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ACP HospitalistWeekly 8-19-09

Highlights

• Rapid tests ineffective for swine-origin flu detection
• Hospitals with hospitalists score better on quality, care indicators

Quality of care

• Resident work-hour restrictions have not hurt outcomes in ICU

Cardiology

• ACE inhibitors before cardiac surgery may increase risk of death

FDA update

• Glucose monitoring strips may lead to fatal errors

From the blog

• Medical news of the obvious on Mondays

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

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Highlights

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Rapid tests ineffective for swine-origin flu detection

Rapid flu tests have low sensitivity for detecting novel swine-origin influenza A (H1N1), warns a new report from the CDC.

Three rapid influenza diagnostic tests were evaluated with 65 specimens (either nasopharyngeal or oropharyngeal swabs) that had been collected in April and May 2009. All samples had previously been tested using real-time reverse transcription-polymerase chain reaction (rRT-PCR) assay and were positive for either novel influenza A (H1N1) or for seasonal influenza A (H1N1 or HmN2). The comparison of results revealed that the rapid tests were capable of detecting the novel influenza A (H1N1) when there were high levels of virus present, but the tests had a low overall sensitivity (40% to 69%).

Based on these findings, the CDC advised that positive rapid test results can be used in making treatment decisions, although the results should be interpreted in the context of currently circulating strains. However, negative results should not be assumed to indicate the absence of infection. Patients who test negative but have suspicious symptoms should be treated empirically based on the level of clinical suspicion, underlying medical conditions, severity of illness, and risk for complications. If a more definitive diagnosis is needed, the rRT-PCR assay or a virus isolation test should be used, according to the CDC. The report was published in the Aug. 7 Morbidity and Mortality Weekly Report.

The World Health Organization also issued a reminder regarding swine-origin flu last week. Per WHO guidelines, antiviral medications may be beneficial, especially in pregnant patients (while carefully evaluating the benefits and risks), patients with rapidly progressing lower respiratory disease or pneumonia, and patients with underlying medical conditions. The reminder was issued in response to an analysis published last week in the BMJ about the use of antivirals in children with seasonal flu.

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Hospitals with hospitalists score better on quality, care indicators

Hospitals with hospitalists perform better on quality indicators for acute myocardial infarction (AMI) and pneumonia, as well as on two dimensions of care, than hospitals without hospitalists, a new study found.

Researchers used data from the Hospital Quality Alliance (HQA) to measure hospital-level process indicators of care for AMI, congestive heart failure (CHF) and pneumonia at 3,619 hospitals from Oct. 1, 2005 through Sept. 31, 2006. They linked these data to a second set of data on medical and surgical hospital characteristics, including whether a hospitalist program existed, from the American Hospital Association's 2005 National Survey of Hospitals. The main outcome measures were composite measurements of hospital-level quality of care for AMI, CHF and pneumonia, as well as two dimensions of care: treatment and diagnosis, and counseling and prevention. Results were reported in the August 10/24 Archives of Internal Medicine.

Forty percent of the HQA hospitals had hospitalists; these facilities tended to be large, private, nonprofit teaching institutions in the southern U.S. For all three quality of care conditions, unadjusted composite scores were higher at hospitals with hospitalists than without (93% vs. 86% for AMI, 82% vs. 72% for CHF, and 75% vs. 71% for pneumonia; P<0.001 for all). Scores on treatment and diagnosis were also higher at hospitals with hospitalists (87% vs. 77%, P<0.001), as were scores on counseling and prevention (75% vs. 66%, P<0.001). In all areas except CHF, hospitals with hospitalists still scored significantly better after controlling for variables such as size, location and staffing availability.

The study was limited in that the data measured hospital-level performance, rather than matching individual patient care to whether a hospitalist provided care, the authors said. It also focused on only three diseases, while hospitalists care for many more than this, they noted. An accompanying editorial said the study contained too many confounding variables to definitively conclude that hospitalists improve the quality of care at hospitals, and suggested future research focus on the best ways to structure hospitalist programs rather than trying to prove the value of hospitalists.

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Quality of care

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Resident work-hour restrictions have not hurt outcomes in ICU

In-hospital mortality in intensive care units has decreased since restrictions on resident work hours were instituted in 2003, suggesting that the rules have not compromised patient care, a new study concluded.

The retrospective cohort study compared mortality before and after July 1, 2003 in 104 ICUs at 40 teaching and nonteaching hospitals from July 1, 2001 to June 30, 2005. Out of a total of 230,151 adult patients admitted to the ICUs, risk-adjusted mortality improved in hospitals of all teaching levels and there were no significant differences in mortality trends between hospitals of different teaching intensities. Since the decrease was not associated with teaching status, the authors concluded that resident work-hour rules had no net positive or negative association with major outcomes. The results appear in the September 2009 Critical Care Medicine.

The findings build upon previous research by showing that work-hour rules have not affected major outcomes in the ICU, where patients are at high risk for adverse events and sensitive to changes in staffing, the authors said. While proponents and critics of the reforms have argued, respectively, that patients would be either positively or negatively affected by the rules, these results do not provide evidence for either a dramatic improvement or decline in patient outcomes, they added. Several factors may explain the findings, including that many institutions have increased the role of nonphysician providers and/or have transferred more decision making to more senior physicians.

The authors acknowledged that the study has several limitations, including its observational nature using an existing database that could not provide specific details on ICU staffing, whether or when programs complied with the new rules, and whether there were changes in admission policies or resident case loads. The study assumes that all hospitals adhered to the regulations within two years of the implementation date when, in reality, many programs are still struggling to comply or adopted reform at different times, they added. The study also did not account for patients who died after being transferred to other facilities.

While the findings show that more humane resident work hours are possible without compromising patient care, the authors stressed that their study did not measure nonfatal medical errors or the impact of the regulations on costs or education. They concluded that further study is needed in order to understand the implications for resource utilization and to inform efforts to balance patient care with physician education and training.

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Cardiology

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ACE inhibitors before cardiac surgery may increase risk of death

Angiotensin-converting enzyme (ACE) inhibitor therapy before coronary artery bypass grafting (CABG) was associated with an increased risk of death and post-operative cardiac events, a recent large observational study reported.

The retrospective cohort study included data on 10,023 consecutive patients undergoing CABG between 1996 and 2008. About 3,000 of the patients who received pre-operative ACE inhibitors were matched to a control group by propensity score analysis. Those who received inhibitors before surgery had a twofold increase in the risk of death compared with patients who did not receive preoperative therapy (1.3% vs. 0.7%; odds ratio: 2.00, 95% confidence interval, 1.17 to 3.42; P=0.013). The ACE inhibitor group also had a higher risk of post-operative renal dysfunction (defined as a serum creatinine level >200 µmol/L plus an increase of at least 1.5 times preoperative baseline concentrations), atrial fibrillation (AF), and increased use of inotropic support. The study was published online Aug. 12 in the Journal of the American College of Cardiology.

The results are significant considering that ACE inhibitors have been shown in past studies to reduce the rate of mortality and to prevent cardiovascular events in patients with CAD, especially after MI. The authors theorized that the discrepancies might be because other studies were small with insufficient power to detect differences in mortality. In addition, two previous meta-analyses did not include any cardiac surgery patients, making the evidence weak for the potential benefit of ACE inhibitors to prevent post-operative AF. In contrast, the current study included a very large cohort that examined only patients undergoing CABG.

The authors also noted that the increased risk of post-operative AF found during the study may stem from ACE inhibitors’ effect on lowering systemic vascular resistance and vasoplegia in the early postoperative phase, resulting in hypotension and administration of more fluids and inotropic/vasoconstrictor drugs, which are risk factors for new onset of AF. In light of their findings, the authors suggested that omitting ACE inhibitors before surgery and restarting them postoperatively might be a reasonable approach to improving outcomes after CABG.

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FDA update

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Glucose monitoring strips may lead to fatal errors

Glucose testing with GDH-PQQ strips could lead to fatal errors in patients consuming nonglucose sugars, the FDA reported in a public health notification last week.

Because GDH-PQQ test strips do not distinguish between types of sugars, they may falsely indicate hyperglycemia in patients consuming products containing nonglucose sugars such as maltose, xylose and galactose. This can lead to inappropriate dosing and administration of insulin, potentially resulting in hypoglycemia, coma, or death, the FDA said. In addition, actual hypoglycemia could be missed if patients and practitioners rely only on the GDH-PQQ test result. From 1997 to 2009, the FDA has received 13 reports of deaths associated with GDH-PQQ glucose test strips where interference from maltose or other nonglucose sugars was documented.

The FDA noted that this problem does not apply to other glucose test strip methods or laboratory-based blood glucose assays. A list of recommendations to reduce the risk associated with GDH-PQQ test strips is available online.

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From the blog

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Medical news of the obvious on Mondays

Each Monday, the ACP Hospitalist blog will publish Medical News of the Obvious, a staff column that playfully jabs at recent studies with all-too-apparent conclusions. Also new on the blog, evidence that MRSA hospitalizations are on the rise, and a look at why you might soon prescribe chocolate and tickle therapy at discharge.

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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. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries by Aug. 20. ACP staff will choose three finalists and post them in the Aug. 26 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Sept. 2 edition.

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