COPD transitions, afib in sepsis

Summaries from ACP Hospitalist Weekly.

Transition and self-management program helps reduce COPD readmissions

A three-month program that combined transition and long-term management support resulted in fewer hospitalizations and ED visits related to chronic obstructive pulmonary disease (COPD) and improved health-related quality of life at six months, a study found.

The single-site randomized clinical trial included 240 participants who were either hospitalized for an acute COPD exacerbation or had a previous COPD diagnosis and were receiving additional treatment to control COPD symptoms during the current hospitalization. They were randomized to the intervention or usual care. Results were published by JAMA on Nov. 12, 2018, and appeared in the Dec. 11 issue.

Image by Getty Images
Image by Getty Images

The intervention was a three-month program delivered by specially trained nurses. It included transition support to help patients and caregivers prepare for discharge and understand the postdischarge plan of care; individualized self-management support to help patients take medications correctly, recognize exacerbations signs and follow an action plan, practice breathing exercises and energy conservation techniques, maintain an active lifestyle, seek help as needed, and stop smoking; and facilitated access to community programs and treatment services. Usual care included transition support for 30 days after discharge to ensure adherence to the discharge plan and connection to outpatient care.

The primary outcome, COPD-related hospitalizations and ED visits per participant at six months, was 0.72 (95% CI, 0.45 to 0.97) in the intervention group versus 1.40 (95% CI, 1.01 to 1.79) in the usual care group (difference, 0.68; 95% CI, 0.22 to 1.15; P=0.004). The co-primary outcome was change in participants' health-related quality of life measured by the St. George's Respiratory Questionnaire (SGRQ), a 50-item questionnaire with scores ranging from 0 (best) to 100 (worst); a four-point difference is clinically meaningful. The mean baseline SGRQ score was 63.1 in the intervention group and 62.6 in the usual care group. The mean change in participants' SGRQ total scores at six months was −1.53 in the intervention group and 5.44 in the usual care group (adjusted difference, −6.69; 95% CI, −12.97 to −0.40; P=0.04). During the study period, there were 15 deaths (seven in the intervention group and eight in the usual care group) and 337 hospitalizations (135 in the intervention group and 202 in the usual care group).

The researchers wrote that several features of the program may have increased its efficacy, including starting COPD self-management conversations and connecting patients with the COPD nurse during hospitalization, providing at-home and telephone support, and individualizing care to patient needs and priorities.

“In addition, early communications with clinicians, which were encouraged whenever signs of exacerbation were detected, may have provided a mechanism for reducing hospitalizations as clinic-based clinicians may be less likely to admit patients who have an acute COPD exacerbation than ED clinicians,” the authors wrote.

An accompanying editorial noted the study represents “an important contribution” but expressed concerns about the generalizability of the results, noting that the intervention was time- and resource-intensive, relied on creation of a care team, and targeted a specific patient population (many with low income and education levels). “The narrow focus of the intervention on COPD-specific management may also miss the opportunity for more comprehensive patient-centered care,” the editorial said, calling for additional research before the study's findings are applied widely.

New-onset afib in sepsis related to sepsis risk factors, review finds

New-onset atrial fibrillation in patients with sepsis is more likely to be linked to sepsis risk factors than conventional risk factors, according to a recent systematic review and meta-analysis.

Researchers analyzed English-language observational and randomized, controlled studies that identified risk factors for new-onset atrial fibrillation or new-onset atrial flutter in adult patients with sepsis. Studies were excluded if they involved only unadjusted risk factors, did not distinguish between paroxysmal atrial fibrillation and new-onset atrial fibrillation, or involved new-onset atrial fibrillation only after cardiothoracic surgery. Risk factors for new-onset atrial fibrillation during sepsis were classified according to type, factor effect sizes were quantified, and sepsis-associated risk factors were compared with community-associated risk factors. The results were published online Dec. 4, 2018, by Critical Care Medicine and appeared in the February 2019 issue.

Eleven studies were included in qualitative assessment, and eight studies were included in the quantitative meta-analysis. Forty-four potential risk factors were examined, 18 of which were seen in at least two studies and included in the pooled meta-analysis. Twenty-six additional factors that were seen in only one study were evaluated in the qualitative analysis. While certain demographic characteristics and comorbid conditions appeared to increase risk for new-onset atrial fibrillation in sepsis, sepsis-related factors were associated with the strongest risk. Corticosteroid use, right-heart catheterization, fungal infection, vasopressor use, and a mean arterial pressure target of 80 to 85 mm Hg were associated with a greater than 50% change in odds of new-onset atrial fibrillation. However, some conditions known to be risk factors for community-associated atrial fibrillation, such as hypertension and diabetes, were not associated with higher risk for new-onset atrial fibrillation in sepsis.

The researchers noted that the included studies were heterogeneous, that some studies used administrative claims codes to identify atrial fibrillation and sepsis, and that none used the Sepsis-3 criteria to define sepsis or septic shock, among other limitations. However, they concluded that certain acute and chronic risk factors are associated with risk for new-onset atrial fibrillation during sepsis and that most are associated with the sepsis event itself, most strongly with the effects of catecholamines or inflammation. “Recognition of sepsis-related factors points to potential differences in the mechanisms of [atrial fibrillation] development in sepsis versus in the community and provides potential targets for future treatment studies and clinicians focusing on [atrial fibrillation] prevention in sepsis,” the authors wrote.

Hospitalizations, heart valve surgeries for drug-associated infective endocarditis increase

Rates of overall hospitalizations, as well as hospitalizations with surgery, for drug use-associated infective endocarditis markedly increased from 2007 to 2017, according to a recent study of North Carolina hospitals.

Using a statewide hospital discharge database, researchers analyzed all adult patients hospitalized for infective endocarditis from July 1, 2007, through June 30, 2017. Drug use-associated infective endocarditis was identified by a diagnosis code indicating recreational drug use, withdrawal, dependence, poisoning, or a diagnosis of hepatitis C virus infection in patients born after 1965 (codes for marijuana use or unspecified drug use were excluded). Results were published online on Dec. 4, 2018, by Annals of Internal Medicine and appeared in the Jan. 1, 2019, issue.

Of 22,825 infective endocarditis hospitalizations during the 10-year period, 2,602 (11%) were associated with drug use. Valve surgery was performed in 1,655 (7%) infective endocarditis hospitalizations, including 285 (17%) for drug use-associated infective endocarditis.

Annual hospitalizations for drug use-associated infective endocarditis increased from 64 (0.92 per 100,000 persons) in 2007 to 2008 to 867 (10.95 per 100,000 persons) in 2016 to 2017, an increase of about 12-fold. Until mid-2013, fewer than 10 drug use-associated infective endocarditis hospitalizations with surgery occurred each year in North Carolina. By 2016 to 2017, there were 109 (1.38 per 100,000 persons), an increase of 13-fold. Similar increases were not observed in cases of infective endocarditis without drug use. The most common drugs observed in drug use-associated infective endocarditis were opioids, which were involved in 1,626 (62%) cases. Of all patients hospitalized with drug use-associated infective endocarditis, 333 (13%) were discharged against medical advice.

Compared to patients with non-drug use-associated infective endocarditis, those hospitalized for drug use-associated infective endocarditis were younger (median age, 35 years vs. 67 years), were more often female (51% vs. 48%) and of non-Hispanic white ethnicity (81% vs. 61%), and had longer lengths of stay (median, 11 vs. 7 days) with higher median charges ($60,333 vs. $34,968). The same differences were found in comparisons of patients having surgery for infective endocarditis that was or was not drug use-associated.

The authors noted that the study used administrative data lacking granular clinical information and may have been subject to inaccurate coding of drug use or other diagnoses. They added that using hepatitis C virus infection as an indicator of drug use (which accounted for 18% of cases) may have artificially increased the number of drug use-associated infective endocarditis cases detected.

Clinicians must take action to improve care for patients with drug use-associated infective endocarditis, according to an accompanying editorial. For instance, they should know that no evidence exists to support concerns around providing postdischarge outpatient parenteral antibiotic therapy to people with a history of substance use, according to the editorialist. In addition, to help avoid discharge against medical advice and readmissions, addiction medicine clinicians must be involved soon after infected patients are admitted, the editorialist said. “Initiating medical treatment for substance use disorder during hospitalization is acceptable, feasible, and sustainable after discharge,” the editorialist wrote.

Sodium bicarbonate and acetylcysteine did not reduce AKI after PCI in patients with CKD

Rates of acute kidney injury after percutaneous coronary intervention (PCI) were not reduced by use of IV sodium bicarbonate or oral acetylcysteine, according to a recent study of patients with chronic kidney disease.

Image by Getty Images
Image by Getty Images

Researchers conducted a subgroup analysis of the PRESERVE (Prevention of Serious Adverse Events Following Angiography) trial. PRESERVE randomized 5,177 patients with stage III or IV chronic kidney disease undergoing angiography to IV 1.26% sodium bicarbonate or IV 0.9% sodium chloride and five days of oral acetylcysteine or placebo. The current analysis looked at the 1,161 patients in the trial who had PCI. Their median estimated glomerular filtration rate was 50.7 mL/min/1.73 m2, and 82% had diabetes. Results were published by JACC: Cardiovascular Interventions on Nov. 19, 2018.

The study's primary endpoint was a composite of death, need for dialysis, or persistent kidney impairment at 90 days. It occurred in 15 of 568 patients (2.6%) in the IV sodium bicarbonate group and 24 of 593 patients (4.0%) in the IV sodium chloride group (odds ratio, 0.64; 95% CI, 0.33 to 1.24; P=0.41) and in 23 of 598 patients (3.8%) in the acetylcysteine group and 16 of 563 patients (2.8%) in the placebo group (odds ratio, 1.37; 95% CI, 0.71 to 2.62; P=0.29). A secondary endpoint, contrast-associated acute kidney injury, did not differ significantly between groups.

Previous trials and meta-analyses on this topic have had inconsistent results, and many had methodological limitations, the study authors noted. They believe the current study to be the largest trial to date of IV sodium bicarbonate and acetylcysteine in patients undergoing PCI. Based on the findings, they recommended that PCI guidelines from the American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions be revised to recommend IV sodium chloride. Sodium chloride is more readily available than sodium bicarbonate and does not have as many incompatibilities with cardiac medications, the authors noted. They did caution that their analysis was limited because it excluded very high-risk patients and involved mostly men.

An accompanying editorial comment described how a profusion of small trials of sodium bicarbonate and acetylcysteine and inclusion of these trials in meta-analyses led to confusion about the evidence base. “The PRESERVE trial closes the lengthy chapter on N-acetylcysteine and sodium bicarbonate for [contrast-induced acute kidney injury] prevention almost 2 decades after it began. The arc of the research universe can be long, but it bends toward the truth,” the comment said.

Physician-specific discharge practice patterns related to LOS in heart failure

Certain physician discharge practice patterns were associated with shorter length of stay (LOS) in hospitalized patients with heart failure, a recent study found.

Researchers used a five-point Likert scale survey to assess physician-specific discharge strategies for patients with heart failure at a large academic teaching hospital in Texas. The survey was administered to cardiologists and hospitalists and asked about the influence of 10 discharge readiness factors, including physical examination findings, diuretics, and kidney function, on discharge decisions. A mean Likert scale score above 3.00 was considered more influential, and a mean score below 3.00 was considered less influential. Data on physician-specific LOS and 30-day readmission rates from July 1, 2015, to June 30, 2016, were extracted from the electronic medical record. Study results were published online by Circulation: Cardiovascular Quality and Outcomes on Nov. 14, 2018.

Sixty-nine physicians were surveyed, and 58 physicians, 32 hospitalists and 26 cardiologists, returned responses and had data available on heart failure utilization metrics. Physicians' median time in practice was 7 years (interquartile range, 3 to 13 years), and 48% were women. For the 753 heart failure discharges included in the study, the median LOS was 4.5 days (interquartile range, 4.0 to 5.8 days). The total 30-day readmission rate was 17.0%, involving 128 unique readmissions, and the expected 30-day readmission rate was 25%. The observed-to-expected readmission ratio was 0.67 for the full cohort.

The most influential factors in determining discharge readiness reported by the physicians were resolution of exertional dyspnea and resolution of orthopnea, while a recorded downtrend of N-terminal pro-B-type natriuretic peptide level was the least influential factor. Compared with physicians whose patients had a LOS above the median, physicians whose patients had a LOS below the median were less likely to emphasize the influence of observing a patient on oral diuretics for 24 hours before discharge (P=0.01), reaching documented dry weight (P=0.02), and achieving complete resolution of dyspnea on exertion (P=0.03). In particular, hospitalists who placed more emphasis on 24 hours of oral diuretics before discharge had a length of stay almost one day longer than those who did not. No association was seen between any of the discharge practices included in the survey and physician-specific 30-day readmission rate.

The study was done at a single center among a small number of physicians, the authors noted. In addition, they said the readmission rate and observed-to-expected readmission ratio did not include readmissions to other local medical facilities and that their survey did not capture daily practice patterns of heart failure management, among other limitations. However, they concluded that individual physicians vary substantially in the value placed on factors used to determine whether a patient with heart failure is ready for discharge and that addressing these variations might help influence outcomes. They called for larger prospective studies to confirm their findings.

An accompanying editorial also noted the study's limitations but said the authors should be commended for addressing an innovative question on a complex topic, where decisions involve so many different variables that two equally skilled clinicians can vary widely in how they choose to care for the same patient.

“Before we can disseminate best practices, we have to understand what works and what does not,” the editorialists wrote. “Through rigorous examination of the factors impacting timing of hospital discharge in [heart failure], we can identify useful benchmarks and subsequently work toward reducing unnecessary variation and improving outcomes.”

Inpatient exercise program reversed functional decline among hospitalized elderly

A twice-daily inpatient exercise program reversed functional decline among hospitalized patients ages 75 years and older, according to a recent single-center study.

The trial was conducted from Feb. 1, 2015, to Aug. 30, 2017, in an acute care unit in a tertiary hospital in Navarra, Spain, and included 370 patients (median age, 87.3 years; range, 75 to 101 years). While in the hospital, they were randomized to either usual care, which included physical rehabilitation when needed, or an individualized moderate-intensity exercise program for 20 minutes twice a day. Morning sessions consisted of supervised progressive resistance, balance, and walking exercises, while unsupervised evening sessions consisted of light weights, extension, and flexion of the knee and hip along with walking. The median length of stay was eight days in both groups, and the median duration of the intervention was five days.

At discharge, the exercise group showed significant improvement on the primary outcome, change in functional capacity from baseline. Compared to the usual care group, they had a mean increase on the Short Physical Performance Battery scale of 2.2 points (0.2 point vs. 2.4 points; 95% CI for difference between groups, 1.7 to 2.6 points) and 6.9 points on the Barthel Index (−5.0 points vs. 1.9 points; 95% CI for difference, 4.4 to 9.5 points). The study also found improvements from baseline to discharge in measures of cognitive status, depression, quality of life, and hand grip in the intervention group but not in the usual care group. Results were published by JAMA Internal Medicine on Nov. 12, 2018, and appeared in the January 2019 issue.

The authors noted that, in contrast with these results, a recent randomized trial showed no significant benefit from a simple in-hospital mobility program. “Thus, our data, together with those of previous research, suggest that interventions beyond walking stimulation are needed to preserve functional capacity in older patients during acute hospitalization,” they wrote.

The intervention did not affect incidence of delirium during hospitalization or readmission or mortality at three months, the authors observed. Limitations include the lack of data gathering on patients' function and cognitive status prior to the acute illness; self-reported baselines could have been subject to retrospective bias, they said.

“A singular feature of the program was that patients had significant personal responsibility for the program,” said an accompanying commentary. Another strength of the study was that the program incorporated readily available, reasonably priced, low-technology exercise equipment that could be used in virtually any hospital, the commentary noted, calling for future research to provide increased clinical granularity.