In the News

Readmissions and infection, earnings gaps, antimicrobial stewardship programs, and more.

Readmissions after intracerebral hemorrhage often related to infection, study finds

Most 30-day readmissions after hospitalization for intracerebral hemorrhage are related to infection, according to a recent study.

Researchers performed a retrospective cohort study of patients who were discharged from nonfederal acute care hospitals in California between 2006 and 2010 with a primary diagnosis of intracerebral hemorrhage. Patients who died during the index admission, who were discharged against medical advice, or who did not live in California were excluded. The study's main outcome was unplanned readmission within 30 days for an ICD-9-CM code related to infection. The study results were published in the July Stroke.

Of 24,540 index intracerebral hemorrhage admissions during the study period, 3,550 (14.5%) had an unplanned readmission. Of this 3,550, 777 (22%) had a primary diagnosis code related to infection. After all primary and secondary diagnosis codes were evaluated, infection was determined to be associated with 1,826 (51%) of readmissions. Other common readmission reasons were stroke-related codes and aspiration pneumonitis (23.7% and 4.3%, respectively). For infection, the most common codes were septicemia (11.8%), pneumonia (3.5%), urinary tract infection (4.0%), and gastrointestinal infection (1.2%).

Patients readmitted with an infection had higher in-hospital mortality rates than patients with other reasons for readmission (15.6% vs. 8.0%; P<0.001), with a relative risk of 1.7 (95% CI, 1.3 to 2.2) after the authors controlled for other predictors of mortality, such as age and insurance status. Older patients, patients with more comorbid conditions, and patients whose index hospital stays were longer were more likely to have primary infection-related ICD-9-CM codes on readmission.

The researchers noted that they used only ICD-9-CM codes to identify patients with intracerebral hemorrhage and that they could not determine if any patients died out of the hospital, among other limitations. However, they concluded that infections are associated with most 30-day readmissions to acute care hospitals after intracerebral hemorrhage.

“Our findings suggest the need for improved post-discharge infection prevention in the outpatient and immediate care setting, including adoption of best practices for tracheostomy and wound care, aspiration precautions, continued mobilization, and other infection prevention measures,” they wrote. “Patients with advanced age, medical comorbidities, and longer index admission lengths of stay should specifically be targeted given our finding that they are more likely to be readmitted with infection.”

Earnings gaps exist between black and white male physicians, male and female physicians

White male physicians in the United States earn substantially more than black male physicians, even after accounting for medical specialty, years of experience, and hours worked each week, researchers reported. And, while incomes of black and white female physicians are similar to each other, they are significantly lower than men's.

Researchers estimated differences in income by race and sex among U.S. physicians using data from 2 sources: the 2000-13 American Community Survey (ACS), a nationally representative, cross sectional survey of about 3 million households annually, administered by the U.S. Census Bureau, and the 2000-08 Center for Studying Health System Change (HSC) physician survey, which provided representative samples of physicians across 51 metropolitan areas and 9 non-metropolitan areas and is supplemented by a national sample. Annual income was adjusted for several factors from both surveys, including age, specialty, hours worked, years in practice, and percentage of revenue from Medicare and Medicaid. Results were published by The BMJ on June 7.

In the ACS, mean annual income was highest among white male physicians ($255,383), followed by black male physicians ($210,544; P<0.001 compared with white males), white female physicians ($174,106; P<0.001 compared with white males), and black female physicians ($166,833; P<0.001 compared with white males). Mean age was highest among white men at 53.2 years, which was about 7 years older than the lowest mean age of the groups, black women at 46 years. The average number of hours worked per week was 51.2 for white male physicians and 51.9 for black male physicians (P=0.08), both of which were greater than the 45.2 for white female physicians and 48.0 for black female physicians.

Also from the ACS, differences in median income by race did not significantly vary over the study period. During 2000-04, the adjusted difference in median income was $27,108 ($183,258 vs. $156,150; 95% CI for difference, $18,118 to $36,097), compared with $37,841 in 2005-09 ($209,803 vs. $171,962; 95% CI, $31,068 to $44,613; P=0.06 for difference compared with difference in 2000-04), and $34,141 in 2010-2013 ($228,585 vs. $194,444; 95% CI, $21,746 to $46,535; P=0.37 for difference compared with difference in 2000-04).

Because differences in physicians' income by race estimated from the ACS did not adjust for physician specialty or practice characteristics, researchers also analyzed data from the HSC physician surveys. From this data, researchers learned that 27.3% of white male physicians made $150,000 or less compared with 40.8% of black male physicians (absolute difference 13.5%, 95% CI, 9.6% to 17.4%). In contrast, 59.4% of white female physicians made $150,000 or less compared with 58.8% of black female physicians. On the other end of the earning spectrum, 30.9% of white male physicians made above $250,000, compared with 18.3% of black male physicians (absolute difference 12.5%, 95% CI, 8.5% to 16.6%). Similarly, 9.6% of white female physicians made above $250,000, compared with 7.3% of black female physicians (absolute difference 2.3%, 95% CI, −0.9% to 5.6%).

Researchers wrote that race- and sex-based disparities in earnings potential “cannot be closed simply by opening up opportunities for minorities and women in higher paying specialties” and say “efforts to eliminate these disparities might need to look beyond medical school admissions and training to the broader workplace.”

Pharmacist-run antimicrobial stewardship programs may be useful in hospitals without ID subspecialists

Antimicrobial stewardship programs run by pharmacists may help curb antibiotic resistance in areas where infectious disease subspecialists are scarce, according to a recent study of 47 hospitals in South Africa.

Between Oct. 1, 2009, and Sept. 30, 2014, the study authors implemented a pharmacist-run antimicrobial stewardship program in 47 urban and rural private hospitals in South Africa, focusing on a prospective audit and feedback strategy. During the study's preimplementation phase (Oct. 1, 2009, to Jan. 31, 2011), baseline stewardship activities were surveyed at all 47 hospitals. Forty-one hospitals (87%) did not practice antibiotic stewardship and 6 (13%) did. None of the hospitals had local policies or guidelines on antibiotics in place.

After the preimplementation phase, the authors initiated a stepwise implementation phase (Feb. 1, 2011, to Jan. 31, 2013) aimed at reducing antibiotic consumption by targeting prolonged duration of use, use of multiple antibiotics, and use of redundant antibiotic coverage. Finally, once the model was in place in each hospital, a postimplementation phase (Feb. 1, 2013, to Sept. 30, 2014) assessed the effect of the program on antibiotic consumption by using the World Health Organization index of defined daily doses per 100 patient-days. The study's primary outcome was change in antibiotic consumption between phases. The results were published online June 13 by The Lancet Infectious Diseases.

The pharmacists participating in the study were trained to audit 5 process measures: cultures not done before commencement of empirical antibiotics, more than 7 days of antibiotic treatment, more than 14 days of antibiotic treatment, use of more than 4 antibiotics concurrently, and redundant or “double” antibiotic coverage. Pharmacists audited only systemic antibiotic use and consulted a physician before changes were made for all interventions. During 104 weeks of measurement, 116,662 patients received antibiotics at 47 hospitals and pharmacists performed 7,934 interventions. Of the interventions, the greatest number (3,116 [39%]) were for excessive duration of use. Mean antibiotic defined daily doses per 100 patient-days decreased from 101.38 (95% CI, 93.05 to 109.72) in the preimplementation phase to 83.04 (95% CI, 74.87 to 91.22) in the postimplementation phase (P<0.0001).

The authors noted that they didn't record patient outcomes, that they did not know where in the hospital patients were treated (e.g., ICUs vs. general medicine units), and that the study used only basic interventions. However, they concluded that while implementation of an antimicrobial stewardship program is especially challenging in nonacademic and rural settings, stepwise implementation of the type of model they tested can be successful. “By focusing on the so-called vital few (interventions), health-care facilities with limited resources and infectious disease and microbiology expertise can have a substantial effective on antibiotic use with less effort, while embedding antimicrobial stewardship practices within existing resource structures and systems,” they wrote.

The authors of an accompanying comment congratulated the study authors on their successful initiative. “By patient and meticulous planning and the adoption of a few simple sequential interventions, they have shown that a significant reduction in antimicrobial prescribing can be achieved,” the comment authors wrote. They noted that antimicrobial resistance has no quick fix and said that the current study emphasizes the fact that cooperation and collaboration, not prescriptive policies and coercion, are the keys to success. To tackle the problem, they wrote, “The only practical solution is to preserve whatever weaponry remains at our disposal, to avoid wastage, and to take more careful aim.”

Primary care, discharging, and admitting physicians disagree about readmission causes

A recent survey found little agreement among treating physicians about the causes of their patients' readmissions.

The study looked at 993 readmissions at 12 U.S. academic medical centers. Researchers surveyed the patients' primary care physicians, discharging physicians from index admissions, and admitting physicians. The physicians were asked which of a list of factors contributed to the readmission and which strategies might have been helpful to prevent readmission. The results were published online by the Journal of General Internal Medicine on June 9.

In general, the physicians most commonly cited factors related to patient understanding and ability to self-manage as contributing causes to readmission. Similarly, their most commonly cited strategies for preventing readmission involved providing patients with enhanced post-discharge instructions or support, including improved self-management plans at discharge, improving engagement of home and community supports, and providing resources to manage care and symptoms after discharge.

However, the physicians showed little agreement in their selection of causes and potential preventive measures for individual readmissions (maximum kappa 0.30). The primary care, discharging, and admitting physicians all had equally discordant views on these questions. “Our findings may reflect the lack of a clear and objective answer regarding what caused a readmission in most cases, as well as the multifactorial nature of readmissions,” the authors said.

The differences in opinion also highlight the importance of inpatient and outpatient physicians communicating during care transitions to share their perspectives, as well as suggesting that multifaceted, broadly applied interventions to reduce readmissions, particularly those focused on patient activation and self-care, may be the most successful, the authors said. A major limitation of the study was the low response rate from primary care physicians: only 36% of those surveyed, compared to 68% of discharging physicians and 74% of admitting physicians.