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ACP HospitalistWeekly 2-4-09

Physician editor: John A. Mitas II, FACP

Highlights

• Good hospitals are wired and already delivering better care
• Newer drug may offer sedation advantage in critically ill

Cardiology

• ICD guidelines not always followed

Annals of Internal Medicine

• Comprehensive hospital discharges can reduce re-hospitalization
• Not all immunochemical fecal occult blood tests equally effective
• Immediate listing for liver transplantation is not a better strategy

FDA Update

• ETHEX Corp. expands recall of generics to more than 60 drugs

From ACP Internist

• The latest issue of ACP Internist is online
• On the blog: Infectious diseases taking over

Cartoon caption contest

• January's winning entry

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Highlights

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Good hospitals are wired and already delivering better care

Wired hospitals with automated notes and records, order entry, and clinical decision support had fewer complications, less mortality and lower costs, a study concluded.

Researchers conducted a cross-sectional study of 72 of general acute-care hospitals located in 10 metropolitan statistical areas in Texas. They measured automation based on physician interactions with the information system to determine whether more automation reduced rates of inpatient mortality, complications, costs and length of stay. The results are in the Jan. 26 Archives of Internal Medicine.

For 167,233 patients older than age 50 admitted between December 2005 and May 2006:

• A 10-point increase in the automation of notes and records was associated with a 15% decrease in the adjusted odds of fatal hospitalizations (0.85; 95% confidence interval [CI], 0.74-0.97);
• Better order entry was associated with decreases in the adjusted odds of death for myocardial infarction (9%) and coronary artery bypass graft procedures (55%);
• For all causes of hospitalization, higher decision support scores were associated with a 16% decrease in the adjusted odds of complications (0.84; 95% CI, 0.79-0.90);
• Hospitals with the highest third of the notes and records scores had a 1.4% adjusted rate of mortality, compared with a 1.9% adjusted rate among hospitals in the lowest third. Or, for every 1,000 patients, five fewer died at hospitals with the better notes and records scores; and
• Higher scores on test results, order entry, and decision support lowered hospital costs by $110, $132, and $538, respectively (P <0.05).

An accompanying editorial said that "More of such analyses should be done, and they are likely to be helpful in convincing policy experts including skeptics like those at the [Congressional Budget Office] of the benefits when these technologies are in routine use."

In other news, health care ratings company HealthGrades found that Medicare patients treated at top-rated hospitals nationwide across the most common Medicare diagnoses and procedures are 27% less likely to die and have an average 8% lower risk of complications during their stay than those admitted to all other hospitals. That's 152,666 potentially preventable deaths and 11,772 major complications between 2005 and 2007.

HealthGrades compared the top 5% of hospitals in terms of mortality and complication rates across 26 procedures and diagnoses (HealthGrades used its term "Distinguished Hospitals for Clinical Excellence") and analyzed nearly 41 million patient records from CMS to arrive at the conclusion, posted on the company's Web site.

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Newer drug may offer sedation advantage in critically ill

Dexmedetomidine may be a better choice for sedation in critically ill patients than more commonly used agents, a new study found.

Researchers from the SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group performed a double-blind, randomized trial to determine whether dexmedetomidine offered efficacy and safety advantages when used to sedate critically ill patients on mechanical ventilation. The study was funded by Hospira, the manufacturer of dexmedetomidine. It was released early online Feb. 2 and appears in the Feb. 4 Journal of the American Medical Association.

The study involved 68 ICUs in five countries and was conducted between March 2005 and August 2007. Eligible patients were those at least 18 years of age who had been receiving mechanical ventilation for less than 96 hours before the study drug was started and who were expected to be ventilated and sedated for at least three additional days. Two hundred forty-four patients received dexmedetomidine, and 122 received midazolam. The primary end point was the percentage of time spent in the ideal sedation range. Secondary end points included rates and duration of delirium, duration of mechanical ventilation, and length of ICU stay.

The primary outcome did not differ between the study groups. However, patients receiving the study drug were less likely to develop delirium (54% vs. 76.6%; P< 0.001) and had shorter duration of intubation (median time to extubation, 3.7 days vs. 5.6 days; P= 0.01). Patients receiving the study drug were more likely to develop bradycardia (42.2% vs. 18.9%; P< 0.001) but less likely to develop tachycardia (25.4% vs. 44.3%; P< 0.001) or severe hypertension (18.9% vs. 29.5%; P= 0.02).

The study had several limitations, such as its lack of an "intent-to-treat-as-randomized" group. Although the authors didn't detect a difference between the tested drugs in achieving the desired sedation level, they concluded that dexmedetomidine improved time on the ventilator and delirium rates when compared with a more traditional sedating agent. An accompanying editorial noted that the secondary outcome of reduced delirium is an important finding. "Clinicians now have a widened choice of sedatives and should always consider not only the need for sedation but also the possible clinical implications of the choice of sedative," the editorialists wrote.

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Cardiology

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ICD guidelines not always followed

Guidelines for the use of implantable cardioverter-defibrillators (ICDs) are often not followed in U.S. hospitals, according to a new study.

Researchers from the 'Get with the Guidelines' steering committee performed a study to determine how hospitals varied in application of guidelines for ICD use. Data from 10,148 patients treated at 134 hospitals were examined. Eligible patients were those who met Class I recommendations for ICDs according to the American College of Cardiology/American Heart Association 2005 guidelines on heart failure. All hospitals were voluntary participants in the 'Get with the Guidelines-Heart Failure' registry. The researchers calculated rates of ICD prescriptions from January 2005 to June 2007. Their results appear in the Feb. 3 Journal of the American College of Cardiology.

Overall, 20% of patients received a prescription for an ICD. ICD use varied considerably from hospital to hospital (range, 0% to 80%) and was more common in larger hospitals and those that were able to perform percutaneous coronary intervention, coronary artery bypass grafting, and heart transplants. Hospitals that had higher ICD prescription rates also had higher rates of adherence to other, newer heart failure performance measures, such as beta-blocker use.

The study had several limitations, including the possibility that hospitals participating in 'Get with the Guidelines' were more likely to follow evidence-based recommendations than nonparticipating hospitals. However, the authors concluded that ICD use in U.S. hospitals varies significantly by hospital and called for future studies to determine how wider use could be achieved. An accompanying editorial said the study will help improve therapy for heart failure because it described for the first time the type of hospital most likely to adopt newer evidence-based measures.

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Annals of Internal Medicine

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Comprehensive hospital discharges can reduce re-hospitalization

Researchers followed 749 hospitalized adults for 30 days to test the effects of an intervention designed to minimize hospital use after discharge. Half of the patients received normal care, while the other half worked with a nurse discharge advocate during their hospital stay to arrange follow-up appointments, confirm medications and receive patient education. A clinical pharmacist called patients soon after discharge to reinforce the discharge plan and review medications. The intervention resulted in a 30% reduction in hospital use, improved patient self-perceived preparation for discharge, and increased primary care physician follow up, even among participants who frequently used hospital services.

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Not all immunochemical fecal occult blood tests equally effective

New qualitative immunochemical fecal occult blood tests (FOBT) use specific antibodies against human blood components to detect traces of blood in the stool, and may yield fewer false-positive and false-negative results. To determine if efficacy was similar among the various qualitative immunochemical FOBTs, researchers compared screening results for six different tests against findings at colonoscopy. Sensitivity for detecting advanced adenomas ranged from 25% to 72%, and specificity ranged from 70% and 97%.

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Immediate listing for liver transplantation is not a better strategy

Researchers randomly assigned 120 patients with Child-Pugh stage B alcoholic cirrhosis to either immediate listing for liver transplantation or standard medical care. Immediate listing for liver transplantation was not associated with improved patient survival. In addition, patients who received a liver transplant had an unexpectedly high rate of extrahepatic cancer. Patients who continued to consume alcohol had a poor result regardless of treatment. Researchers concluded that immediate listing for transplantation is not a better strategy for patients with Child-Pugh stage B cirrhosis, especially when alcohol withdrawal is associated with recovery of liver function. The best strategy would be to consider liver transplantation on the basis of patient outcome and to actively screen patients for extrahepatic cancer before and after liver transplantation.

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FDA update

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ETHEX Corp. expands recall of generics to more than 60 drugs

ETHEX Corp. has expanded two previous recalls to include more than 60 generic drugs, including two at the retail level, the FDA said in an alert.

The retail drugs under recall are hydromorphone HCl tables in 2 mg, 4 mg and 8 mg doses; and metoprolol succinate ER tablets in 25 mg, 50 mg, 100 mg and 200 mg doses. Wholesale drugs being recalled include benazepril, diltiazem HCl, morphine sulfate, oxycodone and potassium chloride in various doses. The drugs may not comply with good manufacturing practices, ETHEX said. Some of the products already had specific lots recalled in 2008 due to defects such as oversized tablets that delivered higher doses than the label indicated.

FDA advised patients currently taking these medications to continue doing so, as there may be a risk of suddenly stopping, but to contact their providers if they have any problems they think may be linked to the drugs. A full list of drugs being recalled is available online.

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From ACP Internist

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The latest issue of ACP Internist is online

The February issue of ACP Internist is online, featuring stories on how consumers' disposal of their unused meds is possibly polluting our drinking water. And, polycystic ovary syndrome is a stealthy disease whose distressing symptoms can masquerade as other conditions. Experts offer advice on how to manage these patients. And don't miss coverage of the American Heart Association Scientific Sessions.

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On the blog: Infectious diseases taking over

The Salmonella outbreak that sickened more than 500 people and killed eight was traced back to the peanut processor, who detected the bacteria at its facility 12 times in the two years leading up to the outbreak. That revelation sickened our blogger, too. And C. diff spores can be found well outside hospital isolation rooms, in work areas and on portable equipment. Finally, substance abuse is fairly common among people with tuberculosis, and makes them harder to treat.

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Cartoon caption contest

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January's winning entry

ACP HospitalistWeekly and ACP InternistWeekly have compiled the results from its 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 David P. Perkins, ACP Member, in private practice in Wayne, Pa. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 204 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry:

"No, I've just come to start my overnight call. Why do you ask?"

The winning entry captured 53.9% of the votes. The runners up were:
Third-year medical student to his first patient: "Dude, that sounds radical!" (15.7%)
"You threw me out of your bar, and now look how the tables have turned!" (30.4%)

Our cartoon caption contest continues in February.

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