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ACP HospitalistWeekly 12-16-09

Highlights

• Patients can name fewer than half of in-hospital medications
• Simple bedside risk calculator helps predict mortality in heart failure patients

Cardiology

• Contraindicated drugs raise risk of bleeding in dialysis patients after PCI
• Paper summarizes best evidence on managing heart disease patients undergoing elective GI procedures

Influenza

• Seasonal flu vaccination rates steady but earlier compared to last year

Cartoon caption contest

• Vote for your favorite entry

Physician editor: A. Scott Keller, FACP

Highlights

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Patients can name fewer than half of in-hospital medications

On average, patients can name fewer than half of the medications they are given while in the hospital, a new study found.

Researchers conducted a cross-sectional pilot study of 50 cognitively intact medicine inpatients at an academic hospital in Colorado. To qualify, patients had to self-identify as knowing their outpatient medications, speak English, and have been admitted from the community. Subjects completed a list of outpatient medications and of medications they believed had been prescribed in the hospital, and a survey of attitudes about in-hospital medications and medication errors. Primary outcomes were the proportions of scheduled, PRN and total hospital medications omitted by the patient compared to inpatient records, while a secondary outcome was the number of medications listed by a patient that weren't in the official record. Results were published in the Dec. 10 Journal of Hospital Medicine online.

Patients were prescribed an average of 11.3 scheduled and PRN medications in the hospital. Ninety-six percent of patients omitted at least one of those medications from their list, with patients omitting 6.8 medications on average. Antibiotics, cardiovascular medications and antithrombotics were the most commonly omitted among the scheduled medications, while analgesics and gastrointestinal medications were the most commonly omitted among PRN drugs. Forty-four percent of patients thought they were getting a medication in the hospital that they weren't. Patients younger than 65 years omitted 60% of their PRN medications, while patients older than 65 years omitted 88% (P=0.01), but there was no significant difference by age in the ability to name scheduled medications. Seventy-eight percent of patients said they'd like to be given their hospital medication list, but only 28% said they'd actually seen it.

When patients aren't systematically educated about their hospital medications, knowledge gaps are inevitable, the authors noted. While it's not known whether making patients aware of medications will reduce medication errors, it's plausible that the lack of this knowledge makes them disenfranchised about medication safety, they said. Of particular note is the fact that the most common scheduled inpatient medications that patients weren't able to name belong to classes—such as antithrombotics and antibiotics—that carry a risk of serious adverse events, the authors said.

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Simple bedside risk calculator helps predict mortality in heart failure patients

A risk scoring system using commonly available clinical variables offers a convenient bedside tool for stratifying risk and predicting in-hospital mortality in patients with heart failure, a new study concluded.

Researchers studied data on almost 40,000 participants in the American Heart Association’s Get With the Guidelines-Heart Failure (GWTG-HF) Program. Using the GWTG-HF risk scoring system, researchers found that older age, low systolic blood pressure, elevated heart rate, low serum sodium, elevated blood urea nitrogen (BUN), presence of chronic obstructive pulmonary disease and nonblack race were predictive of in-hospital mortality. Age, systolic blood pressure and BUN contributed more to the overall point score than other factors. The results were published online Dec. 8 in Circulation: Cardiovascular Quality and Outcomes.

The risk model is applicable to a broad spectrum of HF patients and was equally effective in patients with preserved and impaired left ventricular systolic function, the authors noted. The GWTG-HF risk score has several advantages over other HF mortality risk models, they added. It uses a contemporary cohort of population-based patients with diverse demographic characteristics and a wide range of comorbidities and includes patients regardless of left ventricular systolic function.

In addition, the GWTG-HF model includes variables that are routinely collected at time of admission, the authors added, and the score can easily be calculated at the bedside or online when data are entered into the GWTG Web-based tool. Applying the risk score has the potential to inform clinical decision-making and improve quality of care for HF patients, they concluded.

Cardiology

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Contraindicated drugs raise risk of bleeding in dialysis patients after PCI

More than 20% of dialysis patients undergoing PCI received a contraindicated antithrombotic drug, and those patients had a significantly higher risk of major bleeding than patients who did not receive the drugs, a study found.

Researchers analyzed data on more than 22,000 patients in the National Cardiovascular Data Registry who underwent percutaneous coronary intervention (PCI) between 2004 and 2008. Just over 22% of the patients received a contraindicated antithrombotic (either enoxaparin, eptifibatide or both) and those patients had a higher risk of in-hospital bleeding (5.6% vs. 2.9%) and death (6.5% vs. 3.9%) compared with patients who did not receive the drugs. There was a significant association with in-hospital bleeding, but not in-hospital death, in a subgroup analysis of patients matched by propensity scores. The association was particularly striking in patients undergoing PCI in the setting of acute coronary syndrome. The results appear in the Dec. 9 Journal of the American Medical Association.

Possible reasons for the use of contraindicated drugs include that enoxaparin, given either intravenously or as a subcutaneous injection without a continuous IV drip, is easier to administer than unfractionated heparin, the authors said. Eptifibatide also is often less expensive and more available than abciximab, they added.

To date, there has been a dearth of direct evidence from clinical trials regarding the use of contraindicated drugs in dialysis patients, who are often excluded from trials, the authors noted. This lack of evidence may have contributed to physicians’ willingness to use the drugs despite labeling about contraindications.

Based on the findings, enoxaparin and eptifibatide should be avoided in dialysis patients in favor of non-renally cleared antithrombotic alternatives, the authors concluded. Quality improvement efforts are needed, they said, such as amending clinical pathway order sets to include consideration of renal function.

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Paper summarizes best evidence on managing heart disease patients undergoing elective GI procedures

The latest evidence on the management of patients with atherosclerotic coronary disease undergoing elective endoscopic gastrointestinal procedures is summarized in a collaborative white paper by the American College of Cardiology and the American College of Gastroenterology.

The paper summarizes the evidence for risk of hemorrhagic and thrombotic events associated with elective endoscopic GI procedures in heart disease patients, particularly those with stents. The authors examined the potential risks of interrupting platelet-directed pharmacotherapy for five or more days before or after the procedure and offer advice on how to identify patients at highest risk. The paper is published in the Dec. 8 Journal of the American College of Cardiology.

A thienopyridine is the standard of care for platelet-directed pharmacotherapy with aspirin among patients with acute coronary syndrome or those undergoing percutaneous coronary intervention (PCI) and stent placement, the paper concluded. The authors recommended deferring elective endoscopic procedures in the first six to 12 months after PCI with drug-eluting stent insertion. Procedures scheduled beyond six months, especially if associated with high bleeding risk, could go forward five to seven days after thienopyridine drug cessation, and aspirin should be continued if possible.

Other evidence presented in the paper includes:

• Once hemostasis has been achieved after a procedure, a thienopyridine can be resumed with or without an initial oral loading dose, depending on risk for thrombosis and delayed bleeding. Continue platelet-directed pharmacotherapy for patients with a low risk for bleeding.
• Bridging with anticoagulants is not supported by evidence. Eptifibatide is the only available platelet antagonist that could be used but evidence-based recommendations are not available.
• Avoiding excessive tissue injury during procedures and using sound technical skills and good clinical judgment lowers the potential for complications associated with high-risk endoscopic procedures.

Influenza

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Seasonal flu vaccination rates steady but earlier compared to last year

Seasonal flu vaccination rates among American adults slightly improved over the previous year, a study found.

As of the middle of November, about 32% of all U.S. adults and 37% of adults recommended to receive a flu vaccination had been vaccinated. (Recommended are those 50 years of age and older, those with at-risk medical conditions, health care workers and those who are in close contact with people in high-risk categories.) One difference from last year is that more adults began getting the flu vaccine earlier this year. Vaccination during September increased from 3% in 2008 to 9% in 2009. Yet overall vaccination through mid-November of this year was comparable to the same period last year.

In addition, about half of health care workers had been vaccinated by the middle of November this year, roughly the same proportion that was vaccinated during the entire influenza season last year, according to a press release by the National Foundation for Infectious Diseases. Nonetheless, 39% of health care workers reported they had no intention of being vaccinated despite the risk of transmitting influenza to patients.

Other findings from the study include:

• Of those who'd sought vaccination, about 38% said there was none available when they tried;
• There was little evidence that people were forgoing seasonal influenza vaccine in order to be vaccinated against H1N1;
• About 44% of vaccinated adults said their health care provider was the most influential source of information;
• Unvaccinated adults relied less on health care providers and more on news reports than vaccinated adults;
• Whites were more likely to have been vaccinated; Hispanics adults were the least likely.

The findings are from a national survey of 5,679 adults conducted online between Nov. 4-16, 2009.

"Health care workers are at the front lines of patient care, so it is critical for them to be vaccinated, not only for their own protection, but for their patients," said William Schaffner, MACP, president-elect, National Foundation for Infectious Diseases, in the release. "These data also draw important attention to the fact that, despite overwhelming expert advice, they are not taking precautions against influenza."

The survey was done by RAND and supported by GlaxoSmithKline, a manufacturer of flu vaccine.

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Cartoon caption contest

Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

"Let's celebrate. I have been converted from observation to inpatient status."
"Way to go on the champagne tap! This round's on me."
"I have one of those 'Cadillac' health care plans."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Dec. 21, with the winner announced in the Dec. 23 issue.

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