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In the News
for the Week of 12-22-10
Highlights
Hospitalist-neurosurgery comanagement lowers costs, doesn't change outcomes
A comanagement program between hospitalists and neurosurgeons lowered one hospital's costs, but didn't change patient satisfaction scores or outcomes, a new study found. More...
Opioids for nonmalignant pain have different adverse event profiles
Adverse events among older adults using opioids for nonmalignant pain vary significantly by agent, contrary to the commonly held belief that all opioids are associated with a similar risk, a study found. More...
Critical care
About 15% of unplanned ICU transfers tied to preventable errors
Approximately 15% of unplanned transfers to medical ICUs are associated with preventable errors, such as inappropriate admission triage, a new study found. More...
HIV
HIV reduction efforts should target risky behaviors
Expanding HIV screening and treatment would help reduce new HIV infections, but prevention efforts should also target risky behaviors to be most effective, a new study indicates. More...
From ACP Hospitalist
The next issue is online
The December issue of ACP Hospitalist is online. Don't miss stories on dealing with addiction, boosting referrals to cardiac rehabilitation and judicious use of CT scans. More...
Cartoon Caption Contest
Put words in our mouth
ACP HospitalistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...
Physician editor: A. Scott Keller, FACP
Highlights
.
Hospitalist-neurosurgery comanagement lowers costs, doesn't change outcomes
A comanagement program between hospitalists and neurosurgeons lowered one hospital's costs, but didn't change patient satisfaction scores or outcomes, a new study found.
Researchers conducted a retrospective, interrupted time-series analysis of data from adults admitted to the neurosurgery service of an academic hospital between June 2005 and December 2008. Researchers also collected data from a control group of adults admitted for major noncardiac surgery during the same time period. A hospitalist-neurosurgery comanagement service (CNS) was implemented at the hospital on July 1, 2007. Researchers collected data from administrative sources on length of stay, costs, inpatient mortality rate and 30-day readmission rate, and used surveys to assess patient and caregiver satisfaction. Results were published in the December 13/27 Archives of Internal Medicine.
During the study period, 7,596 patients were admitted to the neurosurgery service; about 55% (n=4,203) of these were admitted before the CNS was implemented and 44.7% (n=3,393) after. Of those admitted after CNS implementation, 29.1% (n=988) were comanaged. Hospital costs fell $1,439 per admission after CNS was implemented (adjusted cost ratio, 0.94; range, 0.88-1.00). There were no differences in patient mortality, readmissions or length of stay after CNS was implemented, nor any improvements in patient satisfaction (which was generally high to begin with). Nurses and other health care professionals reported strong perceived improvements in quality of care, especially regarding attention to medical issues during hospitalization (mean score of 2.9 on this measure before CNS vs. 4.8 after, P<.001).
Although the findings on outcomes are similar to other studies on comanagement, the finding of cost savings is new, the authors noted. The data lacked specific information on which areas of practice (such as laboratory or radiology) were responsible for the cost reduction, however. The lack of an effect on mortality or readmission rates may be because hospitalist involvement doesn't affect the more powerful determinants of outcomes in these patients, they noted. On the whole, the study—while "well-performed"—doesn't provide definitive evidence to support or refute the value of comanagement, an editorialist wrote. "In the absence of solid evidence, I would argue that even the economic rationale for comanagement is poor because it really involves shifting work to lower-paid workers (internists), allowing surgeons to spend more time in the operating room, where they get paid more by a dysfunctional reimbursement system that disproportionately rewards procedural care over more cognitive services," he wrote. He added that he worried about "the degradation of basic clinical inpatient skills of our subspecialty colleagues" and was concerned that, with the looming shortage of primary care internists, comanagement may exacerbate this shortage even more.
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Opioids for nonmalignant pain have different adverse event profiles
Adverse events among older adults using opioids for nonmalignant pain vary significantly by agent, contrary to the commonly held belief that all opioids are associated with a similar risk, a study found.
Researchers devised a propensity-matched cohort analysis that used health care utilization data collected from 1996 to 2005 among Medicare beneficiaries from Pennsylvania and New Jersey who started opioid therapy for nonmalignant pain. The five studied opioids were codeine phosphate, hydrocodone bitartrate, oxycodone hydrochloride, propoxyphene hydrochloride and tramadol hydrochloride. None of the patients had a cancer diagnosis, and none were using hospice or nursing home care. Main outcome measures were incidence rates and rate ratios (RRs) with 95% confidence intervals (CIs) for cardiovascular events, fractures, gastrointestinal events, and several composite end points. Results appeared in the Dec. 13/27 issue of Archives of Internal Medicine.
In the study, 143,482 (26.5%) potentially eligible subjects were available for matching. The study looked at 6,275 subjects in each of the five opioid groups. Their mean age was 79 years; 80.9% were women; 91.0% were white. Researchers looked at fractures (including hip, pelvis, wrist, and humerus fractures, but not spine fractures), cardiovascular events (myocardial infarction, stroke, heart failure, revascularization and out-of-hospital cardiac death) and gastrointestinal bleeding or bowel obstruction.
Results showed that the risk of cardiovascular events was elevated for codeine (RR, 1.62; 95% CI, 1.27-2.06) after 180 days. Compared with hydrocodone, after 30 days of opioid exposure, the risk of fracture was significantly reduced for tramadol (RR, 0.21; 95% CI, 0.16-0.28) and propoxyphene (RR, 0.54; 95% CI, 0.44-0.66) users. Gastrointestinal safety events did not differ across opioid groups. All-cause mortality was elevated after 30 days for oxycodone (RR, 2.43; 95% CI, 1.47-4.00) and codeine (RR, 2.05; 95% CI, 1.22-3.45) users compared with hydrocodone users.
Limitations include that the study analyzed typical, nonrandomized practice data, leading to potential residual confounding, which in turn limits causality. Second, the study database consisted of health care and pharmacy data without corroboration from death certificates, or other details such as pain levels, functional status, aspirin or tobacco use, or over-the-counter medication use. Third, the study occurred among older, low-income adults, limiting generalizability, and fourth, the study looked at a limited number of events in several outcome-exposure relationships, limiting the ability to prove the safety of an opioid for a specific outcome.
Editorialists commented that there is now a need to re-examine the widespread use of codeine. "If codeine is of middling efficacy for pain and is more risky than other opioids, there would be little reason to use it. ... [T]his large observational study revealing a previously unknown risk makes further research imperative." Also, the editorial said, elevated fracture risk with opioid use is suspected from increased fall risk and the drugs' effects on bone metabolism. Starting opioids at low doses, monitoring for side effects, and avoiding polypharmacy have been used to prevent adverse events. But, said the editorialists, "[T]hese studies strongly suggest that implementation of these basic safety measures is suboptimal for patients taking opioids."
Critical care
.
About 15% of unplanned ICU transfers tied to preventable errors
Approximately 15% of unplanned transfers to medical ICUs are associated with preventable errors, such as inappropriate admission triage, a new study found.
Researchers conducted a retrospective cohort study of adult patients who were transferred to the medical ICU from non-ICU medicine units at a public safety-net hospital between June 2005 and May 2006. They searched medical records of eligible patients for demographic information, admitting and transfer diagnoses, clinical triggers preceding transfers, and mortality. Three independent observers, all board certified in internal medicine and hospitalists for at least three years, reviewed records to determine the cause of the unplanned transfers according to a taxonomy the researchers developed for classifying the transfers. They also determined whether the transfer could have been prevented. The results were published online Dec. 13 by the Journal of Hospital Medicine.
Of the 4,468 general medicine admissions during the study period, 152 met inclusion criteria for an unplanned medical ICU transfer. Heart failure and community-acquired pneumonia were the most common admitting diagnoses, while the most common diagnoses to which unplanned transfers were attributed were respiratory failure (27%) and sepsis (9%). The highest percentage (48%) of unplanned transfers were attributed to worsening of the problem for which a patient was initially admitted, followed by development of a new problem unrelated to the admitting diagnosis (39%). Errors in care were judged to be present in 19% (n=29) of unplanned transfer patients, about half (n=15) of which were due to incorrect triage at admission and the other half (n=14) to iatrogenic errors, such as opiate overdose during pain treatment or delayed treatment. Of the iatrogenic errors, eight transfers might have been prevented by earlier intervention, the observers said. Observer agreement was moderate to almost perfect (κ 0.55-0.90).
Eighteen percent of patients with unplanned transfers died in the medical ICU, while 6% of patients admitted directly from the emergency department to the medical ICU died (P<0.05). Mortality was lower for patients transferred within 24 hours of admission compared to those transferred more than 24 hours after admission (4% vs. 22% mortality, respectively; P<0.05; 95% confidence interval [CI], 0.09-0.89). There was no difference in mortality as a function of time of admission or time of transfer, suggesting that differences in staffing or the availability of services didn't contribute to unplanned transfers, the authors wrote.
Study limitations include that the data came from a single teaching hospital, and only those patients who were admitted to general medicine units and transferred to medical ICUs were assessed. Thus, the data may not generalize to other types of hospitals or transfer situations. Since objective criteria weren't used, the researchers may have misclassified patients as to the cause of their unplanned ICU transfer, they noted. Still, the findings suggest that unplanned transfers could be reduced by more closely screening patients for the presence of defined medical ICU admission criteria at the time of admission from the ED, they concluded.
HIV
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HIV reduction efforts should target risky behaviors
Expanding HIV screening and treatment would help reduce new HIV infections, but prevention efforts should also target risky behaviors to be most effective, a new study indicates.
Approximately 56,000 people become infected with HIV each year in the U.S., and recent clinical guidelines recommend expanding HIV screening to all patients 13 and older regardless of risk factors in high-prevalence areas. Researchers developed a mathematical model and performed a cost-effectiveness analysis to evaluate the effect of expanded screening, antiretroviral therapy (ART) and behavioral counseling on the U.S. HIV epidemic. The goal of the study was to determine whether expanding screening, treatment or both could significantly decrease the U.S. HIV epidemic, and whether more infections could be prevented by allocating resources to screening or to treatment. Effects of reductions in risky behavior were also evaluated. The study results appear in the Dec. 21 Annals of Internal Medicine.
The authors' model projected that about 1.23 million new HIV infections would occur in 20 years, 74% in persons at high risk. In the base-case analysis, one-time HIV screening in low-risk persons and annual screening of high-risk persons prevented 6.7% of these infections at a cost per quality-adjusted life-year (QALY) gained of $22,382 when a 20% reduction in sexual activity after screening was assumed. When ART use was expanded to 75% of eligible patients, 10.3% of infections were prevented at a cost of $20,300 QALY gained. A strategy that combined both expanded screening and treatment prevented 17.3% of infections at a cost of $21,580 per QALY gained. The sensitivity analysis, meanwhile, found that expanded screening could prevent 3.7% of infections if sexual activity wasn't reduced, that earlier initiation of ART could prevent 20% to 28% of infections, and that efforts to halve high-risk behavior could reduce new infections by 65%.
The study used a simplified model of disease progression and treatment, did not consider variations in race or ethnicity, and excluded acute HIV screening. Nevertheless, the authors wrote, their results indicate that a multimodal program could markedly affect HIV incidence in the U.S. over the next two decades, with expanded screening and treatment programs leading to a potential 24% reduction. They pointed out that the cost-effectiveness of one-time HIV screening in low-risk persons and annual screening in high-risk persons is comparable to that of screening for type 2 diabetes and mammography screening for breast cancer. "If these [screening and treatment] programs are accompanied by additional interventions that halve risky sexual and needle-sharing behavior, the epidemic could be reduced by 65%, suggesting the need for a comprehensive portfolio of HIV prevention, screening, and treatment," they concluded.
From ACP Hospitalist
.
The next issue is online
The December issue of ACP Hospitalist is online. Don't miss stories on:
Dealing with addiction. Screening and coordinated treatment for substance abuse improves outcomes.
Boosting referrals to cardiac rehabilitation. Overcome barriers to referral and enrollment.
Value and risks of CT scans. Correct use or overuse lies in the hands of individual physicians.
These features and more, including Test Yourself with the MKSAP Quiz: Alcohol abuse, are now online.
Are you involved in hospital medicine? Then you should be getting ACP Hospitalist and ACP HospitalistWeekly . Click here to subscribe.
Cartoon Caption Contest
.
Put words in our mouth
ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. 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 finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.
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