In the news

Rehospitalizations and sickle-cell patients, prescription drug poisoning, and more.

One-third of sickle cell patients rehospitalized within 30 days of discharge

One-third of people with sickle cell disease are rehospitalized within 30 days of discharge, and 18- to 30-year-olds are particularly likely to be rehospitalized or have return visits to the emergency department, a study found.

Researchers examined data on 21,112 patients from the 2005 and 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department (ED) Databases. Patients came from eight geographically diverse states–together comprising 33% of all people with sickle cell disease in the U.S.–and had had sickle cell-related treat-and-release ED visits or inpatient hospitalizations. Results were published in the April 7 Journal of the American Medical Association.

The 30-day rehospitalization rate was 33.4% (95% confidence interval [CI], 33.0% to 33.8%), while the 14-day rate was 22.1% (95% CI, 21.8% to 22.4%). In addition to rehospitalizations, 15% of hospital discharges were followed by a treat-and-release ED visit within 30 days (95% CI, 14.7% to 15.3%). Rehospitalization rates were highest for patients age 18 to 30 years: 41.1% were rehospitalized within 30 days (95% CI, 40.5% to 41.7%) and 28.4% within 14 days (95% CI, 27.8% to 29%). This age group was also more likely to go to the ED for treatment of pain than to be released (20% of patients within 30 days). The 18- to 30-year-old sickle cell patients had approximately 3.5 hospital visits per year, compared to two visits per year for children age 10 to 17. Medicaid patients, or those with other types of public insurance, had higher rates than privately insured or uninsured patients.

About 29% of patients with sickle cell disease experienced no acute care encounters in a given year, while 16.9% had three or more per year. A shorter length of stay was not evident with rehospitalization: Those hospitalizations followed by a rehospitalization within 30 days had an average length of stay of 6.1 days, compared to 5.6 days for those without subsequent hospitalization.

Fourteen-day rehospitalization rates may seem a more appropriate time period to evaluate inpatient care, while 30-day rates may assess the quality of and access to ambulatory care; however, two-thirds of those rehospitalized within 30 days were rehospitalized within 14 days, the authors noted. Preventing 14-day rehospitalizations “may require evaluation and intervention during the (original) hospitalization,” they noted. The high utilization rate among 18- to 30-year-olds probably reflects the fact that those with severe disease die earlier, they said. Identifying benchmarks can help with efforts to improve quality of care and reduce morbidity, they concluded.

Hospitalizations for prescription drug poisoning increasing

Hospitalizations for overdoses of certain prescription drugs increased dramatically between 1999 and 2006, according to a study.

Researchers used data from the Nationwide Inpatient Sample to examine U.S. hospitalizations for intentional and unintentional poisoning by prescription opioids, sedatives and tranquilizers. The study looked at the demographics and characteristics of such hospitalizations and compared them with hospitalizations for other poisonings in the same time period. The study results were published in the May American Journal of Preventive Medicine.

All hospitalizations due to overdoses of prescription opioids, sedatives and tranquilizers increased by 65% from 1999 to 2006, the researchers found. Unintentional poisonings involving these drugs increased by 37%, and intentional poisonings increased by 130%. Hospitalizations for poisonings by other drugs and substances increased by 33% over the same period. Unintentional poisonings increased by 21%, and intentional poisonings increased by 53%. The increase in number of poisonings was greatest for benzodiazepines (a difference of 10,379 hospitalizations between 1999 and 2006), while hospitalization for methadone poisoning saw the largest percentage increase (400%). Patients hospitalized for overdoses of prescription opioids, sedatives and tranquilizers compared with other drugs were more likely to be women, to be older than age 34, to be covered by Medicare, and to be seen at a rural or urban nonteaching hospital. Men were more likely to be hospitalized with unintentional poisoning, while intentional poisoning was more common in women.

The authors noted that their study had a retrospective design and used only the principal discharge diagnosis to classify poisoning cases, among other limitations. However, they concluded that it provides the first comprehensive examination about U.S. hospitalizations for poisoning by prescription opioids, sedatives and tranquilizers, showing substantial increases in both intentional and unintentional overdoses. Patients who overdose are hospitalized for an average of three days, they noted, giving future researchers an opportunity to gather more information and to help aid prevention. “Interviews with survivors could provide important additional details regarding the pathways to abuse of these drugs, the methods used to obtain the medications, the sequencing and combination of drugs that result in overdose, and the immediate precursors to these serious events,” they wrote.

Newer assessment tool detects more poststroke cognitive abnormalities than MMSE

The Montreal Cognitive Assessment (MoCA) detects substantially more cognitive abnormalities after stroke and transient ischemic attack than does the widely used Mini-Mental State Examination (MMSE), a study found.

In a prospective, population-based cohort study, English researchers administered both assessments to 493 consecutive stroke and transient ischemic attack (TIA) patients at either their six-month or five-year follow-up appointments. The MMSE was administered at the beginning and the MoCA at the end of the 30-minute appointment, along with a modified Rankin score. Normal cognitive function was defined as 27 or greater on the MMSE, and 26 or greater on the MoCA. Results were published in the June 1 Stroke.

Of the 493 patients, 413 were testable (nontestable patients were older and more likely to have had a previous cerebrovascular event, dysphasia, and dementia). In testable patients, MMSE and MoCA scores were highly correlated (r2 =0.80, P<0.001), but MoCA scores were normally distributed while MMSE scores were skewed toward higher values (ceiling effect). Of the 413 testable patients, 291 had MoCA less than 26; of those 291, 162 had MMSE of 27 or higher. On the other hand, only five patients with normal MoCA had MMSE of less than 27 (P<0.0001). Rankin scores, which measure the degree of disability (lower scores indicate less disability), were significantly lower in patients with MMSE ≥27 and MoCA ≥26 than in those with MMSE ≥27 and MoCA >26, or in those with MMSE <27 (P<0.001).

Given that 58% of patients with normal MMSE had abnormal MoCA, and these patients were more dependent by the Rankin scale than those with normal MoCA, this study's findings appear clinically relevant, the authors said. The MoCA differentiated well between cognitive ability levels, and demonstrated deficits in multiple areas–like executive function, recall and repetition–that the MMSE didn't detect, the authors said. Study limitations include that the reproducibility of the MoCA wasn't formally assessed, and its sensitivity and specificity for cognitive impairment weren't determined. Also, the MoCA was always performed at the end of a patient's appointment, when fatigue may have increased the likelihood of error, they noted.

VTE prophylaxis ‘stubbornly low’ despite decades of effort

Prophylaxis rates for venous thromboembolism (VTE), even for patients at highest risk, remain substantially below Joint Commission targets.

The Joint Commission recommends that all hospitalized medical patients receive prophylaxis against VTE within two days of admission or have documentation why none was given. To assess actual rates of use, researchers conducted a retrospective cohort study of adult patients with seven medical diagnoses considered to carry moderate to high risk of VTE at 376 acute care facilities in 2004-2005. Results were published in the June Journal of General Internal Medicine.

The population included all general medical patients 18 and older with moderate to high risk of VTE, including those with pneumonia, respiratory failure with pneumonia, septicemia, heart failure, chronic obstructive pulmonary disease, stroke, and urinary tract infection. Patients with acute coronary syndromes, those who received warfarin, and patients with stays less than two days were excluded.

The authors defined VTE prophylaxis as receipt of at least one dose of low-molecular-weight heparin, unfractionated heparin, a pneumatic compression device, or compression stockings during the first two days of hospitalization. They defined standard prophylaxis as either low-molecular-weight heparin, 40 mg once daily, or unfractionated heparin, 5,000 units two or three times daily, by hospital day two and continued for the duration of the hospitalization, or until the patient was diagnosed and treated for VTE.

Of 351,535 patients, 36% received prophylaxis by hospital day two and 11% received standard prophylaxis. Rates were highest among patients with mechanical ventilation (67%), restraints (57%), central lines (55%), obesity (46%) and prior VTE (44%). Patients with a more than 1% risk of VTE were more likely to receive prophylaxis than patients with a less than 0.5% risk (52% vs. 34%, P<0.001).

Rates were highest at hospitals with more than 500 beds compared to less than 200 beds (43% vs. 26%, P<0.001) and at teaching institutions compared to non-teaching institutions (43% vs. 32%). Rates varied widely not only across hospitals but within them. Patients cared for by pulmonologists were most likely (43%) and those cared for by family practitioners were least likely (27%) to receive prophylaxis.

Rates of prophylaxis in this study were lower than in others, and the researchers noted several possible reasons for the difference. First, they measured only prophylaxis by hospital day two, whereas others included prophylaxis at any time. Second, researchers had no information on patient mobility or admission for comfort care only. Third, the study included hospitals where prophylaxis was seldom used, such as small, rural, non-teaching hospitals, and these may not have been included in other studies. The rate seen in large teaching hospitals is closer to what other studies have reported. Finally, because researchers did not have access to medication administration records, low prophylaxis rates may be related to improperly ordered or administered medication, or a failure to bill.

Quality improvement organizations and professional societies have paid substantial attention to VTE, but rates of prophylaxis in the hospital remain “stubbornly low,” the authors said. The new Joint Commission reporting measures may help address this problem, they wrote.