In the News

Alcohol detox protocol, in-hospital STEMI and outcomes, and more.


Protocol may help in evaluating patients for alcohol detox

Development and use of a protocol to evaluate patients for in- hospital or outpatient alcohol detoxification helped standardize care and appeared to decrease admissions, according to a recent study.

Researchers at an academic medical center in North Carolina developed and tested a protocol to help standardize care for patients who requested alcohol detoxification after presenting to the ED. The goal of the study was to determine which patients could receive inpatient versus outpatient treatment. A task force of 3 physicians, a nurse practitioner and a case manager performed a literature search from 1980 to 2011 and examined 1 randomized, clinical trial and 3 cohort studies addressing inpatient and outpatient detoxification, as well as 1 previously published protocol. The task force combined published data with data from members' clinical experience and created a new protocol for the institution.

The new protocol was intended to standardize care in the ED and from the hospitalist group and to provide the hospitalist group with a standardized way to evaluate patients referred for admission. The protocol was implemented on July 1, 2011, with a baseline period of July 2010 through June 2011. The main outcome measures before and after implementation included number of admissions monthly for primary alcohol-related diagnoses, 30-day readmissions, and length of stay. The study results were published in the April Journal of General Internal Medicine.

During the baseline period, 18.9 patients, on average, were admitted for alcohol detoxification each month. The average length of stay was 2.7 days, and the readmission rate was 26.5%. After the protocol was implemented, the number of monthly admissions decreased to 15.9. The average length of stay increased slightly but not statistically significantly after protocol implementation (2.7 days vs. 3.4 days; P=0.09), and readmission rates did not differ (26.5% vs. 28.4%; P=0.33). The authors did not perform a cost-benefit analysis but estimated that a decrease of 3 admissions per month would decrease costs by 315,000 annually. Manual chart review of the last 20 admissions during the observation period showed an implementation rate of 83.3%.

The authors pointed out that their study did not have a control group and that admissions may have decreased for reasons that were not related to the protocol. In addition, they acknowledged that they could not address safety outcomes or the potential for adverse events among patients who were discharged from the ED on the basis of the protocol. However, they noted that the protocol had helped their hospitalist group standardize care for a particularly challenging issue and that it led to statistically and clinically significant decreases in alcohol-related admissions. “Given the widespread and common problem of alcohol dependence, there is great potential for application of similar protocols at other institutions and further study to optimize care for this population,” the authors concluded.

In-hospital STEMI may increase risk for poor outcomes

Patients who have an ST-segment elevation myocardial infarction (STEMI) while in the hospital often do worse than those who experience STEMI off-site, according to a recent study.

Researchers in Minneapolis used a regional STEMI database to examine characteristics and outcomes of patients who had STEMI after they were admitted to the hospital. Patients with STEMI who were treated between March 1, 2003, and Jan. 1, 2013, were classified as having presented via emergency medical services (EMS), as having been driven to the hospital by themselves or their family, or having had a STEMI in the hospital. Door-to-balloon times were calculated for the first 2 groups, and diagnostic EKG-to- balloon times were used as a surrogate measure for the third group. In all groups, length of stay was defined as the time from STEMI onset to discharge. The study results were published in the March 18 Circulation.

Overall, 3,795 consecutive patients with STEMI were treated via the Minneapolis Heart Institute's regional STEMI program, and of these, 990 patients presented directly to the percutaneous coronary intervention (PCI) facility and were included for final analysis. Six hundred forty (64.7%) arrived via EMS, 267 (27.0%) drove themselves or were driven by a family member, and 83 (8.4%) had STEMI after admission to the hospital. Patients who had STEMI in the hospital were older and had higher BMIs and rates of hypertension than patients in the other 2 groups. In addition, they more commonly had a history of coronary artery disease and were more likely to present with cardiac arrest and cardiogenic shock and to have a higher Killip class.

The in-hospital patients had longer median length of stay than those in the other 2 groups (5 days vs. 3 days each; P<0.001 for both comparisons). In-hospital patients also had a longer diagnostic EKG-to-balloon time than door-to-balloon time in EMS patients (76 vs. 51 minutes; P<0.001), although the door-to-balloon time in self- or family-driven patients was similar (76 vs. 66 minutes; P=0.13). One-year mortality among in-hospital patients was 16.9% compared with 10.3% in EMS patients (P=0.0073) and 7.1% in self- or family-driven patients (P=0.032). In-hospital patients were also more likely to have high-risk, complex reasons for admission, such as acute coronary syndrome and ventricular fibrillation. The authors also analyzed patients who presented with in-hospital STEMI before and after a standardized in-hospital STEMI protocol was implemented and found that those treated afterward had lower mortality rates at 1 year (10.5% vs. 30.8%; P=0.022).

The authors noted that their data were obtained from a registry and came from patients at only 1 center. They also acknowledged that their sample size was relatively small, among other limitations. However, they concluded that patients who develop STEMI while hospitalized “represent a unique, high-risk group of patients,” with more comorbid conditions, longer time to reperfusion and higher 1-year mortality rates. “Our results suggest the implementation of a standardized protocol for patients who develop STEMI after admission to the hospital may improve recognition, decrease time to reperfusion and subsequently improve clinical outcomes including mortality,” the authors wrote.

An accompanying editorial pointed out that the study was affected by identification and selection bias because it included only patients who were referred for angiography and PCI. In addition, the editorialists said, no data yet exist on patients who have in-hospital STEMI at facilities without PCI capability and require transfer to another hospital, and the current study included patients admitted after PCI who would probably have been more closely monitored for cardiac ischemia. However, the editorialists also praised the study as a welcome addition to the evidence base on in-hospital STEMI. “These data suggest that we must also translate our evidence-based, life-saving therapies to all STEMI patients, whether they present outside or inside the hospital setting,” they wrote.

Disparities in cardiac surgery mortality partially caused by hospital quality

Much, but not all, of the racial disparity in cardiac surgery outcomes can be explained by nonwhite patients being treating at lower-quality hospitals, a recent study found.

Researchers used the Medicare database to identify 173,925 patients who underwent coronary artery bypass grafting (CABG) at U.S. hospitals in 2007-2008. Hospital quality was judged by risk-adjusted mortality rate, and patients' socioeconomic status was determined by the ZIP code in which they lived. Results were published in the March JAMA Surgery.

Using logistic regression, the researchers calculated that nonwhite patients had 33% higher risk-adjusted mortality after CABG than whites (odds ratio [OR], 1.33; 95% CI, 1.23 to 1.45). Differences in hospital quality explained 35% of this mortality disparity. Adding in adjustments for socioeconomic status, the researchers were able to explain 53% of the disparity. Still, nonwhite patients had a 16% higher mortality rate that could not be explained by any factor analyzed in the study. At the hospitals that treated the most nonwhite patients, CABG mortality was 4.8% in nonwhite patients and 3.8% in white patients.

The researchers noticed that associations found among hospital quality, socioeconomic status and race suggested that nonwhite and poor patients tend to seek care in lower-quality hospitals. Although the study couldn't explain the remaining disparity in mortality, the study authors offered some theories, including that black patients may present with more advanced disease or acute myocardial infarction. Some physician practices may contribute too, such as segregated referral patterns or offering CABG surgery to nonwhites only when disease is more severe.

Solutions are needed, but it is uncertain what will be effective, the authors said. Disproportionate share payments by Medicare have not remedied the problem. Patient navigators may be helpful. Referral of nonwhite patients to higher-quality centers could be considered, but such a policy (along with pay for performance) risks diverting resources away from low-quality centers, increasing the issues with the care they provide. More research is needed to accurately understand the barriers to high-quality care for nonwhite patients, the authors concluded.

An accompanying commentary offered another possible explanation for the unexplained disparity: “The nature of coronary disease and risk in underserved, impoverished predominately black communities may be responsible.” The commentary author noted that the nonwhite patients in the study were more likely to be female and had more hypertension, heart failure and emergency admissions than the white patients. To resolve the disparities, the commentary recommended better preventive strategies and early detection for affected populations.

Diuretic efficiency may be best metric for predicting survival of heart failure patients

A metric of diuretic efficiency provided better prognostic information about decongestive treatment for acute decompensated heart failure than did fluid output or diuretic dose, a recent study found.

Researchers retrospectively and separately analyzed data from 2 sources: consecutive admissions of 657 patients with a primary discharge diagnosis of heart failure at 1 academic center, and 390 inpatient records from the multi-site Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. Diuretic efficiency (DE) was defined as the mL of net fluid output per mg of loop diuretic received, with 40 mg of furosemide equivalents as the reference. Results were published in the March Circulation: Heart Failure.

There was a modest correlation between DE and the IV diuretic dose and between DE and net fluid output. Most baseline characteristics—such as right-heart catheterization variables, heart rate, and physical examination findings—were not associated with DE, although blood urea nitrogen and estimated glomerular filtration rate (eGFR) were. Unexpectedly, since renal function is a determinant of diuretic responsiveness, the correlations were small between eGFR and diuretic dose (academic center r2=0.05, P<0.001; ESCAPE r2=0.0, P=0.76), net fluid output (center r2=0.0, P=0.35; ESCAPE r2=0.03, P=0.002), and diuretic efficiency (center r2=0.02, P<0.001; ESCAPE r2=0.04, P<0.001).

Low DE was associated with worse survival even after adjustment for in-hospital diuretic dose, fluid output, and baseline characteristics (academic center hazard ratio [HR], 1.36, 95% CI, 1.04 to 1.78; P=0.02; ESCAPE HR, 2.86, 95% CI, 1.53 to 5.36; P=0.001). Indeed, after adjustment for baseline characteristics, DE was the only factor significantly associated with mortality in both cohorts.

Diuretic efficiency is easily calculated and provides distinct and seemingly superior information about prognosis compared to diuretic dose and fluid output, the authors wrote.

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