ACP issues best practice advice on evaluating suspected PE
Physicians evaluating patients for acute pulmonary embolism (PE) should first establish pretest probability by using such measures as the Wells and Geneva rules, along with physician gestalt and the Pulmonary Embolism Rule-Out Criteria (PERC), according to recent advice from ACP.
Members of ACP's Clinical Guidelines Committee performed a literature search from 1966 to 2014 for English-language clinical trials and meta-analyses on diagnostic strategies, decision rules, laboratory tests, and imaging studies for diagnosing PE. A formal systematic review of the evidence was not performed; instead, the goal was to provide practical, evidence-based advice for clinicians evaluating adult inpatients and outpatients in whom acute PE is suspected.
The following principles of best practice advice were developed:
- 1. Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.
- 2. Clinicians should not obtain D-dimer measurements or imaging studies in patients who have a low pretest probability of PE and meet all PERC.
- 3. Clinicians should obtain a high-sensitivity D-dimer measurement as the initial diagnostic test in patients who have an intermediate pretest probability of PE or in patients with low pretest probability of PE who do not meet all PERC. Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE.
- 4. Clinicians should use age-adjusted D-dimer thresholds (age × 10 ng/mL rather than a generic 500 ng/mL) in patients older than 50 years to determine whether imaging is warranted.
- 5. Clinicians should not obtain any imaging studies in patients with a D-dimer level below the age-adjusted cutoff.
- 6. Clinicians should obtain imaging with CT pulmonary angiography (CTPA) in patients with high pretest probability of PE. Clinicians should reserve ventilation-perfusion scans for patients who have a contraindication to CTPA or for instances when CTPA is not available. Clinicians should not obtain a D-dimer measurement in patients with a high pretest probability of PE.
The guidance was published in the Nov. 3 Annals of Internal Medicine.
Hospitals with high readmission rates may be penalized largely because of patients they serve
Medicare could be inadvertently penalizing hospitals with higher than expected readmission rates because of the type of patients who seek care at these facilities, a recent study found.
The researchers used survey data from the national Health and Retirement Study and identified 8,067 hospital admissions of 3,470 participants enrolled in Medicare. They split the 1,896 hospitals into quintiles based on publicly reported hospital-wide readmission rates. CMS adjusts expected rates for patients' age, sex, discharge diagnosis, and recent diagnoses, the authors noted, so they assessed the effect of applying 29 other patient characteristics. Results were published in the November JAMA Internal Medicine.
Of these additional characteristics, 22 significantly predicted readmission beyond standard adjustments, and 17 were distributed differently between the highest- and lowest-quintiles of hospitals (P≤0.04 for all comparisons). For example, patients admitted to hospitals in the highest quintile had higher chronic disease burden, less education, fewer assets, worse self-reported health status, more depressive symptoms, worse cognition, worse physical functioning, and more difficulties with activities of daily living than those admitted to hospitals in the lowest quintile.
After adjusting for all patient characteristics they assessed, the researchers determined that the difference in the probability of readmission between participants admitted to hospitals in the highest versus lowest quintile was reduced by 48% from 4.41 percentage points with Medicare's standard adjustments to 2.29 percentage points after the adjustment (reduction in difference, –2.12; 95% CI, –3.33 to –0.67; P=0.003).
“These data indicate how incomplete adjustment and differential misclassification can lead to unreliable comparisons,” said an accompanying editorial. Many patient and hospitalization characteristics influence the likelihood of readmissions, so readmission rates must be adjusted for these characteristics if they are to fairly compare these rates between facilities, the editorial stated.
Such an adjustment could be done with multivariable models with data from health administrative databases, but even then, these models are only moderately successful at predicting readmission risk, according to the editorial.
HCAHPS physician communication scores improve as gap closes between hospitals
Patient satisfaction scores for physician communication have improved, with hospitals in the lowest quartile of scores showing a greater rate of improvement than those in the highest quartile, according to a recent analysis.
Researchers used CMS’ Hospital Compare database to study Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data from 2007 to 2013. Specifically, they focused on 1 of 3 HCAHPS questions about physician communication, using the percentage of survey participants who responded that physicians “always” communicated well as a measure. Results were published online on Sept. 25 by the Journal of Hospital Medicine.
Of 4,353 hospitals with data for the 7-year period, mean patient satisfaction with physician communication was 78.9% (SD, 5.7%) in 2007 and 81.7% (SD, 5.4%) in 2013, a trend of 0.33% improvement per year (P<0.001).
Researchers divided the 2,273 hospitals that reported data in 2007 into quartiles based on their satisfaction scores, and this quartile allocation was maintained during subsequent years. The mean satisfaction scores of the lowest and highest quartile were 72% (SD, 3.2%) and 86.9% (SD, 3.2%), respectively.
The researchers noted that perhaps their most intriguing finding was the difference in the change in scores between the lowest and highest quartiles. In fact, highest-quartile hospitals had a statistically significant decrease in scores during the observation period (-0.23% per year; P<0.001).
However, hospitals that were in the highest quartile in 2007 still had higher satisfaction scores in 2013 than 2007's lowest-quartile hospitals (85% [SD, 4.2%] versus 77% [SD, 3.6%], respectively). Only 4 of the 584 hospitals in the lowest quartile in 2007 climbed to the top in 2013, whereas 22 hospitals that were in the highest quartile in 2007 dropped to the lowest in 2013.
The 2007 satisfaction quartiles remained significantly associated with subsequent change in scores during the 7-year period after adjustment for hospital and local population characteristics. Survey response rate, number of physicians, and number of acute care hospital beds within the hospital service area were positively associated with patient satisfaction, whereas having higher local population density and being a teaching hospital were negatively associated with patient satisfaction.
The study authors noted that a possible explanation for these findings is that high-performing hospitals may become complacent and divert resources to improvement efforts for other quality measures. There could also be more improvement among the lower-quartile hospitals for the same degree of investment as those in higher quartiles, they wrote. Limitations of the study include the possible response and selection bias of HCAHPS surveys resulting from low response rates.
Contamination frequently occurs when hospital personnel remove protective gear, study finds
Health care personnel frequently contaminated their skin and clothing when doffing gloves or gowns smeared with fluorescent lotion in a recent study of 4 Cleveland-area hospitals.
Researchers determined the frequency and sites of contamination during removal of personal protective equipment (PPE) and evaluated an intervention's effect on the frequency of contamination. Results were published online on Oct. 12 by JAMA Internal Medicine.
During 435 simulations of donning and/or doffing of gowns and gloves, contamination of the skin or clothing with fluorescent lotion occurred in 200 cases (46%), with a similar frequency among the 4 hospitals (range, 42.5% to 50.3%). Contamination occurred more frequently during removal of gloves than gowns (52.9% vs. 37.8%, P=0.002), with the hands and neck being the most frequently contaminated sites during glove and gown simulations, respectively.
Compared to the CDC's procedures for donning and doffing PPE, observers noted incorrect technique in 172 simulations (39.5% of participants). Contamination occurred more frequently when these lapses in technique were observed versus not observed (70.3% vs. 30%, P<0.001). “The finding that contamination occurred frequently even when no lapses in technique were observed likely reflects the high risk of contamination when PPE is heavily contaminated,” the study authors noted.
Because of these findings of frequent contamination, 1 Veterans Affairs medical center implemented a facility-wide intervention that included educational sessions for personnel from long-term care and hospital wards. This intervention resulted in a reduction of skin and clothing contamination during gown and glove removal (60% before the intervention vs. 18.9% after, P<0.002), and this reduction was sustained after 1 and 3 months (12% at both time points, P<0.001 compared with before intervention).
A standardized training procedure on the recommended donning and/or doffing techniques is “long overdue,” according to an accompanying editorial. “It is now up to individual hospitals to ensure effective use of PPE through selective and judicious use of contact precautions and mastering of PPE donning and doffing techniques,” the editorialist wrote. “Optimizing the removal of PPE via targeted training with adherence assessments and feedback and an ongoing emphasis on rigorous hand hygiene are critical steps toward empowering health care workers to practice consistent infection prevention, not only for special pathogen protection but also for routine care interactions.”
The study's authors noted several limitations to the study, such as how the outcome was based on simulations with fluorescent lotion rather than on contamination with pathogens during real patient encounters. These simulations are likely to mimic situations in which PPE is heavily contaminated and may not reflect findings when lower levels of contamination are present, they wrote. They also noted that the intervention was conducted in only 1 facility, was quasi-experimental, and had a relatively short follow-up period.
Guideline advises diagnoses, referrals, treatments for supraventricular tachycardia
Three medical societies released a guideline aimed at helping inpatient and outpatient clinicians treat patients with supraventricular tachycardia (SVT) other than atrial fibrillation.
The guideline was a collaboration of the American College of Cardiology, American Heart Association, and Heart Rhythm Society. The overall goal of the guideline is to provide clinicians with the tools needed to successfully diagnose and treat patients with SVT other than atrial fibrillation, including regular narrow–QRS complex tachycardias or irregular ones such as atrial flutter with irregular ventricular response and multifocal atrial tachycardia. It includes tools for quick diagnosis, referrals to cardiology and electrophysiology specialists, discussion and collaboration with the patient, and prescription of appropriate treatment.
The guideline also aims to aid clinicians to help patients differentiate between SVT and other disorders, such as panic attack and chest pain, as well as shortness of breath and syncope or near syncope, which may cause similar symptoms. Among the many recommendations are ones focused on acute treatment and ongoing management.
- Vagal maneuvers are recommended for acute treatment in patients with regular SVT (class of recommendation, 1; level of evidence, B-randomized);
- Adenosine is recommended for acute treatment in patients with regular SVT (class of recommendation, 1; level of evidence, B-randomized);
- Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable SVT when vagal maneuvers or adenosine are ineffective or not feasible (class of recommendation, 1; level of evidence, B-nonrandomized);
- Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically stable SVT when pharmacological therapy is ineffective or contraindicated (class of recommendation, 1; level of evidence, B-nonrandomized);
- Intravenous diltiazem or verapamil can be effective for acute treatment in patients with hemodynamically stable SVT (class of recommendation, 2a; level of evidence, B-randomized); and
- Intravenous beta-blockers are reasonable for acute treatment in patients with hemodynamically stable SVT (class of recommendation, 2a; level of evidence, C-limited evidence).
- Oral beta-blockers, diltiazem, or verapamil is useful for ongoing management in patients with symptomatic SVT who do not have ventricular pre-excitation during sinus rhythm (class of recommendation, 1; level of evidence, B-randomized);
- Electrophysiological study with the option of ablation is useful for the diagnosis and potential treatment of SVT (class of recommendation, 1; level of evidence, B-nonrandomized);
- Patients with SVT should be educated on how to perform vagal maneuvers for ongoing management of SVT (class of recommendation, 1; level of evidence, C-limited data);
- Flecainide or propafenone is reasonable for ongoing management in patients without structural heart disease or ischemic heart disease who have symptomatic SVT and are not candidates for, or prefer not to undergo, catheter ablation (class of recommendation, 2; level of evidence, B-randomized);
- Sotalol may be reasonable for ongoing management in patients with symptomatic SVT who are not candidates for, or prefer not to undergo, catheter ablation (class of recommendation, 2b; level of evidence, B-randomized);
- Dofetilide may be reasonable for ongoing management in patients with symptomatic SVT who are not candidates for, or prefer not to undergo, catheter ablation and in whom beta-blockers, diltiazem, flecainide, propafenone, or verapamil is ineffective or contraindicated (class of recommendation, 2b; level of evidence, B-randomized);
- Oral amiodarone may be considered for ongoing management in patients with symptomatic SVT who are not candidates for, or prefer not to undergo, catheter ablation and in whom beta-blockers, diltiazem, dofetilide, flecainide, propafenone, sotalol, or verapamil is ineffective or contraindicated (class of recommendation, 2b; level of evidence, C-limited data); and
- Oral digoxin may be reasonable for ongoing management in patients with symptomatic SVT without pre-excitation who are not candidates for, or prefer not to undergo, catheter ablation (class of recommendation, 2b; level of evidence, B-randomized);
This guideline supersedes the organizations' 2003 guidelines on management of patients with supraventricular arrhythmias. It was jointly published Sept. 23 in the Journal of the American College of Cardiology,Circulation, and HeartRhythm.
Anticoagulation beneficial for patients with afib plus 1 stroke risk factor
Patients with atrial fibrillation and a single additional stroke risk factor benefited from oral anticoagulation, but those with only afib did not, according to a recent study.
The observational study included 8,962 patients with atrial fibrillation seen in the cardiology department of a French hospital between January 2000 and December 2010. They were followed for a median of 979 days to determine the risk of ischemic stroke, systemic embolism, and death, as well as major bleeding. Results were published online in CHEST on Oct. 1.
About a quarter of the patients (24%) had 1 or no risk factors in addition to afib, according to the CHA2DS2-VASc score, and 53% of the patients in that group were prescribed oral anticoagulation. During follow-up, 7% of the 0 or 1 risk-factor patients had a stroke, systemic embolism, or death. Among the patients with 1 additional risk factor (a CHA2DS2-VASc of 1 for men and 2 for women), anticoagulation was associated with a reduced risk for the adverse outcomes (P=0.01), even after adjustment for age and gender. Adding major bleeding as an endpoint led to similar findings. However, for patients with no additional stroke risk factors (CHA2DS2-VASc of 0 for men and 1 for women), oral anticoagulant use was not associated with any difference in stroke, embolism, or death rates, before or after adjustment for age and gender (P=0.67 and 0.25, respectively).
These findings support current European and British guidelines but differ from the American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines, the authors said. The latter recommend no antithrombotic therapy or treatment for patients with a CHA2DS2-VASc of 1, a recommendation the study authors described as “do what you like.” Disagreeing with that advice, they wrote that “physicians should appreciate that even a single risk factor confers real risks of stroke/systemic thromboembolism/death, and [oral anticoagulation] would reduce this overall risk.”
Prior studies have found differences in risk associated with the various factors included in the CHA2DS2-VASc score, the authors noted. This study did not find significant differences in hazard among risk factors, except gender, although it may have suffered from lack of power for some subgroups. The study was also limited by the risk of residual confounding intrinsic to the observational method, the authors said.