Data breaches, infective endocarditis

Summaries from ACP Hospitalist Weekly.

About 70% of recent U.S. health data breaches compromised sensitive demographic, financial information

More than 70% of the major protected health information breaches in the U.S. over the past 10 years have compromised patient data that can be exploited for identity and financial fraud, a recent study found.

Image by Getty Images
Image by Getty Images

Researchers used data from the U.S. Department of Health and Human Services to examine details of published breaches affecting 500 or more people from Oct. 21, 2009, to July 1, 2019. The sample included 1,461 breaches from 1,388 entities (several breaches from 63 entities) that affected a total of 169 million patients. Results were published online on Sept. 24, 2019, as a brief research report by Annals of Internal Medicine and appear in the Jan. 21 issue.

Based on keywords in the event description text, researchers classified compromised protected health information into three categories: demographic information (e.g., patient names, email addresses, phone numbers, other personal identifiers), service or financial information (e.g., service dates, billing amounts, payment information), and medical or clinical information (e.g., diagnoses and treatment). They further categorized sensitive demographic information (e.g., Social Security numbers, driver's license numbers, dates of birth), sensitive financial information (e.g., payment cards, banking accounts), and sensitive medical information (e.g., substance abuse, HIV, sexually transmitted diseases, mental health, cancer). One breach could compromise several types of protected health information.

All 1,461 breaches involved at least one piece of demographic information, and 964 (66%) breaches, which affected 150 million (89%) patients, compromised sensitive demographic information. A total of 513 (35%) breaches compromised service or financial information, and 186 (13%) breaches affecting 49 million (29%) patients compromised sensitive financial information. The 964 breaches involving sensitive demographic information and the 186 breaches involving sensitive financial information accounted for 71% of breaches and 94% of affected patients. A total of 944 (65%) breaches compromised medical or clinical information, affecting 48 million (28%) patients, and of these, 22 (2%) breaches, affecting 2.4 million (1%) patients, involved sensitive medical information. Overall, 16% of the breaches, affecting 6 million patients, compromised medical information only, without compromising sensitive demographic or financial information.

The main limitation of the study is data quality, as entities may fail to discover or report data breaches, the study authors noted. They added that their keyword-based analysis of the descriptions of the breaches may be subject to measurement error.

“Policymakers may consider requiring entities to provide standardized documentation of the types of compromised [protected health information], in addition to persons affected, when reporting breaches,” the authors concluded. “Such information will facilitate the analysis and understanding of breaches and their consequences and the development and adoption of [protected health information] security practices.”

Hospitalizations for drug abuse-related infective endocarditis increased from 2002 to 2016

Hospitalizations for drug abuse-related infective endocarditis have been increasing annually in the U.S., and the highest-risk patient population is young with few cardiac comorbidities, a recent study found.

Researchers used the National Inpatient Sample registry to perform a retrospective cohort study of adult patients admitted from 2002 to 2016 with a primary or secondary diagnosis of infective endocarditis. They assessed national and geographic trends and compared patient characteristics and outcomes between drug abuse-related infective endocarditis and non–drug abuse-related infective endocarditis. Results were published Sept. 18, 2019, by the Journal of the American Heart Association and appear in the Oct. 1, 2019, issue.

Overall, 954,709 hospitalizations for infective endocarditis were included in the analysis. About 10% of participants (n=94,350) were found to have abused drugs, and 860,359 had not. The median age of participants was 68 years, 51% were men, and 72% were white. From 2002 to 2016, the overall incidence rate of infective endocarditis increased from 18 per 10,000 to 29 per 10,000. The incidence rate of drug abuse-related infective endocarditis increased from 48 per 10,000 in 2002 to 79 per 10,000 in 2016. Despite a decrease in incidence from 2002 to 2008, there was an overall positive trend in drug abuse-related infective endocarditis between 2002 and 2016 (P<0.001) across the U.S., with an annual percent change (APC) of 1.8% (95% CI, 1.7% to 1.9%), which was highest in Southern states (2.5%). Between 2008 and 2016, the prevalence of drug abuse among infective endocarditis cases nearly doubled across the U.S. (from 8.0% to 16.3%), with an APC of 3.5% (95% CI, 3.3% to 3.6%), which was highest in the Midwest (4.9%).

Patients with drug abuse-related infective endocarditis were younger (median age, 70 vs. 38 years; P<0.001) and more commonly male (50.8% vs. 55.5%; P<0.001), and they were less likely to have hypertension (53.8% vs. 24.7%; P<0.001), diabetes (28.7% vs. 10.3%; P<0.001), congestive heart failure (21.9% vs. 9.1%; P<0.001), renal disease (27.0% vs. 10.3%; P<0.001), or chronic lung disease (22.0% vs. 16.4%; P<0.001). Those with drug abuse were more likely than those without drug abuse to have hepatitis C (8.2% vs. 1.2%; P<0.001), liver disease (18.6% vs. 4.9%; P<0.001), HIV (6% vs. 1.2%; P<0.001), or concomitant alcohol abuse (13.6% vs. 3.0%; P<0.001). Patients with drug abuse-related infective endocarditis had cardiac or valve surgery more often than those without drug abuse (7.8% vs. 6.2% and 7.1% versus 5.1%, respectively; P<0.001 for both comparisons), and they had a higher median length of stay (9 vs. 7 days; P<0.001). While they had higher hospitalization costs ($52,744 vs. $37,373; P<0.001), they had lower inpatient mortality (6.4% vs. 9.1%; P<0.001).

Limitations of the study include those inherent to the administrative database and billing codes that were used, as well as the fact that APC assumes a linear trend and may be misleading, the study authors noted. “Care for patients with [drug abuse-related infective endocarditis] is very complex, and we agree with the American Association for Thoracic Surgery guidelines that it involves a ‘specialized endocarditis team’—including cardiology, cardiac surgery, infectious disease, neurologist, nephrologist, addiction specialists, case management, and nursing,” they concluded. “Unfortunately, treatment for opioid addiction after hospitalization is low.”

Pathway from ACC offers recommendations on inpatient heart failure care

A decision pathway from the American College of Cardiology (ACC) offers guidance on management of patients hospitalized with heart failure (HF).

Image by Getty Images
Image by Getty Images

The “2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure” focuses on care extending from ED presentation through the first postdischarge visit. The primary purpose is to optimize patient care and improve outcomes, rather than reducing length of stay and readmission, although practice improvement may enhance effective resource allocation, the pathway document noted.

The pathway, which was published online by the Journal of the American College of Cardiology on Sept. 13, 2019, and appears in the October 2019 issue, is structured by five nodes of care: admission, daily trajectory check, transition to oral therapies, discharge day, and early postdischarge follow-up. Its recommendations are also summarized in 10 key points:

  1. 1. The pathway to improve outcomes after HF hospitalization begins with admission, continues through the process of decongestion and transition to oral therapies before the day of discharge, and connects through the first postdischarge follow-up.
  2. 2. Clinical trajectory of HF should be assessed continuously during admission. Three main in-hospital trajectories have been defined: improving toward target, stalled after initial response, or not improved/worsening. These translate into different management strategies throughout hospitalization and postdischarge.
  3. 3. Evaluation of the long-term course of HF should be included in the initial comprehensive assessment, reviewed on the day of transition to oral therapy, and reassessed at the first follow-up visit for persistent or new indications of high risk leading to consideration of advanced therapies or revision of goals of care.
  4. 4. Key risk factors modifiable during hospitalization include the degree of congestion as assessed by clinical signs and natriuretic peptides and the lack of appropriate guideline-directed medical therapies (GDMTs). Improvement in these factors is associated with improved prognosis, but lack of improvement, including inability to tolerate GDMT for HF, is associated with a much worse prognosis.
  5. 5. Common comorbidities, including diabetes, anemia, and kidney, lung, and liver disease, should be assessed during initial evaluation and addressed throughout hospitalization and discharge planning.
  6. 6. The day of transition from IV to oral diuretic therapy should trigger multiple considerations related to the overall regimen for discharge, verification of completion of patient education components, caregiver education, and plans for discharge.
  7. 7. The discharge day should be a time to review and communicate with identified clinicians rather than to initiate new therapies.
  8. 8. The elements of the hospitalization events and plans that are most crucial for continuity of care after discharge should be documented in a format that is available to all members of the outpatient team and easily accessible when a patient calls or returns with worsening symptoms.
  9. 9. Principles of palliative care applied by the in-hospital care team or by palliative care specialists may be particularly relevant when an unfavorable trajectory warrants communication about prognosis, options, and decision making with patients and families.
  10. 10. The first follow-up visit should address specific aspects, including volume status, hemodynamic stability, kidney function and electrolytes, the regimen of recommended therapies, patient understanding, adherence challenges (including insurance/coverage issues), and goals of care.

SHM issues recommendations on ultrasound guidance for vascular access procedures

The Society of Hospital Medicine recently issued recommendations on the use of ultrasound guidance for central and peripheral vascular access.

The 29 recommendations were published as a position statement online on Sept. 6, 2019, by the Journal of Hospital Medicine. They provide four preprocedural recommendations, including being familiar with the ultrasound machine before a vascular access procedure.

For central venous access procedures, the recommendations favor use of a standardized checklist with real-time ultrasound guidance for central venous catheter (CVC) insertion and use of ultrasound for both internal jugular vein catheterization and femoral venous access, among other advice. Regarding peripheral venous access, the statement recommends use of ultrasound for insertion of peripherally inserted central catheters and placement of peripheral intravenous lines in patients with difficult peripheral venous access. Ultrasound is also recommended for arterial access.

There are five general recommendations on technique:

  • Clinicians should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures.
  • Clinicians should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for CVC insertion, regardless of their level of experience.
  • It is suggested to use either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures.
  • Clinicians should visualize the needle tip and guidewire in the target vein prior to vessel dilatation.
  • To increase the success rate of ultrasound-guided vascular access procedures, clinicians should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available.

The statement also includes recommendations on training and postprocedure care, specifically ruling out pneumothorax and detecting catheter tip misplacement.

The statement acknowledges that not all hospitalists perform vascular access procedures but asserts that those who do “should be trained and use ultrasound to do them,” said an accompanying editorial. “We would advocate further that, regardless of their practice, hospitalists have a role in expanding ultrasound use for vascular access given its direct impact on the patients they care for,” added the editorialists. As with other new technologies, the use of ultrasound varies in part due to resources, part of an “equity gap” in quality improvement, the editorial pointed out. “Without a focus on equity, the benefits offered by ultrasound will continue to be limited in their reach,” the editorialists wrote.