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HospitalistWeekly 10-22-08

Highlights

• Top-ranked hospitals have 70% fewer deaths, report finds
• Intestinal Clostridium difficile not always linked to antibiotics

Cardiology

• Stress testing often skipped before elective PCI

Disease management

• Smoking cessation programs effective if continued after discharge

From Annals of Internal Medicine

• USPSTF recommends primary care providers promote breastfeeding
• Combining therapies may improve outcomes for pulmonary hypertension patients
• Nurse-led heart failure management reduces cost, burden
• Call for papers

FDA review

• ETHEX recalls potentially oversized Dextroamphetamine tablets
• New treatment approved for benign prostatic hyperplasia

From ACP Hospitalist

• The October issue is online and in your mailbox
• Mindful Medicine case studies wanted

Cartoon caption contest

• Vote for your favorite entry

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Highlights

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Top-ranked hospitals have 70% fewer deaths, report finds

The death rate at top-ranked U.S. hospitals is on average 70% lower than at the lowest-ranked hospitals, according an annual report that ranks hospitals on 17 conditions and procedures from 2005 to 2005.

Healthgrades, which prepared the report, examined 41 million Medicare patient records at the nation's approximately 5,000 hospitals. The company estimated that 237,420 deaths could potentially have been prevented if all hospitals performed at the "five star" level (the report gives one, three or five stars to each hospital based on how many patients develop complications and die after being treated).

More than half (54%) of the deaths during the study period were associated with four conditions: sepsis, pneumonia, heart failure and respiratory failure, according to a Healthgrades news release. The report noted that the overall in-hospital risk-adjusted mortality rate declined by almost 15% from 2005 to 2007. However, top-performing hospitals reduced their death rates more significantly than low performing hospitals, 13.2% vs. 12.3%.

The data illustrate that significant gaps persist between the best and the worst hospitals, according to the report. Five-star hospitals had significantly lower risk-adjusted mortality across all procedures and diagnoses that were studied. Patients have a 50% lower chance of dying in a five-star rated hospital compared with the U.S. hospital average, according to the release. The report also found regional differences: the East-North-Central region had the lowest overall risk-adjusted mortality while the East-South-Central region had the highest mortality.

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Intestinal Clostridium difficile not always linked to antibiotics

Contrary to common thought, community-acquired Clostridium difficile infections develop even in the absence of prior exposure to antibiotics, according to a study published in the Canadian Medical Association Journal. Researchers urged physicians to test for the infection in all patients who have severe diarrhea, particularly when it requires a hospital visit.

The study relied on two health databases to perform a matched, nested case-control study of elderly patients admitted to a hospital with community-acquired C. difficile infection. For each of the 836 cases, the researchers first selected 10 controls and determined the proportion of cases that occurred without prior antibiotic exposure and then estimated the risk related to exposure to different antibiotics and the duration of increased risk.

The study found that the highest risk of C. difficile infection from antibiotic use happens in the month following treatment and that the risk declines significantly after 45 days. For the eight-year study period, researchers identified 5,673 hospital admissions for which C. difficile-associated diarrhea was listed as the primary diagnosis. Of these, 836 cases met their definition of community-acquired C. difficile infection. About half of the patients admitted to a hospital because of community-acquired C. difficile infection had no recent antibiotic exposure.

The relative risk of C. difficile infection associated with antibiotic exposure declined from 15.4 about 20 days after exposure to 3.2 at 45 days after exposure. Use of a proton pump inhibitor was associated with increased risk, as was concurrent diagnoses of inflammatory bowel disease, irritable bowel syndrome and renal failure.

The study’s findings are limited, according to an editorial because of narrow inclusion criteria. For instance, the study population was restricted to patients age 65 or older with at least one prior hospital admission in the previous eight years.

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Cardiology

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Stress tests often skipped before elective PCI

Less than half of Medicare patients with stable coronary artery disease have documentation of ischemia by noninvasive stress testing prior to elective percutaneous coronary intervention (PCI), according to a retrospective, observational study published in the Journal of the American Medical Association.

This finding is in direct opposition to guidelines for PCI published jointly by the American College of Cardiology, the American Heart Association and the Society for Cardiovascular Angiography and Intervention. The guideline states that for patients with stable angina, any vessels to be dilated must have a shown association with a moderate to severe degree of ischemia on noninvasive testing.

Researchers analyzed 23,887 Medicare claims and 1,630 private insurance claims. They found that 45% of the entitlement program patients underwent stress testing in the three months before angioplasty and that 34% of the non-Medicare beneficiaries underwent stress testing within 12 months of their PCI.

Women, patients treated by physicians under age 40, and patients treated by physicians who perform large numbers of angioplasties were less likely to have test-confirmed ischemia. Patients over age 85 and those with concomitant heart conditions such as congestive heart failure or chronic obstructive pulmonary disease were also less likely to undergo a pre-PCI stress test. Conversely, black patients and those with a history of chest pain were more likely to have a stress test before undergoing angioplasty.

The study revealed regional distinctions in pre-PCI stress testing as well, with physicians in the Midwest and Northeast most likely to order stress tests.

The authors point out that elective angioplasty has increased by 300% during the past decade and has accounted for at least 10% of the increase in Medicare spending since the mid-1990s. Current proposals to restructure Medicare payments to reward hospitals and physicians who adhere to guidelines would improve the safety and delivery of health care to Medicare beneficiaries, the authors said.

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Disease management

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Smoking cessation programs effective if continued after discharge

Smoking cessation programs for hospitalized patients are effective, but only if they are maintained for at least a month after discharge, a new review found.

The review included 33 randomized and quasi-randomized trials of smoking cessation interventions that began during hospitalization. Researchers found the programs that included supportive contacts for more than one month after discharge increased the percentage of patients who were nonsmoking six to 12 months later by 65%. Shorter interventions, both counseling and pharmacotherapy, showed no benefit.

There was also an indication that programs were particularly effective when provided to patients admitted for cardiovascular disease and when they included nicotine replacement therapy in addition to counseling, but neither of those findings reached the level of statistical significance. The study was published in the Oct. 13 Archives of Internal Medicine.

Study authors noted that the counseling interventions in the included studies were usually delivered by research nurses or trained counselors and that the results might be difficult for clinical staff to replicate. They did conclude that the results of the review support the decision by the Joint Commission and CMS to include a tobacco measure in the national hospital quality-of-care standards. Based on the study, the current quality measure could reasonably be expanded to apply to all hospitalized smokers and strengthened to require that smoking interventions begun in the hospital continue after discharge, the authors said.

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From Annals of Internal Medicine

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USPSTF recommends primary care providers promote breastfeeding

The U.S. Preventive Services Task Force concluded that doctors, nurses, hospitals and health systems encourage and support breastfeeding in an update to its 2003 recommendation. The Task Force evaluated more than 25 randomized trials of breastfeeding interventions conducted in the U.S. and in developed countries around the world. Coordinated interventions throughout pregnancy, birth and infancy can increase breastfeeding initiation, duration and exclusivity and emphasized health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support, the Task Force concluded. The guideline and background paper are online. ACP has prepared a video news release.

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Combining therapies may improve outcomes for pulmonary hypertension patients

Adding sildenafil (Viagra) to epoprostenol therapy may improve some outcomes for patients with pulmonary hypertension. Researchers conducted an open-label randomized study of 267 patients to determine whether the combination improves outcomes more than epoprostenol alone. All of the patients in the study had been receiving intravenous epoprostenol for at least three months, and were randomly assigned either oral sildenafil or placebo for 16 weeks. At the end of the study, patients given sildenafil could walk longer distances and had a longer period of time before getting worse than those given placebo.

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Nurse-led heart failure management reduces cost, burden

Nurse-led disease management is a reasonably cost-effective way to reduce the burden of heart failure in an ethnically diverse urban setting, a study concluded. Randomized, controlled trials have shown that nurse-led disease management for patients with heart failure can reduce hospitalizations. However, there is less evidence about the cost-effectiveness of these programs. Researchers looked at cost data from a randomized trial of 203 usual care patients versus 203 nurse-managed patients with heart failure. The study consisted mainly of black and Hispanic patients with lower socioeconomic status. Patients in the nurse-managed group maintained better physical functioning throughout the 12-month intervention than did usual care patients. In addition, nurse-led case management cost $20,000 per additional year of survival in good health.

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Call for papers

Annals of Internal Medicine invites submissions of papers reporting on studies that will be presented at the March 2009 American College of Cardiology meeting. Annals staff will coordinate publication and press releases for all accepted papers to coincide with the presentation. To be eligible for potential publication coincident with the meeting, submit your manuscript online no later than Jan. 5, 2009. Clearly indicate in the cover letter that the manuscript reports findings that will be presented at the meeting.

Annals is particularly interested in 1) trials with clinical end points that test pharmacotherapies, devices, or behavioral interventions and 2) systematic reviews or meta-analyses that address benefits and harms of widely used therapies. The journal reaches a broad audience of clinicians and decision makers through print, electronic, video, and audio-related content. Annals' recent impact factor is 15.5, and its print circulation is over 90,000.

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FDA review

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ETHEX recalls potentially oversized Dextroamphetamine tablets

ETHEX Corporation voluntarily recalled three lots (77946, 81141 and 81142) of Dextroamphetamine Sulfate 5 mg tablets, as a precaution, due to the possible presence of oversized tablets. Oversized tablets may contain as much as about twice the labeled amount of the active ingredient. The recalled lots were distributed under an "ETHEX" label between January 2007 and May 2008. The 5 mg product is an orange round tablet debossed with "ETHEX" and "311" on one side.

A larger dose would increase the risk of adverse effects such as tachycardia, hypertension, tremors, decreased appetite, headache, insomnia, dizziness, blurred vision, stomach upset, and dry mouth. An FDA alert is online.

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New treatment approved for benign prostatic hyperplasia

The FDA approved Rapaflo (silodosin) capsules for symptoms due to benign prostatic hyperplasia (BPH). Rapaflo works by blocking the ÿ-1 adrenoreceptors in the prostate, bladder, and urethra, allowing the smooth muscle in these tissues to relax.

Rapaflo will be available in a once-daily capsule. An 8 mg daily dose is recommended for men who do not suffer from kidney or liver impairment. A 4 mg daily dose will be available for men with moderate renal impairment. Rapaflo is not recommended for men with severe kidney or liver impairment and is not approved for pediatric use.

The most common side effect seen with Rapaflo is reduced or no semen during orgasm. This side effect does not pose a safety concern and is reversible with discontinuation of the product. Patients planning cataract surgery must notify their ophthalmologist that they are taking Rapaflo because of the possibility of Intraoperative Floppy Iris Syndrome (IFIS), a complication associated with cataract surgery. Patients on alpha-blockers or those who have severe kidney or liver impairment should not use Rapaflo.

An FDA press release is online.

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From ACP Hospitalist

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The October issue is online and in your mailbox

The next issue of ACP Hospitalist is online and in your mailbox.

Hospitalist teams embrace age, experience. Physicians who move from the community to the hospital mid-career present a potential solution to the hospitalist field's perennial workforce shortage.
Be your own boss. Hospitalists face issues as they decide whether to start up or join a local hospitalist group, become part of a large group or management company, or be a hospital employee.
Married hospitalists benefit work-life balance. By working as hospitalists in the same practice, some doctors are able to take care of families and spend quality time together.

The latest issue is online. Not a subscriber? Call for a free subscription at 800-523-1546.

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Mindful Medicine case studies wanted

ACP Hospitalist columnists Jerome Groopman, FACP, and Pamela Hartzband, FACP, would like to hear about your stories of difficult or missed diagnoses for possible use in their next Mindful Medicine column.

Dr. Groopman, a hematologist/oncologist and author of the bestselling "How Doctors Think," and Dr. Hartzband, an endocrinologist, are on the Harvard Medical School faculty and serve as staff physicians at Boston's Beth Israel Deaconess Medical Center. In issues of ACP Internist and ACP Hospitalist, the columnists consider cases submitted by readers describing a difficult or missed diagnosis, and provide commentary on how a mistake was, or might have been, avoided.

Please e-mail your suggestions to Drs. Groopman and Hartzband. The authors will contact you to discuss the case if your submission is selected for the column.

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Cartoon caption contest

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Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. ACP staff has selected three 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 $50 gift certificate good for any ACP product, program or service.

EDITOR'S NOTE: For all our readers who submitted their captions through ACP Internist's new Web site at www.acpinternist.org, we did receive your captions despite an error message you saw upon submission. That glitch is fixed.

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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