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ACP HospitalistWeekly 10-21-09
Highlights
- H1N1 studies offer insight into potential pandemics' presentation
- Mortality rates improve in U.S. hospitals, but quality gaps persist
End-of-life care
- Proxies’ perceptions about dementia guide decisions about interventions
Perioperative care
- High oxygen levels during abdominal surgery do not lower infection risk
Quality improvement
- Hospital to Home project launches
Resource use
- Don’t base benchmarks on incomplete data, study warns
From ACP Hospitalist
- The next issue of ACP Hospitalist is online and in your mailbox
Cartoon caption contest
- Put words in our mouth
Highlights
.H1N1 studies offer insight into potential pandemics' presentation
Studies from around the globe are offering initial glimpses into who might be at more risk during a potential H1N1 influenza pandemic and how the disease course for the sickest patients might strain available hospital resources.
Three studies from Journal of the American Medical Association reported on the effects of H1N1 in Australia/New Zealand, Canada and Mexico. Generally, reports considered what course illness took in the regions and found that:
- the median patient age was 30s or 40s,
- patients were frequently obese, or had comorbid medical conditions,
- patients were ill for a long time (four to seven days) before going to the hospital,
- once patients were admitted to the hospital, severe cases went to the ICU within a day,
- critical illness was associated with severe hypoxemia and other organ failures, and
- severe respiratory illness required mechanical ventilation for a median of 12 days or extracorporeal mechanical oxygenation (ECMO) for a median of 15 days (for survivors) and 7.5 days (for non-survivors).
ECMO was used to treat 68 H1N1 patients in Australia and New Zealand, or one-third of 194 study patients who'd been ventilated. The average age of patients who got ECMO was 34 years, with the most common comorbidities being obesity, asthma and diabetes. Six patients were pregnant and four were post-partum. Fourteen of the 68 died by the end of the reporting period, although six were still in the ICU and two were still on ECMO. In Australia and New Zealand, only 15 of the 187 ICUs provide ECMO, and the number of days on ECMO created a substantial burden during the weeks-long peak period of the outbreak, authors reported. Rough estimates are that 800 Americans and 1,300 European Union residents might undergo ECMO this flu season.
In Canada, researchers reported on 168 critically ill cases. The mean age was 32 years, with an overall mortality of 14.3% at 28 days and 17.3% at 90 days. All the patients were severely hypoxemic, with shock and acute organ dysfunction common. Mechanical ventilation was required by 136 patients, with a median of 12 days' duration.
In Mexico, researchers reported on 58 patients admitted to six hospitals with critical illness. The median patient age was 44 years. In the study, 54 of the 58 received ventilation. By 60 days, 24 patients had died, and those patients were more likely to have had greater initial severity, worse hypoxemia, higher creatinine kinase levels, higher creatinine levels and ongoing organ dysfunction. Because of increased patient volumes during the disease peak, ICU admission was delayed and four died in the ED.
Survival will depend on how physicians and hospitals apply ventilation and adjunct therapies, and many hospitals lack the expertise or around-the-clock staffing structures, according to an accompanying editorial.
In the U.S., health officials now say that 46% of 1,400 adults hospitalized with H1N1 influenza did not have a chronic underlying condition, according to preliminary data from the largest analysis to date.
The study looked at adults and children hospitalized from April through August in 10 states at medical centers participating in a special disease surveillance network. Anne Schuchat, FACP, who heads the CDC's National Center for Immunization and Respiratory Diseases, said the larger analysis looked at underlying conditions not previously examined. Among adults, 26% had asthma, 10% had diabetes, 8% had some other chronic lung disease, 8% had weakened immune systems and 6% were pregnant.
A Michigan study found that severe H1N1 influenza placed patients at risk of pulmonary embolism. Researchers based at the University of Michigan examined the medical condition of 66 patients diagnosed with H1N1 influenza. Of these, 14 patients were severely ill and were admitted to the ICU for mechanical ventilation. CT scans identified PE in five cases. Results were reported online by the American Journal of Roentgenology.
.Mortality rates improve in U.S. hospitals, but quality gaps persist
Mortality rates in U.S. hospitals improved from 2006 through 2008, but care quality continues to vary, according to a new study.
In its 12th annual Hospital Quality in America Study, health care ratings company HealthGrades analyzed data on approximately 40 million Medicare discharges to measure variations in quality of care. Researchers found that although U.S. in-hospital risk-adjusted mortality rates improved an average of 10.99% from 2006 to 2008, quality of care improved more quickly at highly rated (five-star) hospitals than at lower rated (one- or three-star) hospitals (11.89% vs. 10.14% or 10.72%, respectively).
Large gaps in quality between hospitals were also observed, the researchers noted. For all procedures and diagnoses studied, patients cared for in a five-star hospital had a 71.64% lower risk for death than those cared for in a one-star hospital. Of 224,537 potentially preventable Medicare deaths, approximately 56% (127,488) were associated with four diagnoses:
- sepsis (44,622 deaths),
- pneumonia (29,251 deaths),
- heart failure (26,374 deaths) and
- respiratory failure (27,241 deaths)
The full HealthGrades report is available online.
End-of-life care
.Proxies’ perceptions about dementia guide decisions about interventions
Patients with advanced dementia were less likely to undergo interventions of questionable benefit near the end of life if their families and caregivers understood the patients' prognoses and likely complications, a recent study found.
Researchers followed 323 residents of nursing homes with advanced dementia and their health care proxies for 18 months. By the end of the study period, 54.8% of patients died and many experienced complications, including pneumonia (41.1%), febrile episodes (52.6%) and eating problems (85.8%). Almost 41% of residents underwent interventions such as hospitalization or tube feeding during the last three months of life, but interventions were much less likely among patients whose proxies had an understanding of the prognosis and expected complications of dementia (adjusted odds ratio, 0.12; 95% CI, 0.04 to 0.37). The results appear in the Oct. 15 New England Journal of Medicine.
The findings can be used to inform families that infections and eating problems should be expected in patients with advanced dementia and that they often signal that the end of life is near, the authors said. The study also underscores that while these complications may precede death, dementia is the underlying cause.
Knowing that certain complications are associated with high rates of death within six months gives families and caregivers time to discuss the goals of care and potential hospice referral, said an accompanying editorial. The findings highlight that advanced dementia is a terminal illness that requires palliative care, the editorial continued, and that patients with advanced dementia do not need to have another serious illness to qualify for hospice care.
Discussions of the issues raised in the study by providers and families have the potential to modify the perceptions of health care proxies and affect their decisions about the use of interventions and hospice care, the editorial said. The findings could also inform public policy decisions about hospice and trigger funding for research on the use of palliative care and improving current systems of care.
Perioperative care
.High oxygen levels during abdominal surgery do not lower infection risk
Administering high levels of oxygen during abdominal surgery does not lower the risk of surgical site infection, according to a recent trial.
Researchers randomly assigned 1,400 patients undergoing acute or elective laparotomy to receive either 80% or 30% oxygen during and for two hours following surgery. There were no significant differences in the number of surgical site infections (19.1% in the 80% group vs. 20.1% in the 30% group), pulmonary complications or mortality between the two groups. The results are published in the Oct. 14 Journal of the American Medical Association.
Previous trials have suggested that high oxygen levels may be effective in preventing surgical wound infections, noted an accompanying editorial. However, fluid volumes administered in this trial were smaller than in previous studies and normothermia was not maintained in all patients. Because these factors raise the possibility of vasoconstriction, the editorialist said, the current study would have been stronger if researchers had measured wound partial pressure of oxygen in order to show that supplementary oxygen reached the wounds.
The current findings inform the debate over whether high levels of oxygen can prevent infections, the editorial continued, but more research is needed before the practice becomes standard. For now, physicians should focus on ensuring rigorous perioperative care, including adequate fluid administration, maintenance of normothermia and normoglycemia, and appropriate use of perioperative antimicrobial agents.
Quality improvement
.Hospital to Home project launches
The American College of Cardiology and the Institute for Healthcare Improvement will launch their joint Hospital to Home (H2H) initiative tomorrow.
The national quality improvement project, for which ACP is a strategic partner, aims to improve inpatient to outpatient transitions in patients with cardiovascular disease. Its goal is to achieve a 20% reduction in 30-day all-cause risk-adjusted hospital readmission rates for patients with heart failure or acute myocardial infarction by December 2012. The initiative will focus on three main areas: medication management post-discharge, early follow-up and symptom management.
H2H will launch with a kickoff Webinar on Oct. 22 at 1 p.m. Eastern time.
More information is available online.
The September 2009 ACP Hospitalist included an interview with John Rumsfeld, FACP, co-chair of the H2H quality initiative.
Resource use
.Don’t base benchmarks on incomplete data, study warns
Including only patients who died in studies of resource use results in misleading data, according to a recent study.
The study included 3,999 patients hospitalized for heart failure at six California teaching hospitals between 2001 and 2005. By including all admitted patients, as opposed to only those who died, researchers were able to identify differences in outcomes. The variation in resource use among hospitals was 27% to 44% less than observed in studies that analyzed only patients who died, and hospitals that used the most resources had the lowest mortality rates. The results appear in the November 2009 Circulation: Cardiovascular Quality and Outcomes.
Previous studies that have used the “looking back” method, including only expired patients, have two serious shortcomings, the authors said. The method does not take into account the possibility that resource-intensive care may improve outcomes because all outcomes are 100% mortality. In addition, this method misses the possibility that some hospitals may selectively direct resources based on which patients are most likely to benefit.
The findings have important implications because “looking back” studies have been used to set performance benchmarks, the authors noted. While this study does not mean that there is a causal relationship between higher resource use and better outcomes, it suggests that more study is needed about how resource use during initial hospitalization influences outcomes, the authors said.
Future studies should include all hospitalized patients to ensure that important outcomes are not missed, the authors added. More research is needed that includes outcomes and resource use, as well as smaller and nonteaching hospitals, in order to develop accurate methods of ranking hospitals according to resource use, they concluded.
From ACP Hospitalist
.The next issue of ACP Hospitalist is online and in your mailbox
The next issue of ACP Hospitalist is online, featuring the following stories and more.
Hold on to your hospitalists. Compensation helps retention, but intangibles are important too. Learn how to foster a team environment that turns new hires into long-term employees.
Not a time for modesty. More and more hospital administrators and consultants are asking hospitalists to demonstrate their value. Be ready to show how your program is earning its keep.
Code status discussions sometimes difficult, but necessary. Experts offer tips on broaching the subject.
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 October 22. ACP staff will choose three finalists and post them in the Oct. 28 issue of ACP HospitalistWeekly for an online vote by readers. The winner will appear in the Nov. 4 edition.
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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