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ACP HospitalistWeekly 3-11-09

Highlights

• Recession hurting hospitals' bottom line
• Guidelines on aneurysmal subarachnoid hemorrhage call for quick treatment

Cardiology

• PPIs may weaken the benefits of clopidogrel after acute coronary syndrome
• Cardiovascular risk factors could predict safety of IV immunoglobulin treatment

FDA update

• Some transdermal patches can cause burns during MRI

From ACP Internist

• March ACP Internist is online and coming to your mailbox

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, MD

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Highlights

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Recession hurting hospitals' bottom lines

Hospitals' median profit margin fell to 0% in the third quarter of 2008, according to an analysis by Thomson Reuters.

The health care surveying firm based the findings on proprietary and public data gathered from 439 hospitals in the U.S. About 50% of the studied hospitals were unprofitable, and the median profit margin of zero was a historic low. Growth in payments from private and public payers had slowed toward the end of the year as well.

The credit crunch also had an impact on hospitals, the report found. The median cash-on-hand held by hospitals fell to an unprecedented low—110 days in the third quarter of last year. There was also significant variability in the median cash-on-hand, from 57 days in the lowest quartile of hospitals to 203 in the highest. However, it is difficult to attribute all of the economic decrease to the recession since the downward trend started well before late 2007.

The shortages of profit and cash can hinder hospitals' ability to buy new equipment or expand, noted the study's lead author in a press release.

He said that economic indicators suggest hospitals' financial situations would get worse before they get better. Analysts are closely watching hospital operating margins and the frequency of elective procedures, because a decline in either could have contagious negative effects, he said. The 2008 data did not show a rise in hospital unemployment rates, an increase in bed closures, or deferral of elective procedures but did indicate total inpatient admissions may be falling below expectations.

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Guidelines on aneurysmal subarachnoid hemorrhage call for quick treatment

Quick treatment is key to survival in patients with aneurysmal subarachnoid hemorrhage, according to recent guidelines from the American Heart Association's Stroke Council.

To update the 1994 guidelines on this topic, experts reviewed 38 relevant studies published between June 30, 1994, and Nov. 1, 2006 and developed new evidence-based recommendations. The guidelines appear in the March issue of Stroke. Key findings are as follows:

• Early definitive treatment for aneurysm is indicated for most patients and can reduce death and disability.
• Subarachnoid hemorrhage is a medical emergency and is misdiagnosed in up to 12% of patients, usually by failing to obtain a head CT.
• The severity of the initial bleed should be determined rapidly because it is the most useful indicator of outcome.
• Although new noninvasive diagnostic tools such as CT angiography and MR angiography can be useful, catheter angiography is still considered the gold standard for diagnosis and treatment.
• Patients with subarachnoid hemorrhage benefit when cared for at high-volume compared with low-volume hospitals.
• The rapid assessment and transport model widely adopted to optimize thrombolytic therapy in acute ischemic stroke needs to be broadened and reemphasized for hemorrhagic stroke.
• Standardized protocols should be used to manage subarachnoid hemorrhage in the emergency department.
• The current standard of practice calls for microsurgical clipping or endovascular coiling of the aneurysm neck whenever possible.

“It’s very important for people to know the signs of a brain bleed and know to get help quickly. Treatment protocols are most effective when we can get to the patient early,” the chair of the guidelines committee said in a press release.

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Cardiology

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PPIs may weaken the benefits of clopidogrel after acute coronary syndrome

Proton pump inhibitors (PPIs) combined with clopidogrel after an acute coronary syndrome (ACS) may increase risk of death or readmission, leading some to suggest that the combination not be used for prophylaxis.

PPIs are frequently prescribed to reduce the risk of gastrointestinal tract bleeding from taking clopidogrel and aspirin. But studies have reported that omeprazole decreases clopidogrel's platelet inhibitory effect. Researchers did a retrospective cohort study of 8,205 ACS patients taking clopidogrel after discharge from 127 Veterans Affairs hospitals between Oct. 1, 2003, and Jan. 31, 2006. They reported results in the Journal of the American Medical Association.

Of the 8,205 patients, 63.9% were prescribed PPI (60% of which was omeprazole) in addition to clopidogrel at discharge, during follow-up, or both, and 36.1% were prescribed clopidogrel only. Death or rehospitalization for ACS occurred in 29.8% (1,561) of patients taking both medications versus 20.8% (615) of patients taking clopidogrel without PPI. The combination was associated with increased risk of death or rehospitalization for ACS compared with use of clopidogrel only and a higher risk for revascularization procedures, but no higher risk for all-cause mortality. PPI therapy without clopidogrel was not associated with adverse outcomes. The increased risk of adverse events observed with the concomitant use of clopidogrel and PPI was seen even after controlling for the use of aspirin, as well as after excluding patients with a history of gastrointestinal bleeding.

Because this was an observational study, no conclusion can be drawn as to whether the adverse events seen were caused by the combination of PPI and clopidogrel. Randomized, controlled trials are needed, researchers wrote, because the "modest" risk seen in the study translates to a considerable number of people because of how frequently PPIs are prescribed to patients receiving dual-antiplatelet therapy. They added that PPIs should be used only for patients with a clear indication, such as a history of gastrointestinal tract bleeding, rather than for routine prophylaxis.

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Cardiovascular risk factors could predict safety of IV immunoglobulin treatment

Elderly patients' cardiovascular risk burden could predict their likelihood of suffering a thromboembolic event after intravenous (IV) immunoglobulin treatment, a new study found.

Researchers performed a case-control study to determine whether the presence of cardiovascular risk factors (coronary artery disease, cerebrovascular disease, cigarette use, hypertension, hyperlipidemia and diabetes mellitus) increased risk for thromboembolic events during IV immunoglobulin infusion. The results were published early online by the Journal of Neurology.

Nineteen elderly patients (mean age, 71 years) who had a thromboembolic event (primarily stroke, but also myocardial infarction, deep venous thrombosis, or pulmonary embolism) within two weeks of immunoglobulin treatment were compared with 38 age-matched control patients who received the same treatment but did not suffer a thromboembolic event. Risk for thromboembolic events was elevated in patients with two or more cardiovascular risk factors (odds ratio, 1.39 [95% CI, 0.45 to 4.30]) and was statistically significantly elevated in patients with four or more cardiovascular risk factors (odds ratio, 10.50 [95% CI, 1.91 to 57.58]). No difference was seen in 30-day mortality between the case and control groups.

The authors acknowledged their study's limitations, including its retrospective design and the wide CIs resulting from the low number of thromboembolic events. They concluded that patients with more cardiovascular risk factors are more likely to have thromboembolic events after IV immunoglobulin treatment, but the degree of increased risk is difficult to predict. They recommended that clinicians prescribing IV immunoglobulin to elderly patients with cardiovascular risk factors carefully consider the risk of stroke and myocardial infarction, and called for future prospective studies to better quantify risk and incidence.

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FDA update

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Some transdermal patches can cause burns during MRI

Certain medicated skin patches contain metal in the backing that can overheat during MRI scans and cause burns, the FDA said in a safety alert.

Providers who refer patients to have MRI scans should check whether they are wearing a patch, advise them how to remove the patch before the scan, then tell them how to replace it after the scan. MRI facilities should follow published safe practice recommendations about patients wearing patches, the FDA said.

The FDA has gotten reports of patients getting burned, and was told in January that an MRI warning was missing on Teva Pharmaceutical's fentanyl transdermal system. The agency is in the process of reviewing the labeling and composition of other patches to make sure those containing metal have a warning about the burn risk. The affected products include nicotine patches, and may be brand name, generic or over-the-counter, the alert said.

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From ACP Internist

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March ACP Internist is online and coming to your mailbox

The next issue of ACP Internist is online. Find all of our print and online content, including ACP InternistWeekly, our blog, and polls and surveys (including our cartoon caption contest). Go online for the following stories:

• Intimate partner violence. Unexplained bruising or injuries are red flags for intimate partner violence, but less obvious signs might include chronic pain, depression or anxiety. Experts advise how to help victims at risk.
• Sjögren's syndrome explained. Lack of awareness compounds a condition that is exceedingly difficult to diagnose. Experts offer signs and symptoms for ruling it out or diagnosing it more quickly.
• Mindful Medicine. Would you pass "the eyeball test" if a patient with chest pain presented in your hospital's emergency room? Find out how one physician pressed for a better answer on a patient who presented with cardiac pain but no evidence of a heart attack.

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Cartoon caption contest

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Put words in our mouth

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

E-mail all entries by March 19. ACP staff will choose three finalists and post them in the March 25 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the April 1 issue. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

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About ACP HospitalistWeekly

ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

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Copyright 2009 by the American College of Physicians.

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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