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ACP HospitalistWeekly 8-25-10

Highlights

• Confusion Assessment Method ranks highest for diagnosing inpatient delirium
• Survival benefit seen with combination antibiotics in patients with high death risk

Palliative care

• Early palliative care improves quality of life in patients with metastatic lung cancer

Heart failure

• AHRQ releases data on preventable heart failure hospitalizations

FDA update

• Hypotension drug faces withdrawal

From ACP Hospitalist

• Send us your coding questions

Cartoon contest

• Vote for your favorite entry

Physician editor: A. Scott Keller, FACP

Highlights

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Confusion Assessment Method ranks highest for diagnosing inpatient delirium

The Confusion Assessment Method (CAM) is the best of 11 bedside instruments for assessing delirium, a review found.

Researchers used MEDLINE and EMBASE to find 25 prospective studies (n=3,027 patients) of diagnostic accuracy that compared at least one bedside instrument for delirium to a diagnosis made by a geriatrician, neurologist or psychiatrist that was based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R or DSM-IV). Studies with hospitalized patients in the ICU were excluded, as were studies involving mostly alcohol-related delirium and those in which the index and reference tests were performed by the same person. Studies had to involve a bedside instrument that didn't require special equipment and could be administered by a non-expert. Results were published in the Aug. 18 Journal of the American Medical Association.

The 11 bedside instruments included in the analysis were the Clinical Assessment of Confusion (CAC), CAM, Delirium Observation Screening Scale (DOSS), Delirium Rating Scale (DRS), Delirium Rating Scale-Revised-98 (DRS-R-98), Digit Span Test, Global Attentiveness Rating (GAR), Memorial Delirium Assessment Scale (MDAS), Mini-Mental State Examination (MMSE), Nursing Delirium Screening Scale (Nu-DESC) and Vigilance "A" Test. Of these, the following had positive results that suggested delirium with likelihood ratios (LRs) greater than 5.0: GAR, MDAS, CAM, DRS-R-98, CAC and DOSS. Normal results that decreased the likelihood of delirium with LRs less than 0.2 were calculated for the GAR, MDAS, CAM, DRS-R-98, DRS, DOSS, Nu-DESC and MMSE. The Digit Span and Vigilance "A" tests had limited utility in isolation.

When the authors considered ease of use, test performance and clinical importance of the heterogeneity in confidence intervals (CIs) of the LRs, the CAM was the best bedside instrument (summary positive LR, 9.6; 95% CI, 5.8 to 16.0; summary-negative LR, 0.16; 95% CI, 0.09 to 0.29). The commonly used MMSE was the least useful for identifying patients with delirium (LR, 1.6; 95% CI, 1.2 to 2.0). The CAM does take five minutes to administer, which may be too much time for busy physicians, the authors noted. The two-minute general conversation that defines the GAR could be a good alternative, but its generalizability may be limited to those with expertise in this patient population, they said.

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Survival benefit seen with combination antibiotics in patients with high death risk

Combination antibiotics improve survival for patients with infections who have a high risk of death, but they may be harmful to low-risk patients, a meta-analysis found.

After searching several databases, researchers found 50 randomized or observational studies of antimicrobial therapy for serious bacterial infections that were potentially associated with sepsis or septic shock. The studies needed sufficient data to calculate an odds ratio (OR) between single versus combination antibiotic therapy. Combination therapy was defined as a combination of two or more antibiotics of different antimicrobial class and mechanism of action. Mortality and infection-related mortality were the primary outcomes, though "clinical failure" was acceptable when these weren't provided. Results were published in the August Critical Care Medicine.

A pooled OR indicated no overall mortality/clinical response benefit with combination therapy (OR, 0.856; 95% CI, 0.71 to 1.03; P=0.0943), but when datasets were stratified by monotherapy mortality risk, the most severely ill subset saw significant benefit (monotherapy risk of death >25%; OR of death, 0.51; 95% CI, 0.41 to 0.64). Of these datasets that could be stratified by the presence of shock/critical illness, the more severely ill group saw increased efficacy of combination therapy (OR, 0.49; 95% CI, 0.35 to 0.70; P=0.0001). Meanwhile, low-risk patients had a higher risk of death with combination therapy (OR, 1.53; 95% CI, 1.16 to 2.03; P=0.003), and meta-regression showed that the benefit of combination therapy depended only on the risk of death in the monotherapy group.

In contrast with previous meta-analyses, this one showed that combination antibiotics do lower mortality in patients with serious infections, but only in those at highest risk of death (i.e., a projected mortality/clinical failure rate of >25%), the authors said. Further, the analysis of the studies that could be split into septic shock and nonshock strata indicates the benefit may be restricted to septic shock cases. It also seems that combination therapy may increase the risk of death in patients whose mortality risk is 15% or lower. "The presence of septic shock may be a simple prospective method to identify patients who may benefit from combination therapy," the authors concluded. "Alternately, severity of illness scoring systems could be used to identify patients most likely to benefit."

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Palliative care

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Early palliative care improves quality of life in patients with metastatic lung cancer

Introducing palliative care soon after diagnosis of metastatic non-small-cell lung cancer improves quality of life, mood and survival, while decreasing aggressive end-of-life care, according to a new study.

Researchers at Massachusetts General Hospital performed an unblinded randomized, controlled trial that assigned 151 patients with a new diagnosis of metastatic non-small-cell lung cancer to receive standard care or early palliative care plus standard care. Those assigned to early palliative care met with a clinician from the palliative care team within three weeks of study enrollment and a minimum of once a month thereafter; patients could schedule additional visits at their own or their clinicians' discretion. The palliative care visits were used to assess physical and psychosocial symptoms, outline care goals, help patients make decisions about treatment and coordinate care. Patients who were assigned to standard care didn't meet with the palliative care team unless they, their family or their oncologist requested a visit.

The study measured quality of life at baseline and at 12 weeks with the Functional Assessment of Cancer Therapy–Lung (FACT-L) scale, which ranges from 0 to 136 (higher scores indicate better quality of life). Patients' mood was measured at baseline and at 12 weeks using the Hospital Anxiety and Depression Scale. The authors also looked at the type and amount of end-of-life care that patients received, according to electronic medical records. The study results were in the Aug. 19 New England Journal of Medicine.

Seventy-four patients were assigned to the standard care group, and 77 were assigned to receive early palliative care. One hundred seven patients (86%) survived to 12 weeks and completed the study assessments. Patients in the early palliative care group had better quality of life at 12 weeks than those receiving standard care (mean FACT-L score, 98.0 vs. 91.5; P=0.03) and were also less likely to report depressive symptoms (16% vs. 38%; P=0.01). Fewer patients receiving early palliative care also received aggressive end-of-life care (33% vs. 54%; P=0.05) but they had longer median survival after diagnosis (11.6 months vs. 8.9 months; P=0.02).

The authors pointed out that their study involved highly trained clinicians at a single facility, as well as only one disease, limiting its generalizability. Among other limitations, the patients were not ethnically diverse and all parties were aware of the study group assignments. However, the authors concluded that early palliative care can improve quality of life and survival in patients recently diagnosed with metastatic non-small-cell lung cancer, and that it may also lead to more appropriate end-of-life care.

An accompanying editorial noted that the study challenged conventional ideas about palliative care, which is often considered an alternative to standard life-prolonging or curative care rather than an adjunct. The editorialists said that the findings on improved survival, while supported by other studies, need to be replicated. In addition, they pointed out that the beneficial effect of additional time with and attention from health care providers, as opposed to a specific benefit derived from palliative care itself, was not assessed. However, they called the study "an important step in confirming the beneficial outcomes of a simultaneous care model that provides both palliative care and disease-specific therapies beginning at the time of diagnosis." The editorialists concluded that “we now have both the means and the knowledge to make palliative care an essential and routine component of evidence-based, high-quality care for the management of serious illness."

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Heart failure

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AHRQ releases data on preventable heart failure hospitalizations

U.S. states in the Mountain region had the lowest average rate of potentially avoidable heart failure hospitalizations in 2006, while states in the East South Central region had the highest, according to data released last week by the Agency for Healthcare Research and Quality (AHRQ).

The data, which appear in the latest AHRQ News and Numbers, were based on information from AHRQ State Snapshots, which looks at health care quality information by state. The Mountain region, including Montana, Wyoming, Idaho, Utah, Nevada, Colorado, Arizona and New Mexico, had a rate of potentially avoidable heart failure hospitalizations of 266 admissions per 100,000 population. In contrast, the rate in the East South Central region, which includes Alabama, Mississippi, Tennessee and Kentucky, had a rate of 583 admissions per 100,000 population.

The next lowest and highest admission rates were as follows:

• 316.5 per 100,000 population in the Pacific states (California, Oregon, Washington and Alaska);
• 362 per 100,000 population in the West North Central region (North Dakota, South Dakota, Nebraska, Iowa, Missouri, Minnesota and Kansas);
• 364 per 100,000 population in New England (Connecticut, Rhode Island, Massachusetts, New Hampshire, Vermont and Maine);
• 430 per 100,000 population in the Mid-Atlantic region (New Jersey, New York and Pennsylvania).
• 460 per 100,000 population in the Southeast (Florida, Georgia, North Carolina, South Carolina, Virginia, West Virginia, Maryland and Delaware);
• 496 per 100,000 population in the West South Central region (Texas, Oklahoma, Arkansas and Louisiana) and
• 502 per 100,000 population in the East North Central region (Wisconsin, Michigan, Illinois, Indiana and Ohio).

ACP Hospitalist looks at preventing readmissions for heart failure in our August cover story.

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FDA update

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Hypotension drug faces withdrawal

The FDA proposed to withdraw approval of midodrine hydrochloride (ProAmatine), a drug used to treat orthostatic hypotension, because required post-approval studies to verify the clinical benefit of the medication have not been done.

Patients who currently take this medication should not stop taking it but should consult their health care professional about other treatment options, advised the FDA announcement. The agency is working with the drug’s manufacturers to develop an expanded-access program to allow patients who currently receive the drug (which is produced under its brand name and as a generic) to continue to receive it. This is the first time the FDA has issued such a notice for a drug approved under its accelerated approval regulations.

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From ACP Hospitalist

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Send us your coding questions

Got a documentation or coding conundrum? Let ACP Hospitalist help you. Coding guru Richard Pinson, FACP, responds to selected questions from readers each month in his Coding Corner column. E-mail your questions to acphospitalist@acphospitalist.org. Please include your name, city and state, and professional credentials with your question.

Dr. Pinson, an internist for 30 years and a certified coding specialist, also provides monthly documentation tips to help hospitalists accurately capture their patients' complexity of care—and ensure their hospital is reimbursed accordingly.

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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.

"Did you say you were a little horse? Or a little hoarse?"
"I think we need to up your dose of Lasix."
"I’ll need to take a look with my oatoscope."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through Monday, August 30, with the winner announced in the September 1 issue.

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