Journal watch: Recent studies of note

Recent studies of note.

Larger, for-profit hospitals use feeding tubes more often in some patients

Acute care hospitals that are larger, have greater ICU use, and operate for profit are more likely than other hospitals to insert feeding tubes in patients admitted from nursing homes with advanced cognitive impairment, a study found.

Researchers studied 163,022 nursing home residents aged 66 years and older who had advanced cognitive impairment and had been admitted to at least one of 2,797 acute care hospitals between 2000 and 2007. To determine feeding tube placements, they took a 20% sample of all Medicare claims files; hospitals that had at least 30 of these admissions during the study period were included in the study.

Bed size, ownership, urban location, and medical school affiliation were examined in relation to endoscopic or surgical insertion of a gastrostomy tube during hospitalization. Researchers also evaluated hospital care practices for chronically ill patients, including ICU use in the last six months of life, use of hospice, and ratio of specialists to primary care physicians. Results appeared in the Feb. 10 Journal of the American Medical Association.

For-profit hospitals had higher feeding tube insertion rates than government-owned hospitals (8.5 vs. 5.5 insertions per 100 hospitalizations; adjusted odds ratio [AOR], 1.33; 95% CI, 1.21 to 1.46). Hospitals with more than 310 beds also had more insertions than those with less than 101 beds (8.0 vs 4.3 insertions per 100 hospitalizations; AOR, 1.48; 95% CI, 1.35 to 1.63), as did those with more ICU use in the last six months of life (highest vs. lowest decile: 10.1 vs 2.9 insertions per 100 hospitalizations; AOR, 2.60; 95% CI, 2.20 to 3.06). The differences remained after researchers adjusted for patient-level characteristics. About 12% of the hospitals didn't insert any feeding tubes; these tended to be smaller, located in rural regions and unaffiliated with a medical school. White nursing home residents had the lowest likelihood of feeding tube insertion, while black residents had an almost two-fold increase in the likelihood of feeding tube insertion (absolute difference in insertions per 100 admissions, 8.5; AOR, 1.96; 95% CI, 1.89 to 2.04).

Limitations of the study include the fact that information on physician counseling and patient preferences about feeding tube insertion was lacking, except for orders noted in the Minimum Data Set to forgo artificial hydration and nutrition, the authors noted. In addition, researchers relied on ICD-9 and CPT procedure codes to indicate whether a feeding tube was placed, and these data may not have been entirely accurate. While only a first step toward understanding feeding tube insertion practices, the findings suggest a need for interventions to ensure that the use of these tubes is in line with patients' wishes and reflects a clear discussion of risks and benefits, which often doesn't occur in nursing homes, the authors noted.

Using no sedation lowers number of days on ventilator vs. daily sedation interruption

Critically ill patients on mechanical ventilators who don't receive sedation spend fewer days on the ventilators than patients who are sedated with daily interruption, a study found.

Danish researchers performed a randomized, prospective study of 140 critically ill patients on mechanical ventilators who were expected to need ventilation for more than 24 hours. Seventy patients received no sedation. The other 70 patients received 20 mg/mL of propofol for 48 hours and 1 mg/mL of midazolam after 48 hours, with daily interruption until they were awake. All patients were given bolus doses of 2.5 or 5 mg of morphine. The study was published in the Feb. 6 issue of The Lancet.

Twenty-seven patients were excluded from the study because they died or were successfully extubated within 48 hours. Of the remainder, patients who weren't sedated had significantly more days without ventilation in a 28-day period than patients who had interrupted sedation (13.8 days without ventilation vs. 9.6 days, mean difference of 4.2 days; 95% CI, 0.3 to 8.1; P=0.0191). As a group, patients without sedation stayed 9.7 fewer days in the ICU (hazard ratio, 1.86; 95% CI, 1.05 to 3.23; P=0.0316) and 24 fewer days in the hospital for the first 30 days studied (HR, 3.57; CI, 1.52 to 9.09; P=0.0039). Sedation had no effect on length of stay after 30 days. There was no significant difference in mortality, though there were more deaths in the sedation group.

There was no difference in the number of complications (cases of ventilator-associated pneumonia, accidental extubations or need for reintubation, or the need for CT or MRI brain scans). Patients with no sedation experienced agitated delirium more often than those with interrupted sedation (20% vs. 7%; P=0.04). Haloperidol was used more often in the no sedation group, but doses were very low for both groups. An extra person was needed to comfort more patients in the no sedation than the sedation group (11 patients vs. 3 patients; P=0.025). Physical restraints were never used.

A strength of the study was its inclusion of both medical and surgical patients, where previous studies had used only medical patients, the authors noted. Limitations included the fact that patients came from a single center; the study was unblinded; and the ICU had a nurse-to-patient ratio of 1:1, which is unattainable in many units, they said. Also, 18% of the no sedation group didn't tolerate the strategy, they said. An editorialist suggested that patients who aren't sedated may need supplemental drugs to address an increased risk of delirium, and may also need an extra person for comfort. While long-term follow-up of patients for psychological effects will be important, the overall results are “impressive and promising,” the editorialist said.

Withholding anticoagulation after negative compression ultrasound carries low VTE risk

Withholding anticoagulation following a single negative whole-leg compression ultrasound (CUS) had a low risk for venous thromboembolism (VTE) during three-month follow-up in patients with suspected deep vein thrombosis (DVT), according to a meta-analysis.

CUS is typically the first test to confirm or exclude proximal DVT, but its accuracy for distal (below-the-knee) DVT has been questioned. Because up to 25% of distal DVTs may propagate into proximal veins, patients with a negative exam often require repeat exams five to seven days later. Researchers examined whether a single whole-leg CUS would exclude suspected proximal and distal DVT just as well among patients not treated with anticoagulation.

Researchers conducted a meta-analysis of seven studies totaling 4,731 patients with negative whole-leg CUS examinations who did not receive anticoagulation. Most participants were identified from an ambulatory setting. All were followed for 90 days. Results were reported in the Feb. 3 Journal of the American Medical Association.

VTE or suspected VTE-related death occurred in 34 patients (0.7%), including 11 patients with distal DVT (32.4%), seven patients with proximal DVT (20.6%), seven patients with non–fatal pulmonary emboli (20.6%), and nine patients (26.5%) who died possibly due to VTE. Isolated distal DVT represented 52.1% of all DVTs diagnosed by the initial whole-leg CUS.

A random-effects model with inverse variance weighting found the combined VTE rate at three months was 0.57% (95% CI, 0.25% to 0.89%). The exact binomial method calculated individual VTE rates among the studies as low as 0.24% (95% CI, 0.01% to 1.34%) and as high as 1.95% (95% CI, 0.94% to 3.56%) at three-month follow-up. The pooled incidence rate was 0.57% (95% CI, 0.25% to 0.89%).

Researchers wrote that because many distal thrombi appear to resolve without anticoagulants, detection and treatment of distal DVT may be unnecessary. This could potentially improve patient outcomes as there is an estimated 1.1% annual risk for major bleeding with treatment. However, current clinical practice guidelines recommend three months of anticoagulation for distal DVT.

Whole-leg CUS has a low failure rate and is more convenient than repeated evaluations, the researchers said, and bilateral whole-leg CUS requires only 10 to 15 minutes to perform compared to venography, which requires 30 to 90 minutes. Whole-leg CUS may not be widely available, however, they cautioned.

Limitations include that techniques varied slightly across all the studies. The study population also had few pregnant or postpartum patients, and few with cancer. More study is needed in patients with intermediate or high pretest probability for VTE, the authors said.

Heart failure patients discharged from ED often have significant mortality risks

Heart failure patients who are discharged from the emergency department often have significant mortality risks that, for some, exceed those of hospitalized patients, a study found.

Researchers in Ontario, Canada examined outcomes of 50,816 patients who visited an ED from April 2004 to March 2007, using data from the National Ambulatory Care Reporting System Database. Patients aged 20 years and older with a primary diagnosis of heart failure were studied. In patients with multiple ED visits in the study period, the first episode was used as the index heart failure visit. Results were published in the January Circulation: Heart Failure.

Nearly 32% of patients studied were discharged without admission; 4% of these died within 30 days and 1.3% died within a week of ED discharge. Factors that increased the risk of 30-day death included two or more prior heart failure admissions (odds ratio [OR], 1.64; 95% CI, 1.14 to 2.31), valvular heart disease (OR, 1.37; 95% CI, 1.00 to 1.84), peripheral vascular disease (OR, 1.41; 95% CI, 1.00 to 1.93), and respiratory disease (OR, 1.33; 95% CI, 1.08 to 1.63). These same conditions didn't increase the likelihood of hospital admission, however. Instead, patients were more likely to be admitted if they arrived by ambulance (OR, 2.02; 95% CI, 1.93 to 2.12), were older (OR, 1.08; 95% CI, 1.06 to 1.10 per decade), had higher triage acuity score (OR, 4.12; 95% CI, 3.84 to 4.42), or got resuscitation in the ED (OR, 2.85; 95% CI, 2.68 to 3.04). Patients with comparable predicted mortality risks were more likely to die if they were discharged than if they were admitted (11.9% mortality vs. 9.5%; log rank, P=0.016), and had higher rates of repeated ED visits within 90 days.

For every 25 heart failure patients discharged, one patient died within 30 days, and more than one of 80 discharged patients died within one week. This amounts to thousands of early deaths after ED discharge each year in North America, the authors noted. Their results suggest that decisions to discharge are based largely on clinical judgment, and a validated tool is needed to better determine the risk of death for heart failure patients who present to the ED, and to help guide decision-making, they said.