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ACP HospitalistWeekly 12-23-09
Highlights
- Elderly see biggest drops in potentially preventable hospitalization rates between 2003 and 2007
- Web-based tool may help predict short-term risk for stroke recurrence
Perioperative care
- Bleeding risk after MI increases with number of antithrombotic agents given
CT scans
- New estimates on cancer risk of CT scans
From ACP Hospitalist
- The next issue of ACP Hospitalist is online
Cartoon caption contest
- And the winner is…
Physician editor: A. Scott Keller, FACP
Editorial note: ACP HospitalistWeekly will not be published for the next two weeks due to the Christmas and New Year’s holidays. See you next year!
Highlights
.Elderly see biggest drop in potentially preventable hospitalization rates between 2003 and 2007
Although seniors are more likely than younger patients to be hospitalized for a potentially preventable condition, hospitalization rates fell more dramatically for patients age 65 and older than for younger patients between 2003 and 2007, a new report said.
The Agency for Healthcare Research and Quality examined hospitalization rates for 11 conditions, such as diabetes and angina, which may be controllable with improved quality and effectiveness of outpatient services and disease management. Researchers compared hospitalizations for patients age 65 and older to those age 18 through 64. Rates of decline by condition were as follows:
- Angina: 43% decline for seniors vs. 39% for ages 18-64
- Uncontrolled diabetes: 21% decline for seniors vs. 5% for ages 18-64
- Dehydration: 20% decline for seniors vs. 16% for ages 18-64
- Short-term diabetes complications: 19% decline for seniors vs. 10% increase for ages 18-64
- Lower-extremity amputation, usually due to diabetes: 17% decline for seniors vs. 3% for ages 18-64
- Bacterial pneumonia: 16% decline for seniors vs. 8% for ages 18-64
- Congestive heart failure: 14% decline for seniors vs. 9% for ages 18-64
An increase in hypertension admission rates was about equal for the two groups, while admissions for urinary tract infections rose by 15% for seniors and 1% for the younger group. Adult asthma also saw a 15% decline in the younger group versus a 7% decline in the older group.
Overall in 2007, seniors accounted for many more potentially preventable hospitalizations than younger adults. For example, potentially preventable diabetes-related hospitalizations occurred 2.6 times more often among older adults than among younger adults (49.9 vs. 19.4 discharges per 10,000 population), while potentially preventable stays for chronic respiratory conditions were 5.4 times more common among older adults (99.9 vs. 18.5 discharges per 10,000 population). Potentially preventable hospitalizations for chronic cardiac conditions occurred more than 10 times more often among the elderly. For acute conditions, potentially preventable stays occurred nearly 10 times as often among older adults as younger, with bacterial pneumonia having the highest hospitalization rate for both groups.
Data for the AHRQ report came from the 2007 Nationwide Inpatient Sample, a database of hospital inpatient stays that is nationally representative of inpatient stays in all short-term, nonfederal hospitals. The data are drawn from hospitals that comprise 90% of all discharges in the United States and include insured and uninsured patients.
.Web-based tool may help predict short-term risk for stroke recurrence
A new Web-based prediction tool combining clinical and imaging information may be effective in predicting short-term risk of recurrent stroke, according to a recent study.
Researchers analyzed data on more than 1,400 consecutive ischemic stroke patients and calculated the 90-day risk of recurrent stroke. Predictors of recurrence included etiologic stroke subtype at admission, history of transient ischemic attack or stroke, and topography, age and distribution of brain infarcts. The recurrence risk estimator at 90 days (RRE-90) demonstrated good discrimination (area under the curve=0.80) in predicting 14- and 90-day risk of recurrence. The results were published online Dec. 16 and will appear in the Jan. 12 Neurology.
The findings suggest that combining clinical variables with imaging information has better predictive value than clinical information alone or scores based on long-term risks, such as hypertension, diabetes and smoking, the authors said. The potential effectiveness of the RRE-90 is particularly significant considering that about half of 90-day recurrent strokes occur in the first two weeks.
Although the RRE-90 is easy to apply, several issues must be considered before incorporating the tool into clinical practice, said an accompanying editorial. For example, no follow-up information was available for almost half of the patients and the actual number of recurrent strokes was relatively small. In addition, the effect of early preventive treatment is unclear. For example, atrial fibrillation had no impact on recurrence using the RRE-90, suggesting that these patients may have been treated with early anticoagulation.
Independent, prospective validation is needed before the tool can be recommended for broader use, the editorial added. However, once validated, the Web-based tool can be easily and quickly expanded to many clinical settings, it said.
Perioperative care
.Bleeding risk after MI increases with number of antithrombotic agents given
The risk of bleeding increases with the number of antithrombotic agents used in patients with myocardial infarction, a recent study found.
Researchers studied more than 40,000 patients age 30 or older admitted to hospitals in Denmark between 2000 and 2005 for first-time myocardial infarction (MI). During a mean follow-up of 476.5 days, 4.6% of the patients were admitted with bleeding. The annual incidence of bleeding increased with the number of agents prescribed, with the highest risk in the groups taking aspirin plus vitamin K antagonist or triple therapy including clopidogrel. In addition, almost 38% of patients with nonfatal bleeding had recurrent MI or died during the study period compared with 18.4% without nonfatal bleeding. The results appear in the Dec. 12 issue of The Lancet.
The study also found that aspirin plus clopidogrel was associated with an increased risk of bleeding compared with aspirin alone, regardless of whether patients had percutaneous coronary intervention. Treatment with a vitamin K antagonist alone was not associated with an increased risk compared with aspirin alone, the authors said, but the result might be influenced by the fact that many participants taking vitamin K antagonists were already taking the drug at the time of MI.
The authors acknowledged the limitations of an observational study and noted that they had no knowledge of why physicians prescribed different combinations of antithrombotic agents. However, the findings suggest that a thorough individual risk assessment and careful consideration of the risk-benefit ratio precede any decision to prescribe triple or dual therapy with clopidogrel plus vitamin K antagonist, they concluded.
CT scans
.New estimates on cancer risk of CT scans
Two new studies warn of the cancer risk posed by computed tomography scans and suggest some risk-reduction strategies.
A retrospective cross-sectional study calculated the radiation doses delivered by computed tomography (CT) scans performed at four different California hospitals. Doses ranged from 2 millisieverts (mSv) for a routine head CT to 31 mSv for a multiphase abdomen and pelvis scan. Many of the scans provided more radiation than is usually assumed to be the case; the median dose for a routine abdomen and pelvis scan was 66% higher than the expected 8 to 10 mSv. Even within each type of study, the effective dose varied significantly within and among the hospitals. There was a mean 13-fold variation between the highest and lowest doses for each procedure.
Extrapolating from these data, researchers calculated cancer risks, including that one in 270 women who underwent CT coronary angiography at age 40 would develop cancer from the scan. Risks were lower for men than women, and higher for younger than older patients (20-year-olds faced double the risk, 60-year-olds only half). The study was published in the Dec. 14/28 Archives of Internal Medicine.
Another study in the same issue used risk models to calculate how many cancers could eventually be attributed to CT scans based on current scanning rates. Overall, they estimated that 29,000 future cancers could be caused by CT scans performed in the U.S. in 2007. Scans of the abdomen and pelvis contributed the most to the tally, and one-third of the cancers would be due to scans performed on patients between the ages of 35 and 54.
The authors of the studies and an accompanying editorial offered a number of solutions to this problem, including standardized protocols (such as have been applied to mammography), fewer multiple series examinations, dose reduction and registration, and greater use of American College of Radiology accreditation and criteria. The experts also called for a reduction in the number of inappropriate and unnecessary CT scans.
From ACP Hospitalist
.The next issue of ACP Hospitalist is online
The next issue of ACP Hospitalist is online, featuring stories on the following topics and more.
A bundle of joy or trouble? Bundled payments could prove the value of hospitalists or destroy their income, dramatically improve patient care or hurt outcomes, or be a return to capitation or a new way forward.
So you want to be an academic hospitalist. For those contemplating an academic career, it may not always be easy to arrive at the right mix of clinical practice, teaching and research. Learn what to look for.
Results pending at discharge often stay in limbo. How can hospitalists separate the wheat from the chaff?
Cartoon caption contest
.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 Brian Clay, ACP Member, associate professor of medicine, division of hospital medicine, UC San Diego Medical Center, who will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 119 ballots online to choose the winning entry. Thanks to all who voted!
"I have one of those 'Cadillac' health care plans."
The winning entry captured 42% of the votes.
The runners up were:
"Let's celebrate. I have been converted from observation to inpatient status."
"Way to go on the champagne tap! This round's on me."
ACP Hospitalist continues a new year of cartoon caption contests in January.
About ACP HospitalistWeekly
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Copyright 2009 by the American College of Physicians.
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