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HospitalistWeekly 11-12-08

Highlights

• Patient satisfaction not related to quality indicators
• Unfractionated heparin may decrease septic shock mortality

Cardiology

• Heart failure but not ischemia ups risk of death after MI
• Two performance measurement tools refine heart care

From ACP Hospitalist

• First annual "Top Docs" issue now online

From ACP Internist

• On the blog: Onsite coverage of AHA's scientific sessions

Cartoon caption contest

• Put words in our mouth …

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Highlights

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Patient satisfaction not related to quality indicators

The quality of care that patients receive does not affect their level of satisfaction with their hospital experience, according to a new study of patients who had myocardial infarctions (MI).

In this cohort study, patient satisfaction surveys were collected from 1,866 patients who had acute MI. Overall, 92% of patients reported that they were satisfied with their care. Researchers compared patient-reported satisfaction with clinical characteristics, measures of function, quality indicators and outcomes. The study found no association between the quality of MI care and satisfaction. There was also no relationship between satisfaction and survival. However, patients were more likely to be satisfied if they were older, not depressed and had better functional capacity. The research was published in the Nov. 4 issue of Circulation.

The absence of a relationship between quality and satisfaction may be due to a number of factors, but one likely cause is differences in treatment expectations between patients and physicians, the study authors said. Patients generally report higher satisfaction when their functional capacity meets their expectations. Therefore, better communication between physicians and patients could improve satisfaction by reducing the discrepancy in expectations, the researchers suggested.

They also concluded that, based on the study results, attempts to relate patient satisfaction data to quality of care could be misleading and should be discouraged. Examinations of patient satisfaction ratings should be undertaken with care and should account for patients' physical and psychological characteristics, the researchers said.

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Unfractionated heparin may decrease septic shock mortality

Intravenous unfractionated heparin (UFH) is associated with reduced mortality in patients with septic shock according to a retrospective, propensity matched Canadian cohort study published in the journal Critical Care Medicine.

The study included 2,326 patients age 18 or above who were diagnosed with septic shock and admitted to intensive care units between May 1989 and July 2005.The primary study outcomes were 28-day mortality and mortality stratified by illness severity. Researchers assessed the safety of heparin administration by comparing rates of gastrointestinal hemorrhage, intracranial hemorrhage and the need for allogeneic transfusion.

The mean duration of heparin therapy was 4.7 days, and low-dose prophylactic heparin was administered to 73.7% of patients in the control group within 48 hours of shock. Systemic heparin therapy was associated with decreased 28-day mortality, with a 44.2% survival rate, in comparison to a matched control group, which had a 40.1% survival rate. Among patients having the highest severity of illness, heparin administration was associated with a clinically and statistically significant reduction in 28-day mortality, with a 69% survival rate, compared with 56% in the matched control group. Researchers did not identify any significant differences between the groups as far as rates of major hemorrhage or need for transfusion.

The authors acknowledge that while the study cannot justify the use of full-dose intravenous heparin therapy for septic shock, the results highlight the need to conduct a prospective randomized control trial.

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Cardiology

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Heart failure but not ischemia ups risk of death after MI

During the first month after a myocardial infarction, patients have a higher than average risk of sudden cardiac death, and after 30 days, the death risk is increased by heart failure but not by recurrent ischemia, a new study found.

The population-based surveillance study included 2,997 residents of Olmsted County, Minn., who experienced a myocardial infarction (MI) between 1979 and 2005. Patients were followed for a median of 4.7 years. Of the patients who survived to hospital discharge, 1.2% had sudden cardiac death during the next 30 days, four times higher than the rate in the general population. After 30 days, however, the survivors' risk declines significantly, to 1.2% per year, which is lower than the risk in the general population. The study was published in the Nov. 5 Journal of the American Medical Association.

If the patients experienced heart failure during followup, the risk of sudden cardiac death more than quadrupled. The researchers also tracked patients with recurrent ischemia and they did not find it to be associated with a higher death risk. The findings highlight the importance of continued surveillance of patients after MI and remind clinicians to be particularly concerned about the development of heart failure in these patients, the study authors said.

The study also found that the risk of sudden cardiac death after MI declined more than 40% over the study period. Because the decrease in risk predated the widespread use of defibrillators, the study authors attributed it to changes in medical therapy, including reperfusion and secondary prevention. In contemporary times, the risk of sudden cardiac death after MI is quite low, except in cases of intercurrent heart failure, the authors concluded.

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Two performance measurement tools refine heart care

Two clinical performance measurement tools are aimed at helping doctors and hospitals give the best possible care to heart attack patients by gauging how closely they stick to guidelines after a heart attack.

Physicians can use the new heart attack performance measure, jointly developed by the American College of Cardiology and the American Heart Association, to track the following:

• Prescribing statins before discharge (Previous performance measures called for "lipid lowering therapy");
• Timely percutaneous coronary intervention (PCI) when the patient must be transferred from a hospital without a cardiac catheterization laboratory;
• Referral to a cardiac rehabilitation program (Only about one in three patients participate in such programs);
• Evaluation of left ventricular systolic function during hospitalization, which is essential for subsequent decisions about care;
• Several test performance measures, including evaluation of blood levels of low-density-lipoprotein cholesterol, dosage of several types of blood-thinning medications, and prescription at hospital discharge of clopidogrel.

They continue to track use of aspirin therapy, both at hospital arrival and as a discharge medication; beta blocker prescription at discharge; prescription of an angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker at discharge for patients with reduced pump function; time to delivery of clot-busting medications or PCI (in patients who are not transferred to another hospital); and counseling to stop smoking.

Also, the two groups released a performance measurement statement that clarifies key issues in measuring reperfusion therapy for patients with ST-segment elevation myocardial infarction. Major points include:

• Fibrinolysis should be provided within 30 minutes of first medical system contact and primary PCI should be provided within 90 minutes of first contact for patients with ST-segment elevation myocardial infarction (STEMI);
• Reperfusion performance measures should provide a quantitative assessment, introduce accountability for providing timely reperfusion, improve the quality of care, and to reduce adverse outcomes of patients with STEMI;
• An additional measure should be developed and implemented that includes patients who are transferred from one hospital to another for reperfusion;
• An exclusion should account for patient-centered reasons for delaying reperfusion therapy;
• Systems providing reperfusion therapy should time-synchronize all ECG machines and electronic catheterization lab documentation systems;
• Measure interventions from the time of first device use rather than the time of restoration of flow or time to first angiography; and
• Report separately the time to PCI for patients who are transferred for reperfusion from those who are not.

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From ACP Hospitalist

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First annual 'Top Docs' issue now online

The November ACP Hospitalist is now online, featuring its first annual Top Hospitalists issue highlighting doctors reinventing and expanding the role of the hospitalist at their facilities.

Also in this issue:

• The hospitalized hospitalist. James S. Newman, FACP, recalls (somewhat fuzzily) his hip transplant
• Calling for backup before it’s needed. Hospitals tackle ‘failure to rescue' errors
• Windshield time and North Dakota nice. One of the country’s least populous states offers lessons for the rest
• Q&A: Finding an algorithm for heart failure. William T. Abraham, FACP, discusses OPTIMIZE-HF trial

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From ACP Internist

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On our blog: Onsite coverage of AHA's Scientific Sessions

Conference coverage continues with a look at the American Heart Association's Scientific Sessions. Also, look for the latest installment of Medical News of the Obvious, new every Monday.

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Cartoon caption contest

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Put words in our mouth

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

E-mail all entries by Nov. 14. ACP staff will choose three finalists and post them in the Nov. 18 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Nov. 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 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