

Renovating a hospital to have a more patient-centered design improved patient ratings of the building but didn't significantly affect other measures of overall satisfaction, a recent study found.

For the study, researchers used Press Ganey and HCAPHS scores collected from patients who were treated at a new hospital building that had healing gardens with a water feature, soaring lobbies, an art collection, well-decorated and light-filled patient rooms with sleeping accommodations for family members, features to reduce noise, and an interactive television network. Their scores were compared to data from the year before the move and from patients treated concurrently on units that hadn't moved to the new building.

Patients in the new building reported significantly higher satisfaction in facility-related survey areas, especially the pleasantness of the décor (64.8% scoring it highly vs. 33.6%) and visitor accommodation and comfort (70.3% vs. 50.0%). However, their satisfaction ratings of physicians, nurses, housekeeping, and other service staff didn't change in the new building. Results were published in the March Journal of Hospital Medicine.

“Contrary to our hypothesis and a belief held by many, we found that patients appeared able to distinguish their experience with the hospital environment from their experience with providers and other services,” the study authors said. The study's generalizability was limited by its setting in a single academic center that treats mostly an inner-city population or patients referred for specialty care, they noted.

However, the findings suggest that clinician-level interventions may have more impact on overall patient satisfaction than hospital renovations and that such renovations may not be cost-effective responses to value-based payment systems. The lessons apply to both planning of interventions and interpretation of satisfaction scores, since the “study suggests that hospitals should not use outdated facilities as an excuse for achievement of suboptimal satisfaction scores,” the authors said.

NSAIDs, frequently taken after MI, may increase bleeding and thrombotic events

Nonsteroidal anti-inflammatory drugs (NSAIDs) were associated with increased risk of bleeding and thrombotic events, even during short-term treatment, among patients receiving antithrombotic therapy after myocardial infarction, a study found.

Researchers studied 61,971 patients 30 years or older who were admitted with first-time myocardial infarction and who were alive 30 days after discharge by using Danish registries of data from 2002 to 2011. Treatment with aspirin, clopidogrel, or oral anticoagulants and their combinations, as well as at least 1 NSAID, was examined. Results appeared in the Feb. 24 Journal of the American Medical Association.

During a median follow-up of 3.5 years, there were 18,105 deaths (29.2%), 5,288 bleeding events (8.5%), and 18,568 cardiovascular events (30%). The crude incidence rates of bleeding (events per 100 person-years) were 4.2 (95% CI, 3.8 to 4.6) with NSAID treatment and 2.2 (95% CI, 2.1 to 2.3) without NSAID treatment. The rates of cardiovascular events were 11.2 (95% CI, 10.5 to 11.9) with NSAIDs and 8.3 (95% CI, 8.2 to 8.4) without. The increased risk of bleeding and cardiovascular events happened with NSAIDs regardless of antithrombotic treatment, types of NSAIDs, or duration of use.

The researchers said that while more research is needed to confirm these findings, physicians should exercise appropriate caution when prescribing NSAIDs for patients who have recently experienced myocardial infarction, even for treatment periods of 3 days or less.

“Although it seems unlikely that physicians can completely avoid prescription of NSAIDs, even among high-risk patients,” they wrote, “these results highlight the importance of considering the balance of benefits and risks before initiating any NSAID treatment.”

The authors of an accompanying editorial voiced their concern that one-third of patients in the cohort were prescribed concomitant NSAIDs despite their recent myocardial infarction.

They wrote, “Because the present study tracked only prescription NSAID use, it is plausible that an even greater health care effect might occur in many countries, such as the United States, where NSAIDs are widely available as over-the-counter medications and physicians may be unaware whether their patients are taking NSAIDs.”

8 health organizations, American Bar Association call for gun policies

A call for policies to help mitigate the rate of firearm injuries and deaths in the U.S. was announced by the American College of Physicians, 7 other national health professional organizations, and the American Bar Association.

Broadly, the organizations support a public health approach to reducing firearm injuries and fatalities, similar to approaches used to reduce tobacco use, motor vehicle fatalities, and unintentional poisoning.

The paper, which was published online Feb. 24 in Annals of Internal Medicine, recommends ways to reduce firearm-related injuries and death:

  • Support criminal background checks for all firearm purchases, including sales by gun dealers, sales at gun shows, and private sales from one person to another;
  • Oppose state and federal mandates that interfere with physician free speech and the patient-physician relationship, including physician “gag laws” that forbid physicians to discuss a patient's gun ownership;
  • Oppose the sale or ownership of “assault weapons” and large-capacity magazines for private citizens; and
  • Advocate for research into the causes and consequences of firearm violence and unintentional injuries so that evidence-based policies may be developed.

The American Bar Association notes in the paper that these recommendations “are constitutionally sound.” The health professional societies made 2 additional recommendations:

  • Support improved access to mental health care, with caution against broadly including all persons with any mental or substance use disorder in a category of persons prohibited from purchasing firearms; and
  • Oppose blanket reporting laws that require physicians to report patients who are displaying signs that they may cause serious harm to themselves or others, as these laws may stigmatize patients with mental or substance-abuse use disorders and inhibit them from seeking treatment.

ACP was joined by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Emergency Physicians, the American Congress of Obstetricians and Gynecologists, the American College of Surgeons, the American Psychiatric Association, and the American Public Health Association, as well as the American Bar Association.

In an accompanying editorial, the author stressed that firearm-related violence is a public health threat and that physicians should focus on studying and preventing it. The editorial called for new research and funding to fill knowledge gaps and referred to a study in the same issue of Annals finding that being hospitalized for a firearm-related injury is associated with a heightened risk of subsequent violent victimization or committing a crime.

Using a retrospective cohort study design, researchers identified all gun trauma patients hospitalized during 2006-2007 in the state of Washington and compared their risk of subsequent violent injury, death, or crime perpetration to the rates among a random sample of patients with a noninjury-related hospitalization and the general population of the state.

Patients with a hospitalization due to firearm violence were ats a significantly greater risk for subsequent firearm-related hospitalization, firearm-related death, or violence-related arrest in comparison with noninjury patients. Among 613 patients with an index firearm-related hospitalization, compared to those with a non-injury-related index hospitalization, there was a greater risk for subsequent firearm-related hospitalization (subhazard ratio [sHR], 21.2; 95% CI, 7.0 to 64.0), firearm-related death (sHR, 4.3; 95% CI, 1.3 to 14.1), and firearm- or violence-related arrest (sHR, 2.7; 95% CI, 2.0 to 3.5).

The researchers noted that the condition of prior criminality had a stronger association with subsequent firearm or violence-related arrest than did a diagnosis of prior mental illness.

“One avenue for further research is to operationalize a collaborative intervention, considering that a FRH [firearms-related hospitalization] can potentially play an important role in identifying and reaching high-risk persons,” the authors concluded. “Those already involved in a cycle of violence who have a medical encounter may benefit from interventions to change a trajectory that would otherwise result in subsequent violent injury, death, or crime perpetration. Secondary and tertiary prevention measures may begin in the outpatient, emergency department, or inpatient setting and continue afterward in conjunction with community services and assistance from law enforcement to offer counseling on avoiding repeated injury and new criminal activity.”

Duty hours may have no effect on patient safety, resident well-being, care continuity

A randomized trial did not find a patient safety benefit from shorter duty schedules.

Researchers studied how 12-, 16-, and 24-hour shifts among residents in the intensive care unit (ICU) affected patient safety, resident well-being, and continuity of care. Forty-nine residents in 2 academic ICUs at Mount Sinai Hospital and St. Michael's Hospital in Toronto, Ontario, were randomly assigned in 2-month rotation-blocks from January to June 2009 to the in-house overnight schedules. Nearly half the residents were from internal medicine, with the rest from anesthesia, surgery, and emergency medicine training programs. Results appeared online Feb. 9 at CMAJ.

During the day, the mean rating on the Stanford Sleepiness Scale was 2.39 (SD, 1.13). This rating did not differ significantly between schedules (P=0.3). At night, the mean rating was 2.72 (SD, 1.37). Sleepiness increased from 8 p.m. to 4 a.m. (P<0.001), and the change was not statistically different between schedules (P=0.2). With all 3 schedules, sleepiness was greatest at 4:00 a.m., consistent with the circadian rhythms of nocturnal sleepers and with the idea that time of day may be a more important determinant of fatigue than duration of duty.

There was no effect of schedule on adverse events (12-hour shift, 78.2 events per 1,000 patient days; 16-hour shift, 76.3; 24-hour shift, 81.3; P=0.7). Seven of 8 preventable adverse events occurred during the 12-hour schedule, and mortality rates were similar for the 3 schedules.

ICU staff rated residents' knowledge and decision-making worst with the 16-hour schedule and noted that the residents on that schedule knew fewer clinical and social details about patients.

The results also highlight the tradeoffs residents face, the researchers noted. Many residents reported disliking overnight duty in the 12-hour schedule due to the disconnection from the ICU team and loss of social contact with family and loved ones as a consequence of starting work at 8:30 p.m. for 3 or 4 consecutive nights.

“Our findings that overnight duty periods of 12 or 16 hours may be somewhat better for residents and worse for patients are relevant in Canada, the United States and Europe, where these shorter schedules are increasingly used, and underscore the need to further delineate this emerging signal before widespread system change,” the authors concluded.