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ACP HospitalistWeekly



In the News for the Week of February 27, 2013




Highlights

Death and readmission rates not associated for three common conditions

Hospital mortality and readmission rates were not associated for patients admitted with acute myocardial infarction or pneumonia and were only weakly associated for patients admitted with heart failure, a study found. More...

Opioids a major player in drug overdose deaths

Opioids are a major contributor to drug overdose deaths, either when taken alone or in combination with other drugs, a new research letter said. More...


Critical care

Meta-analyses results don't support hydroxyethyl starch in critically ill

Hydroxyethyl starch for fluid resuscitation fared poorly in two recent meta-analyses involving critically ill patients. More...


Venous thromboembolism

Dabigatran noninferior to warfarin for preventing VTE recurrence

In patients who had a previous venous thromboembolism, dabigatran prevented recurrence about as well as warfarin and caused fewer bleeding events, according two new manufacturer-sponsored trials of extended treatment. More...


Testing

Specialty organizations highlight tests and procedures to rethink

Several medical organizations last week released lists of tests or procedures which might be overused in clinical practice, as part of the Choosing Wisely initiative of the American Board of Internal Medicine Foundation. More...


From ACP Hospitalist

The latest issue of ACP Hospitalist is online

The February issue of ACP Hospitalist is online. Featured stories examine the best use of ICU beds, how to teach residents to lead, and perioperative care of cancer patients. More...


Cartoon caption contest

Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...


Physician editor: James S. Newman, MD, FACP



Highlights


.
Death and readmission rates not associated for three common conditions

Hospital mortality and readmission rates were not associated for patients admitted with acute myocardial infarction or pneumonia and were only weakly associated for patients admitted with heart failure, a study found.

To determine the relationship between 30-day mortality and readmission rates, researchers studied Medicare beneficiaries admitted for acute myocardial infarction, heart failure or pneumonia from July 2005 to June 2008. Acute myocardial infarction (AMI) data included 590,809 admissions considered for mortality and 586,027 readmissions from 4,506 hospitals. Heart failure data included 1,161,179 admissions considered for mortality and 1,430,030 readmissions from 4,767 hospitals. Pneumonia data included 1,225,366 admissions considered for mortality and 1,297,031 readmissions from 4,811 hospitals.

The mean mortality rate for AMI was 16.60% and the mean readmission rate was 19.94%. Heart failure and pneumonia mortality rates were 11.17% and 11.64%, respectively; their respective readmission rates were 24.56% and 18.22%. Correlations between mortality and readmissions were 0.03 for AMI, −0.17 for heart failure, and 0.002 for pneumonia. Correlations were similar when considering hospital region, safety net status, urban vs. rural status and—for readmissions—high vs. low performance status.

Although there was a significant negative linear relationship between mortality and readmissions for heart failure, the shared variance between them was only 2.9% (r2=0.029), with the strongest correlation for hospitals with mortality rates less than 11%.

The failure to find a strong association between readmission and mortality rates "should allay concerns that institutions with good performance on [risk-standardized mortality rates] will necessarily be identified as poor performers on their [risk-standardized readmission rates]," researchers wrote. The two measures convey distinct information, they said. This may be because factors important in mortality, such as rapid triage and early intervention and coordination in the hospital, may not affect readmission risk. More important influences may include transition from inpatient to outpatient care, patient education and support, the availability of outpatient support, and admission thresholds, they wrote.

Also, although mortality and readmission measures both span 30 days, their starting times for outcomes differ. Mortality is measured from admission onwards, and more than half of the deaths occur before discharge, while readmissions are measured from discharge onwards. The study appeared in the Feb. 13 issue of JAMA.


.
Opioids a major player in drug overdose deaths

Opioids are a major contributor to drug overdose deaths, either when taken alone or in combination with other drugs, a new research letter said.

Researchers examined 2010 data from the National Vital Statistics System multiple cause-of-death file, which is based on death certificates. They found there were 38,329 drug overdose deaths in the U.S., of which 57.7% involved pharmaceuticals and 24.6% involved unspecified drugs. Seventy-four percent of the pharmaceutical-related overdose deaths were unintentional, 17% were suicides and 8.4% were of undetermined intent. Results were published in the Feb. 20 issue of JAMA.

The drugs most commonly involved in pharmaceutical-related overdose deaths—either alone or in combination with other pharmaceuticals—were opioids (75.2%), benzodiazepines (29.4%), antidepressants (17.6%) and antiepileptic and antiparkinsonism drugs (7.8%). Opioids were involved in 77% of deaths that also involved benzodiazepines, 65.5% of deaths that involved antiepileptic and antiparkinsonism medications, 58% of deaths that involved antipsychotic and neuroleptic drugs, 57.6% of deaths involving antidepressants, 56.5% of deaths involving other analgesics, antipyretics, and antirheumatics, and 54.2% of deaths involving other psychotropic drugs.

The analysis is limited by the fact that 25% of death certificates analyzed didn't specify the drugs involved in the overdose, the authors noted, meaning the numbers in the analysis are undercounts. The analysis does confirm the large role that opioids play in pharmaceutical overdose deaths, as well as the "frequent involvement of drugs typically prescribed for mental health conditions such as benzodiazepines, antidepressants and antipsychotics," they wrote. It's important for clinicians to appropriately screen for, identify and manage mental health disorders, as well as use prescription drug monitoring programs and electronic health records when possible, the authors concluded.



Critical care


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Meta-analyses results don't support hydroxyethyl starch in critically ill

Hydroxyethyl starch for fluid resuscitation fared poorly in two recent meta-analyses involving critically ill patients.

In the first study, reviewers identified 38 randomized controlled trials that compared hydroxyethyl starch (HES) to crystalloids, albumin or gelatins in 10,880 critically ill patients receiving acute volume resuscitation. The risk ratio for death among those who received HES was 1.07—a figure which included results from seven trials performed by a researcher whose later work was retracted due to scientific misconduct. When those seven trials (and their 590 patients) were excluded, HES was found to be significantly associated with death (risk ratio [RR], 1.09) among the remaining 10,290 patients, as well as with increased renal failure among 8,725 patients (RR, 1.27) and with increased use of renal replacement therapy among 9,258 patients (RR, 1.32).

In addition to emphasizing "the potentially important and adverse effects of scientific misconduct," this study demonstrates the importance of revising and revisiting recommendations and guidelines, editorialists wrote. The study doesn't settle the controversy about colloids vs. crystalloids because the HES comparators were too heterogeneous—a fault of the existing literature pool, not the meta-analysis itself, they wrote. High-quality trials that compare HES 130/0.4 starch vs. crystalloids need to be done; in the meantime, the results of this analysis suggest the harms of HES probably outweigh the benefits, and HES shouldn't be used in critically ill patients who need acute volume resuscitation, they wrote. The meta-analysis and editorial appeared Feb. 20 in JAMA.

In the second study, reviewers found nine studies of 3,456 patients with sepsis who had been randomized to HES 130/0.38-0.45 vs. crystalloid, or HES 130/0.38-0.45 vs. human albumin. While HES didn't seem to affect the relative risk of death for relevant trials (RR, 1.04 in eight trials), the relative risk was 1.11 in the predefined analysis of trials with low risk of bias (four trials). Renal replacement was used more in the HES group (RR, 1.36, five trials) and acute kidney injury was more common (RR, 1.18, four trials). Also, more patients in the HES group were transfused with red blood cells (RR, 1.29, three trials), and more in this group had serious adverse events (RR, 1.30, four trials). The authors concluded that it "seems unlikely that hydroxyethyl starch 130/0.38-0.45 provides overall clinical benefit for patients with sepsis." The study was published Feb. 15 by BMJ.

As reported last month, the 2012 Surviving Sepsis Guidelines Committee recommended using crystalloids for initial fluid resuscitation in their recently updated guidelines.



Venous thromboembolism


.
Dabigatran noninferior to warfarin for preventing VTE recurrence

In patients who had a previous venous thromboembolism, dabigatran prevented recurrence about as well as warfarin and caused fewer bleeding events, according two new manufacturer-sponsored trials of extended treatment.

The first double-blind trial involved almost 3,000 patients with venous thromboembolism (VTE) who were thought to be at high risk of recurrence. They completed three months of initial therapy and then were randomized to warfarin or twice-daily dabigatran at a dose of 150 mg. The length of study treatment ranged from six to 36 months. Recurrent VTE occurred in 1.8% of dabigatran patients compared to 1.3% of warfarin patients, a finding that met the study's pre-specified threshold for noninferiority. The dabigatran patients had fewer major bleeds and fewer major or clinically relevant bleeds, but only the latter outcome showed a statistically significant difference.

In the second double-blind trial, about 1,300 similar patients were randomized to the same dabigatran treatment or to placebo. The dabigatran group had many fewer VTE reccurences (0.4% vs. 5.6%; hazard ratio, 0.08; P<0.001) than the placebo group, but more major (0.3% vs. 0) and major or clinically relevant (5.3% vs. 1.8%) bleeds. The results of both trials were published together in the Feb. 21 New England Journal of Medicine.

The study authors concluded that dabigatran was effective in extended treatment of VTE and carried a lower risk of major or clinically relevant bleeding than warfarin, but a higher one than placebo. They noted that the efficacy of dabigatran compared to placebo was similar to that shown by rivaroxaban and warfarin in other trials. However, the study was not able to resolve concerns about an association between dabigatran and acute coronary syndromes (ACS). In the first trial, ACS occurred in 13 (0.9%) dabigatran patients and 3 (0.2%) warfarin patients, and it occurred in one patient in each of the groups in the placebo trial.

Based on results like these, targeted anticoagulants are an appealing alternative to warfarin, according to an accompanying editorial, which noted that dabigatran has not yet been FDA-approved for extended treatment of VTE. However, the editorialist cautioned, there are still questions and concerns about these new drugs, including the current lack of an antidote and the challenge of selecting appropriate patients for treatment.



Testing


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Specialty organizations highlight tests and procedures to rethink

Several medical organizations last week released lists of tests or procedures which might be overused in clinical practice, as part of the Choosing Wisely initiative of the American Board of Internal Medicine Foundation.

In 2012, a number of groups supporting the initiative, including ACP, released lists of five commonly used tests or procedures whose necessity should be questioned and discussed. The most recent release added to that collection of recommendations.

Several of the groups' new recommendations may be relevant to hospitalist practice, including:

Society of Hospital Medicine (adult medicine)

  • Don't place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis).
  • Don't prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications.
  • Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke.
  • Don't order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation.
  • Don't perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

American Academy of Hospice and Palliative Medicine

  • Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
  • Don't delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.
  • Don't leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care.
  • Don't use topical lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol) ("ABH") gel for nausea.

American Geriatrics Society

  • Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
  • Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.
  • Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

New lists were also released by the American Academy of Family Physicians,

American Academy of Neurology, American Academy of Ophthalmology, American Academy of Otolaryngology—Head and Neck Surgery Foundation, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Rheumatology, American Society for Clinical Pathology, American Society of Echocardiography, American Urological Association, Society for Vascular Medicine, Society of Cardiovascular Computed Tomography, Society of Hospital Medicine, Society of Nuclear Medicine and Molecular Imaging and the Society of Thoracic Surgeons. All of the recommendations are available online.



From ACP Hospitalist


.
The latest issue of ACP Hospitalist is online

The February issue of ACP Hospitalist is online. Featured stories include the following:

acph-20130227-hospitalist.jpg

Who belongs in the ICU? Some experts are beginning to question how the nation's critical care beds are being used. While little guidance exists for admission and transfer decisions, experts have many ideas on the best ways to make use of costly ICU care.

Grooming residents to lead. Recognizing that residents need to know more than just clinical skills, some hospitals and health systems are teaching them about business and management as well.

Caring for cancer patients. Hospitalists working in perioperative settings are increasingly involved in decisions regarding the care of cancer patients who undergo surgery as part of their treatment. It's thus become more important than ever to know about the effects of cancer treatments on organ systems and the potential risks of surgery unique to cancer patients.



Cartoon caption contest


.
Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acph-20130227-cartoon.jpg

E‑mail all entries to acphospitalist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.





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