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ACP HospitalistWeekly 11-25-09

Highlights

• Groups issue update on management of PCI and STEMI
• Timely hospital report cards didn’t improve overall cardiac care

Infection control

• Guidelines for health care-associated pneumonia not always followed
• Mechanical valve needleless connectors associated with higher bloodstream infection rates

FDA update

• Patch approved to treat shingles pain
• FDA warns against giving clopidogrel with PPIs

CMS update

• Medicare extends provider enrollment period

Cartoon caption contest

• And the winner is…

Physician editor: A. Scott Keller, FACP

Editorial note: ACP HospitalistWeekly will not be published next week due to the Thanksgiving holiday.

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Highlights

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Groups issue update on management of PCI and STEMI

Updated guidelines for managing ST-elevation myocardial infarction (STEMI) and percutaneous coronary intervention (PCI) call for integrating prasugrel into treatment and for new standards on efficient transfer of patients needing PCI.

The update, compiled by the American College of Cardiology, the American Heart Association and the Society of Cardiovascular Angiography and Interventions, noted new evidence about prasugrel, but does not explicitly endorse its use over clopidogrel. A recent large trial found that prasugrel reduced nonfatal MIs in STEMI patients undergoing PCI, compared with clopidogrel, but also increased the risk of bleeding, the authors said. In addition, there is not yet enough information to guide identification of patients who might do better with prasugrel, they said.

The authors also highlighted the importance of speeding transfer to PCI-capable facilities for patients with high-risk features such as high bleeding risk from fibrinolytic therapy and presentation more than four hours after symptom onset. They urged communities to develop regional systems of STEMI care, such as the AHA’s “Mission: Lifeline” initiative which encourages closer cooperation among pre-hospital emergency services and cardiac care professionals.

Other recommendations in the update include:

• Use of a glycoprotein IIb/IIIa antagonist cannot be recommended as routine therapy for dual-antiplatelet therapy with UFH or bivalirudin as the anticoagulant, although it can be useful at the time of primary PCI;
• There is insufficient evidence to recommend the use of dual antiplatelet therapy with proton pump inhibitors in the setting of acute coronary syndrome;
• Bivalirudin is useful as a supportive measure for primary PCI in STEMI whether or not the patient received pretreatment with unfractionated heparin;
• Early glycoprotein IIb/IIIa therapy is reasonable in patients with unstable angina or non-ST-elevation MI undergoing angiography who are at high risk of thrombotic events relative to bleeding risk.

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Timely hospital report cards didn’t improve overall cardiac care

Giving hospitals early publicly reported feedback on their quality scores for cardiac care did not significantly improve composite process-of-care indicators, a new study found.

Researchers randomized 86 hospitals in Ontario, Canada, to either early (January 2004) or delayed (January 2005) feedback on their performance scores on a set of 12 measures for acute myocardial infarction (AMI) and six for congestive heart failure (CHF) between 1999 and 2001. There were no significant systemic improvements in the early feedback group on composite process-of-care indicators for AMI or CHF, but 30-day AMI mortality rates were 2.5% lower in the early feedback group during the one-year follow-up period. The study appears in the Nov. 18 Journal of the American Medical Association.

The authors noted that while many hospitals in the early feedback group undertook improvement initiatives, each hospital tended to target different areas depending on their local results. This might explain why the study did not detect significant improvements across two large groups of hospitals and a wide range of indicators, they said.

While individual process-of-care indicators were not significantly improved, the lower mean 30-day AMI mortality rate in the early feedback group suggests that the diverse local improvements collectively may have improved outcomes, the authors said. Almost two-fifths of hospitals in the early feedback group initiated processes to improve timely reperfusion, the authors noted, while five hospitals opened CHF clinics, and early feedback appeared to lead to greater use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers.

The authors concluded that while releasing report card data did not result in systemic improvements in cardiac care, it likely triggered some important local changes that may have contributed to better outcomes. In the future, developing common improvement strategies across hospitals might make the report cards more effective systemwide, they added.

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Infection control

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Guidelines for health care-associated pneumonia not always followed

Physicians are aware of and even agree with guidelines for antibiotic treatment of health care-associated pneumonia but don't always follow them, according to a new survey.

Guidelines for treatment of health care-associated pneumonia (HCAP) stress appropriate use of antibiotics to avoid development of multidrug resistance. Researchers conducted an online survey at four academic medical centers to determine whether physicians would select guideline-approved therapy in nine hypothetical cases, seven involving HCAP and two involving community-acquired pneumonia (CAP). Physicians were also asked about their knowledge of and agreement with current guideline recommendations for HCAP. The study results were published online Nov. 12 by Clinical Infectious Diseases and will appear in the Dec. 15 issue.

Overall, 855 of 1,313 physicians completed the survey (response rate, 65%). Sixty percent of respondents were hospitalists or internists, 25% were emergency medicine physicians, and 13% specialized in critical care. Respondents were much more likely to select guideline-concordant therapy for the CAP cases than for the HCAP cases (78% vs. 9%). Hospitalists and internists performed worse on HCAP questions than emergency medicine and critical care physicians, but the scores overall were so low that differences were too small to be meaningful, the study authors wrote. Seventy-one percent of physicians reported being familiar with the HCAP guidelines, and 79% reported agreeing with and following them in clinical practice.

The researchers acknowledged their study's limitations, including uncertainty about how closely physicians' responses to hypothetical cases mirrored their clinical practice and potential lack of generalizability. However, their findings could have "potentially serious implications" since inappropriate antibiotic treatment is known to increase mortality rates in patients with HCAP. "Clearly the need to improve our understanding of which patients benefit most from broad spectrum therapy needs to be advanced, and a better understanding of the barriers to translating guidelines into practice is critical," they concluded.

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Mechanical valve needleless connectors associated with higher bloodstream infection rates

Mechanical valve needleless connectors (MV-NCs) are associated with higher health care-associated, central venous catheter-related bloodstream infection rates than split septum needleless connectors (SS-NCs), a new study found.

Researchers studied health care-associated bloodstream infection (HA-BSI) rates on 16 intensive care units, one oncology ward, and one whole hospital, all of which had switched from SS connectors or needles to MV-NCs. Three of the hospitals studied were in the U.S. and two were in Australia; all five had done HA-BSI surveillance during use of both connectors. Researchers compared bloodstream infection rates and prevention practices in the pre-MV-NC period, the MV-NC period, and the post MV-NC period. Results were published in the November 13 online Clinical Infectious Diseases.

The HA-BSI rate increased in all ICUs and wards when MV-NCs replaced SS-NCs, from a mean of 3.80 infections per 1,000 central venous catheter (CVC) days with SS-NCs, to 6.83 infections per 1,000 CVC days with MV-NCs. In the 16 ICUs combined, the rate increased significantly with replacement of SS-NCs or needles (6.15 vs. 9.49 bloodstream infections per 1,000 CVC days; relative risk, 1.54; 95% confidence interval, 1.37-1.74; P<.001). Fourteen ICUs switched back to SS-NCs, and saw significant reductions in bloodstream infection rates (9.49 vs. 5.77 BSIs per CVC-days; RR, 1.65; 95% CI, 1.38-1.96; P<.001). Strategies to prevent BSIs were similar in all facilities, and none achieved baseline pre-MV-NC BSIs while the MV-NCs remained in use, even though prevention efforts were stepped up once the higher infection rates were detected.

MV-NCs are associated with higher bloodstream infection rates than are SS-NCs and needles, even when surveillance remains the same and prevention efforts are steady or increase, the authors concluded. As such, inferior infection control practices alone can't explain the higher infection risk with MV-NCs, they said. Possible reasons for the higher risk are that health care workers are unaware of the manufacturer's recommendations for MV-NC use, or that the impact of infection control breaches may be greater with MV-NC use than SS-NC use. Hospitals should monitor their HA-BSI rates and carefully consider the role MV-NCs may be playing if they find the rates elevated, the authors said. Hospitals should also include infection control personnel in the evaluation of new technologies before they are used in a facility, not after a problem has been discovered, they said.

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FDA update

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Patch approved to treat shingles pain

A medicated skin patch containing capsaicin (Qutenza 8%) was approved last week to treat pain from post-herpetic neuralgia in patients with shingles, the FDA announced.

Lower concentrations of capsaicin, a compound found in chili peppers, are available over the counter, but this patch is the first pure, concentrated, synthetic capsaicin-containing prescription drug to undergo FDA review. The most frequently reported adverse drug reactions included pain, swelling, itching, redness and bumps at the application site.

The patch must be applied to the skin by a health care professional since placement can be quite painful, requiring use of a local topical anesthetic, as well as additional pain relief such as ice or use of opioid pain relievers, according to the FDA. The patient must also be monitored for at least one hour since there is a risk of a significant rise in blood pressure following patch placement.

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FDA warns against giving clopidogrel with PPIs

Clopidogrel (Plavix), an anti-clotting medication, and omeprazole (Prilosec/Prilosec OTC), a proton pump inhibitor (PPI), should not be used together, the FDA warned health care professionals last week.

The notification, which came with a labeling change for clopidogrel, was based on new manufacturer data showing that when the drugs are taken together, the effectiveness of clopidogrel is reduced. Patients at risk for heart attacks or strokes who use clopidogrel to prevent blood clots will not get the full effect of this medicine if they are also taking omeprazole, the FDA said.

The agency also warned that separating the dose of clopidogrel and omeprazole in time will not reduce this drug interaction. Other drugs that are expected to have a similar effect and should be avoided in combination with clopidogrel include: esomeprazole, cimetidine, fluconazole, ketoconazole, voriconazole, etravirine, felbamate, fluoxetine, fluvoxamine and ticlopidine. There is no evidence that other drugs that reduce stomach acid, such as most H2 blockers [ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), except cimetidine (Tagamet and Tagamet HB — a CYP2C19 inhibitor)] or antacids interfere with the anti-clotting activity of clopidogrel.

The FDA does not have sufficient information about drug interactions between clopidogrel and PPIs other than omeprazole and esomeprazole to make specific recommendations about their co-administration, the agency said.

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CMS update

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Medicare extends provider enrollment period

Last week, CMS announced it would extend the 2010 Annual Participation Enrollment period until Jan. 31, 2010.

The effective date for any status change, however, will still be Jan. 1, 2010. This means that if you choose to change your status from participating to non-participating after Jan. 1, Medicare's non-participating provider conditions will be in force for your claims with dates of service on or after Jan. 1.

Additional information about provider enrollment is available on the CMS Web site.

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Cartoon caption contest

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And the winner is …

ACP HospitalistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by Harrison Weed, FACP, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 158 ballots online to choose the winning entry. Thanks to all who voted!

"And then Timmy says to me, 'Jump, girl. You can make it.'"

The winning entry captured 40.5% of the votes.

The runners up were:
"Doc says my gait disturbance is caused by Barkinson's disease." (34.8%)
"I'm the new CAT scanner." (24.7%)

ACP Hospitalist is also starting its next cartoon caption contest this week. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries to acphospitalist@acponline.org. ACP staff will choose three finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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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