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HospitalistWeekly 6-11-08

Highlights

• QRS duration predicts outcomes in patients hospitalized for heart failure
• No difference in PCI outcomes between men and women, study finds

Health care disparities

• Quality of health care affected by race and geography, report finds

Quality improvement

• New defibrillators and debriefings improved CPR

End-of-life care

• Survey raises questions about nurses' role in discussing DNR orders with patients

Ethics

• Student organization rates med schools on pharma interactions

From ACP Hospitalist

• Recommend your colleagues as Hospitalists of the Year

From ACP online

• What they’re saying on the blogs and in our newsgroups

Cartoon caption contest

• Put words in our mouth

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Highlights

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QRS duration predicts outcomes in patients hospitalized for heart failure

Patients with prolonged QRS durations do worse than those with normal QRS durations after hospitalization for heart failure, according to a new study.

Researchers from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) performed a retrospective post hoc analysis to determine whether duration of QRS interval predicted outcomes in patients hospitalized for heart failure with decreased left ventricular ejection fraction (LVEF). The study involved 2,962 patients, 1,641 with normal QRS durations at baseline (defined as <120 ms) and 1,321 with prolonged QRS durations at baseline (defined as >120 ms). The study's primary end points were death from all causes and cardiovascular death or hospitalization for heart failure. Patients were followed for a median of 9.9 months. The study appears in the June 11 Journal of the American Medical Association.

Patients with prolonged QRS duration were more likely to be older and male, have lower LVEF and systolic blood pressure, and have higher levels of serum brain natriuretic peptide and serum urea nitrogen. During the follow-up period, patients in the normal group had lower rates of all-cause mortality (18.7% vs. 28.1%; hazard ratio, 1.61 [95% CI, 1.38 to 1.87]) and cardiovascular death or heart failure hospitalization (32.4% vs. 41.6%; hazard ratio, 1.40 [95% CI, 1.24 to 1.58]) than those in the prolonged group. These increased risks persisted after adjustment for multiple variables.

The authors acknowledged several limitations of their study, including its post hoc design and the lack of information available about QRS duration before study enrollment. However, they concluded that patients hospitalized for heart failure with reduced LVEF often have prolonged QRS intervals and that this variable indicates high rates of morbidity and mortality after discharge, even when optimal therapy is provided.

The Journal of the American Medical Association is online.

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No difference in PCI outcomes between men and women, study finds

The gender gap in outcomes after percutaneous coronary intervention (PCI) has disappeared, with women faring as well as men in both the short- and long-term, a new study found.

Earlier studies have shown that PCI was riskier in women than men, in part because women have smaller arteries. PCI has improved over the last decade, however, with new techniques, stents and medications.

To test the effects of the recent advances, researchers analyzed data from 18,885 patients who underwent PCI at the Mayo Clinic in Rochester, Minn. between 1979 and 2004. Patients were divided into two groups: those treated between 1979 and 1995 (“early group”) and those treated between 1996 and 2004 (“recent group”). Women were older than men at the time of PCI by an average of about five years, and were more likely to have severe or unstable chest pain, diabetes and high blood cholesterol levels. The study is published in the June 10 online issue of the Journal of American College of Cardiology.

The immediate success rate for PCI was 89% in women and 90% in men. Among women, 30-day mortality fell from 4.4% in the early group to 2.9% in the recent group (P= 0.002). Among men, 30-day mortality fell from 2.8% to 2.2% in the same time period (P= 0.04). When researchers adjusted for the greater age and health problems of women at the time of PCI, there were no significant mortality differences between men and women either at 30 days or one year after PCI.

The study should reassure many physicians who, research has shown, are more reluctant to refer women for invasive procedures like PCI, said lead author Mandeep Singh, ACP Member, in a release. “Raising awareness among physicians will help us overcome this referral bias. The decision to refer a patient for PCI should not be influenced by gender,” Dr. Singh said.

The Journal of the American College of Cardiology is online.

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Health care disparities

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Quality of health care affected by race and geography, report finds

Getting mammograms and other basic recommended health care varies significantly by race and geographic region, according to a new report on Medicare beneficiaries released last week by the Robert Wood Johnson Foundation.

Researchers at the Dartmouth Atlas Project at the Dartmouth Institute for Health Policy and Clinical Practice analyzed Medicare claims on five quality measures and found that overall, blacks were less likely than whites to get recommended care and that quality varied across regions. One in three women did not get mammograms in 2004-05, the study reported. Blacks were less likely than whites to undergo the screening (57% vs. 64%, respectively) while Maine fared best (74%) and Mississippi worst (57%) in regional comparisons.

The most striking racial disparity was for leg amputations due to complications from peripheral vascular disease and diabetes, the report said. African Americans were five times as likely to lose a leg as were whites (4.17 per 1,000 beneficiaries vs. 0.88 per 1,000, respectively), with the highest rate of amputations in Louisiana (1.66 per 1,000 patients).

Researchers also reported that one in seven patients with diabetes were not getting important blood tests, with 85% of white patients with diabetes getting a hemoglobin A1c test between 2003-05 compared with 79% of blacks. There was a 20-point gap between the state with the highest percentage of diabetics getting the blood tests (Vermont) and the state with the lowest percentage (Alaska).

In conjunction with the report's release, the Robert Wood Johnson Foundation announced a $300 million initiative called Aligning Forces for Quality aimed at improving care in 14 communities across the U.S., according to a June 5 foundation news release. The effort is aimed at improving overall health care quality, reducing racial and ethnic disparities and providing models for national reform.

The Robert Wood Johnson news release and full report are online.

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Quality improvement

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New defibrillators and debriefings improved CPR

Regular debriefings can improve residents’ performance during in-hospital cardiopulmonary resuscitations, according to a new study.

During the year-long study, internal medicine residents at one university hospital attended weekly debriefing sessions on the prior week’s resuscitations. The sessions reviewed performance transcripts from a CPR-sensing and feedback-enabled defibrillator that was used for all cardiac arrests. Quality and outcome data for 123 patients who had a cardiac arrest during the study were compared with data from 101 control resuscitations. The resuscitations in the control period also used a feedback-delivering defibrillator, but no debriefings were conducted.

The study found that the quality of CPR was improved under the debriefing system, as measured by a decrease in the mean ventilation rate and an increase in compression depth. The intervention group of patients also had a higher rate of return of spontaneous circulation (59.4% vs. 44.6%) but no difference in survival to discharge. The study was published in the May 26 Archives of Internal Medicine.

The study authors concluded that the debriefing system (which they called resuscitation with actual performance integrated debriefing [RAPID]) increases the benefits of the audiovisual feedback which is now available from many defibrillators. RAPID may work by sensitizing rescuers to the prompts that the defibrillators offer during resuscitations, or by making residents aware that their performance will be reviewed in an open forum.

Although the study found no difference in survival, the authors concluded that RAPID has the potential to improve both resuscitation training and patient outcomes. They noted that many other post-resuscitation quality factors, such as therapeutic hypothermia and tight glycemic control, could have affected the rates of survival to discharge.

The Archives of Internal Medicine is online.

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End-of-life care

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Survey raises questions about nurses' role in discussing DNR orders with patients

Nurses are more comfortable discussing do-not-resuscitate (DNR) orders with patients than are doctors, according to a new survey.

Researchers surveyed 217 attending internists, 132 medical house officers and 219 staff nurses from two teaching hospitals to directly compare their feelings about DNR orders, specifically the role nurses should play in the DNR process. The survey results appear in the June Critical Care Medicine.

Overall, approximately 82% of nurses, 69% of attendings and 69% of house officers disagreed somewhat or disagreed strongly with the statement that nurses should never initiate DNR discussions. Of the three groups, nurses were least likely to report that discussing DNR orders with patients or families was difficult but were most likely to believe that they should not recommend a DNR order. Nurses were less confident than attendings but as confident as house officers in their ability to discuss consent for DNRs with patients.

Although the survey was small and involved only two hospitals in the same city, the authors concluded that the results may have value for future discussions of nurses' roles in the DNR process. In particular, they questioned why nurses are often not allowed to initiate DNR discussions and suggested a reevaluation of nurses' and physicians' roles in this area of end-of-life care.

Critical Care Medicine is online.

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Ethics

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Student organization rates med schools on pharma interactions

Many U.S. medical schools still have work to do on their efforts to restrict conflicts of interest caused by pharmaceutical marketing, according to the American Medical Student Association (AMSA).

Last week, AMSA released its PharmFree Scorecard which rated the country’s 150 medical schools on their conflict-of-interest policies. The scorecard evaluated the schools’ regulations on gifts, paid speaking for products, acceptance of samples, interaction with sales representatives and industry-funded education, among other criteria.

Only seven schools received an A, and 14 scored a B. The A-rated schools were: Mount Sinai School of Medicine, the University of Pittsburgh Medical Center, the Uniformed Services University of the Health Sciences, the University of California Los Angeles David Geffen School of Medicine, the University of Pennsylvania School of Medicine, the University of California, Davis School of Medicine, and the University of California, San Francisco School of Medicine.

Of the remaining schools, four received a C, 19 received a D and 60 received an F. Schools that declined to submit policies or did not respond to requests for their policies received an automatic F. An additional 28 respondents received a grade of “in process” because their policies are currently under review or revision.

AMSA collaborated with the Prescription Project, an industry watchdog group, to develop the methodology of the scorecard and an interactive Web site that offers a school-by-school look at policies regarding industry interaction with medical school faculty and trainees.

The scorecard is online.

The May ACP Hospitalist cover story, which looked at changes to conflict-of-interest policies, is online.

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From ACP Hospitalist

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Recommend your colleagues as Hospitalists of the Year

ACP Hospitalist is seeking candidates for its first annual Hospitalists of the Year issue. To recommend a colleague who made notable contributions to the field in 2008, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement, readers can fill out the online form. All recommendations must be received by July 14. Hospitalists of the Year will be profiled in our November 2008 issue.

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From ACP online

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What they’re saying on the blogs and in our newsgroups

Join your colleagues on ACP's blogs and online newsgroups, which let our member internists talk directly to one another about what's on their minds. Clinical issues, politics, practice management issues and even some humor are part of the mix.

In the past week alone, ACP Internist's blog has updated clinicians on breaking medical advances, highlighted two useful resources for keep abreast of guidelines and drug alerts, and continued its feature on "Medical News of the Obvious," new every Monday.

Updates happen daily, so keep checking back.

ACP’s discussion boards let internists reach one another about clinical and practice management issues. The newsgroups have been active for years and have a core of members who post items ranging from curbside consultation on patients to passionate political debate.

In the Clinical Practice newsgroup, one participant wrote: “The speaker [at Internal Medicine 2008] indicated that he told his medical students and residents that to him this drug was more than just equal to placebo, it was a drug that seemed to work 40% of the time and he reminded the students that in real life practice placebo is not an option.”

A respondent replied: “In oncology, we'll reject a therapy that isn't significantly better than placebo. Not only must the benefit (as defined prior to the trial)—be it progression free interval, response rate, etc. must be statistically better than placebo; but the result must be clinically meaningful. A treatment that improves survival by one week isn't worthless, even if the p value is <0.00001.”

Join discussions at http://www.acponline.org/auth-cgi/readnews.pl.

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Cartoon caption contest

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Put words in our mouth

ACP HospitalistWeekly and ACP InternistWeekly want readers to create captions for this cartoon and help choose the winner.

E-mail acphospitalist@acponline.org all entries by June 13. ACP staff will choose three finalists and post them in the June 18 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the June 25 issue.

Pen the winning caption and win a copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history.

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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