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ACP HospitalistWeekly 10-27-10

Highlights

• New CPR guidelines: compressions first, then rescue breathing
• Hospitalizations for diabetes increase, especially among younger women

Preoperative evaluation

• Sleep apnea questionnaire predicts postop complications

Stroke

• Dysphagia screening can help predict pneumonia risk after stroke

Prescribing patterns

• Drug company information might influence prescribing habits

FDA news

• Warnings added to prostate cancer drugs

Resources

• AAIM offers textbook for internal medicine education programs

Cartoon caption contest

• Vote for your favorite entry

Physician editor: A. Scott Keller, FACP

Highlights

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New CPR guidelines: compressions first, then rescue breathing

Updated cardiopulmonary resuscitation (CPR) guidelines say to start with chest compressions, followed by checking the airway and giving rescue breaths.

The guidelines by the American Heart Association published in the Nov. 2 Circulation update those issued in 2005. The previous guidance to check the airway and give breaths before compression results in a potential delay of compressions while a responder retrieves a barrier device or positions a victim's head to open the airway, the new guidelines said. Other changes of particular interest to health care providers include:

• "Look, Listen and Feel" has been removed from the Basic Life Support (BSL) algorithm, as those steps are time-consuming and inconsistent. Instead, providers should immediately activate the emergency response system and start chest compressions for unresponsive adults who are not breathing or not breathing normally (i.e., gasping). Chest compressions should be started before giving rescue breathing.
• The recommended depth of chest compression for adult victims is now at least 2 inches (previously 1½ to 2 inches). The rate, 100 compressions per minute, should allow for complete recoil of the chest after each compression while minimizing pauses and avoiding excessive ventilation.
• Many tasks performed by health care providers during resuscitation attempts can be done concurrently by a team of trained rescuers. Those tasks include compressions, airway management, rescue breathing, rhythm detection, shock delivery and drug delivery, if appropriate. Provider training "should focus on building the teams as each member arrives or quickly delegating roles if multiple rescuers are present," they said.
• Untrained bystanders should be encouraged to use compression-only CPR.

Points of "continued emphasis" include that providers should take no more than 10 seconds to see if a pulse is present; be trained to spot unusual presentations of sudden cardiac arrest; and keep interruptions of chest compressions to a minimum. The guidelines also identify these objectives of post-cardiac arrest care:

• Optimize cardiopulmonary function and vital organ perfusion after return of spontaneous circulation;
• Transport victim to an appropriate hospital or critical care unit with a comprehensive post-cardiac arrest treatment system of care;
• Identify and intervene for acute coronary syndrome;
• Control body temperature to optimize neurologic recovery; and
• Anticipate, treat and prevent multiple organ dysfunction.

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Diabetes care

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Hospitalizations for diabetes increase, especially among younger women

The number of hospitalizations with a primary or secondary diagnosis of diabetes increased dramatically between 1993 and 2006, especially among younger people, a new study found.

Researchers gathered their statistics from hospital discharges included in the Nationwide Inpatient Sample and the results were published online Oct. 12 by the Journal of Women’s Health. Over the 14-year period, diabetes hospitalizations increased 65.3% overall. The largest increase in hospitalizations, of 102%, was among patients 30-39 years old. Younger women saw greater increases than younger men, with diabetes hospitalizations increasing 63% in 20- to 29-year-old women and 118% in 30- to 39-year-olds (compared to 46% and 85% respectively in men). At age 50, the trend flipped, with more men over age 50 being hospitalized for diabetes than women. During this same time period, overall hospitalization rates for adults declined, the study authors noted.

The analysis also looked at the primary diagnoses associated with these hospitalizations. Excluding pregnancy-related hospitalizations, diabetes with complications was the top diagnosis in all age groups, but psychiatric disorders also accounted for a substantial proportion of younger patients’ hospitalizations. Affective disorders were the second most common diagnosis in women 20-39, while schizophrenia was the fifth biggest among young men. Younger age and female gender have been associated with increased risk of depression in diabetics, and atypical neuroleptics have been associated with incident diabetes, the study authors noted.

Overall, the increases found by the study may reflect increasing diabetes prevalence in the adult population, the authors said. The differences between men and women may be related to previous findings that women diabetics receive less preventive care and aggressive medical management. However, the study was limited by several potential confounding factors, including increasing awareness of type 2 diabetes during the time period (which could lead to more diagnoses recorded in hospital records) and the change in 1997 to defining diabetes as a fasting blood glucose of 126 mg/dL or higher, instead of 140 mg/dL or higher.

Still, the statistics indicate that the cost burden of diabetes hospitalizations will continue to escalate as these patients age, the authors concluded. They recommended more focus on diabetes prevention and research to assess whether the growth in hospitalizations has resulted from increasing prevalence of diabetes or an increasing burden of comorbid disease.

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Preoperative evaluation

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Sleep apnea questionnaire predicts postop complications

A questionnaire designed to identify patients with obstructive sleep apnea also predicted surgical patients’ risk of postoperative complications, according to a recent study.

The historical cohort study included 135 patients undergoing elective surgery at one hospital. Before surgery, all patients were given the eight-question STOP-BANG (Snoring, Tiredness during daytime, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, Gender) questionnaire. Responses to the questionnaire indicated that 41.5% of the patients were at high risk of obstructive sleep apnea syndrome. Patients in this high-risk group had a higher rate of postoperative complications than those who were at low risk of sleep apnea (19.6% vs. 1.3%, P<0.001). These patients also had a longer length of stay compared to those at low risk (3.6 days vs. 2.1 days, P=0.003).

After multivariate analysis, high risk of obstructive sleep apnea and American Society of Anesthesiologists class 3 or higher were associated with a significantly higher risk of postoperative complications. The researchers also assessed the accuracy of the questionnaire by calculating the area under the receiver operating characteristic curve, which was 0.82. A STOP-BANG score of 3 or higher had a sensitivity of 91.7%; a specificity of 63.4%; a positive predictive value of 19.6%; and a particularly high negative predictive value, the study authors noted, of 98.7%. The results were published in the October Archives of Otolaryngology-Head and Neck Surgery.

This is the first study to find that the concise, easy-to-administer questionnaire can indicate heightened (approximately 10-fold) risk of postoperative complications in elective surgery patients, the study authors concluded. Other research has proposed a number of causes for the association between sleep apnea and postoperative complications, but data on the ideal perioperative management of patients with the condition is limited. The perioperative use of continuous positive airway pressure may be beneficial, the study authors said. They called for future research to provide external validation of this study’s results.

In September, ACP Hospitalist covered the preoperative pulmonary evaluation, including screening for obstructive sleep apnea.

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Stroke

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Dysphagia screening can help predict pneumonia risk after stroke

Screening for dysphagia helped predict pneumonia risk in poststroke patients, a study found.

Using observational data, researchers analyzed outcomes for 18,017 patients with stroke who were discharged from 222 hospitals in six states between March 1 and Dec. 31, 2009. The patients were classified as having been unscreened for dyphagia before oral intake of food, liquid or medicine; screened and passed before oral intake; or screened and failed before oral intake. The main outcome, pneumonia, was defined as having occurred during hospitalization at least 48 hours after admission, and having necessitated antibiotics. The researchers used logistic regression models to determine the association between screening status and pneumonia rate. Results were published online October 14 in Stroke.

Twenty-five percent (n=4,509) of patients were unscreened; 47% (n=8,406) were screened and passed; and 28% (n=5,099) were screened and failed. Patients who were screened were more likely to have aphasia or weakness compared with those who weren't screened. Patients who failed screening were older (median, 74 years vs. 70 years), and had longer hospital stays (median, 6 days vs. 5 days) compared to the other two groups. Pneumonia rates were lower in patients who were unscreened (4.2%) than those who were screened and failed (6.8%), but higher than those who were screened and passed (2.0%). Unscreened patients were still at a higher risk of pneumonia than screened-and-passed patients after adjustment for clinical and demographic features (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.7-2.7). Those who failed screening were also at a higher risk for pneumonia than those who passed (OR, 3.6; 95% CI, 3.0-4.3).

The data suggests patients are selectively screened based on their stroke severity, and the higher pneumonia rate in the unscreened vs. the screened-and-passed patients shows clinical judgment is imperfect at determining which patients to screen, the authors said. Since patients who failed screening had a higher risk than those who passed, dysphagia screening results appear to add accuracy in predicting pneumonia risk. Heightened vigilance in those who fail screening could help with identifying and treating pneumonia, the authors said. Furthermore, the "lack of National Quality Forum-endorsed DS [dysphagia screening] performance measures in the stroke measure set for The Joint Commission may reduce overall screening rates, which could increase poststroke complication rates," they wrote. "Given our results, a new stroke measure for DS/pneumonia prevention should be developed for acute stroke care."

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Prescribing patterns

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Drug company information might influence prescribing habits

Information from drug companies does not improve prescribing, according to a meta-analysis.

Researchers reviewed studies of prescribing physicians who were exposed to sales visits, journal advertisements, attendance at pharmaceutical company-sponsored meetings, mailed information, prescribing software and participation in sponsored clinical trials. The outcomes measured were quality, quantity and cost of physicians’ prescribing.

The meta-analysis included mostly cross-sectional studies, but also included cluster randomized controlled trials, time series analyses, before-after studies, cohort studies, and case-control studies. Studies were included if they both measured exposure to any type of information directly provided by pharmaceutical companies and physicians' prescribing. Studies were excluded if they looked at the indirect information, such as continuing medical education courses funded by unrestricted grants, or if they were case series, case reports, abstracts, news items and short reports.

Results were published Oct. 19 in PLoS Medicine.

Of the studies, 38 found associations between exposure to drug company information and more-frequent prescribing, while 13 did not. Among the many analyses of potentially influential factors:

• Of studies of pharmaceutical sales representative visits, 17 found an association with increased prescribing of the promoted drug. None found less frequent prescribing. Of the remaining 11, six had mixed results.
• Of the four studies that measured journal advertisements and included statistical tests, one found that journal advertisements had a more pronounced effect on market share for the advertised drug than did positive scientific information published in medical journals.
• Of eight studies of pharmaceutical company-sponsored meetings, five found positive associations with prescribing frequency and three did not.
• Of three studies of mailed promotional material, one found an association with increased prescribing and two did not.
• A single study that examined the effect of advertising in clinical practice software found no association with prescribing frequency for six medications and less prescribing of one medication.
• Several studies combined the outcome measures for various exposures to pharmaceutical company information or measured overall promotional investment, a proxy for the amount of exposure to information from pharmaceutical companies. Three studies found that total promotional investment was positively associated with prescribing frequency. Two studies found both positive results and no association. One study did not detect an association.

While the limitations of the original studies and of the nature of meta-analysis itself means that researchers cannot prove causality between drug company information and prescribing habits, they found some evidence of increased costs and decreased quality of prescribing.

Researchers did not find evidence of net improvements in the quality of prescribing associated with exposure to information from pharmaceutical companies. In the absence of such evidence, researchers wrote, "We recommend that practitioners follow the precautionary principle and thus avoid exposure to information from pharmaceutical companies unless evidence of net benefit emerges."

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FDA news

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Warnings added to prostate cancer drugs

New warnings will be added to the labels of gonadotropin-releasing hormone (GnRH) agonists, a class of drugs primarily used to treat men with prostate cancer, the FDA announced last week.

The warnings will alert patients and their health care professionals to the potential risk of heart disease and diabetes in men treated with these medications, based on an FDA analysis which found that patients receiving GnRH agonists were at a small increased risk for diabetes, heart attack, stroke, and sudden death.

GnRH agnoists are marketed under the brand names Eligard, Lupron, Synarel, Trelstar, Vantas, Viadur, and Zoladex. Several generic products are also available.

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Resources

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AAIM offers textbook for internal medicine education programs

The Alliance for Academic Internal Medicine is offering The Toolkit Series: A Textbook for Internal Medicine Education Programs for internal medicine residency and fellowship education. The series is a valuable resource for tackling common problems encountered by faculty and staff in undergraduate and graduate medical education. Released in July 2010, the 10th edition includes more than 50 chapters—six new and 25 updated—written by expert faculty and staff in departments of internal medicine.

Available for $75, each book includes a disc with all the content in PDF format. The complete table of contents and two sample chapters are available for download.

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Cartoon caption contest

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Vote for your favorite entry

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

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Monday, Nov. 1, with the winner announced in the Nov. 3 issue.

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