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HospitalistWeekly 6-18-08
Highlights
- Progress made on surge capacity, but gains may not last, study finds
- In-hospital interventions may show promise for secondary prevention of ACS
Neurology
- Women, Mexican Americans at higher risk for subarachnoid hemorrhage
Annals of Internal Medicine
- Hearing impairment common among adults with diabetes
- Coffee drinkers have slightly lower death rates
- HIV screening cost-effective in patients over 55
Joint Commission update
FDA update
- Boxed warning for becaplermin to reflect increased cancer risk
- Morphine sulfate recalled
- Zoledronic acid can now be used to prevent new fractures
From ACP Hospitalist
- Recommend your colleagues as Hospitalists of the Year
From ACP online
- What they're saying on the blog
Cartoon caption contest
- Put words in our mouth: vote for your favorite entry
For the record
- Clarification of a recent story
Highlights
.Progress made on surge capacity, but gains may not last, study finds
Recent progress toward improved surge capacity in the U.S. may not be permanent, a new study reports.
The Center for Studying Health System Change looked at development of surge capacity programs in six U.S. communities—Boston; Greenville, S.C.; Miami; Phoenix; Orange County, Calif.; and Seattle—and interviewed national experts and officials in New York City, Washington, D.C., and New Orleans. The study aimed to determine how these communities had worked to improve their surge capacity as well as the obstacles they faced in maintaining and furthering these gains.
The authors found that communities have become much more aware of the need for improved surge capacity and have developed multiple plans to deal with possible disasters. However, communities also reported that federal funding for surge capacity efforts has been declining, making it more difficult to keep up and expand existing programs. Hospitals face particular financial pressure because surge capacity programs are not subsidized by private or public payers and because surge capacity development is not profitable, the study authors wrote. Staffing issues are also a matter of concern. Some communities are attempting to take the pressure off hospitals by encouraging patients to seek out other providers for nonemergent care in a disaster and by ensuring that long-term care facilities and mental health facilities are included in disaster planning.
The study authors concluded that broad support, participation and collaboration are necessary for successful surge capacity planning, that adequate funding for surge capacity programs must be maintained, and that workforce and staffing issues must be addressed. "Without continued federal funding and policy attention, surge capacity developments and achievements are likely to erode," they wrote.
The research brief from the Center for Studying Health System Change is online.
.In-hospital interventions may show promise for secondary prevention of ACS
In-hospital interventions may help reduce mortality in patients with acute coronary syndromes (ACS), according to a preliminary study.
Outpatient programs for secondary prevention of ACS have been shown to be effective, but little research has been done on inpatient interventions. Swiss and Canadian researchers performed a systematic review of 26 studies to determine the effectiveness of secondary prevention interventions in the inpatient setting. Before-after studies and controlled clinical trials that involved at least a patient-level intervention in a population with ACS and examined rates of mortality, readmission or reinfarction as outcomes were included. Interventions were classified as patient-level interventions with or without provider-level or system-level interventions. The results were published online June 9 by Circulation.
Among 14 studies that provided follow-up data on all-cause mortality at one year, the relative risk was 0.79 (95% CI, 0.69 to 0.92). However, the mortality benefit was greater in before-after studies than in controlled clinical trials (relative risk, 0.77 vs. 0.96). Greater mortality benefit was also seen with interventions that had a provider- or system-level rather than only a patient-level component (relative risk, 0.77 vs. 0.93).
The authors wrote that the evidence supporting inpatient interventions for ACS is "promising but not definitive" because a statistically significant mortality benefit was seen only in before-after trials involving multilevel rather than solely patient-level interventions. In addition, their study was limited by the design of the included trials and the heterogeneity of the interventions, among other factors. The authors called for future randomized trials to assess which intervention components have the greatest effect on outcomes.
Circulation is online.
Neurology
.Women, Mexican Americans at higher risk for subarachnoid hemorrhage
Mexican Americans and women may be at higher risk for subarachnoid hemorrhage, a new study found.
Researchers screened the medical records of 29,901 people in southwest Texas, 38% of whom were non-Hispanic whites, 55% of whom were Mexican American, and 6% of whom were African American. The median age was 70, and 60% were women. Researchers validated 5,540 cerebrovascular events during the study time period of January 1, 2000 to December 31, 2006; of those, 107 cases were subarachnoid hemorrhages that were used in the final analysis. The study was published in the June 11 online issue of Neurology.
Subarachnoid hemorrhage was 67% more common in Mexican Americans compared to non-Hispanic whites, and 74% more common in women compared to men, after adjustments for age. There were no significant racial/ethnic/gender differences in prevalence of hypertension, excessive alcohol use, tobacco use, hospital length of stay or in-hospital mortality—except that men had greater excessive alcohol use than women.
Past research suggests genetics may play a role in the higher risk of subarachnoid hemorrhage for Mexican Americans, the authors noted. Prior studies have also shown lower treatment rates of hypertension in Hispanics, and more poorly controlled hypertension in racial/ethnic minorities, they said. Past research also suggests that differences in hypertension, smoking and alcohol use, and the role of estrogen might explain the gender disparity, but more research needs to be done on this, as well as on the possibility of a gender/ethnicity interaction in subarachnoid hemorrhage, the authors said.
The Neurology abstract is online.
The American Academy of Neurology press release is online.
Annals of Internal Medicine
.Hearing impairment common among adults with diabetes
Hearing impairment is common in adults with diabetes, and diabetes seems to be an independent risk factor for the condition, according to a new analysis of the National Health and Nutrition Examination Survey.
Researchers analyzed data from 5,140 adults aged 20 to 69 who completed an audiometric examination and a diabetes questionnaire between 1999 and 2004. Hearing impairment was more prevalent among adults with diabetes. Age-adjusted prevalence of low- or mid-frequency hearing impairment of mild or greater severity assessed in the worse ear was 21.3% among 399 adults with diabetes compared to 9.4% among 4,741 adults without diabetes.
These differences in hearing between people with and without diabetes were present in both sexes; all groups of race or ethnicity, education, and income; and all age groups but the oldest. Similarly, age-adjusted prevalence of high-frequency hearing impairment of mild or greater severity assessed in the worse ear was 54.1% among adults with diabetes compared to 32% among adults without diabetes.
"It is possible that high blood sugar levels damage the small blood vessels and nerves of the inner ear, resulting in hearing impairment," said the study's lead author. "People with diabetes might benefit from having their hearing checked."
The study was released early online and will appear in the July 1, 2008, print issue of Annals of Internal Medicine.
View the report in streaming video format.
.Coffee drinkers have slightly lower death rates
Drinking large amounts of coffee (up to six cups per day) does not increase a person's risk for dying sooner than expected and may actually be protective, according to a new study.
Researchers analyzed data of 84,214 women who had participated in the Nurses' Health Study and 41,736 men who had participated in the Health Professionals Follow-up Study. Study participants completed questionnaires every two to four years that included questions about how frequently they drank coffee, other diet habits, smoking and health conditions. The researchers then compared the frequency of death from any cause, death due to heart disease and death due to cancer among people with different coffee-drinking habits.
Women consuming two to three cups of caffeinated coffee per day had a 25% lower risk of death from heart disease during the follow-up period (which lasted from 1980 to 2004) as compared with non-consumers, and an 18% lower risk of death caused by something other than cancer or heart disease. For men, this level of consumption was associated with neither a higher nor a lower risk of death during the follow-up period.
After accounting for other risk factors, such as body size, smoking, diet and specific diseases, the researchers found that people who drank more coffee were less likely to die during the follow-up period. This was mainly because of lower risk for heart disease deaths among coffee drinkers. The researchers found no association between coffee drinking and cancer deaths. These relationships did not seem to be related to caffeine because people who drank decaffeinated coffee also had lower death rates than people who did not drink coffee.
View the report in streaming video format.
.HIV screening cost-effective in patients over 55
A new study examined the cost-effectiveness of HIV screening in patients from age 55 to 75. Recently revised screening guidelines issued by the CDC recommend that all patients aged 13 to 64 be tested.
The study looked at economic effects of voluntary HIV screening in 8,672 inpatients and outpatients at six Department of Veterans Affairs Health Care Systems whose HIV status was unknown. The authors concluded that if the tested population has an HIV prevalence of 0.1% or greater, HIV screening in persons from age 55 to 75 is cost-effective.
The authors also suggest that to be cost-effective, screening decisions in patients older than 64 should include factors such as whether the patient is at increased risk, has a partner at risk for contracting HIV or has other life-threatening conditions. Advanced age alone should not preclude screening for HIV.
Annals of Internal Medicine is online.
Joint Commission update
.New inpatient psychiatric measures announced
The Joint Commission has announced a new set of inpatient psychiatric measures that satisfy current ORYX performance measurement requirements. The new measures will take effect on Oct. 1, 2008, and can be used by accredited hospitals providing acute inpatient psychiatric services.
The final measure set includes the following:
- Admission screening for violence risk, substance use, psychological trauma history and patient strengths completed;
- Hours of physical restraint use;
- Hours of seclusion use;
- Patients discharged on multiple antipsychotic medications;
- Patients discharged on multiple antipsychotic medications with appropriate justification;
- Postdischarge continuing care plan created; and
- Postdischarge continuing care plan transmitted to next level of care provider upon discharge.
Additional information is available online.
.Joint Commission to hold medication safety symposium
The Medication Safety Symposium: Teaming Up for Medication Management and Systems Improvement, convened by The Joint Commission and Joint Commission Resources, will take place August 5-7 at the Westin River North Hotel in downtown Chicago.
Due to the intricate relationships among all who are responsible for safe medication outcomes, the symposium is grounded in an interdisciplinary approach. The symposium's purpose is to examine the major issues that influence medication safety. It will be taught by pharmacists, nurses and physicians who will provide proven approaches and solutions that they have used to overcome these issues in their organizations. In turn, faculty will share tools to effect these changes via a conference CD-ROM that participants can use in their home organizations to speed the change process.
More information is online.
FDA update
.Boxed warning for becaplermin to reflect increased cancer risk
A boxed warning will be added to the becaplermin (Regranex Gel 0.01%) label about an increased risk of cancer death in patients who use three or more tubes of the cream, the FDA said last week.
The product is used to treat leg and foot ulcers that aren't healing in diabetic patients. A retrospective study compared cancer incidence and cancer death among 1,622 patients exposed to Regranex to 2,809 otherwise similar patients who were not exposed. There was no overall increase in cancer among those who used the cream, but there was a fivefold higher risk of cancer death in those who were exposed to three or more tubes of Regranex, the FDA said.
Providers should carefully weigh the risks and benefits of using Regranex; it's not recommended for use on patients with known malignancies, an FDA official said.
The FDA release is online.
.Morphine sulfate recalled
ETHEX Corp. is recalling several lots of morphine sulfate 30-mg and 60-mg extended-release tablets because they may contain tablets of twice the appropriate thickness.
Oversized tablets may contain up to twice as much the labeled level of active morphine sulfate. The lots were distributed under an "ETHEX" label between June 2006 and May 2008. The 30-mg product is a pink oval tablet with "30" on one side and "E" on the other. The 60-mg product is a white oval tablet with "60" on one side and "E" on the other. ETHEX Corp. originally recalled only one lot of the 60-mg product but extended the recall on June 13.
No reports of unexpected side effects or injury from the tablet have been received, the FDA press release said.
The recalled lot numbers are available in the FDA press release online.
The original press release regarding the recall is online.
.Zoledronic acid can now be used to prevent new fractures
Zoledronic acid (Reclast) has been approved to prevent new fractures in patients who recently had a low-trauma hip fracture. The once-yearly, intravenous bisphosphonate is already indicated to treat osteoporosis. The FDA decided to expand the drug's use based on data from a trial that showed a 35% reduction in the risk of new clinical fractures in patients treated with zoledronic acid. The risk of new spine fractures was reduced by 46% and new non-spine fractures by 27%, according to a release by the drug's manufacturer.
Side effects may include transient post-dose symptoms like fever and muscle pain, which usually resolve within three days. These effects can also be reduced by adminstering paracetamol or ibuprofen shortly after Reclast infusion.
The drug manufacturer's press release is online.
From ACP Hospitalist
.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.
From ACP Internist
.What they're saying on the blog
Join ACP Internist's community on our blog, featuring daily updates on news that just can't wait. Find popular features such as Medical News of the Obvious, which trains its critical eye this week on news from the Associated Professional Sleep Society's annual meeting. Post your comments today.
Cartoon caption contest
.Put words in our mouth: vote for your favorite entry
Our cartoon caption contest continues. ACP staff has selected four finalists for the latest contest and is now asking readers to vote for their favorite caption to determine the winner.
Go online to view the cartoon and pick the winner, who receives 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.
For the record
.Clarification of a recent story
A story in the June 4 edition of ACP HospitalistWeekly on nosocomial infection risk with femoral and jugular catheterization should have stated explicitly that the study under discussion involved only short-term dialysis catheters. Only 9% of catheters were in place for more than 15 days.
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