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HospitalistWeekly 9-10-08
Highlights
- Study finds no difference in contrast agents in kidney patients undergoing coronary angiography
- Report shows slow down in hospital cost increases
Cardiology
- Stroke study reveals similar risk with all interventions
From the Annals of Internal Medicine
- Intermittent HIV treatment increases risk for related infections, death
- Medical student burnout linked to suicidal thoughts
- Study documents a decade of whistleblowers against Medicare fraud
Tools and resources
- New tool highlights look-alike/sound-alike drug errors
Drug news
- FDA: TNF blockers must get stronger warnings about infections
- Class 1 recall of Mobile Oxygen Storage Tank
- New cases of PML reported in patients taking natalizumab monotherapy
From ACP Hospitalist
- The latest issue is online and in your mailbox
From ACP Internist
- The latest issue is online
From the blog
- DTC advertising may not increase sales
Cartoon caption contest
- Put words in our mouth…
Highlights
.Study of contrast agents in kidney patients shows little difference
Hydration with sodium bicarbonate did not produce better outcomes than hydration with sodium chloride in patients with moderate to severe renal dysfunction who were undergoing coronary angiography, according to a randomized study reported in the Sept. 3 Journal of the American Medical Association.
Investigators randomized 353 patients (mean age 71) with stable renal disease who were undergoing coronary angiography at a single U.S. center and had an estimated glomerular filtration rate of 60 mL/min per 1.73 m2 or less and one or more of the following conditions: diabetes mellitus, history of congestive heart failure, hypertension, or age older than 75 years. Patients were randomized to receive either sodium chloride or sodium bicarbonate administered at the same rate—3 mL/kg for one hour before angiography, 1.5 mL/kg during the procedure and for four hours afterward.
The primary end point of a 25% or greater decrease in estimated GFR occurred in 14.6% of patients in the sodium chloride group and 13.3% in the sodium bicarbonate, a non-statistically significant difference. There was no distinct difference in the rate of death, dialysis, heart attack or cerebrovascular event in either group during the follow-up period which started 30 days after exposure to the contrast agent and extended to six months.
One difference noted by investigators was the incidence of contrast-induced nephropathy, which was significantly higher at 22.2% in the patients who underwent angiography for acute coronary syndrome indications vs. 7.3% in patients who underwent angiography for indications other than acute coronary syndrome.
.Report shows slow down in hospital cost increases
U.S. hospitals have made significant progress in stemming the rise of patient care costs, according to an Agency for Healthcare Research and Quality (AHRQ) report![[PDF]](/i/pdf.gif){kind=small}
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The cost of patient care in U.S. hospitals rose by just under 1% between 2005 and 2006, down from an average increase of 5.3% per year between 1997 and 2005. Despite this improvement, the overall cost for hospital stays nearly doubled from $177 billion to $329 billion from 1997 to 2006, an average annual increase of 7.1%. The findings suggest that the pervasiveness of managed care and the increased reliance on outpatient services have slowed the growth of inpatient care, according to the report.
Greater use of services was responsible for almost half (47%) of the rise in patient care costs over the nine-year period, AHRQ reported. Baby boomers aged 45 to 64 represented the largest increase in hospitalizations per patient with an upsurge of 40% from 1997 to 2006, followed by adults age 85 and older (26% increase).
The three most costly conditions treated in U.S. hospitals in 2006 were coronary artery disease, heart attack and congestive heart failure. The most frequent principal diagnoses were pregnancy/childbirth, pneumonia and coronary artery disease. The report also noted that the average length of stay (ALOS) in U.S. community hospitals stabilized beginning in 2000 at 4.6 days—almost 20% shorter than in 1993, when the ALOS was 5.7 days.
Also, between 1997 and 2006, the AHRQ analysis found:
- Discharges with a respiratory intubation and mechanical ventilation procedure grew by 41%;
- Discharges to home health grew by 53%;
- Discharges to nursing homes grew by 30%; and
- In-hospital deaths decreased by 5%.
AHRQ News and Numbers is based on data from HCUP Facts and Figures, 2006, which presents information derived from the 2006 HCUP Nationwide Inpatient Sample. The report includes information from a database containing discharge records for all patients treated in a sample of approximately 1,000 non-federal, short-term, acute care community hospitals.
Cardiology
.Dual purpose recurrent stroke study reveals similar risk with all interventions
Neither aspirin plus extended-release dipyridamole (ASA–ERDP) nor clopidogrel is any better or worse at reducing the risk of recurrent stroke, according to a randomized, industry-supported study published in the New England Journal of Medicine. In another arm of the same study, also published in NEJM, researchers found that the angiotensin-receptor blocker telmisartan failed to lower the rate of stroke recurrence, though it did lower blood pressure.
In the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial, 20,332 patients, from 695 centers in 35 countries, with a recent history of ischemic stroke were randomized to either 25 mg of aspirin plus 200 mg of extended-release dipyridamole twice daily or to 75 mg of clopidogrel daily. Patients were followed for 2.5 years, and researchers found that the risk of recurrent stroke or a major hemorrhagic event was similar: 1194 in the ASA–ERDP cohort vs. 1156 among the clopidogrel subjects.
In the antihypertensive arm of the trial, the PRoFESS investigators randomized 10,146 subjects to 80 mg daily of telmisartan and 10,186 subjects to placebo approximately two weeks after an ischemic stroke. In addition to the study medications, patients also received hypertension medication deemed appropriate by the investigators. The primary outcome was recurrent stroke.
Stroke recurrence rates did not differ significantly between the groups after 30 months, although blood pressure was lower among those on telmisartan. Mean blood pressure at the start of the study was 144.1 mm Hg systolic and 83.8 mm Hg diastolic. The between-group difference in diastolic blood pressure favoring telmisartan was 2.9 mm Hg at one month, 2.2 mm Hg at one year and 1.6 mm Hg by the end of the study. The results suggest that improvement in a risk factor does not necessarily result in a patient benefit, according to an observation in Journal Watch Cardiology (subscription required).
The antiplatelet portion of the PRoFESS study was originally supposed to compare clopidogrel plus aspirin with aspirin plus extended-release dipyridamole. The design was changed, however, when the Management of Atherothrombosis with Clopidogrel in High-Risk Patients with Recent TIA or Ischemic Stroke (MATCH) trial showed an increased risk of bleeding with the combination of clopidogrel and aspirin. Subjects who were originally assigned to the clopidogrel plus aspirin cohort had been treated for up to 8 months before the protocol was adjusted.
From the Annals of Internal Medicine
.Intermittent HIV treatment increases risk for related infections, death
Continuous treatment of HIV infection is better than stopping treatment when the patient’s immune status is good and restarting it when immune status deteriorates (interrupted treatment). At the end of this trial, patients assigned to intermittent treatment started continuous treatment and observed for 18 months. When persons assigned to interrupted treatment resumed continuous treatment, their risk for HIV related infections and death declined but was still slightly higher than those who had been receiving continuous treatment from the beginning.
.Medical student burnout linked to suicidal thoughts
Death by suicide is a major occupational hazard for physicians. Male and female physicians have a 40% and 130% higher suicide rate, respectively, than the general population. A survey of 4,287 students at seven medical schools revealed that many U.S. medical students think about suicide, suggesting that physicians’ increased risk for suicide may begin in medical school.
Burnout is common among medical students, and is associated with a two- to three-fold increased risk of thinking about suicide. In the study, 26% of burned out students recovered within the following year, indicating that burnout is reversible.
.Study documents a decade of whistleblowers against Medicare fraud
In the 1990s, the U.S. Department of Justice (DOJ) increased efforts to combat health care fraud, focusing on false claims made to Medicare and Medicaid programs in particular. The volume of litigation and financial recoveries related to health care grew quickly, especially among qui tam actions, those initiated by whistleblowers who are private citizens with inside knowledge of the alleged fraud.
By 2005, 90% of new health care fraud enforcement actions were initiated by whistleblowers. From 1996 to 2005, the DOJ closed 379 health care fraud cases and recovered $9.3 billion from defendants. Of those cases, the most common targets were provider organizations and billing practices. Although pharmaceutical manufacturers accounted for only 13 of the 379 cases, they accounted for nearly 40% of the total recovery because of the very large awards. Researchers concluded that fraud and abuse may increase during periods of rapid market expansion, but closer government oversight may also be a factor in better detection.
These studies are online.
Tools and resources
.New tool highlights look-alike/sound-alike drug errors
A new online tool enables physicians and consumers to look up drug names that have been identified with a medication error. The USP Drug Error Finder, from U.S. Pharmacopeia, is based on the nonprofit group's annual report on medication errors involving drug nomenclature.
The free Web tool includes more than 1,400 drugs that have been involved in look-alike and/or sound-alike errors. It lists the other drugs involved in the mix-up, as well as designating the severity of the reported error.
Drug news
.FDA: TNF blockers must get stronger warnings about infections
The FDA ordered the manufacturers of four tumor necrosis factor-α blockers (TNF blockers) to strengthen existing warnings on their prescribing information about the risk of developing opportunistic infections, a news release said.
The drugs, adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel) and infliximab (Remicade), can treat conditions ranging from rheumatoid arthritis to plaque psoriasis to Crohn's disease. Their packaging already includes information about infection risk, but reports to the FDA indicate health providers aren't consistently recognizing cases of histoplasmosis and other invasive fungal infections, leading to delays in treatment and sometimes death.
The FDA has reviewed 240 reports of histoplasmosis in patients treated with etanercept, adalimumab and infliximab, mostly in the Ohio and Mississippi River Valleys. In at least 21 of the 240 cases, the infections weren't initially recognized and treatment was delayed, and 12 of the patients died. All together, 45 of the 240 patients with histoplasmosis have died, the Washington Post reported.
The FDA has also gotten reports of coccidioidomycosis and blastomycosis in patients treated with TNF blockers, some of whom have died. In addition, there has been one reported case of histoplasmosis in a patient taking certolizumab pegol.
For patients who take TNF blockers and develop fever, malaise, cough, shortness of breath, weight loss or sweats, providers should ascertain if the patient lives in, or has traveled to, areas of endemic mycoses. For patients at risk of histoplasmosis and other invasive fungal infections, providers should consider empiric antifungal treatment until the pathogen/s are identified, the FDA said in a safety alert.
.Class 1 recall of Mobile Oxygen Storage Tank
FDA has issued a Class I recall of Pacific Consolidated Industries' Mobile Oxygen Storage Tank, manufactured and distributed between January and March 2007, because the pressure gauge may rupture and catch fire.
The reaction would occur as a result of hydraulic fluid being present in the pressure gauge tubing, the FDA said last week. Facilities that currently have the Mobile Oxygen Storage Tank should keep it in quarantine until arrangements are made to ship it back to the manufacturer.
.New cases of PML reported in patients taking natalizumab monotherapy
Two new cases of progressive multifocal leukoencephalopathy (PML) have been reported in European patients taking natalizumab (Tysabri) monotherapy for multiple sclerosis (MS) for more than a year, the FDA said in a recent alert.
Previous cases were seen only in patients with MS who took natalizumab as part of combination therapy with immunomodulatory agents. The manufacturer plans to revise prescribing information to reflect the cases that occurred with monotherapy, the FDA said. Natalizumab is available in the U.S. only to patients with relapsing MS or Crohn's disease who are enrolled in a risk minimization plan under which every patient is closely monitored for infections.
From ACP Hospitalist
.The latest issue is online and in your mailbox
Check out this month's issue for stories on:
- Post-traumatic stress disorder. While the military screens soldiers returning from combat, post-traumatic stress disorder can show up months or years after, when the person may have left the military health system and returned to private care.
- Ethical Dilemmas. Discontinuing treatment: In hopeless cases, providers have a right to refuse to continue.
- Career News. Which hospitalist model is right for you? Also, an attorney offers tips on contract negotiation.
The September issue of ACP Hospitalist online.
From ACP Internist
.The latest issue is online
Check out this month's issue for stories on:
- Post-traumatic stress disorder. While the military screens soldiers returning from combat, post-traumatic stress disorder can show up months or years after, when the person may have left the military health system and returned to private care.
- E-prescribing. Congressional mandates pushing internists to use e-prescribing could backfire, say experts who have tried—and sometimes failed—to incorporate the technology into their offices.
- Mindful Medicine. Don’t let emotion impede the right diagnosis. A case study shows how even subtle emotions can negatively influence thinking. Commentary by Jerome Groopman, FACP, and Pamela Hartzband, FACP.
The September issue of ACP Internist is online.
From the blog
.DTC advertising may not increase sales
On the blog this week, there's new evidence about the effectiveness of DTC advertising, recent guidelines on an unlikely topic and a special two-part Medical News of the Obvious.
Cartoon caption contest
.Put words in our mouth …
ACP InternistWeekly and ACP HospitalistWeekly want readers to create captions for this cartoon and help choose the winner. Craft your caption “Mad Libs” style by filling in the blanks to the caption we’ve started.
“It’s _______ [noun]. They’re ____ [adjective] about their _____ [noun].”
E-mail all entries to acphospitalist@acponline.org by Sept. 19. ACP staff will choose three finalists and post them in the Sept. 23 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Sept. 30 issue.
Pen the winning caption and win a $50 gift certificate good for any ACP product, program or service.
As a further distraction, more official Mad Libs are online.
Test Yourself
A 52-year-old woman is evaluated for a 6-week history of generalized malaise and fatigue. She received a kidney transplant 15 years ago for hypertension-related renal failure. What type of infection is the most likely cause of this patient’s worsening kidney function?
ACP Career Connection
Looking for a new hospitalist position?
ACP Career Connection can help you find your next job in hospital medicine. Search hospitalist positions nationwide that suit your criteria and preferences. Jobs are posted about two weeks before print publication of Annals of Internal Medicine, ACP Internist, and ACP Hospitalist. Exclusive “Online Direct” opportunities are updated weekly. Check us out online.
Is Your Practice Ready For Meaningful Use?
ACP and AmericanEHR Partners are holding a free Webinar, “Meaningful Use and Its Implications For Your Practice,” featuring Dr. David Blumenthal, National Coordinator for Health Information Technology. Sign up now for this national Webinar on August 4 at 7p.m. ET
MKSAP for Students 4 and Internal Medicine Essentials for Clerkship Students 2 Package
The American College of Physicians introduces the essential book set for medical students. Get both titles for one low price!