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ACP HospitalistWeekly 2-18-09

Physician editor: John Tooker, FACP

Highlights

• New opioid therapy guidelines released
• Survival after surgery at teaching hospitals differs by race, study finds

Infectious diseases

• Some MRSA infections decreasing in U.S. ICUs, study reports

Neurology

• Desmoteplase, placebo no different when given 3-9 hours after stroke onset

Geriatrics

• Acute geriatric units may improve functional outcomes, study finds

Annals of Internal Medicine

• Medicare’s pay for off-label uses of cancer drugs outdated
• Depending on cost, wider statin use could be a good strategy
• State laws may obstruct CDC HIV screening recommendations
• Fact boxes on DTC ads improve consumer knowledge, decisions

Cartoon caption contest

• Put words in our mouth

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Highlights

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New opioid therapy guidelines released

Two professional societies released guidelines last week on opioid therapy to treat chronic, noncancer pain.

The American Pain Society and the American Academy of Pain Medicine convened a multidisciplinary panel of 21 experts to review evidence and compose 25 recommendations. The recommendations, published in the February Journal of Pain, advise providers to:

• Do a history, physical exam and appropriate testing—including a risk assessment of substance abuse—before starting a patient on chronic opioid therapy (COT);
• Consider a COT trial for patients whose pain is moderate or severe and for whom it has an adverse impact on function or quality of life;
• Reassess patients on COT periodically, with monitoring to include documenting pain and functioning levels, adherence, and presence of adverse events;
• Use COT on patients with a history of drug abuse or psychiatric issues only if they can be monitored more frequently and strictly;
• Do periodic urine drug screens on patients at high risk or who engaged in drug-related behavior in the past, and possibly on patients who aren't high-risk, too; and
• Evaluate health status, adherence and side effects on an ongoing basis in patients on high doses of COT, and consider more follow-up visits.

On a related note, FDA last week sent letters to opioid manufacturers asking them to develop plans to reduce the misuse of their drugs, the Feb. 9 Washington Post reported. The plans, which are meant to help reduce the rising incidence of overdose and abuse, might include enhanced warnings on labels or restricting the kinds of patients who can use the drugs, the Post said. A list of affected drugs, most of which are high dose and/or extended release, is online.

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Survival after surgery at teaching hospitals differs by race, study finds

Survival rates after surgery at teaching hospitals are worse for black patients than for white patients, a new study reports.

Researchers performed a retrospective study of Medicare claims for general, orthopedic and vascular surgery from 2000 to 2005 to determine whether lower mortality rates after surgery at U.S. teaching hospitals are due to better complication rates or improved mortality rates after complications occur. They also examined whether this improved postsurgical survival differed by patient race. The main outcome measures were 30-day mortality rate, in-hospital complications, and failure to rescue, defined as "the probability of death after complications." The study appears in the February Archives of Surgery.

Data from over 4 million individual patients at 3,270 hospitals were examined. The authors found that patients undergoing surgery at hospitals with high teaching intensity (defined as 0.6 resident per bed) had a 15% lower risk for death and a 15% lower risk for death after complications than patients at nonteaching hospitals (P< 0.001 for both comparisons), while rates of complications overall did not differ. This benefit was not seen for black patients, whose risk for death and risk for death after complications were similar at teaching and nonteaching hospitals.

The authors acknowledged their study's limitations, including a lack of data from patients' medical records and a lack of information on severity. However, they concluded that improved survival rates after surgery at teaching hospitals are seen only among white patients. Black patients may have worse mortality and failure-to-rescue rates because they are more likely to go to hospitals with worse rates overall, but this possibility can't entirely explain the study results, the authors wrote.

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Infectious diseases

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Some MRSA infections decreasing in U.S. ICUs, study reports

Methicillin-resistant Staphylococcus aureus (MRSA) central line-associated bloodstream infections (BSIs) have been decreasing in the U.S., according to a new study.

MRSA has been the focus of high-profile legislation and infection control campaigns in recent years, but information on its incidence over time has been lacking. Researchers from the CDC used data reported to the agency as part of the National Nosocomial Infections Surveillance system to examine trends in MRSA and methicillin-susceptible S. aureus (MSSA) in seven types of U.S. ICUs from 1997 to 2007. The main outcome measures were the incidence of central line-associated BSIs per 1,000 central line days and the percentage of S. aureus BSIs caused by MRSA. The study results appear in the Feb. 18 Journal of the American Medical Association.

Of 33,587 central line-associated BSIs reported from 1,684 ICUs, 2,498 (7.4%) were MRSA and 1,590 (4.7%) were methicillin-susceptible S. aureus (MSSA). From 1997 to 2001, rates of MRSA central line-associated BSIs increased in surgical, nonteaching-affiliated medical-surgical, cardiothoracic and coronary ICUs, but did not change significantly in medical, teaching-affiliated medical-surgical and pediatric ICUs. Central line-associated BSIs caused by MSSA decreased in all ICU types from 1997 to 2007, and rates of MRSA central line-associated BSIs decreased significantly in all types of ICUs except pediatric ICUs from 2001 through 2007. From 1997 to 2007, the overall percentage of S. aureus central line-associated BSIs caused by MRSA increased by 25.8% while overall MRSA central line-associated BSIs decreased by 49.6%.

The authors concluded that the observed decrease in MRSA incidence could be related to improved infection prevention, implementation of standardized protocols for insertion of central line catheters, and development and use of targeted prevention guidelines. In addition, they noted, "the overall decline in [MRSA] incidence stands in sharp contrast to trends in percent MRSA, which give an incomplete picture of changes in the magnitude of the MRSA problem over time and may have led to a misperception that the MRSA central line-associated BSI problem in ICUs has been increasing." They called for future studies to examine incidence of MRSA infection in other populations and settings and to evaluate the effects of infection control measures.

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Neurology

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Desmoteplase, placebo no different when given 3-9 hours after stroke onset

Acute ischemic stroke patients who were given desmoteplase 3-9 hours after stroke onset had no better response rates than patients given placebo, a study in the February Lancet Neurology found.

While alteplase within three hours of onset is the only approved treatment for acute ischemic stroke, two previous studies suggested desmoteplase may work up to nine hours after onset. To confirm the earlier results, researchers randomly assigned 186 acute ischemic stroke patients to 90 μg/kg desmoteplase, 125 μg/kg desmoteplase or placebo within 3-9 hours after onset of stroke symptoms. The primary endpoint was clinical response rate at day 90, defined by a composite of scores on several stroke scales.

The clinical response rates at day 90 were 47% for patients who got 90 μg/kg desmoteplase, 36% for those who got 125 μg/kg desmoteplase, and 46% for those who got placebo. As for secondary endpoints, the median change in lesion volume between baseline and day 30 was 14% for those who got 90 μg/kg desmoteplase, 11% for those who got 125 μg/kg desmoteplase, and 10% for those who got placebo. The rates of symptomatic intracranial hemorrhage were 3.5% for the 90 μg/kg desmoteplase group, 4.5% for the 125 μg/kg desmoteplase group, and 0% for the placebo group. Overall mortality was 11% for the 90 μg/kg desmoteplase group, 21% for the 125 μg/kg desmoteplase group, and 6% for the placebo group.

Results showed no benefit of giving desmoteplase 3-9 hours after stroke onset. The placebo group may have showed a high response rate due to the mild strokes that were recorded, which may also have reduced the potential to detect an effect from desmoteplase, the study's authors said.

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Geriatrics

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Acute geriatric units may improve functional outcomes, study finds

Elderly patients cared for in acute geriatric units functioned better after their hospital stay than those who received conventional care, according to a new study.

Spanish researchers performed a meta-analysis to determine whether acute geriatric units could improve outcomes in elderly patients admitted to the hospital. The authors assessed functional decline, living at home and case fatality both at hospital discharge and three months. The results were published in the Feb. 7 BMJ.

Of 11 trials reviewed, five were randomized. Meta-analysis of these trials showed that elderly patients in acute geriatric units were less likely to have functional decline at hospital discharge (combined odds ratio, 0.82 [95% CI, 0.68 to 0.99]) and more likely to be discharged home (combined odds ratio, 1.30 [CI, 1.11 to 1.52] than elderly patients receiving conventional care. Patients cared for in acute geriatric units were also more likely to be living at home three months after hospital discharge. Case fatality rates, meanwhile, were similar between the two groups (combined odds ratio, 0.83 [CI, 0.60 to 1.14]).

The authors acknowledged the limitations of their trial, including the small number of studies analyzed, but concluded that acute geriatric units offer benefit to elderly hospitalized patients. "Research should focus on the impact of acute geriatric units on functional decline in the medium term and should try to identify the specific activities associated with this effect," they wrote.

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Annals of Internal Medicine

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Medicare’s pay for off-label uses of cancer drugs outdated

The National Comprehensive Cancer Network estimates that 50%-75% percent of all uses of cancer therapy are off-label. Yet CMS limits coverage of cancer drugs for off-label indications to those indications listed in specified compendia. The authors of a new study titled “Reliability of Compendia Methods for Off-Label Oncology Indications” argue that the current methods for reviewing and updating evidence for compendia are seriously lacking. Two perspective pieces here and here and an editorial accompany the article in the Feb. 17 Annals of Internal Medicine.

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Depending on cost, wider statin use could be a good strategy

The Adult Treatment Panel III (ATP III) recommended statins for patients with higher cholesterol and more risk factors for coronary heart disease. Because of poor adherence to ATP III guidelines, researchers sought to determine the strategy’s cost, complexity and efficiency. They found that while the guidelines are complex, they are relatively cost-effective in comparison with alternatives and would be the preferred strategy if statin pill costs are moderate. However, if statin pill costs were lower, extending statin use to lower-risk patients as well would be better.

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State laws may obstruct CDC HIV screening recommendations

According to CDC guidelines, all patients should be offered HIV screening without a requirement for written consent or prevention counseling. However, state laws may make it difficult for physicians to adhere to these guidelines. Researchers systematically reviewed and analyzed laws in all 50 states and Washington, D.C. to determine which states’ laws would interfere with implementing the guidelines. They found that 34 states and Washington D.C. had laws that were either consistent or neutral to the recommendations, allowing for full implementation. The other 16 states had laws that would preclude implementation of one or more of the novel provisions for HIV screening. The authors urge policymakers, provider groups, consumer advocates and other stakeholders to review their state laws and advocate for amending laws that interfere with implementing the CDC recommendations.

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Fact boxes on DTC ads improve consumer knowledge, decisions

Researchers conducted two randomized trials to see if providing consumers with a drug facts box (a table quantifying outcomes with and without the drug) would improve knowledge and affect patient judgments about which prescription drugs are more effective. Researchers found that after reading the ads with fact boxes, consumers made better choices between drugs for current symptoms. In addition, they were better informed about the actual benefit of drugs intended for prevention.

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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 Feb. 19. ACP staff will choose three finalists and post them in the Feb. 25 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the March 4 issue. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

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