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ACP HospitalistWeekly 4-14-10

Highlights

• VTE prophylaxis 'stubbornly low' despite decades of effort
• Hospitalizations for prescription drug poisoning increasing

Pulmonary embolism

• Magnetic resonance angiography shouldn't be standard practice for diagnosing PE

Readmissions

• One-third of sickle cell patients rehospitalized within 30 days of discharge

Infection control

• Arterial and central venous catheters carry similar infection risk

FDA update

• OxyContin redesigned to reduce risk of abuse

Internal Medicine 2010

• ACP Job Placement Center calls for physician profiles

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

Note: ACP members will receive daily updates from Internal Medicine 2010 in Toronto April 22-24. ACP HospitalistWeekly will not publish on April 21. The April 28 issue will feature highlights from the meeting.

Highlights

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VTE prophylaxis 'stubbornly low' despite decades of effort

Prophylaxis rates for venous thromboembolism (VTE), even for patients at highest risk, remain substantially below Joint Commission targets.

The Joint Commission recommends that all hospitalized medical patients receive prophylaxis against VTE within two days of admission or have documentation why none was given. To assess actual rates of use, researchers conducted a retrospective cohort study of adult patients with seven medical diagnoses considered to carry moderate to high risk of VTE at 376 acute care facilities in 2004-2005. Results were published online March 30 by the Journal of General Internal Medicine.

The population included all general medical patients 18 and older with moderate to high risk of VTE, including those with pneumonia, respiratory failure with pneumonia, septicemia, heart failure, chronic obstructive pulmonary disease, stroke, and urinary tract infection. Patients with acute coronary syndromes, those who received warfarin, and patients with stays less than two days were excluded.

The authors defined VTE prophylaxis as receipt of at least one dose of low-molecular-weight heparin, unfractionated heparin, a pneumatic compression device, or compression stockings during the first two days of hospitalization. They defined standard prophylaxis as either low-molecular-weight heparin, 40 mg once daily, or unfractionated heparin, 5,000 units two or three times daily, by hospital day two and continued for the duration of the hospitalization, or until the patient was diagnosed and treated for VTE.

Of 351,535 patients, 36% received prophylaxis by hospital day two and 11% received standard prophylaxis. Rates were highest among patients with mechanical ventilation (67%), restraints (57%), central lines (55%), obesity (46%) and prior VTE (44%). Patients with a more than 1% risk of VTE were more likely to receive prophylaxis than patients with a less than 0.5% risk (52% vs. 34%, P<0.001).

Rates were highest at hospitals with more than 500 beds compared to less than 200 beds (43% vs. 26%, P<0.001) and at teaching institutions compared to non-teaching institutions (43% vs. 32%). Rates varied widely not only across hospitals but within them. Patients cared for by pulmonologists were most likely (43%) and those cared for by family practitioners were least likely (27%) to receive prophylaxis.

Rates of prophylaxis in this study were lower than in others, and the researchers noted several possible reasons for the difference. First, they measured only prophylaxis by hospital day two, whereas others included prophylaxis at any time. Second, researchers had no information on patient mobility or admission for comfort care only. Third, the study included hospitals where prophylaxis was seldom used, such as small, rural, non-teaching hospitals, and these may not have been included in other studies. The rate seen in large teaching hospitals is closer to what other studies have reported. Finally, because researchers did not have access to medication administration records, low prophylaxis rates may be related to improperly ordered or administered medication, or a failure to bill.

The authors concluded that although quality improvement organizations and professional societies have paid substantial attention to VTE, rates of prophylaxis in the hospital remain "stubbornly low." The new Joint Commission reporting measures may help to address this problem, they wrote.

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Hospitalizations for prescription drug poisoning increasing

Hospitalizations for overdoses of certain prescription drugs increased dramatically between 1999 and 2006, according to a new study.

Researchers used data from the Nationwide Inpatient Sample to examine U.S. hospitalizations for intentional and unintentional poisoning by prescription opioids, sedatives and tranquilizers. The study looked at the demographics and characteristics of such hospitalizations and compared them with hospitalizations for other poisonings in the same time period. The study results were published online April 6 by the American Journal of Preventive Medicine.

All hospitalizations due to overdoses of prescription opioids, sedatives and tranquilizers increased by 65% from 1999 to 2006, the researchers found. Unintentional poisonings involving these drugs increased by 37%, and intentional poisonings increased by 130%. Hospitalizations for poisonings by other drugs and substances increased by 33% over the same period. Unintentional poisonings increased by 21%, and intentional poisonings increased by 53%. The increase in number of poisonings was greatest for benzodiazepines (a difference of 10,379 hospitalizations between 1999 and 2006), while hospitalization for methadone poisoning saw the largest percentage increase (400%). Patients hospitalized for overdoses of prescription opioids, sedatives and tranquilizers compared with other drugs were more likely to be women, to be older than age 34, to be covered by Medicare, and to be seen at a rural or urban nonteaching hospital. Men were more likely to be hospitalized with unintentional poisoning, while intentional poisoning was more common in women.

The authors noted that their study had a retrospective design and used only the principal discharge diagnosis to classify poisoning cases, among other limitations. However, they concluded that it provides the first comprehensive examination about U.S. hospitalizations for poisoning by prescription opioids, sedatives and tranquilizers, showing substantial increases in both intentional and unintentional overdoses. Patients who overdose are hospitalized for an average of three days, they noted, giving future researchers an opportunity to gather more information and to help aid prevention. "Interviews with survivors could provide important additional details regarding the pathways to abuse of these drugs, the methods used to obtain the medications, the sequencing and combination of drugs that result in overdose, and the immediate precursors to these serious events," they wrote.

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Pulmonary embolism

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Magnetic resonance angiography shouldn't be standard practice for diagnosing PE

Physicians should use magnetic resonance pulmonary angiography to diagnose pulmonary embolism (PE) only in patients for whom standard tests are contraindicated, and only at centers that routinely perform it well, a new study found.

In a prospective, multicenter study between April 2006 and September 2008, researchers examined 371 adults at seven hospitals who had PE either diagnosed or excluded. They measured sensitivity, specificity and likelihood ratios for PE diagnosis by comparing gadolinium-enhanced magnetic resonance angiography with a reference standard that included computed tomographic angiography and venography, ventilation-perfusion lung scan, venous ultrasonography, D-dimer assay and clinical assessment.

Criteria for diagnosing acute PE with magnetic resonance imaging—which was performed within 72 hours of the reference test—were a partially occlusive intraluminal filling defect or complete arterial occlusion with termination of the column of contrast material in a meniscus that outlined the trailing edge of the embolus. Both the angiogram and venogram were required to be technically adequate to exclude PE; the combined result was considered positive if either result was positive. Study results were published in the April 6 Annals of Internal Medicine.

The reference test was positive in 104 of 371 patients. Eighty-four percent of patients received gadobenate dimeglumine; 14% received gadopentetate dimeglumine. Magnetic resonance angiography identified 57% of patients with PE, including patients with technically inadequate images; the angiography was technically inadequate due to poor quality in 25% of patients, averaged across centers. The adequacy of images varied widely, ranging from 11% to 51% of images being technically inadequate at various centers. Among patients who didn't have PE according to the reference test, angiography excluded PE in 75%, including those with technically inadequate images. When images were technically adequate, magnetic resonance angiography was 78% sensitive and 99% specific. Combined venography and angiography was 92% sensitive and 96% specific, though 52% of patients had technically inadequate results as images were harder to obtain in the lungs and lower extremities.

Study limitations included that many of the patients who had suspected PE declined to participate in the study, or were ineligible to do so, mostly due to concerns about nephrogenic systemic fibrosis, the authors said. Also, imaging results may not apply to pregnant women, patients with renal failure, or patients who are critically ill, on ventilator support, or in shock. The results suggest that magnetic resonance pulmonary angiography is often technically inadequate, and should therefore be reserved for use at centers that consistently perform it well, and with patients who have contraindications to standard tests, the authors concluded.

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Readmissions

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One-third of sickle cell patients rehospitalized within 30 days of discharge

One-third of people with sickle cell disease are rehospitalized within 30 days of discharge, and 18- to 30-year-olds are particularly likely to be rehospitalized or have return visits to the emergency department, a new study found.

Researchers examined data on 21,112 patients from the 2005 and 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department (ED) Databases. Patients came from eight geographically diverse states—together comprising 33% of all people with sickle cell disease in the U.S.—and had had sickle cell-related treat-and-release ED visits or inpatient hospitalizations. Results were published in the April 7 Journal of the American Medical Association.

The 30-day rehospitalization rate was 33.4% (95% CI, 33.0% to 33.8%), while the 14-day rate was 22.1% (95% CI, 21.8% to 22.4%). In addition to rehospitalizations, 15% of hospital discharges were followed by a treat-and-release ED visit within 30 days (95% CI, 14.7% to 15.3%). Rehospitalization rates were highest for patients age 18 to 30 years: 41.1% were rehospitalized within 30 days (95% CI, 40.5% to 41.7%) and 28.4% within 14 days (95% CI, 27.8% to 29%). This age group was also more likely to go to the ED for treatment of pain, then be released (20% of patients within 30 days). The 18- to 30-year-old sickle cell patients had approximately 3.5 hospital visits per year, compared to two visits per year for children age 10 to 17. Medicaid patients, or those with other types of public insurance, had higher rates than privately insured or uninsured patients.

About 29% of patients with sickle cell disease experienced no acute care encounters in a given year, while 16.9% had three or more per year. A shorter length of stay was not evident with rehospitalization: Those hospitalizations that were followed by a 30-day rehospitalization had an average length of stay of 6.1 days, compared to 5.6 days for those without subsequent hospitalization.

Fourteen-day rehospitalization rates may seem a more appropriate time period to evaluate inpatient care, while 30-day rates may assess the quality of and access to ambulatory care; however, two-thirds of those rehospitalized within 30 days were rehospitalized within 14 days, the authors noted. Preventing 14-day rehospitalizations "may require evaluation and intervention during the (original) hospitalization," they noted. The high utilization rate among 18- to 30-year-olds probably reflects the fact that those with severe disease die earlier, they said. Identifying benchmarks can help with efforts to improve quality of care and reduce morbidity, they concluded.

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Infection control

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Arterial and central venous catheters carry similar infection risk

Arterial catheters and central venous catheters carry similar risk for bacterial colonization and catheter-related infection, according to a recent study.

Infection risk is generally thought to be lower with arterial catheters than with central venous catheters, and guidelines do not recommend that either type of catheter be routinely replaced although supporting data on arterial catheters are lacking. French researchers evaluated data from a previously conducted infection control trial to compare the risk for colonization and catheter-related infection (CRI) in arterial versus central venous catheters. A total of 3,532 catheters and 27,541 catheter-days in seven ICUs were included. The study results appear in the April Critical Care Medicine.

The authors found that rates of colonization did not differ significantly between arterial catheters and central venous catheters (7.9% vs. 9.6%, respectively), and CRI rates were also similar (0.68% vs. 0.94%). Arterial catheters were associated with a steady increase in daily hazard rate for colonization over time (1.3% on day 5, 2.4% on day 10 and 3.0% on day 15) while with central venous catheters this rate remained stable (1.2% on day 5, 1.6% on day 10 and 1.4% on day 15). The hazard for colonization did not differ by catheter type during the first seven days of catheterization but was higher with arterial catheters after seven days. The researchers identified respiratory failure and femoral insertion as independent risk factors for arterial catheter colonization and trauma or absence of septic shock at ICU admission, femoral or jugular insertion and absence of antibiotic treatment as independent risk factors for central venous catheter colonization.

The authors acknowledged that their study was observational and used catheter colonization as an end point because CRI rates were low. However, they concluded that rates of both catheter colonization and CRI were similar with arterial and central venous catheters, and that infection in both types of catheters should be targeted for prevention in the ICU. They called for a randomized, controlled trial to more definitively examine whether the risk of arterial catheter infection increases over time, as their results seemed to suggest.

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FDA update

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OxyContin redesigned to reduce risk of abuse

A new formulation of OxyContin specially designed to help discourage misuse and abuse of the drug was approved last week by the FDA.

OxyContin is made to slowly release oxycodone to treat severe pain for an extended period of time. Because of the drug’s controlled-release properties, each tablet contains a large quantity of oxycodone and, under the previous formulation, abusers of the drug have been able to release high levels of oxycodone all at once.

The reformulated OxyContin is intended to prevent the opioid medication from being cut, broken, chewed, crushed or dissolved to release more medication. The new formulation may provide an incremental advantage over the current version and is likely to result in less abuse by snorting or injection, FDA officials said.

The drug still can be abused by simply ingesting larger doses than are recommended, and the manufacturer will be required to conduct a post-market study on the extent to which the new formulation reduces abuse and misuse, according to an FDA press release.

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Internal Medicine 2010

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ACP Job Placement Center calls for physician profiles

Physicians looking for a new job may submit a Job Seeker's Profile to the ACP Job Placement Center, a service available at Internal Medicine 2010 in Toronto, Canada. The Center, located in the Metro Toronto Convention Centre’s Exhibit Hall, Booth 222, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Profiles are distributed to numerous employers participating in Internal Medicine 2010, which will be held April 22-24. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the Convention Centre. Profiles can be submitted online.

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Cartoon caption contest

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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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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated