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HospitalistWeekly 12-17-08

Highlights

• No single treatment best for pressure ulcers
• Data on errors collected but rarely used for improvements

Cardiology

• Women with STEMI have higher death rates than men, study finds

Annals of Internal Medicine

• Interruptions in Medicaid coverage increase unnecessary hospitalizations
• Family members want straight talk about poor patient prognosis
• Home rehab safe, viable for COPD

FDA update

• Boxed warning ordered for bowel prep used before colonoscopy

From ACP Hospitalist

• Read about nocturnists in the latest issue, now online

From ACP Internist's blog

• A wrap-up of the week's strange and fascinating events

Cartoon caption contest

• Pick the year's best

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Highlights

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No single treatment best for pressure ulcers

No pressure ulcer treatment is better than any other, and a lack of high-quality studies makes it difficult to parse out comparisons, concluded a review of support surfaces, nutritional supplements, wounds dressings, biologic agents and adjunctive therapies.

Researchers found that of 103 randomized, controlled clinical trials that met inclusion criteria, most did not provide enough information about potential financial conflicts of interest, and study methodology varied too widely to perform a meta-analysis. The review was published in the Dec. 10 issue of JAMA.

• Twelve trials evaluated support surfaces. But evidence did not favor powered vs. non-powered surfaces, and no trials compared a support surface to a standard mattress and repositioning. Support surfaces only address the role of pressure in decubitus ulcers, and not shear, friction, temperature and moisture. Regular turning and transferring schedules may be less expensive, but no trial examined these regimens.
• Seven trials evaluated nutritional supplements. One higher-quality trial found that protein supplementation improved wound healing compared with placebo (improvement in Pressure Ulcer Scale for Healing mean of 3.55 [standard deviation 4.66] vs. 3.22 standard deviation 4.11]; P <.05). But little evidence existed that nutritional supplements improve healing in patients without nutritional deficiencies.
• Fifty-four trials evaluated absorbent wound dressings. In one, calcium alginate dressings improved healing compared with dextranomer paste (mean wound surface area reduction per week, 2.39 cm² vs. 0.27 cm²; P <.001). No single dressing was consistently superior to others.
• Nine trials evaluated biological agents. However, their incremental benefit remains uncertain. Recombinant human platelet–derived growth factor and nerve growth factor may improve healing, but more study is needed.
• Twenty-one trials looked at adjunctive therapies. No clear benefit was seen to electric current, ultrasound, light therapy and vacuum therapy. And overall, there were limited data to support routine use.

ACP Internist examined evidence-based ways to treat pressure ulcers.

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Data on errors collected but rarely used to improve

Almost 90% of hospitals nationwide collect information about medical error-related patient injury or death, but only about 20% have procedures in place to address the problems and make improvements, according to a study published in the journal Quality and Safety in Health Care.

The study, conducted by the Agency for Healthcare Research and Quality, was based on a survey of risk managers at more than 1,600 hospitals in an effort to estimate how many hospitals report patient injuries or deaths that result from medical errors, the status of reporting practices, how information on reported occurrences is shared and if it is used for practice improvement.

While virtually all the surveyed hospitals’ systems had the capability to record type, place and time of errors, only 32% of hospitals have established "supportive environments" that allow staff to report anonymously patient injuries or deaths resulting from errors and only 13% have comprehensive staff involvement in the error reporting process.

The survey also found that physicians often do not report adverse events because of liability, embarrassment and time constraints. The study authors point out that physician participation may be higher than observed, however, if physicians are actually asking other staff members, such as nurses, to report identified adverse events, rather than doing it themselves.

Results will provide baseline information to enable tracking of trends in adverse-event-reporting practices across the country as well as to assess the effects of the Patient Safety and Quality Improvement Act of 2005, which was enacted to reduce the fragmentation of information on reported patient-safety events and issues.

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Cardiology

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Women with STEMI have higher death rates than men, study finds

Women hospitalized with heart attacks receive less evidence-based medical care than men and have higher rates of death after ST-elevation myocardial infarction (STEMI) according to a study of U.S. hospitals published in Circulation.

Researchers examined the treatment of 78,254 heart attack patients over five years. Data were generated from a retrospective review of charts at 420 hospitals enrolled in an American Heart Association program aimed at motivating physicians to follow guidelines for treating heart attack patients.

Overall, hospitalized women survive heart attacks about as often as their male counterparts, but a gender gap exists when women have STEMI. Women presenting with STEMI appeared to have a high risk of dying in the first 24 hours, warranting "prompt and aggressive therapies."

The study suggests that women get less of the recommended therapeutics and procedures than men, and that it takes longer to get them. Compared with men, women were less likely to receive early aspirin treatment, early beta-blocker treatment, reperfusion therapy or timely reperfusion. Women also experienced lower use of cardiac catheterization and revascularization procedures after AMI, according to the study. Median door-to-needle for reperfusion and door-to-balloon for catheterization times for women vs. men were 47 vs. 39 minutes and 103 vs. 95 minutes, respectively.

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Annals of Internal Medicine

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Interruptions in Medicaid coverage increase unnecessary hospitalizations

A study of more than 4.7 million California adults on Medicaid found an association between interruptions in coverage and a higher rate of hospitalization for ambulatory care-sensitive conditions such as diabetes and chronic obstructive pulmonary disease. Hospital admissions for these types of conditions indicate a decline in the quality of health care that lower-income people receive outside the hospital. Authors suggest that policies that reduce the frequency of interruptions in Medicaid coverage might prevent some of these hospitalizations and reduce health care costs.

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Family members want straight talk about poor patient prognosis

Researchers conducted face-to-face interviews with 179 family members of seriously ill patients to determine their opinions about balancing hope and telling the truth about a poor prognosis. Nearly all of the surrogates said that withholding bad news was not acceptable. They felt that knowing the truth was important because it gave them an opportunity to prepare emotionally and practically for a loved one's death.

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Home rehab safe, viable for COPD

Exercise training can reduce shortness of breath, even in severe chronic obstructive pulmonary disease (COPD). While hospitals have programs that provide closely supervised exercise training, access to these programs is limited. Researchers conducted a study of 252 COPD patients to find out if a home-based, largely unsupervised exercise program could be as effective as a hospital-based program. All patients had four weeks of education about living with COPD before being randomly assigned to either hospital or home rehabilitation. In both programs, patients were instructed to perform three exercise sessions per week for eight weeks. During the eight weeks, trainers called home exercisers weekly to provide encouragement. After eight weeks, trainers called once every two months. At one year, patients in both groups reaped equal benefits, with both reporting less shortness of breath than before. Researchers conclude that tailoring pulmonary rehabilitation to meet individual needs could improve accessibility to this effective intervention.

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FDA update

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Boxed warning ordered for bowel prep used before colonoscopy

The FDA will add a boxed warning to prescription oral sodium phosphate (OSP) products Visicol and OsmoPrep, often used for bowel prep before colonoscopy, due to risk of acute phosphate nephropathy.

The warning applies to both prescription and over-the-counter OSP products, such as Fleet Phospho-soda, the FDA said. There is no apparent risk of kidney injury when the OTC products are used as laxatives at lower doses, but the risk increases when they are used at higher doses for bowel cleansing.

The agency recommended caution in using OSP prescription products for:

• people over age 55,
• those who suffer from dehydration, kidney disease, acute colitis, or delayed bowel emptying, and
• people taking certain medicines that affect kidney function, such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and possibly nonsteroidal anti-inflammatory drugs.

The FDA safety alert is online.

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From ACP Hospitalist

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Read about nocturnists in the latest issue, now online

ACP Hospitalist's December cover story looks at the emerging need for nocturnists. Disparities between day and night care, as well as new guidelines and public pressure, are pushing hospital administrators and hospitalist practices to offer 24/7 care. Also in this issue:
Errors. Hospitals should always work to prevent serious or fatal medical errors, but they also need to have a plan in place for what to do if an error occurs.
Careers. Clinical research at community hospitals in collaboration with academic medical facilities is gaining traction around the U.S.

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From ACP Internist's blog

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A wrap-up of the week's strange and fascinating events

There are kids taking CAM, surgeons on Ritalin, Kool-Aid as bowel prep, and a new gun for the disabled. ACP Internist's blog reports and analyzes the strange and fascinating events in medicine this week. As always, Medical news of the obvious is new on Monday.

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Cartoon caption contest

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Pick the year's best

December's Grand Prize cartoon contest will pit the three top vote getters from 2008 head-to-head, with one lucky voter winning a $100 gift certificate. Voting continues through Dec. 22, with the winner announced in the Dec. 23 issue of ACP InternistWeekly.

Voting is online.

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ACP JournalWise:
Reviews of the World's Top Medical Journals—FREE to ACP Members!

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