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ACP HospitalistWeekly 9-16-09

Highlights

• Blacks more likely than whites to die after in-hospital cardiac arrest
• CDC, CMS offer new guidance on H1N1 flu

Cardiology

• Ticagrelor led to lower mortality rates than clopidogrel in ACS patients

Infectious disease

• Procalcitonin test can be used to guide antibiotic use

Critical care

• Protein may be marker for circulatory failure in sepsis patients

From ACP Internist

• Your Thoughts Exactly: town hall meetings on health reform

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

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Highlights

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Blacks more likely than whites to die after in-hospital cardiac arrest

Survival rates are worse for black patients admitted to the hospital after cardiac arrest than for whites, largely because blacks are more likely to be treated at low-performing hospitals, a recent study found.

Researchers studied a cohort of 10,011 patients (18.8% black; 81.2% white) with cardiac arrests due to ventricular fibrillation or pulseless ventricular tachycardia at 274 hospitals between 2000 and 2008. Black patients had a 27% lower relative risk and a 12% lower absolute rate of survival to hospital discharge than whites. The disparities were largely due to blacks being more likely than whites to be admitted to hospitals with worse outcomes, the authors said, as well as to differences in quality of care during the acute and post-resuscitation phases. The study appears in the Sept. 16 Journal of the American Medical Association.

The results suggest that black patients are more likely to have cardiac arrests in hospitals with higher rates of delays in defibrillation time, the authors said. They noted physician bias does not explain racial differences during the acute resuscitation phase because they found no evidence of differences in aggressiveness of resuscitation, such as the number of attempted defibrillations and total treatment time.

In the post-resuscitation phase, the hospital itself accounted for most of the racial differences, they said. Further study is needed to determine whether the lower rates of post-resuscitation survival in blacks are due to specific hospital characteristics, such as lower-quality ICU expertise or less aggressive use of therapies such as hypothermia and cardiac catheterization, the authors said.

The authors concluded that strategies to eliminate racial disparities must involve improving resuscitation survival and post-resuscitation care in poor-performing hospitals that serve large populations of black patients.

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CDC, CMS offer new guidance on H1N1 flu

The Centers for Disease Control and Prevention updated guidance on the use of antiviral drugs to treat or prevent H1N1 and seasonal flu to help clinicians prioritize their use.

Watchful waiting is a new option, said Anne Schuchat, FACP, director of the National Center for Immunization and Respiratory Diseases at the CDC. Also, to speed up treatment, physicians could write prescriptions for high-risk patients, who would fill them only after they develop symptoms, she told CNN.

Other highlights include:

• Oseltamivir (Tamiflu) or zanamivir (Relenza) is recommended for all hospitalized patients with suspected or confirmed flu.
• Oseltamivir or zanamivir is generally recommended for children younger than 5, adults 65 years and older, pregnant women, persons with certain chronic medical or immunosuppressive conditions, and children younger than 19 taking long-term aspirin.
• Any suspected flu patient presenting with warning symptoms such as dyspnea or signs such as tachypnea or unexplained oxygen desaturation for lower respiratory tract illness should promptly receive empiric antiviral therapy.
• Treatment should not wait for laboratory confirmation. Clinicians should prioritize real-time reverse transcriptase-polymerase chain reaction tests for those with suspected or confirmed flu requiring hospitalization and based on guidelines from local and state health departments.
• To reduce delays in starting treatment, tell high-risk patients to look for signs and symptoms, ensure access to phone consultation and clinical evaluation, and consider treating high-risk patients based on phone contact if hospitalization is not indicated.
• Postexposure antiviral chemoprophylaxis with either oseltamivir or zanamivir can be considered for health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person with confirmed, probable or suspected 2009 H1N1 or seasonal influenza during that person’s infectious period.

More than 98% of circulating flu viruses were 2009 H1N1, susceptible to both oseltamivir and zanamivir, as of August. Most patients have had a self-limited respiratory illness similar to typical seasonal flu, and those who present with an uncomplicated febrile illness generally do not need treatment.

Outbreaks in schools, camps, workplaces and other group settings should not be managed by giving antivirals to those exposed, but instead, patients should be educated about flu symptoms and urged to consult their health care provider if severe illness develops.

CMS has also issued new guidance on billing for the H1N1 vaccine in a special edition of Medicare Learning Network Matters. The article explains the coverage and reimbursement rules for the new vaccine. The vaccine will be covered under Medicare Part B as an additional preventive immunization service.

Medicare has created two new billing codes:

• G9141—Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)
• G9142—Influenza A (H1N1) vaccine, any route of administration

Because the H1N1 vaccine will be made available to providers at no cost, there is no need for reimbursement for the vaccine itself. Aside from the cost of the vaccine, the procedure is the same as billing for seasonal influenza virus vaccine.

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Cardiology

Ticagrelor led to lower mortality rates than clopidogrel in ACS patients

Treatment with ticagrelor in patients with acute coronary syndrome significantly reduced the rate of death from cardiovascular causes compared with clopidogrel, without raising the rate of overall major bleeding, a recent study concluded.

The multicenter, double-blind, industry-sponsored randomized trial compared outcomes in 18,624 patients admitted with acute coronary syndrome (ACS), with or without ST-segment elevation, who were treated with either ticagrelor (180-mg loading dose, 90 mg twice daily thereafter) or clopidogrel (300- to 600-mg loading dose, 75 mg thereafter). After 12 months, the primary end point of death from vascular causes, myocardial infarction or stroke had occurred in 9.8% of ticagrelor patients compared with 11.7% in the clopidogrel group. Patients taking ticagrelor had significantly lower rates of myocardial infarction alone and death from vascular causes alone as well as from all causes, but there was no difference in stroke rates. There was also no significant difference in the rate of major bleeding between the two groups, but ticagrelor was associated with a higher rate of major bleeding not related to coronary artery bypass grafting, including fatal intracranial bleeding. In addition, there were side effects that included dyspnea, bradyarrhythmias and increased serum creatinine. The results appear in the Sept. 10 New England Journal of Medicine.

An accompanying editorial noted that the availability of three agents for antagonizing platelet ADP receptors gives physicians more options, such as switching patients from clopidogrel or prasugrel to ticagrelor five to seven days before elective surgery. However, ticagrelor, like prasugrel, should likely be avoided in patients with a history of stroke or transient ischemic attacks and in patients with an excessively high risk of bleeding, as well as in those with chronic obstructive pulmonary disease, moderate or severe renal failure or a history of syncope.

Ticagrelor or prasugrel may be the preferred treatments for all remaining patients with ACS, the editorial continued, until there are data comparing these two agents. Future studies should evaluate the adverse effects of ticagrelor in a much larger number of patients, and patients who are given this drug should be carefully monitored for side effects, the editorialist said.

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Infectious disease

Procalcitonin test can be used to guide antibiotic use

Fewer antibiotics were used to treat lower respiratory infections when treatment decisions were based on a measurement of procalcitonin instead of standard guidelines, a new study found.

The randomized controlled trial included 1,359 patients seen in Swiss emergency departments for lower respiratory tract infections. Physicians treated the patients according to either standard guidelines or a new algorithm that used serum procalcitonin (PCT) levels to determine the likelihood of a bacterial infection. Patients who were admitted to the hospital received repeat PCT tests to determine when to discontinue antibiotic therapy.

The intervention group had a lower mean duration of exposure to antibiotics (5.7 days vs. 8.7; 95% CI for difference, −40.3% to −28.7%). Even greater differences in treatment duration were seen in the subgroups of patients who had community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease and acute bronchitis. Antibiotic-associated adverse events were less frequent in the PCT group (19.8% vs. 28.1%, 95% CI, −12.7% to −3.7%), but overall adverse events were similar and the PCT patients had a slightly higher mortality rate.

The use of the PCT algorithm had different effects depending on the patients' diagnoses, the researchers noted. In patients with community-acquired pneumonia, the algorithm was expected to shorten treatment duration, while antibiotics were less likely to be used at all in treatment of acute bronchitis. A reduction in antibiotic use would help to reduce individual antibiotic-associated costs and adverse events as well as discourage the growth of drug-resistant organisms, the researchers concluded. They noted that point-of-care testing for PCT is becoming more available in the U.S.

An accompanying editorial cautioned that more generalizable data on effectiveness and safety will be needed before the algorithm can be widely adopted. The editorialist expressed concern about the mortality difference between the groups, and noted that the study did not assess the cost-effectiveness of PCT testing as a means to reduce antibiotic overuse. The research was published in the Sept. 9 Journal of the American Medical Association.

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Critical care

Protein may be marker for circulatory failure in sepsis patients

High plasma levels of heparin-binding protein may be a marker for identifying patients at risk for sepsis with circulatory failure, a study found.

Researchers studied 233 febrile adult patients with suspected infection and classified them based on systemic inflammatory response syndrome criteria, organ failure and final diagnosis. Blood samples were analyzed for heparin-binding protein (HBP), procalcitonin, interleukin-6, C-reactive protein and number of white blood cells. They found that a plasma HBP level of 15 ng/mL or was a significant indicator of severe sepsis and eventual circulatory failure. The study was published online Sept. 2 in Clinical Infectious Diseases and appears in the Oct. 1 issue.

The results show a close correlation between increased HBP plasma levels and the development of hypotension, organ failure and septic shock, the authors said. Of the 26 patients with septic shock, 24 had increased plasma HBP at enrollment while 37 of the remaining 44 patients with severe sepsis had elevated HBP levels. In contrast, only seven patients among the 100 with nonsevere sepsis had increased HBP.

The findings suggest that a normal HBP level in a febrile patient with suspected infection would likely rule out the risk of severe sepsis, the authors said. The results have important clinical implications since delay of proper treatment has a large impact on mortality in patients with septic shock. The authors noted that in the study, a high HBP level preceded circulatory failure by several hours in many patients.

The findings indicate that intensifying fluid resuscitation and beginning proper antibiotic treatment in febrile patients with high HBP levels has the potential to prevent circulatory failure, the authors said. However, they noted that HBP is not a marker for bacterial infection because patients with some invasive bacterial infections had normal HBP levels.

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From ACP Internist

Your Thoughts Exactly: town hall meetings on health reform

In August, members of Congress and the White House held town hall meetings to discuss health care reform. The meetings were sometimes productive but often contentious. Tell us: Were the meetings more of a success or a failure in terms of making progress on the issue?

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Cartoon caption contest

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 to acphospitalist@acponline.org by Sept. 24. ACP staff will choose three finalists and post them in the Sept. 30 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Oct. 7 edition.

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