In the News

High ICU utilization and costs, discharge checklist and risk assessment, and more.

High ICU utilization for 4 common conditions may drive up costs without improving mortality, study finds

Hospitals that utilize ICUs more frequently for 4 common conditions may be more likely to perform invasive procedures and have higher costs with no improvement in hospital mortality, according to a recent study.

The retrospective cohort study ranked 94 hospitals in Washington State and Maryland by their predicted ICU utilization rates for adult patients hospitalized from 2010 through 2012 for diabetic ketoacidosis (DKA), pulmonary embolism (PE), upper gastrointestinal (GI) bleeding, and congestive heart failure (CHF). Results were published in the October JAMA Internal Medicine.

Researchers analyzed 156,842 hospitalizations for the 4 conditions, using risk-adjusted hospital mortality, use of invasive procedures, and hospital costs as primary outcomes. For lower- versus higher-utilization hospitals, the median ICU admission rates were 43.6% versus 67.2% for DKA, 12.2% versus 26.5% for PE, 23.4% versus 34.2% for upper GI bleeding, and 9.6% versus 28.7% for CHF. For each condition, teaching hospitals and hospitals with fewer beds were more frequently in the higher-utilization group than other types of hospitals.

Increased ICU utilization was not associated with significant differences in hospital mortality for any condition. The slopes of the linear regression analyses between hospital mortality and ICU utilization were −0.0013% mortality per percent predicted ICU admission for DKA (P=0.22), 0.0061% for PE (P=0.59), −0.0061% for upper GI bleeding (P=0.49), and 0.0083% for CHF (P=0.37). The respective risk-adjusted mortality rates in lower- and higher-utilization hospitals were 0.30% and 0.26% for DKA, 2.85% and 2.98% for PE, 2.08% and 2.03% for upper GI bleeding, and 2.99% and 3.02% for CHF.

The slopes of the linear regression analyses between ICU utilization and costs were $33.85 per percent predicted ICU admission for DKA (P<0.001), $30.18 for PE (P=0.02), $29.89 for upper GI bleeding (P=0.01), and $97.83 for CHF (P<0.001). Respective adjusted costs of hospitalization in lower- and higher-utilization groups were $7,141 and $8,204 for DKA; $10,660 and $11,117 for PE; $10,164 and $10,851 for upper GI bleeding; and $10,175 and $13,587 for CHF.

The study authors noted limitations related to the data sources, such as the lack of granular clinical information in administrative hospital databases and the lack of posthospitalization outcomes or care. They also pointed out that the results do not explain the underlying mechanisms that drive ICU utilization.

In light of these findings, hospitals and clinical decision makers should reflect on their care pathways, triage decision processes, patient safety, care effectiveness, and costs, according to an accompanying editorial.

“Although care bundles, standards, and protocols are all the rage today to improve patient care and outcomes and to avoid medical errors, the results of this study suggest that in their haste to apply standardized care pathways (eg, invasive procedures for ICU admissions), the high ICU utilizers forgot to individualize care,” the editorialist wrote.

Discharge checklist and risk assessment helped reduce readmissions after PCI, study finds

Risk scores and discharge checklists reduced readmissions after percutaneous coronary intervention (PCI) at 1 hospital, a study found.

Researchers sought to reduce readmissions after PCI at the Massachusetts General Hospital by targeting problems with care processes before discharge, after discharge, and during any potential re-presentation to the emergency department. The study was published in the September Circulation: Cardiovascular Quality and Outcomes.

During the first hospitalization, researchers assessed patients' readmission risk with a validated risk score that included age, sex, admission status, and insurance status, as well as comorbidities such as previous coronary artery bypass grafting, peripheral arterial disease, renal dysfunction, and lung disease. The risk assessment program also produced estimates for 30-day major adverse cardiovascular events, in-hospital mortality, in-hospital bleeding, acute kidney insufficiency, acute kidney insufficiency requiring dialysis, and maximum recommended contrast dose.

The researchers also implemented a discharge checklist to ensure access to appropriate medications and close follow-up for high-risk patients. The checklist included a sublingual nitroglycerin prescription and confirmation of insurance coverage of prescribed antiplatelet agents. The checklist also recommended timely follow-up, especially for patients at high risk for readmission either by the readmission risk score or by the subjective assessment of the clinician.

They also developed patient education videos about chest discomfort and heart failure, including instructions on how to contact a cardiologist to evaluate low-risk symptoms. Links to web-based versions were provided in discharge instructions, so that patients could view the videos at home as often as needed. After discharge, researchers established a new follow-up clinic with cardiology fellows to ensure patient access after discharge. A system was also set up to automatically notify cardiologists immediately when patients presented to the emergency department within 30 days of PCI.

The interventions resulted in index hospital readmission rates decreasing from 9.6% in 2011 to 5.3% in 2015. The authors noted that these changes could be implemented in other health care centers, both reducing the cost of care and improving the quality of care for patients with PCI.

“At our hospital, we have seen an improvement in readmissions after PCI subsequent to the implementation of these initiatives,” they wrote. “If successful, this program could potentially provide evidence-based tactics that can be implemented in other health care centers, to both reduce the cost of care and improve the quality of care for patients after PCI.”

AHA evaluates heart failure risks from prescription drugs, OTCs, alternative products

A comprehensive and accessible guide to prescription, over-the-counter (OTC), and complementary and alternative medications that could exacerbate heart failure was recently released by the American Heart Association (AHA).

The AHA used case reports, case series, package inserts, meta-analyses, and prospective and observational trials to develop the scientific statement, published in the Aug. 9 Circulation.

It found that prescription medications that may exacerbate underlying myocardial dysfunction include:

  • analgesics such as NSAIDs and COX-2 inhibitors,
  • diabetes drugs and drugs classes such as metformin, thiazolidinediones, and dipeptidyl peptidase-4 inhibitors,
  • antiarrhythmics such as flecainide, disopyramide, sotalol, and dronedarone,
  • calcium-channel blockers such as diltiazem, verapamil, and nifedipine,
  • tricyclic antidepressants and citalopram,
  • ophthalmic drugs such as topical beta-blockers or topical cholinergic agents, or
  • pulmonary medications such as albuterol, bosentan, and epoprostenol.

Prescription drugs known to cause direct myocardial toxicity include:

  • antifungals, such as amphotericin B,
  • antimalarials, such as chloroquine and hydroxychloroquine,
  • antiparkinson agents such as bromocriptine and pergolide, and
  • antipsychotics such as clozapine.

Over-the-counter drugs often contain high sodium, and the daily recommended dosing of these drugs can equal more than 400 mg of sodium, the statement noted. Many cough, cold, and allergy and sinus preparations may also include NSAIDs, such as ibuprofen, or vasoconstrictors, such as phenylephrine or pseudoephedrine.

Among other recommendations, the statement called for physicians to:

  • Conduct comprehensive medication reconciliation at each clinical visit and with each admission. Patients should be specifically asked about drug, dose, and frequency of all of their medications, including OTC medications and alternative products.
  • Consider potential risks and benefits of each medication, categorize them as either essential to desired outcomes or optional, and reduce or eliminate optional ones.
  • Consider combination medications to reduce the number of medications taken daily or medications that can be used to treat more than 1 condition.
  • Avoid prescribing new medications to treat side effects of other medications.