Recent Research

MERS information, NSAIDs and antidepressants, ICDs in older patients, and more.

U.S. clinicians should be prepared to detect, manage MERS, health agencies say

Clinicians and health departments throughout the U.S. should be prepared to detect and manage cases of Middle East respiratory syndrome coronavirus (MERS-CoV), the CDC recently warned.

Clinicians should routinely ask their patients about their travel history and health care facility exposure, the agency said in an interim guidance statement issued June 11. People who meet the updated criteria should be evaluated for MERS-CoV infection in addition to other common respiratory pathogens and should be reported immediately to state and local health departments.

Three combinations of clinical illness and epidemiologic risk should lead clinicians to consider a patient under investigation for MERS-CoV, according to the CDC:

1. Fever and pneumonia or acute respiratory distress syndrome (based on clinical or radiologic evidence) and any of the following:

  • a history of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset, or close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula, or
  • a history of being in a health care facility (as a patient, worker, or visitor) in the Republic of Korea within 14 days before symptom onset, or
  • a member of a cluster of patients with severe acute respiratory illness (such as fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health departments in the U.S.,

2. Fever and symptoms of respiratory illness (not necessarily pneumonia; e.g., cough, shortness of breath) and a history of being in a health care facility (as a patient, worker, or visitor) within 14 days before symptom onset in a country or territory in or near the Arabian Peninsula in which recent health care-associated cases of MERS-CoV have been identified,

3. Fever or symptoms of respiratory illness and close contact with a confirmed MERS-CoV case.

South Korea experienced the largest outbreak of MERS seen outside the Arabian Peninsula, which the World Health Organization noted came from a single infected traveler. WHO noted that the disease spread quickly due to:

  • MERS CoV being unexpected and unfamiliar to most physicians in the Republic of Korea;
  • suboptimal prevention and control measures in some hospitals, related in part to overcrowding in emergency departments and patients staying in rooms with many beds; and
  • visits to hospitalized patients by many friends and family members.

Combination of NSAIDs and antidepressants associated with intracranial hemorrhage

Patients who took antidepressants and NSAIDs concurrently had a significantly increased risk of intracranial hemorrhage, a recent study found.

The propensity-score-matched cohort study used data on more than 4 million Korean patients from 2009 to 2013, half of whom took antidepressants alone and half of whom took antidepressants and an nonsteroidal anti-inflammatory drug (NSAID). The main study outcome was hospital admission with intracranial hemorrhage within 30 days of medication use. Results were published in The BMJ on July 14.

Risk of intracranial hemorrhage was significantly higher in the patients who took both antidepressants and NSAIDs (hazard ratio [HR], 1.6; 95% CI, 1.32 to 1.85) than in those who took only antidepressants. The researchers didn't find any differences in risk among antidepressant drug classes, but they did observe that men who took NSAIDs and antidepressants had a much greater increase in hemorrhage risk than women on the same regimen (HR, 2.6; 95% CI, 1.93 to 3.42 in men vs. HR, 1.2; 95% CI, 0.89 to 1.57 in women, both compared to users of antidepressants who did not take NSAIDs).

This is the first population-based cohort study of this question, the study authors said, and its results are in line with previous case-control research. The results are also biologically plausible, since antidepressants block platelet uptake and NSAIDs also inhibit platelet function. Given the limitations of the observational study design, the results should be interpreted with caution, but clinicians should pay “special attention” to patients taking these medication classes together, the authors concluded.

The results are particularly worrying because depression and pain are so commonly comorbid, noted an accompanying editorial. The availability of NSAIDs over the counter is another concern. However, a number of questions remain, including the risks of long-term use of the medications and the applicability to populations outside of Korea, said the editorialists, calling for additional research.

ICDs may be underused among older patients after heart attack

Fewer than 1 in 10 eligible older patients with low ejection fraction following a myocardial infarction (MI) received an implantable cardioverter-defibrillator (ICD) within 1 year, a study found.

Because ICD implantation is not recommended within 40 days of an MI, the decision to implant one can be overlooked during the transition of post-MI care from inpatient to outpatient care, the study authors noted. They examined ICD implantation rates and associated mortality among more than 10,000 Medicare beneficiaries with a mean age of 78 years and with an ejection fraction of 35% or less after an MI treated at 441 U.S. hospitals between 2007 and 2010. Results appeared in the June 23/30 issue of the Journal of the American Medical Association.

The cumulative 1-year ICD implantation rate among the studied patients was 8.1% (95% CI, 7.6% to 8.7%; n=785). Relative to patients who did not receive an ICD within 1 year, patients with ICD implantation were more likely to have:

  • prior coronary artery bypass graft procedures (31% vs 20%; adjusted hazard ratio [HR], 1.49; 95% CI, 1.26 to 1.78),
  • higher peak troponin levels (median, 85 vs. 51 times the upper limit of normal; adjusted HR, 1.02 per 10-fold increase; 95% CI, 1.01 to 1.03),
  • in-hospital cardiogenic shock (13% vs 8%; adjusted HR, 1.57; 95% CI, 1.25 to 1.97), and
  • cardiology follow up within 2 weeks after discharge (30% vs 20%; adjusted HR, 1.64; 95% CI, 1.37 to 1.95).

Implantation of ICD was associated with lower 2-year mortality (15.3 events per 100 patient-years [128 deaths in 838 patient-years] vs. 26.4 events per 100 patient-years [3, 033 deaths in 11,479 patient-years]; adjusted HR, 0.64; 95% CI, 0.53 to 0.78), the study also found. The authors noted that the “post-MI care transition is a point of vulnerability amenable to potential quality improvement interventions” and called for more research on interventions that “encourage close outpatient follow-up, improve communication and implementation of longitudinal care plans, and educate patients.”

An editorialist called it “concerning” that so few potentially ICD-eligible elderly patients are undergoing implantation, considering the significantly improved survival rates associated with the device. “Even though the use of ICDs for primary prevention may not seem to make as much sense for an 80-year-old patient as it does for a patient in his or her 50s or 60s, an older patient at risk for sudden cardiac death should have the same opportunity to choose potentially lifesaving therapy,” the editorial states.

Even small brain lesions may increase mortality in patients without prior stroke history

Having even very small (<3 mm) brain lesions may triple the risk for stroke and death in asymptomatic patients with no history of stroke, and having both very small and larger lesions may increase the risk 8-fold, a study found.

To determine the association between lesion size and incident stroke, stroke-related mortality, and all-cause mortality, researchers examined MRI data from 1993 to 1995 for 2,892 adults from 2 Atherosclerosis Risk in Communities (ARIC) study sites. Results appeared in the July 7 Annals of Internal Medicine.

Over an average follow-up of 14.5 years, there were 157 strokes, 50 stroke-related deaths, and 576 all-cause deaths. Compared to patients without lesions, stroke risk more than tripled with lesions smaller than 3 mm only (hazard ratio [HR], 3.47; 95% CI, 1.86 to 6.49), nearly doubled with lesions 3 mm or larger only (HR, 1.94; 95% CI, 1.22 to 3.07), and was more than 8-fold higher with lesions of both sizes (HR, 8.59; 95% CI, 4.69 to 15.73). Risk was also more than doubled with a white matter hyperintensities score of at least 3 (HR, 2.14; 95% CI, 1.45 to 3.16). Risk for stroke-related death tripled with lesions smaller than 3 mm only (HR, 3.05; 95% CI, 1.04 to 8.94) and was 7 times higher with lesions of both sizes (HR, 6.97; 95% CI, 2.03 to 23.93).

The authors concluded that clinicians may want to reconsider the practice of dismissing very small cerebral lesions found on MRI. Small lesions may result from vascular pathology or dilated perivascular spaces known as Virchow–Robin spaces, they wrote. But even perivascular spaces are increasingly recognized as potentially pathologic. Lesions of presumed vascular origin and perivascular spaces share similar risk profiles, and perivascular spaces are associated with cerebral small vessel disease severity, stroke and cognitive decline, white matter hyperintensities, and symptomatic lacunar infarctions, all of which support a vascular pathology, they concluded.

The authors wrote, “Regardless of the cause of the lesions, our study shows that even very small lesions are associated with increased risk for stroke and death, adding to a growing corpus of literature supporting associations between very small lesions and cardiovascular risk factors; clinical disease, including atrial fibrillation; and, now, stroke and mortality.”

Extended anticoagulant treatment appears beneficial for first unprovoked PE

Patients who have had a first unprovoked pulmonary embolism (PE) appear to benefit from extended anticoagulant treatment, according to a recent study.

Researchers in France performed a randomized, double-blind trial of 371 adult patients who had had a first symptomatic unprovoked PE and had been treated continuously for 6 months with a vitamin K antagonist. An unprovoked PE was defined as one that occurred with no major risk factor for thrombosis. Patients were assigned to receive warfarin or placebo for 18 months and were followed between July 2007 and September 2014. The study's primary outcome was recurrent venous thromboembolism (VTE) or major bleeding 18 months after randomization. Secondary outcomes were recurrent VTE or major bleeding at 42 months, plus VTE alone, major bleeding alone, and death unrelated to PE or major bleeding at 18 and 42 months. The study results were published in the July 7 Journal of the American Medical Association.

One hundred eighty-four patients were assigned to the warfarin group and 187 patients were assigned to the placebo group. Of the 371 patients, 363 (97.8%) came to the 18-month visit and 283 (76.3%) came to the 42-month visit. After 18 months, 4 patients were lost to follow-up and 1 withdrew from the study because of an adverse event. The study's median follow-up was 23.4 months after the treatment period and 41 months overall.

During the 18 months of treatment, the primary outcome occurred in 6 of 184 patients in the warfarin group and 25 of 187 patients in the placebo group (3.3% vs. 13.5%; hazard ratio [HR], 0.22; 95% CI, 0.09 to 0.55; P=0.001). Three patients in the warfarin group had recurrent VTE versus 25 patients in the placebo group (HR, 0.15; 95% CI, 0.05 to 0.43), while major bleeding was noted in 4 warfarin patients and 1 placebo patient (HR, 3.96; 95% CI, 0.44 to 35.89). After the treatment period, symptomatic recurrent VTE occurred in 25 patients in the warfarin group and 14 patients in the placebo group (9.3 events per 100 person-years vs. 4.7 events per 100 person-years, all while off anticoagulation); major bleeding occurred in 2 patients in the warfarin group (1 nonfatal event while taking warfarin and 1 fatal event after discontinuing warfarin) and 4 patients in the placebo group (all nonfatal, and 2 of them while on warfarin for recurrence). Over the 42-month study period (18 months of treatment plus 24 months of follow-up), the primary outcome occurred in 33 patients in the warfarin group and 42 patients in the placebo group (20.8% vs. 24.0%; HR, 0.75; 95% CI, 0.47 to 1.18). No between-group differences were seen in rates of VTE, major bleeding, or unrelated death.

The authors noted that their primary outcome included 2 outcome measures that may not have been clinically equivalent, that newer anticoagulants were not examined, and that D-dimer levels were not used to guide therapy, among other limitations. However, they concluded that an additional 18 months of warfarin treatment in patients with first unprovoked PE improves outcomes versus placebo, although the improvement was not sustained after anticoagulant treatment was discontinued.

“Our results suggest that patients such as those who participated in our study require long-term secondary prophylaxis measures,” the authors wrote. “Whether these should include systematic treatment with vitamin K antagonists, new anticoagulants or aspirin, or be tailored according to patient risk factors (including elevated D-dimer levels) needs further investigation.”

Study shows differences between the sexes in stroke severity, risk of death

Older women have more severe strokes than older men but have better survival outcomes, according to a recent study.

After age 65, results show an “innate female superiority” in the likelihood of survival after stroke, even though women have more severe strokes, according to the study, published July 6 by the Journal of the American Heart Association.

Researchers used data between 2003 and 2012 from the Danish Stroke Registry, which provided information on all hospital admissions for stroke in Denmark (n=79,617), and the Danish Register of Causes of Death. Using the Scandinavian Stroke Scale, the mean stroke severity score was 40.4 for women (SD, 17.3) and 44 (SD, 15.6) for men (P<0.0001). Lower scores indicate more severe stroke, and severity increased with age, accelerating even more in patients older than 60 years, the study stated.

Researchers studied only deaths caused by the index stroke, assuming that death reported on death certificates attributed to stroke was related to the index stroke if death occurred within the first week or month afterward. Stroke was the cause of death for 4,373 (5.5%) of patients within 1 week and 5,512 (6.9%) within 1 month, according to the study.

Up to ages in the mid-60s, researchers noted no difference in the risk of death from stroke between men and women. However, for patients older than 65, the risk for death from stroke (adjusted for age, marital status, stroke severity, stroke subtype, socioeconomic status, and cardiovascular risk factors) gradually became greater in men, increasing to more than 15% in the mid-70s, the study stated. These results, the study authors noted, were essentially the same when separately analyzing deaths within 1 week and 1 month, as well as when analyzing ischemic and hemorrhagic stroke separately.

They noted limitations of the study, such as how death certificates are subject to some uncertainty and the possibility of bias because not all survival-influencing variables were recorded in the registry. However, when the researchers restricted the analysis to the 33,359 patients with complete information on all variables, their conclusion remained the same: Older women were more likely to survive stroke than older men.

The study was not able to explain the difference in survival and severity of stroke between the sexes, although the authors speculate that the difference could be a result of the progressive decrease of testosterone in older men.

Septic ICU patients had high rate of VTE despite prophylaxis

More than a third of ICU patients with severe sepsis or septic shock had a venous thromboembolism (VTE) despite receiving recommended thromboprophylaxis, a recent study found.

The prospective trial included 113 consecutive ICU patients at 3 hospitals treated for severe sepsis or septic shock. All patients received guideline-recommended thromboprophylaxis, underwent ultrasonography, and were followed for VTE until ICU discharge and for all-cause mortality until 28 days after hospitalization. Their mean Acute Physiology and Chronic Health Evaluation II score was 18.2 and age was 50 years. Results were published in CHEST on June 25.

A VTE was found in 37.2% of the patients (95% CI, 28.3 to 46.8), and 88% of these were clinically significant (defined by the researchers as pulmonary embolism, proximal deep vein thrombosis, and/or symptomatic distal deep vein thrombosis). Patients with VTE had longer length of stay (18.2 days vs. 13.4 days; P<0.05) and higher mortality (although the difference was not statistically significant). The study found insertion of a central venous catheter (CVC) and longer duration of mechanical ventilation to be risk factors for VTE.

The results show a markedly higher incidence of VTE in patients with severe sepsis and septic shock than has been seen in previous research on all (primarily non-septic) ICU patients, the study authors said. This suggests that “the systemic inflammatory milieu of sepsis may uniquely predispose septic patients to VTE,” they concluded. The study also revealed that thromboprophylaxis may be less effective in septic patients, and that recognizing VTE in such patients is challenging, since only 3 patients had ultrasounds ordered due to suspicion of deep vein thrombosis.

Based on these findings, clinicians should maintain a high suspicion for VTE in patients with severe sepsis and septic shock, as well as targeting the factors associated with VTE risk, the authors said. Specifically, this means “removing CVCs when no longer necessary, minimizing the size of CVCs, including [peripherally inserted central catheters], and standardized approaches to mechanical ventilation weaning protocols and early physical therapy.” In addition, other strategies for VTE prevention in these patients should be developed, the authors said.

Perioperative bridging didn't reduce clot risk in afib patients taking warfarin

For patients taking warfarin for atrial fibrillation, perioperative bridging with low-molecular-weight heparin provided no benefit over placebo, a recent study found.

The double-blind BRIDGE trial included 1,884 atrial fibrillation patients who needed an interruption in warfarin treatment for an elective operation or other elective invasive procedure. Warfarin was stopped 5 days before the procedure and resumed within 24 hours afterward in all patients. Nine hundred thirty-four patients were randomized to receive 100 IU of dalteparin per kg of body weight, administered twice daily from 3 days before the procedure until 24 hours before, and then for 5 to 10 days afterward, while 950 patients received placebo injections on the same schedule.

The 2 groups had similar rates of arterial thromboembolism within 30 days of the procedure: 0.4% of the no-bridging group versus 0.3% of the bridging group (risk difference, 0.1 percentage points; 95% CI, −0.6 to 0.8; P=0.01 for noninferiority). The no-bridging group had a lower rate of major bleeding: 1.3% versus 3.2% (relative risk, 0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority). Results were published by the New England Journal of Medicine on June 22.

The no-bridging group also had significantly fewer minor bleeds (12% vs. 20.9%; P<0.001), and there were no significant differences between groups in myocardial infarction, venous thromboembolism, or death. The results “show that there is a net clinical benefit in favor of a strategy of forgoing bridging,” the study authors said. These findings are consistent with previous nonrandomized trials and suggest that “the perioperative risk of arterial thromboembolism in patients with atrial fibrillation during interruption of warfarin treatment may have been overstated and may not be mitigated by bridging anticoagulation,” the authors wrote.

They noted that the study did not include many patients with a CHADS2 score of 5 or 6 or any patients undergoing major surgical procedures. It was also limited by a lower than expected rate of arterial thromboembolism. The results should not be applied to patients with mechanical heart valves (since they were not included in the trial), the authors said, but they may be relevant to the question of whether to bridge patients taking newer direct oral anticoagulants.

Antibiotics effective, but not as effective as surgery, for acute appendicitis

Antibiotics are effective in treating uncomplicated acute appendicitis, but they aren't proven to be noninferior to standard appendectomy, according to results from a recent randomized clinical trial.

The open-label Appendicitis Acuta trial was conducted from November 2009 until June 2012 in 6 Finnish hospitals and enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan. Patients were randomly assigned to standard open appendectomy or antibiotic treatment. Those randomized to antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Results were published June 16 in the Journal of the American Medical Association.

There were 273 patients in the surgical group and 257 in the antibiotic group. In the surgical group, all but 1 patient underwent successful appendectomy, a success rate of 99.6% (95% CI, 98% to 100%). In the antibiotic group, 186 patients (72.7%; 95% CI, 66.8% to 78%) did not require surgery, but 70 patients (27.3%; 95% CI, 22% to 33.2%) underwent appendectomy within 1 year, including 15 during the initial hospitalization. Antibiotic therapy did not meet the researchers' prespecified noninferiority margin of 24%, as the intention-to-treat analysis yielded a difference in treatment efficacy between groups of −27% (95% CI, −31.6% to ∞; P=0.89). However, there were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in the antibiotic group, “suggesting that the decision to delay appendectomy for uncomplicated acute appendicitis can be made with low likelihood of major complications resulting from delayed surgery,” the study authors wrote.

The researchers noted several limitations to the study, such as how they had difficulty enrolling patients, which caused them to re-evaluate the necessary sample size, “potentially underpowering the study and resulting in indeterminate results.” Another limitation is that the majority of patients in the study underwent open appendectomies and not laparoscopic appendectomies, which are commonly performed and associated with less pain and fewer wound infections. Also, these findings do not apply to the patient types excluded from the study, including those with complicated appendicitis, children, and pregnant women.

Although this was technically a negative trial, many of its aspects justify new approaches for treating appendicitis, according to an accompanying editorial. The findings suggest that for CT-diagnosed uncomplicated appendicitis, an initial treatment of antibiotics is “reasonable,” followed by elective appendectomy for patients who do not improve, the editorial stated. “With development of more precise diagnostic capabilities like CT and effective broad-spectrum antibiotics, appendectomy may be unnecessary for uncomplicated appendicitis, which now occurs in the majority of acute appendicitis cases,” the editorialist wrote.

Daptomycin associated with better outcomes than linezolid in VRE bloodstream infections

Treating vancomycin-resistant Enterococcus (VRE) bloodstream infections with daptomycin was associated with lower rates of treatment failure and 30-day mortality compared to linezolid, a recent study found.

The retrospective cohort study included 644 patients treated in the Veterans Affairs system between 2004 and 2013. The primary outcome was treatment failure, which was defined as a composite of 30-day all-cause mortality, microbiological failure, and 60-day recurrence rate. The results were published by Clinical Infectious Diseases on June 10.

The overall rate of treatment failure was 60.9%, and 30-day mortality rate was 38.2%. Compared to patients on daptomycin, those taking linezolid had a significantly higher risk of treatment failure (risk ratio [RR], 1.37; 95% CI, 1.13 to 1.67; P=0.001). After adjustment for confounding factors including severity of illness, the risk difference shrunk but persisted (adjusted RR, 1.15; 95% CI, 1.01 to 1.30; P=0.026). Linezolid was also associated with higher rates of 30-day mortality (42.0% vs. 33.5%; RR, 1.17; 95% CI, 1.04 to 1.32; P=0.014) and microbiological failure (RR, 1.10; 95% CI, 1.01 to 1.18; P=0.011). The groups showed no differences in rates of recurrence.

This is the first nationwide cohort study comparing linezolid and daptomycin for VRE bloodstream infections, and based on it, daptomycin appears to result in better clinical outcomes, the authors concluded. They noted that the study was limited by its observational design and the use of a 6-mg/kg dose of daptomycin, although the use of this relatively low dose would actually favor linezolid. The finding of higher mortality with linezolid differs from a recent meta-analysis of small studies, possibly due to limitations in the included studies or heterogeneous study populations, the authors said.

Not just 1 but 3 meta-analyses comparing daptomycin and linezolid found a survival benefit to linezolid, according to an accompanying editorial. However, they also found significant methodological limitations in the literature, leading the previously existing data to be “not compelling,” wrote the editorialists. Daptomycin is not FDA-approved for VRE bloodstream infections, but it has become a front-line agent anyway, they noted. More data would be helpful, but the current study results “should be reassuring” for clinicians using the drug for this indication, the editorialists wrote.

Score validated for predicting bleeding risk in inpatients

A recent study validated the IMPROVE score for predicting bleeding risk in inpatients and guiding venous thromboembolism prophylaxis.

The study included prospective data on 1,668 patients admitted for a medical illness to the Water Reed Army Medical Center from September 2009 through March 2014. Researchers calculated the IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) bleeding risk score for each patient using admission data. Results were published online by CHEST on July 23.

Bleeding events occurred during 2.7% of the admissions: major bleeds in 1.9% and non-major but clinically relevant bleeds in 0.8%. Overall, 20.7% of the studied patients had an IMPROVE score of 7 or higher, and Kaplan-Meier curves showed these patients to have a higher incidence of major and clinically important bleeding (P=0.02 and 0.06, respectively) than other patients. After adjustment for administration of chemical prophylaxis, a score of 7 or higher was significantly associated with major bleeds (odds ratio [OR], 2.6; 95% CI, 1.1 to 5.9; P=0.03), and there was a trend toward significance with clinically important bleeding (OR, 1.9; 95% CI, 0.9 to 3.7; P=0.07).

This first external validation of the IMPROVE score showed that it predicts major bleeding in medical inpatients and may help with assessing relative risks of bleeding and venous thromboembolism before prescribing prophylaxis, the authors concluded. This study's patient population differed from the score's derivation cohort, with more patients having cancer or requiring ICU admission, which strengthens the generalizability of the findings, they said. The lack of significant association between the score and clinically relevant bleeding events may be due to the study's limited ability to identify these events.

The IMPROVE bleeding score should be used in combination with assessment of venous thromboembolism risk to make prophylaxis decisions. One challenge is that a third of patients in this study would be classified as high risk for both bleeding and a clot, the authors noted. Future research should look for additional predictors of bleeding and identify thresholds for administering or withholding prophylaxis, they said.

Timely palliative care for inpatients with advanced cancer has cost-saving effect, study shows

Providing earlier palliative care consultation to patients with advanced cancer significantly lowers direct costs of hospital care, according to a multicenter study.

The prospective, observational study included 969 patients admitted to 4 hospitals with an advanced cancer diagnosis between 2007 and 2011. A palliative care team saw 256 of the patients, and the other 713 received usual care. The study showed that palliative care interventions within at least 6 days of admission had an estimated mean treatment effect of −$1,312 (95% CI, −$2,568 to −$56; P=0.04) compared with no intervention. Intervention within 2 days had even greater cost savings, with an estimated mean treatment effect of −$2,280 (95% CI, −$3,741 to −$819; P=0.002).

Therefore, the savings equaled 14% of direct hospital costs (which did not include hospital overhead) for a consult within 6 days and 24% for a consult within 2 days when compared with no consultation. Lab costs were significantly reduced irrespective of treatment timing, with a greater effect for earlier palliative care treatment. A secondary analysis attributed the cost savings to a combination of reduced length of stay and reduced intensity of hospital stay. The study was published by the Journal of Clinical Oncology on June 8.

These results show a clear pattern that earlier palliative care treatment is associated with a larger cost-saving effect, according to the study authors. “These results are consistent with a growing body of research on quality and survival, suggesting that early palliative care should be more widely implemented,” they concluded.

The study authors noted the limitations of the observational design and their efforts to correct for this issue. Because patient clinical characteristics are likely correlated with receipt of palliative care and with hospital costs, they used propensity scores to balance observed confounders, including the presence of advance directives and patients' perceived physical states. The study also experienced significant attrition, as it had to exclude about half of enrolled patients because of incomplete data. Another limitation is that the data were collected at hospitals with well-established palliative care programs in the United States, and it's not clear how generalizable the results are to new programs, programs in other health systems, or patients with noncancer diagnoses, according to the study.