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ACP HospitalistWeekly 4-8-09
Highlights
- High rate of readmissions tied to poor transitions at discharge
Infectious disease
- Simple rule predicts patients at risk for recurrent C. diff infections
Cardiology
- Early routine eptifibatide has no benefit in acute coronary syndromes
FDA update
- Digoxin recalled due to errors in pill size
From ACP Internist
- Planning to tweet from Internal Medicine 2009?
Cartoon caption contest
- Put words in our mouth
Physician editor: A. Scott Keller, MD
Highlights
.High rate of readmissions tied to poor transitions at discharge
Poor transitions between hospital and ambulatory care contribute to high rates of rehospitalization among Medicare patients, a recent analysis found.
Researchers analyzed Medicare claims data for almost 12 million beneficiaries who were hospitalized from 2003-04. They found that almost 20% of those patients were readmitted within 30 days and 34% were rehospitalized within 90 days. In addition, more than half of patients discharged with medical conditions or after surgery were rehospitalized or died within the first year following discharge. The results appear in the April 2 New England Journal of Medicine.
Based on billing records, half of the patients who were rehospitalized within 30 days following a medical discharge had not followed up with a physician between hospitalizations, the study found. Researchers estimated that only 10% of rehospitalizations were planned, and that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion. Heart failure and pneumonia were the most common reasons for readmission for both medical and surgical patients. Primary predictors for rehospitalization included the index DRG and length of stay, the previous number of rehospitalizations, and the need for dialysis. Researchers also noted geographic differences in readmission rates.
The study's findings on readmission rates, lack of follow-up, and inadequate communication between doctors and patients and among doctors at the time of discharge suggests that there is a "lack of shared incentives for hospitals and physicians to use hospital care efficiently," said an accompanying editorial. The Medicare Payment Advisory Commission has recommended that Medicare reduce payments to hospitals with relatively high readmission rates for certain conditions, such as heart failure. However, noted the editorial, readmission rates are a "crude outcome" since higher rates may represent more efficient care by reducing the complications and costs associated with longer hospital stays. Also, hospitals are likely to argue that many factors that affect readmission, such as the quality of ambulatory care and physicians’ thresholds for discretionary admissions, are out of their control.
Addressing the problem will require greater integration of the delivery system, the editorialist said. For example, hospitals could receive financial incentives for managing the initial transition and follow-up care. The study's authors added that "from a system perspective, a safe transition from a hospital to the community or a nursing home requires care that centers on the patient and transcends organizational boundaries." Given that the risk of rehospitalization persists over time, the authors suggest that further studies are needed to determine the relative contributions of failure in discharge planning, insufficient outpatient follow-up, and severe progressive illness. The study was limited by its reliance on Medicare billing and DRG data. Also, billing data did not capture most visits to nonphysician providers, and some patients may have had telephone follow-up that was not billed.
Infectious disease
.Simple rule predicts patients at risk for recurrent C. diff infections
A simple clinical rule predicts which patients are at risk for recurrent infections of Clostridium difficile, a recent study reported.
In an independent validation cohort of 89 patients with C. diff infection, 64 of whom had complete follow-up and were analyzed for the study, the rule correctly classified 71.9% (95% CI, 59.2% to 82.4%) of patients with recurrent infections, researchers reported in the April issue of Gastroenterology. The clinical rule assigned one point for each of three risk factors: age greater than 65 years, severe or fulminant illness (by the Horn index), and additional antibiotic use after initial therapy. Patients with two or more risk factors were considered high risk for recurrence, whereas patients with fewer than two risk factors were low risk. The sensitivity and specificity for stratifying risk were 53.8% (95% CI, 25.1% to 80.8%) and 76.5% (95% CI, 62.5% to 87.2%), respectively.
Researchers noted that the rule could facilitate faster recognition, diagnosis and treatment of recurrent C. diff infection in a high-risk population. These patients are most likely to benefit from interventions that prevent recurrence, they added, such as infection control measures, prudent use of antibiotics, prolongation of metronidazole or vancomycin therapy, and use of probiotics. The study was limited by the relatively small number of patients who had recurrent C. diff (13 out of the 64 patients).
Cardiology
.Early routine eptifibatide has no benefit in acute coronary syndromes
Early, routine use of eptifibatide 12 hours or more before angiography is not superior to delayed, provisional administration after angiography but before percutaneous coronary intervention in patients with acute coronary syndromes (ACS) without ST-segment elevation, a new study has found.
Although glycoprotein IIb/IIIa inhibitors are recommended in conjunction with an invasive procedure in patients with ACS, existing evidence guiding the timing of this therapy is inconclusive. The EARLY ACS Investigators compared early, routine use and delayed, provisional use of eptifibatide in 9,492 ACS patients undergoing angiography. The primary end point was a composite of death, myocardial infarction, recurrent ischemia requiring urgent revascularization, or the occurrence of a thrombotic complication during intervention that required bolus infusion opposite the study group assignment ("thrombotic bailout") at 96 hours. The secondary end point was a composite of death or myocardial infarction in the first 30 days. Safety end points were bleeding and transfusion 120 hours or less after random group assignment. The study results were published early online by The New England Journal of Medicine on March 30.
Rates of the primary end point did not differ significantly between the early and delayed therapy groups (9.3% vs. 10.0%; odds ratio, 0.92 [95% CI, 0.80 to 1.06]; P= 0.23). The secondary end point occurred in 11.2% of the early therapy group and 12.3% of the delayed therapy group (odds ratio, 0.89 [95% CI, 0.79 to 1.01]; P= 0.08). Bleeding and red cell transfusion were significantly more common in those receiving early therapy, but severe bleeding and other serious adverse events did not differ between groups. A trend toward fewer ischemic events at 30 days was noted in patients who received early eptifibatide.
The authors pointed out that their patient population was older and higher-risk and received more aggressive concomitant therapy than those in previous studies. They concluded that early, routine use of eptifibatide was not superior to delayed, provisional use in high-risk ACS patients without ST-segment elevation and may increase bleeding and transfusion risk. Although fewer ischemic events were noted in those receiving early therapy, "a routine strategy of administering eptifibatide in patients early after presentation cannot be recommended," they wrote.
FDA update
.Digoxin recalled due to errors in pill size
The FDA last week issued a recall of Caraco brand digoxin, USP 0.125 mg and USP 0.25 mg, because the pills may differ in size and contain more or less digoxin than indicated, the agency said in an alert.
Digoxin (Lanoxin) is used to treat heart failure and abnormal heart rhythms and has a narrow therapeutic index. Patients with renal failure are at particular risk of digoxin toxicity from higher-than-labeled doses; such toxicity can cause nausea, vomiting, dizziness, low blood pressure, cardiac instability, bradycardia and death. Lower-than-labeled doses can result in cardiac instability.
The drugs affected by the recall were distributed before March 31, 2009 and are within the expiration date of September 2011. Caraco digoxin 125 mg is a scored round biconvex yellow tablet imprinted with “437,” while Caraco digoxin 0.25 mg is a scored round biconvex white tablet imprinted with “441.”
From ACP Internist
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Let us know so we can post the best meeting tweets on our blog. For a look at who is already Twittering in medicine, click here.
Cartoon caption contest
.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 April 17. ACP staff will choose three finalists and post them in the April 22 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in Internal Medicine 2009 News, a special e-newsletter that will be generated live from Internal Medicine 2009. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.
About ACP HospitalistWeekly
ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. Please forward any comments or suggestions to acphospitalist@acponline.org.
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Copyright 2009 by the American College of Physicians.
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