MI performance measures, health literacy and LOS, and more

Summaries from ACP Hospitalist Weekly.

ACC and AHA update performance measures for STEMI and NSTEMI

The American College of Cardiology (ACC) and American Heart Association (AHA) recently updated their performance measures for patients hospitalized with ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI).

The measures were last updated in 2008; the new set includes 17 performance measures and seven quality measures. The task force that developed the measures noted that quality measures are “metrics that may be useful for local quality improvement but are not yet appropriate for public reporting or pay for performance programs (uses of performance measures).”

Only one performance measure, smoking cessation counseling, was deleted in the latest update, due to consistently high levels of performance. Eight quality measures were deleted, most relating to anticoagulant and antiplatelet dosing. Four performance measures were revised, mostly to reflect new evidence and guidelines. The revised measures focus on prescription of a statin for acute MI, evaluation of left ventricular ejection fraction, cardiac rehabilitation referral, and P2Y12 receptor inhibitor prescription at discharge.

Four performance measures and seven quality measures were added. The new performance measures are:

  • immediate angiography for resuscitated out-of-hospital cardiac arrest in STEMI patients,
  • noninvasive stress testing before discharge in conservatively treated patients,
  • early cardiac troponin measurement (within six hours of arrival), and
  • participation in a regional or national acute MI registry.

The quality measures are:

  • risk score stratification for NSTEMI patients,
  • early invasive strategy (within 24 hours) for high-risk NSTEMI patients,
  • therapeutic hypothermia for comatose STEMI patients with out-of-hospital cardiac arrest,
  • aldosterone antagonist in eligible patients at discharge,
  • inappropriate in-hospital use of NSAIDs,
  • inappropriate prescription of prasugrel at discharge in patients with history of stroke or transient ischemic attack, and
  • inappropriate prescription of high-dose aspirin with ticagrelor at discharge.

The 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction were published online Sept. 21, 2017, by the Journal of the American College of Cardiology and Circulation: Cardiovascular Quality and Outcomes.

On Sept. 18, 2017, the AHA also released a scientific statement on cardiogenic shock, summarizing the epidemiology, pathophysiology, causes, and outcomes; reviewing contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocating for the development of regionalized systems of care; and outlining future research priorities.

Low health literacy linked to longer length of stay, more transitional care needs

Inadequate health literacy is associated with longer length of stay (LOS) and greater transitional care needs, according to two studies published online on Sept. 20, 2017, by the Journal of Hospital Medicine.

In the LOS study, researchers administered the Brief Health Literacy Screen to 5,540 hospitalized general medicine patients and found that 1,104 (20%) had low health literacy. Compared to patients with adequate health literacy, those with low health literacy had a longer average LOS (6.0 vs. 5.4 days; P<0.001). In multivariate analysis, low health literacy was associated with an 11.1% longer LOS (95% CI, 6.1% to 16.1%; P<0.001).

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Photo by Thinkstock.

The link between health literacy and LOS was significantly impacted by gender (P=0.02) but not by illness severity or older age. Low health literacy was associated with a 17.8% longer LOS in men (95% CI, 10.0% to 25.7%; P<0.001) and a 7.7% longer LOS in women (95% CI, 1.9% to 13.5%; P=0.009). The researchers noted limitations of the study, such as its observational, single-center design and the fact that the largely urban, minority sample (73% black) is not representative of the U.S. population.

In the second study, nurses administered the Brief Health Literacy Screen to 384 patients discharged to home, and 113 (29%) had inadequate health literacy. Nurses documented patients' transitional care needs in 10 domains: caregiver support, transportation, health care utilization, high-risk medical comorbidities, medication management, medical devices, functional status, mental health comorbidities, communication, and financial resources.

Compared to those with adequate health literacy, those with inadequate health literacy had needs in more transitional care domains (mean, 5.29 vs. 4.36; P<0.001). The needs were most commonly identified in the domains of high-risk comorbidities (98.4%), frequent or prior health care utilization (76.6%), medication management (76.3%), functional status (54.9%), and transportation (48.7%).

After adjustment for demographic factors, patients with low health literacy were significantly more likely to have inadequate caregiver support (odds ratio, 2.61; 95% CI, 1.37 to 4.99) and transportation barriers (odds ratio, 1.69; 95% CI, 1.04 to 2.76).

“The prevalence of these needs highlights the importance of using a structured assessment to identify patient concerns so that they may be addressed through discharge planning and follow-up,” the study authors wrote. They noted limitations to the study, such as its single-center design and the fact that the transitional care needs assessment was developed for the study and was not formally validated.

Enoxaparin and dalteparin similarly effective for venous thromboembolism prophylaxis in trauma patients

Rates of venous thromboembolism (VTE) were similar in trauma patients who received enoxaparin or dalteparin during hospitalization, a study found.

The study was conducted in a single U.S. hospital that switched the low-molecular-weight heparin (LMWH) on its formulary from enoxaparin to dalteparin and then back to enoxaparin. Researchers compared rates of VTE under these different policies, using trauma patients who received unfractionated heparin (UFH) as controls. In the enoxaparin period, 2,371 patients were given 30 mg of enoxaparin twice daily and 1,539 controls got UFH. In the dalteparin period, 1,046 patients received 5,000 units of dalteparin once daily and 924 controls were on UFH. Results were published online by CHEST on Aug. 18, 2017.

The change in LMWH was not associated with any significant change in the VTE rate (3.3 per 1,000 days on enoxaparin vs. 3.8 per 1,000 days on dalteparin; rate ratio [RR], 1.16 [95% CI, 0.74 to 1.81]). The UFH controls also showed no significant change between periods (5.7 vs. 5.2 VTEs per 1,000 days; RR, 0.92 [95% CI, 0.61 to 1.38]). After adjustment for confounders, the ratio of the change in VTE rate between the LMWH and UFH groups was also similar. “Despite pharmacodynamic data suggesting substantial differences in anticoagulant potency, we observed similar rates of VTE for enoxaparin vs. dalteparin,” the study authors wrote.

They noted that a secondary analysis of the data, which included only patients who received early (within 24 hours) and consistent (>80% of scheduled doses) LMWH, did find a greater benefit from enoxaparin, although the difference was not significant. That finding “may help to explain discrepancies between efficacy and effectiveness in studies of VTE thromboprophylaxis in trauma patients,” they wrote. Future studies should further investigate how the timing and consistency of prophylaxis affect the effectiveness of these drugs, the authors said.

The study was limited by several factors, including its single-center design, potential bias by unmeasured factors, and lack of data on bleeding outcomes. The confidence intervals of the results also did not rule out potentially important differences between the groups, so additional studies in larger populations are needed, the authors said.

Improvement seen in survival differences by race after in-hospital cardiac arrest

Differences in survival between black and white patients after in-hospital cardiac arrest appear to have decreased, according to a recent study.

Researchers performed a cohort study of data from Get With the Guidelines-Resuscitation to determine whether racial differences in survival after in-hospital cardiac arrest have improved and to examine the factors that may be associated with such improvements. Data from Jan. 1, 2000, through Dec. 31, 2014, were included for patients who had a cardiac arrest in the hospital and who were cared for in general inpatient units or in ICUs. Survival to discharge was the primary outcome; secondary outcomes were acute resuscitation survival and postresuscitation survival. Calendar-year rates of survival by race were calculated after adjustment for characteristics at baseline. The study results were published online Aug. 9, 2017, by JAMA Cardiology, and appeared in the September 2017 issue.

A total of 112,139 patients from 289 hospitals were included in the current study. Of these, 30,241 (27.0%) were black and 81,898 (73.0%) were white. The mean age was 61.6 years for black patients and 67.5 years for white patients. Both black and white patients demonstrated improvements in risk-adjusted survival over time (11.3% and 15.8% in 2000 vs. 21.4% and 23.2% in 2014, respectively; P<0.001 for trend for both). However, survival improvement was more pronounced in black patients than in white patients. The reduced survival difference by race appeared to be linked to elimination of racial differences in survival of acute resuscitation (44.7% in 2000 vs. 64.1% in 2014 for black patients and 47.1% in 2000 vs. 64.0% in 2014 for white patients; P<0.001 for interaction). However, racial differences in postresuscitation survival persisted. Survival gains over time were larger in hospitals where a higher proportion of black patients had an in-hospital cardiac arrest versus hospitals where fewer black patients did.

The study authors noted that their study included only hospitals that participated in Get With the Guidelines-Resuscitation and that their results may not be generalizable to other hospitals. In addition, they noted that information on race was self-reported and that residual confounding and an increase in do-not-resuscitate orders during the study period could have affected their findings, among other limitations. However, they concluded that racial differences in survival after in-hospital cardiac arrest decreased significantly over time, mostly because of elimination of differences in acute resuscitation survival and increased improvement in hospitals with more black patients. “Further understanding the mechanisms of that improvement could provide novel insights for the elimination of racial differences in survival for other conditions,” the authors wrote.

The authors of an accompanying comment agreed that hospitals participating in Get With the Guidelines-Resuscitation are not likely to represent all U.S. hospitals and also mentioned the increase in do-not-resuscitate orders, along with an increase in rapid response teams, as a potential contributor to the study results. In addition, they noted that some of the examined parameters in the medical record may have been subject to recall bias. While the study results are good news, the mechanism behind the improvement “remains unclear and should be a priority for research in the coming decade,” they wrote. “As a nation, we still need data on cardiac arrest incidence and survival that is uniformly collected, with clear attention to changes in factors that may influence survival rate as a reflection of changes in the population under study.”

Bezlotoxumab reduced readmissions for C. diff compared to placebo

Hospitalized patients with Clostridium difficile who took bezlotoxumab were less likely to be readmitted than those on placebo, a recent industry-funded analysis found.

Researchers used data from MODIFY I and MODIFY II trials, which were funded by Merck and randomized patients with C. difficile infection (CDI) to either a 10 mg/kg dose of bezlotoxumab or placebo. The phase 3 trials were conducted at 322 sites in 30 countries between Nov. 1, 2011, and May 22, 2015. This analysis included only patients who were hospitalized at the time of randomization: 530 who received bezlotoxumab and 520 on placebo. Results were published by Clinical Infectious Diseases on Aug. 11, 2017, and appeared in the Oct. 1, 2017, issue.

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Photo by Thinkstock.

The patients who took bezlotoxumab had a significantly lower rate of CDI-associated readmissions in the 30 days after discharge (absolute difference, −6.1%; 95% CI, −9.5% to −2.8%; relative difference, −53.4%). They also had a lower rate of all-cause readmissions, although the difference was not statistically significant (absolute difference, −3.7%; 95% CI, −9.0% to 1.5%; relative difference, −12.1%).

The researchers also looked specifically at patients at high risk for recurrence, which they defined as having age 65 years or older, severe CDI, one or more CDI episodes in the previous six months, infection due to 027 strain, or a compromised immune system. They found reductions in CDI-associated readmissions with bezlotoxumab among those patients, which were significant for older patients and patients with severe cases.

The results of this study, combined with previous research finding a reduction in CDI recurrences with the drug, “provide support for using bezlotoxumab as a valuable treatment option for patients with CDI,” the authors said. They noted that the reduction in hospitalizations could potentially lower the costs associated with CDI and they suggested further economic analysis of this idea. This study was limited by a number of factors, including the possibility of a healthier population compared to real-world practice and underestimates of readmissions and severe baseline CDI, the authors acknowledged.

Patients may have slightly higher in-hospital mortality after percutaneous coronary intervention in safety net hospitals

Patients who receive percutaneous coronary intervention (PCI) at safety net hospitals may have a marginally higher risk of in-hospital mortality than those receiving PCI at non-safety net hospitals, a recent study found.

Researchers used the National Cardiovascular Data Registry from 2009 to 2015 to compare risk-adjusted PCI outcomes between safety net hospitals (defined as hospitals where 10% or more of PCI patients were uninsured) and non-safety net hospitals. They assessed more than 3.7 million patients who underwent PCI at 282 safety net hospitals and 1,134 non-safety net hospitals. Results were published on Aug. 7, 2017, by JACC: Cardiovascular Interventions.

Compared to non-safety net hospitals, safety net hospitals were more likely to be rural institutions, to be located in the southern U.S., and to have lower PCI volume. Patients who received PCI at safety net hospitals had significantly higher risk-adjusted in-hospital mortality (odds ratio, 1.23; 95% CI, 1.17 to 1.32; P<0.001). Overall, they had a 0.4% higher absolute risk of in-hospital mortality than those treated at non-safety net hospitals (number needed to harm, 250).

The mortality difference between safety net and non-safety net hospitals appeared to attenuate as hospital PCI volume increased, albeit with wide confidence intervals, the authors noted. Risk-adjusted rates of periprocedural bleeding and acute kidney injury were not significantly different between the two types of hospitals.

Limitations of the study included its observational nature and the possibility of reporting inaccuracies in the registry. The study authors also noted the registry's omission of potentially important data on the degree of risk factor control at baseline, socioeconomic status, and access to health care.

An accompanying editorial called the slight absolute difference in mortality between safety net and non-safety net hospitals “encouraging” but pointed out that there is great heterogeneity among safety net hospitals and that gaps in the data preclude adequate risk adjustment when making comparisons.

“It may well be that, not only are PCI outcomes noninferior at [safety net hospitals] compared with non-[safety net hospitals], the sicker, more complicated patient with more comorbidities might perhaps be better served at a [safety net hospital],” the editorialist wrote.

No association between appropriate antibiotics and survival of elderly CAUTI patients

Appropriate antibiotic treatment did not extend survival among inpatients with chronic indwelling catheter-associated urinary tract infections (CAUTIs) and sepsis, according to a recent study.

The prospective observational study included 315 Israeli patients hospitalized with CAUTI and sepsis. They were elderly (mean age, 79 years) and chronically ill (62.8% were hospitalized in the three months prior, 63.5% had an indwelling urinary catheter for over 30 days, and only 11% were functionally independent). The primary outcomes were mortality at 30 days and one year. Results were published online by Clinical Infectious Diseases on Aug. 2, 2017, and appeared in the Nov. 13, 2017, issue.

Antibiotic therapy was initiated within six hours of presentation in 94% of patients, and 49% of patients were found to have received appropriate empirical antibiotic treatment. The overall 30-day all-cause mortality rate was 30.8%, and the median survival time was 82 days. Receiving appropriate antibiotic therapy was not associated with any significant difference in 30-day mortality, and patients receiving appropriate therapy actually had higher mortality (32.9% vs. 28.8%; adjusted odds ratio, 1.35; 95% CI, 0.78 to 2.32). Only 33% of patients were still alive at one year. Appropriate antibiotic therapy was not associated with any significant difference in long-term survival (propensity-matched hazard ratio, 0.99; 95% CI, 0.75 to 1.3). The study also found no association between appropriate antibiotic treatment and length of stay or length of febrile illness.

The results differ from previous research on other patient populations with severe bacterial infections, the authors noted. That may be due to the old age and frailty of these patients or the difficulty of distinguishing between symptomatic UTI and febrile illness from a non-urinary source of infection in patients with long-term catheters, they speculated. The study was limited by taking place in a single center with a high rate of resistant pathogens and among a patient population with impaired cognitive function, low functional status, and multiple comorbidities.

Still, the results suggest that clinicians could steward antibiotics by deferring antibiotic treatment of CAUTI until full clinical and microbiologic evaluation is complete, the authors suggested. “Sepsis trend and culture results will dictate directed antibiotic treatment. Our study suggests that such a strategy will not harm patients,” they wrote. Further studies should try to identify subgroups of patients that benefit from early empirical antibiotic treatment, the authors said.

Angiography timing didn't affect mortality in non-ST-elevation acute coronary syndrome

Whether coronary angiography was performed more or less than 24 hours after non-ST-elevation acute coronary syndrome did not affect patient mortality, according to a meta-analysis.

Researchers compiled data from eight trials with 5,324 patients and a median follow-up of 180 days to compare early versus delayed invasive strategies in patients presenting with non-ST-elevation acute coronary syndrome. They found an insignificant reduction in mortality in the early invasive group compared to the late one (hazard ratio [HR], 0.81; 95% CI, 0.64 to 1.03). Results were published online Aug. 1, 2017, by The Lancet and appeared in the Aug. 19, 2017, issue.

Certain subgroups of high-risk patients did appear to have lower mortality with an early invasive strategy, including those with elevated cardiac biomarkers at baseline (HR, 0.761; 95% CI, 0.581 to 0.996), diabetes (HR, 0.67; 95% CI, 0.45 to 0.99), a GRACE (Global Registry of Acute Coronary Events) risk score more than 140 (HR, 0.70; 95% CI, 0.52 to 0.95), or age 75 years or older (HR, 0.65; 95% CI, 0.46 to 0.93). The study authors concluded that the early invasive strategy did not reduce mortality overall but that it might be beneficial for certain high-risk patients.

The authors noted that guidelines currently recommend immediate angiography for all unstable very high-risk patients and angiography within 24 hours for patients with positive biomarkers, dynamic ST-T changes, or a GRACE score more than 140. This study's results might suggest adding older patients and patients with diabetes to that group, but the authors cautioned that tests for interaction were negative in all of their subgroup analyses, so these findings should be considered exploratory and hypothesis-generating.

The study was limited by a number of factors, including relying heavily on the TIMACS (Timing of Intervention in Acute Coronary Syndromes) trial (which contributed 56.9% of patients) and variation in timing of angiography. The median time to angiography with the early invasive strategy was less than three hours in most of the included trials but 14 hours in TIMACS, the authors reported. Most of the data were also gathered before high-sensitivity troponin assays became standard.

An accompanying comment noted that adding older patients and those with diabetes to the group recommended for early treatment has “enormous logistic implications.” The commenters also observed that “the lack of a difference in mortality between invasive strategies suggests that most patients with acute coronary syndrome can be treated safely with either early intervention or delayed intervention.”