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ACP HospitalistWeekly 11-24-10

Highlights

• AEDs used in hospitals don’t improve cardiac arrest survival
• New rules allow hospital patients to choose who can visit them

Diagnostic testing

• Appropriate uses considered for echocardiography in common clinical scenarios

Heart failure

• Telemonitoring no more effective than usual care after hospitalization in heart failure patients

Medicare update

• Senate acts to prevent Medicare payment cut

From ACP Hospitalist

• The next issue is online

Cartoon caption contest

• Vote for your favorite entry

Physician editor: A. Scott Keller, FACP

Editorial note: ACP HospitalistWeekly will not be published next week due to the Thanksgiving holiday.

Highlights

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AEDs used in hospitals don’t improve cardiac arrest survival

Automatic external defibrillators (AEDs) don’t improve survival rates when used for cardiac arrest in hospitals, a new study found.

Researchers used data from the National Registry of Cardiopulmonary Resuscitation to study 11,695 patients at 204 U.S. hospitals who had had cardiac arrests between Jan. 1, 2000 and Aug. 26, 2008, after AEDs had been introduced on general medicine wards. Of these patients, 2,079 (17.8%) had shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia) and 9,616 (82.2%) had nonshockable rhythms (asystole and pulseless electrical activity). AEDs were used to assess initial rhythm in 4,515 patients (38.6%). The primary outcome measure was survival to hospital discharge by AED use. Researchers used multivariable hierarchical regression analysis to adjust for patient factors and hospital site.

Overall, 2,117 patients (18.1%) survived to hospital discharge. Within the whole study population, survival to hospital discharge was 16.3% for those on whom AEDs were used, significantly lower than the 19.3% survival for patients on whom AEDs weren’t used (adjusted rate ratio [RR], 0.85; 95% CI, 0.78 to 0.92; P<0.001). The association between survival and AED use varied by initial cardiac arrest rhythm. Those with a nonshockable rhythm had lower in-hospital survival with AED use (10.4% for AED use vs. 15.4% for non-AED use; adjusted RR, 0.74; 95% CI, 0.65 to 0.83; P<0.001). Those with a shockable rhythm had no association between survival and AED use (38.4% with vs. 39.8% without use; P=0.99). Results were published in the Nov. 17 Journal of the American Medical Association.

The study authors noted that the results differ from research that has found AEDs improve survival for cardiac arrests witnessed in public, non-hospital settings, which may be because the arrests in those settings are more often the shockable type, they said. The lower survival rates found for those with nonshockable rhythms in this study may be due to the time required for an AED to assess initial cardiac rhythm, which interrupts chest compressions at a crucial point, they added. The results should prompt consideration of a change in practice for in-hospital cardiac arrest, with chest compressions being the top priority for first responders, an editorialist wrote. “The AED may be used in the automatic mode by non-advanced cardiac life support-trained personnel, but the device should be converted to the manual mode immediately on arrival of the advanced cardiac life support-trained resuscitation team,” he wrote.

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New rules allow hospital patients to choose who can visit them

Medicare- and Medicaid-participating hospitals must allow inpatients to choose who can and can't visit them, according to rules issued by the Centers for Medicare and Medicaid Services (CMS) last week.

The rules take effect in mid-January and apply to all patients of Medicare- and Medicaid-participating hospitals regardless of payer source. They require the hospitals to have written policies and procedures regarding visitation rights, including details on clinical circumstances that might call for restricting visits. Hospitals must explain to patients their right to choose who can and cannot visit them during their stay, including that patients can withdraw visitation consent at any time.

The CMS action follows an April 15 memorandum from President Obama that directed the Centers to develop rules to prohibit hospitals from denying visitation privileges on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity, or disability.

“Today’s rules help give ‘full and equal’ rights to all of us to choose whom we want by our bedside when we are sick, and override any objection by a hospital or staffer who may disagree with us for any non-clinical reason,” said U.S. Department of Health and Human Services Secretary Kathleen Sebelius, in a press release.

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Diagnostic testing

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Appropriate uses considered for echocardiography in common clinical scenarios

In the face of new evidence and new technologies, 10 medical specialty and subspecialty societies reviewed common clinical scenarios where echocardiography is frequently considered.

The review combines and updates the original transthoracic and transesophageal echocardiography appropriateness criteria published in 2007 and the original stress echocardiography appropriateness criteria published in 2008. New to the report are:

• new clinical data, changes in test utilization patterns, and clarifications to echocardiography use,
• expanded tables with more comprehensive coverage of various clinical situations,
• revised or new clinical scenarios such as valvular heart disease, perioperative evaluation and evaluation of thoracic aortic disease, and
• indications to better address evolving therapeutic options such as cardiac resynchronization therapy or treatment/follow-up of pulmonary hypertension.

Writers tried to harmonize the indications across noninvasive modalities, and added sections of specific assumptions and definitions to clarify interpreting the review. The complete review was published online Nov. 19 by the Journal of the American College of Cardiology. The 202 indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies.

Indications were scored on a scale of 1 to 9, to designate appropriate use (median, 7 to 9), uncertain use (median, 4 to 6), and inappropriate use (median, 1 to 3). Authors acknowledged that the division was somewhat arbitrary, and the numbers should be viewed as a continuum. Ninety-seven indications were rated as appropriate, 34 were rated as uncertain, and 71 were rated as inappropriate. In general, echocardiography is appropriate for initial diagnosis when there is a change in clinical status or when the results of the echocardiogram are anticipated to change patient management. Routine testing when there is no change in clinical status or when results of testing are unlikely to modify management was more likely to be inappropriate.

In the report, 18 tables document appropriate use by test and condition (such as "TTE [Transthoracic Echocardiogram] for Cardiovascular Evaluation in an Acute Setting" or "Stress Echocardiography for Assessment of Viability/Ischemia"), while three more tables break down all tests into their indications of appropriate, uncertain or inappropriate. One table specifically covers contrast use as applied to all of the echocardiographic modalities, and another covers indications related to patients with adult congenital heart disease, a growing population.

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Heart failure

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Telemonitoring no more effective than usual care after hospitalization in heart failure patients

Telemonitoring after hospitalization for heart failure did not improve outcomes compared with usual care, according to a new study.

Researchers performed a six-month multicenter trial in which 1,653 patients recently hospitalized for heart failure were randomly assigned to receive usual care or telemonitoring. All patients were given educational information on heart failure, along with a scale to weigh themselves if needed. Patients in the telemonitoring group also received instructions on how to report their symptoms and weight daily over the phone using an interactive voice-response system; these data were reviewed by the patients' clinicians, who then took action as necessary. The study's primary end point was any hospital readmission or death from any cause up to 180 days after enrollment. Heart failure hospitalizations, hospital days, and number of hospitalizations were secondary end points. The study results were published online Nov. 16 by the New England Journal of Medicine.

Overall, 826 patients were assigned to the telemonitoring group and 827 were assigned to the usual care group. Forty-two percent of the patients were women, 39% were black and the mean age was 61 years. The primary end point did not differ significantly between the groups (52.3% vs. 51.5%; difference, 0.8 percentage points [95% CI, −4.0 to 5.6 percentage points]; P=0.75). In the telemonitoring group, 49.3% of patients were readmitted to the hospital for any reason and 11.1% died, versus 47.4% and 11.4% in the usual care group (differences, 1.9 percentage points [95% CI, −3.0 to 6.7 percentage points]; P=0.45 and −0.2 percentage points [95% CI, −3.3 to 2.8 percentage points]; P=0.88). The study groups also did not differ significantly in rates of the secondary end points. Approximately 14% of patients assigned to the telemonitoring system never used it, and only approximately 55% continued to use the system at least three times a week by the end of the study. No adverse events were reported in either group.

The authors noted that the automated telemonitoring used in their study might have been more effective if it had involved more direct contact between clinicians and patients. However, they also pointed out that even though patients were actively encouraged to participate in telemonitoring and were given considerable support, a significant number did not adhere to instructions or did not use the system at all. The authors concluded that telemonitoring had no effect on outcomes compared with usual care in patients who had recently been hospitalized for heart failure. Previous studies showing a benefit, they wrote, were probably too small and had methodologic weaknesses that affected their results. "There remains a need for strategies to improve heart-failure outcomes, and our findings indicate the importance of a thorough, independent evaluation of disease-management strategies before their widespread implementation," the authors concluded.

An accompanying editorial pointed out other potential reasons why the intervention might not have improved outcomes, including that the symptoms measured may not have been accurate in predicting clinical deterioration. Although the telemonitoring system was set up to alert clinicians to "variances" indicating a potential clinical problem, they noted, the timeliness and appropriateness of the clinicians' responses were not detailed. The trial's "neutral findings," the editorialists wrote, "highlight a need for caution before inserting additional loops into disease management."

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Medicare update

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Senate acts to prevent Medicare cut

On Nov. 18, the Senate unanimously approved legislation that would avert the Medicare payment cut scheduled for Dec. 1. The House is expected to take up and pass identical legislation when it returns from Thanksgiving, on Nov. 29, that would prevent the cut from going into effect.

The legislation extends current payment rates for 30 days, allowing Congress additional time before the end of the year to prevent the payment cut from going into effect on Jan. 1. ACP will continue to press the “lame duck” Congress to pass legislation that would fix payments through the end of 2011. ACP will then advocate that the new 112th Congress, which takes office in January, enact a long-term solution to the sustainable growth rate (SGR).

For additional information, and to find out how to help let Congress know the importance of preventing these payment cuts, visit the ACP Legislative Action Center.

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From ACP Hospitalist

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The next issue is online

The November issue of ACP Hospitalist is online. Don't miss stories on:

Top Hospitalists. Meet this year's crop of outstanding physicians working in hospital medicine.
End-of-life-care disputes. Education, conversation and empathy can help mediate disagreements.
Peripheral neuropathy. Learn the right way to diagnose this common, painful condition.

These features and more, including Test Yourself with the MKSAP Quiz: Renal insufficiency, are now online.

Are you involved in hospital medicine? Then you should be getting ACP Hospitalist and ACP HospitalistWeekly. Click here to subscribe.

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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 captions to determine the winner.

"I should have listened when you told me Ehlers-Danlos and monkey bars don't mix."

"Most men your age would be more than pleased to be able to touch their toes."

"If this impresses you, just wait until the genital exam."

"I've never seen a case of palmar fasciitis."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through the Thanksgiving holiday and ends on Monday, Dec. 6, with the winner announced in the Dec. 8 issue.

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