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ACP HospitalistWeekly 6-23-10

Highlights

• Documented follow-up appointments don't lower readmissions for general medicine inpatients
• Oral low-dose steroids yield similar outcomes as high-dose IV steroids for COPD exacerbations

Opioid dependence

• Emergency department visits up for nonmedical use of opioids, benzodiazepines

Critical care

• Little difference between antibiotics in treating acute exacerbation of COPD

Drug alerts

• Tylenol recall expanded

From ACP Hospitalist

• Suggest a colleague as a Top Hospitalist

Cartoon caption contest

• Vote for your favorite entry

Physician editor: A. Scott Keller, FACP

Highlights

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Documented follow-up appointments don't lower readmissions for general medicine inpatients

Providing detailed instructions for follow-up appointments to general medicine patients at discharge doesn't appear to reduce hospital readmissions or mortality rates 30 or 180 days later, a new study found.

Researchers retrospectively reviewed all hospital discharge records for general internal medicine inpatients dismissed from the Mayo Clinic in Rochester, Minn. in 2006. Patients discharged to home with skilled nursing services weren't included; neither were patients discharged to a long-term care facility or hospice, or transferred to another inpatient service. Those discharged to home with home health services were included. To be considered complete, appointment documentation had to include a specific date and time, and a location or physician. Results were published in the June 14 Archives of Internal Medicine.

Of the 4,989 patient records reviewed, 60.9% (n=3,037) had detailed follow-up appointment instructions. Appointments were scheduled a median of six days after discharge, though they ranged from the same day as discharge to nine months later. The mean age of patients with follow-up appointments was 62.3 years vs. 61 years without (P=0.02). Those with appointments also had a longer length of stay (3.3 days vs. 2.7 days; P<0.001).

There were no significant associations between having a scheduled follow-up appointment at discharge and related hospital readmission or emergency department visits, within 30 days. There were also no associations between appointments and mortality at 30 days. When data were adjusted for factors including age, sex and illness severity, however, patients with appointments were more likely than those without to have a readmission or an emergency department visit at 180 days after discharge (hazard ratio=1.10; P=0.03), though they weren't more likely to die. Patients with a longer span between discharge and scheduled appointments were less likely to be readmitted within 30 days. For patients with appointments scheduled within seven days of discharge, no significant relationship was seen with any of the 30-day outcomes.

The results raise doubt about whether using documented follow-up appointments is appropriate for gauging a hospital's efforts to reduce readmissions, as the Centers for Medicare and Medicaid Services proposes, the authors said. Focusing on documentation doesn't guarantee patients will actually show up for the appointments, they noted. Further, this study found most readmissions were unrelated to the original admission, which "calls into question the concept of using readmissions as a quality indicator for the original hospitalization," they noted. Though some past research has found a readmissions benefit from follow-up, the follow-up in those studies was usually one element within a group of interventions, they said. Financial incentives to reduce readmissions may have unintended consequences, the authors said, and efforts to ensure follow-up for all patients may not be beneficial or cost-effective. More research is needed as to which specific patient populations might get the greatest benefit from follow-up, as is research on the optimal timing of appointments.

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Oral low-dose steroids yield similar outcomes as high-dose IV steroids for COPD exacerbations

Low doses of steroids administered orally were not associated with worse outcomes than high-dose IV steroids in patients with exacerbations of chronic obstructive pulmonary disease (COPD), according to a new study.

Although clinical guidelines recommend low-dose oral steroids for COPD exacerbations, the ideal form and route of administration are unclear. The authors conducted a cohort study of patients admitted to 414 U.S. hospitals with COPD exacerbations in 2006 and 2007, comparing outcomes of those treated with low-dose oral steroids and those treated with high-dose IV steroids during the first two days of their hospitalization. Data were obtained from a fee-supported, voluntary database used to measure quality and health care utilization. Patients who were admitted directly to the intensive care unit were excluded. The authors used a composite measure of treatment failure, defined as mechanical ventilation after the second day of hospitalization, in-hospital death, or readmission for acute COPD exacerbation within 30 days, as the main outcome measure. Secondary outcomes included length of stay and hospital costs. The study results appear in the June 16 Journal of the American Medical Association.

Overall, 79,985 patients met the study's enrollment criteria. COPD was the principal diagnosis in 71,628 (90%), and respiratory failure was the principal diagnosis in the remainder (8,357, or 10%). Seventeen percent and 12%, respectively, had been admitted to the hospital for COPD once or at least twice in the preceding year. The authors found that 92% of patients (n=73,765) were treated with IV steroids initially and 8% (n=6,220) initially received oral treatment. In-hospital mortality rates (1.4%; 95% CI, 1.3% to 1.5% vs. 1.0%; 95% CI, 0.7% to 1.2%) and rates of the composite outcome (10.9%; 95% CI, 10.7% to 11.1% vs. 10.3%; 95% CI, 9.5% to 11.0%) were similar regardless of whether IV or oral treatment was received. After multivariable adjustment, risk for treatment failure was not higher in patients treated with low-dose oral steroids than in those who received high-dose IV steroids (odds ratio, 0.93; 95% CI, 0.84 to 1.02). The authors also performed a propensity-matched analysis and found that orally treated patients had a significantly lower risk for treatment failure, as well as shorter length of stay and lower costs.

The authors noted that their study was observational and that the results should not be generalized to patients with more severe disease who are treated in the intensive care unit. They also noted that physician decisions regarding the choice of therapy may have been influenced by initial disease severity. However, they concluded that low doses of oral steroids were not associated with worse outcomes than high doses of IV steroids in patients with COPD exacerbations, and that "opportunities may exist to improve care by promoting greater use of low-dose steroids given orally." Physicians may favor high-dose IV steroids over low-dose oral steroids because they may believe high doses are more effective and may lack knowledge of pharmacokinetics, among other factors, the authors wrote.

The authors of an accompanying editorial pointed to the study as a good example of cost-effectiveness research using linked databases and asserted that the data should spur changes in practice. "To ensure that potential benefits supported by observational data are realized, further follow-up evaluations are needed to measure time-trends in quality metrics, health outcomes, and health care costs," the editorialists concluded.

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Opioid dependence

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Emergency department visits up for nonmedical use of opioids, benzodiazepines

Emergency department visits for nonmedical opioid use rose 111% between 2004 and 2008, according to new data from the Centers for Disease Control and Prevention (CDC).

Oxycodone, hydrocodone and methadone were the opioids associated with the greatest number of emergency department (ED) visits in the five-year period ending in 2008, according to the CDC's June 18 Morbidity and Mortality Weekly Report (MMWR). There was also an estimated 89% increase in ED visits involving nonmedical use of benzodiazepines, said the report, which is based on data submitted by 231 hospitals. Approximately one in four patients who visited the ED for nonmedical opioid or benzodiazepine use was admitted, it said.

For individual drugs, the estimated increases in ED visits for nonmedical use between 2004 and 2008 were:

• oxycodone: 152% increase (P<0.001)
• alprazolam: 125% increase (P=0.01)
• clonazepam: 72% increase (P<0.001)
• diazepam: 70% increase (P=0.02)
• lorazepam: 107% increase (P=0.006)
• zolpidem: 121% increase (P=0.002)
• carisoprodol: 132% increase (P=0.04).

Based on this new data, peak visit rates for both opioids and benzodiazepines appear to have shifted into the 21- to 24-year and 25- to 29-year age groups by 2008, and away from the 30- to 34-year and 35- to 44-year age groups, the report said. As late as 2006, the peak mortality rate for fatal drug overdoses involving opioid analgesics had been in the 35- to 54-year age group, it noted.

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Critical care

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Little difference between antibiotics in treating acute exacerbation of COPD

Two recent studies compared the effectiveness of different antibiotics in treating acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and, in both cases, found little difference. Specifically, the studies found:

• Macrolide and quinolone antibiotics have similar rates of treatment failure in AECOPD, according to a meta-analysis in the May/June Journal of Hospital Medicine. The analysis of 19,608 patients at 375 acute care hospitals found 69% of patients were treated with quinolone and 31% with macrolide within the first two hospital days. Treatment failure (defined as a composite of inpatient mortality, readmission for AECOPD within 30 days, or starting mechanical ventilation after day two) was the same in both groups in grouped-treatment analysis; there were also no differences in adjusted length of stay or adjusted cost. Antibiotic-associated diarrhea was more common with quinolones (1.2% vs. 0.6%; P=0.0003), as was late mechanical ventilation (1.3% vs. 0.8%; P=0.02), thus "macrolides appear to be the safer of the two," the authors wrote.
• Outcomes were similar for patients with severe AECOPD who took ciprofloxacin vs. a combination of trimethoprim and sulfamethoxazole, found a randomized, double-blind trial published in the July 15 Clinical Infectious Diseases. Of 170 patients with AECOPD requiring mechanical ventilation, 85 received trimethoprim-sulfamethoxazole and 85 received ciprofloxacin for 10 days. The combined outcome of in-hospital death and need for additional antibiotics was similar in the two groups, as was the time to occurrence of the first relapse, duration of mechanical ventilation and length of hospital stay. There were no serious adverse events and tolerance was good overall. The findings highlight the need to reevaluate standard antibiotic therapy regarding its low cost and ability to decrease the use of new, broad-spectrum agents, the authors said.

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Drug alerts

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Tylenol recall expanded

Two products—Benadryl Allergy Ultratab tablets and Extra Strength Tylenol rapid release gels—were added to the large January recall by McNeil Consumer Healthcare.

The products were inadvertently omitted from the initial recall action, according to a press release. The original recall was motivated by consumers reporting a moldy, musty or mildew-like odor, which was eventually linked to trace amounts of a chemical called 2,4,6-tribromoanisole (TBA) in wooden pallets that transport and store product packaging materials.

Anyone who purchased product from the five newly recalled lots or other lots included in the January recall should stop using the product and contact McNeil Consumer Healthcare for instructions on a refund or replacement.

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From ACP Hospitalist

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Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our third annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2010, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, leadership, mentorship or quality improvement.

Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 16, 2010, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2010 issue.

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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.

 

 

 

 

 

 

 

 

".sessalg deen yam uoY"
"In a world of no drug reps, no standardized eye charts."
"No, you don't have situs inversus; you have 'sighted inversus.'"

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Monday, June 28, with the winner announced in the June 30 issue.

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