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In the News

From the April ACP Hospitalist, copyright © 2009 by the American College of Physicians

New opioid therapy guidelines

Two professional societies recently released guidelines on opioid therapy to treat chronic, noncancer pain.

The American Pain Society and the American Academy of Pain Medicine convened a multidisciplinary panel of 21 experts to review evidence and compose 25 recommendations. The recommendations, published in the February Journal of Pain, advise providers to:

• Do a history, physical exam and appropriate testing— including a risk assessment of substance abuse—before starting a patient on chronic opioid therapy (COT);
• Consider a COT trial for patients whose pain is moderate or severe and for whom it has an adverse impact on function or quality of life;
• Reassess patients on COT periodically, with monitoring to include documenting pain and functioning levels, adherence, and presence of adverse events;
• Use COT on patients with a history of drug abuse or psychiatric issues only if they can be monitored more frequently and strictly;
• Do periodic urine drug screens on patients at high risk or who engaged in drug-related behavior in the past, and possibly on patients who aren’t high-risk, too; and
• Evaluate health status, adherence and side effects on an ongoing basis in patients on high doses of COT, and consider more follow-up visits.

Survival after surgery at teaching hospitals differs by race, study finds

Survival rates after surgery at teaching hospitals are worse for black patients than for white patients, a recent study reports.

Researchers performed a retrospective study of Medicare claims for general, orthopedic and vascular surgery from 2000 to 2005 to determine whether lower mortality rates after surgery at U.S. teaching hospitals are due to better complication rates or improved mortality rates after complications occur. They also examined whether this improved postsurgical survival differed by patient race. The main outcome measures were 30-day mortality rate, in-hospital complications, and failure to rescue, defined as “the probability of death after complications.” The study appeared in the February Archives of Surgery.

Data from over 4 million individual patients at 3,270 hospitals were examined. The authors found that patients undergoing surgery at hospitals with high teaching intensity (defined as 0.6 resident per bed) had a 15% lower risk for death and a 15% lower risk for death after complications than patients at nonteaching hospitals (P< 0.001 for both comparisons), while rates of complications overall did not differ. This benefit was not seen for black patients, whose risk for death and risk for death after complications were similar at teaching and nonteaching hospitals.

The authors acknowledged their study’s limitations, including a lack of data from patients’ medical records and a lack of information on severity. However, they concluded that improved survival rates after surgery at teaching hospitals are seen only among white patients. Black patients may have worse mortality and failure-to-rescue rates because they are more likely to go to hospitals with worse rates overall, but this possibility can’t entirely explain the study results, the authors wrote.

ICD guidelines often not followed, study finds

Guidelines for the use of implantable cardioverter-defibrillators (ICDs) are often not followed in U.S. hospitals, according to a recent study.

Researchers from the “Get with the Guidelines” steering committee performed a study to determine how hospitals varied in application of guidelines for ICD use. Data from 10,148 patients treated at 134 hospitals were examined. Eligible patients were those who met Class I recommendations for ICDs according to the American College of Cardiology/American Heart Association 2005 guidelines on heart failure. All hospitals were voluntary participants in the “Get with the Guidelines-Heart Failure” registry. The researchers calculated rates of ICD prescriptions from January 2005 to June 2007. Their results appeared in the February 3 Journal of the American College of Cardiology.

Hospitals that had higher ICD prescription rates also had higher rates of adherence to other, newer heart failure performance measures.

Overall, 20% of patients received a prescription for an ICD. ICD use varied considerably from hospital to hospital (range, 0% to 80%) and was more common in larger hospitals and those that were able to perform percutaneous coronary intervention, coronary artery bypass grafting, and heart transplants. Hospitals that had higher ICD prescription rates also had higher rates of adherence to other, newer heart failure performance measures, such as beta-blocker use.

The study had several limitations, including the possibility that hospitals participating in “Get with the Guidelines” were more likely to follow evidence-based recommendations than nonparticipating hospitals. However, the authors concluded that ICD use in the U.S. varies significantly by hospital and called for future studies to determine how wider use could be achieved. An accompanying editorial said the study will help improve therapy for heart failure because it described for the first time the type of hospital most likely to adopt newer evidence- based measures.

In the News is a product of ACP HospitalistWeekly, an e-newsletter provided every Wednesday by ACP Hospitalist. If you’re not already receiving ACP HospitalistWeekly, contact Customer Service at 800- 523-1546, ext. 2600, or directly at 215-351-2600 (M-F, 9 a.m. to 5 p.m. EST) or send an e-mail to custserv@acponline.org.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated