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HospitalistWeekly 8-6-08

Cardiology

• Aging population spurs sharp rise in heart failure hospitalizations

Critical care

• Mobility therapy may shorten hospital stays in ICU patients with acute respiratory failure

Patient safety

• Surgical errors costly after hospital discharge, AHRQ reports

Annals of Internal Medicine

• Rapid HIV test yields lower-than-expected specificity
• Survey finds chronic illness common among uninsured

From ACP Internist

• On the blog: More exercise needed to maintain weight loss

Cartoon caption contest

• July's winning entry

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Cardiology

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Aging population spurs sharp rise in heart failure hospitalizations

Hospitalizations for heart failure more than tripled between 1979 and 2004, with the sharpest increase among older patients covered by Medicare, a recent study found.

Researchers used data from the National Hospital Discharge Survey to assess trends in hospitalizations for heart failure as either a first or additional diagnosis. Hospitalizations with any mention of heart failure rose from 1.27 million in 1979 to 3.86 million in 2004, with more than 80% of the hospitalizations among patients 65 years or older.

Heart failure was listed as the first diagnosis in 30% to 35% of total hospitalizations. However, researchers noted increases in hospitalizations that listed respiratory diseases and noncardiovascular, nonrespiratory diseases as the first diagnosis, as well as an increase in transfers of heart failure patients to long-term care facilities. Meanwhile, in-hospital mortality and length of stay declined. The study appears in the Aug. 5 Journal of the American College of Cardiology.

Better control of other diseases that can exacerbate heart failure, such as pneumonia, diabetes and kidney disease, may help reduce hospitalizations of people with heart failure, a study author told the July 28 Washington Post. However, more research is needed to develop in-hospital treatments for severe heart failure, the author continued, since there is currently no effective treatment for heart failure severe enough to cause hospitalization.

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Critical care

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Mobility therapy may shorten hospital stays in ICU patients with acute respiratory failure

Mobility therapy performed early in an intensive care unit (ICU) stay may shorten length of stay in patients with acute respiratory failure, a new study reports.

Previous studies have shown that physical therapy can improve the immobilization and weakness that may lead to prolonged hospitalization in ICU patients, but a uniform approach to providing such therapy had not previously been tested. Researchers performed a prospective cohort study at a North Carolina hospital to determine whether a dedicated mobility protocol led to increased rates of physical therapy versus usual care in 330 mechanically ventilated patients with acute respiratory failure.

Over a 24-month period, 165 patients were assigned to the usual care group (daily passive range of motion therapy and, in unconscious patients, repositioning every two hours) and 165 were assigned to the protocol group. Beginning within 48 hours of mechanical ventilation, protocol patients received physical therapy daily from a dedicated ICU mobility team composed of a critical care nurse, a nursing assistant, and a physical therapist. The study appears in the August issue of Critical Care Medicine.

Physical therapy was much more likely to have been received in the protocol group: 80% of protocol patients had at least one physical therapy session before hospital discharge compared with 47% in the usual care group (P< 0.001). Patients in the protocol group also got out of bed earlier and were more likely to receive therapy in the ICU (5 vs. 11 days and 91% vs. 13%, respectively; P< 0.001 for both comparisons). Both hospital and ICU stays were shorter in the protocol group than in the usual care group (5.5 days vs. 6.9 days [P= 0.025] and 11.2 vs. 14.5 days [P= 0.006], respectively), while overall costs were similar. No therapy-related adverse events occurred in the ICU in either group.

Although the study was not blinded and involved therapy only in the ICU, the authors concluded that a dedicated mobility team increased provision of physical therapy to mechanically ventilated patients with acute respiratory failure. They also noted that while costs did not differ significantly between groups, the absolute costs were lower in the protocol group, probably due to the decrease in length of stay. Future studies, they wrote, should validate the possible cost benefits of a dedicated mobility protocol and try to determine the effect of early mobilization on patients' long-term functional outcomes.

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Patient safety

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Surgical errors costly after hospital discharge, AHRQ reports

Potentially preventable adverse events that occur during or after surgery can be costly even 90 days after discharge, according to a new study from the Agency for Healthcare Research and Quality (AHRQ).

AHRQ researchers analyzed data from 161,004 patients in employer-based health plans who had surgery between 2001 and 2002. The authors identified 14 patient safety indicators and looked at associated medical expenditures, death, readmission and outpatient care within 90 days of surgery. The results appear in the July 2008 Health Services Research.

Insurers paid an additional 52%, or $28,218, and an additional 48%, or $19,480, for each surgery patient who had acute respiratory failure or postoperative infections, respectively, than for those who didn't, according to an AHRQ press release. The excess mortality rate and excess 90-day admission rate associated with preventable events were 0% to 7% and 0% to 8%, respectively. Eleven percent of deaths, 2% of readmissions and 2% of expenditures were probably related to potentially preventable events, the authors reported.

The authors concluded that medical errors can affect patient outcomes and health care costs even after hospital discharge and that focusing only on inpatient costs can underestimate errors' overall impact. In the agency's press release, AHRQ's director called for continued attention to eliminating medical errors and their after effects.

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Annals of Internal Medicine

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Rapid HIV test yields lower-than-expected specificity

Information is lacking about how often patients who have a positive rapid test in the emergency department actually have HIV infection confirmed with traditional HIV testing. In 2006, the Centers for Disease Control and Prevention (CDC) recommended that all persons aged 13 to 64 be offered HIV screening in health care settings.

In a study, 849 adults underwent HIV testing with the rapid test when they visited an emergency department for another reason. Of these, 39 tested positive. However, only five of the 39 were shown to actually have HIV infection after traditional testing was done. Twenty-six of 39 were negative and eight refused traditional testing. This study suggests that many patients who test positive with this rapid HIV test are "false positives," meaning that they do not truly have HIV infection. The authors concluded that quick and more reliable methods of testing are needed.

In related news, the CDC reported this week that the number of new cases of HIV infection in the U.S. is approximately 40% higher than originally thought. The revised numbers are based on new laboratory testing methods that allow more precise measurements of HIV incidence, the CDC said in a press release. Further details are available in the Aug. 6 issue of JAMA.

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Survey finds chronic illness common among uninsured

An analysis of data from the National Health and Nutrition Examination Survey (1999-2004) involving more than 12,000 patients aged 18 to 64 concluded that an estimated 11.4 million Americans with chronic medical conditions, such as cardiovascular disease, hypertension and diabetes, were uninsured.

The survey found that chronically ill patients without insurance were less likely than those with coverage to report a physician visit within the last 12 months and more likely to report using an emergency department as a standard site for care. The authors estimated that nearly one-third of uninsured U.S. adults had at least one chronic condition. However, the authors said that given the limited access to care among those without insurance, undiagnosed conditions in this population may be common. The authors called for advocacy focused on expansion of health insurance coverage, as lack of health insurance is strongly associated with poor access to care.

Annals of Internal Medicine is online.

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From ACP Internist

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On the blog: More exercise needed to maintain weight loss

Overweight and obese women need to exercise almost an hour a day, five days a week, just to sustain weight loss. And they must do that in addition to continuing to limit their calories. Find this and Medical News of the Obvious new every Monday at ACP Internist's blog.

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Cartoon caption contest

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July's winning entry

ACP HospitalistWeekly and ACP InternistWeekly have compiled the results from their latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Jerry Antonini, ACP Member, at OSF HealthCare in Bloomington, Ill. He will receive a $50 gift certificate good for any ACP program, product or service. Readers cast 183 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

"Your insurance plan considers all of your conditions 'pre-existing.'"

The winning caption received 54.6% of the votes cast. The runners up were:
"Please stop comparing me to your last doctor." (29.5%)
"In your condition, I consider your gait to be normal." (15.8%)

The cartoon contest continues in August.

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ACP JournalWise:
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Learn on the Go with Internal Medicine 2012 Digital Presentations!

© ACP Hospitalist and American College of Physicians

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