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ACP HospitalistWeekly 9-1-10

Highlights

• Statin prescriptions at discharge increasing in patients with intracerebral hemorrhage
• Black and low-income patients more likely to leave hospital against medical advice, be readmitted

Infections

• Ceftaroline monotherapy is effective in treating complicated skin and skin structure infection
• Inappropriate therapy for health care-associated skin infections may lengthen hospital stay

Medicare update

• Medicare expands tobacco cessation coverage

Cartoon contest

• And the winner is…

Physician editor: A. Scott Keller, FACP

Editorial note: ACP HospitalistWeekly will not be published next week due to the Labor Day holiday.

Highlights

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Statin prescriptions at discharge increasing in patients with intracerebral hemorrhage

Rates of statin prescriptions at discharge have been increasing in patients hospitalized for intracerebral hemorrhage (ICH), a new study has found.

Patients with ICH can potentially benefit from statins, but the SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) trial found a higher risk for hemorrhagic stroke in its statin treatment arm. Researchers analyzed data from the Get with the Guidelines–Stroke Program to determine whether discharge prescriptions in patients hospitalized for ICH have changed over time, especially after the SPARCL results were released.

Data from 25,673 hemorrhagic stroke patients treated at Get with Guidelines-Stroke participating hospitals from Jan. 1, 2005 to Dec. 31, 2007 were analyzed to determine factors related to statin prescription at discharge. The study results were published online by Stroke on Aug. 19.

Overall, 39.5% of the study population received a statin prescription at hospital discharge. Patients were less likely to receive statins at discharge if they were women, had previously had a stroke or a transient ischemic attack, or were treated at an academic medical center or in the Midwest. Patients with known coronary artery disease or previous myocardial infarction, diabetes, dyslipidemia, and hypertension and those who had used a lipid-modifying drug before admission were more likely to be discharged on statins. Statin prescriptions among 10,341 patients who would have been eligible for the SPARCL trial increased from 66.9% in 2005 to 74.5% in 2007 (P<0.001). Rates decreased significantly (P=0.03) while the SPARCL results were being reported but then rebounded.

The authors noted that the hospitals participating in Get with the Guidelines were highly motivated to provide optimal care and that their results therefore may not be generalizable to other institutions, among other limitations. However, they concluded that use of statins at discharge is increasing among patients with ICH, and that the benefits and risks of statins in this population need to be examined in a randomized trial. Until such a trial is conducted, they wrote, "Studies of clinical effectiveness to explore the overall and differential effects of statin therapy in 'real-world' patients with ICH are warranted."

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Black and low-income patients more likely to leave hospital against medical advice, be readmitted

Low-income and black patients are more likely to leave the hospital against medical advice (AMA), which puts them at higher risk for 30-day readmission or mortality, a new study found.

In a five-year retrospective cohort study, researchers examined records from 1,930,947 medical admissions to 129 VA acute care hospitals, from which 32,819 (1.7%) patients were discharged AMA. Excluded patients included those discharged to a nursing home or transferred to another hospital. Primary outcomes were readmission to a VA hospital or death within 30 days of discharge. Potential covariates for the study models included age, sex, race, income and comorbidities. Results were published in the September Journal of General Internal Medicine.

AMA patients were more likely to be younger, male and black, and have a lower income and comorbid alcohol abuse, compared to patients who were discharged home (P<0.001 for all comparisons). AMA patients had a higher rate of 30-day readmission (17.7% vs. 11.0%, P<0.001) and 30-day mortality (0.75% vs. 0.61%, P=0.001). Surprisingly, the authors said, alcohol abuse wasn't a significant predictor of mortality and was associated with a lower risk of readmission, even though nearly 25% of AMA patients had a history of alcohol abuse compared to about 8% of regularly discharged patients. This may reflect the fact that those who abuse alcohol tend to avoid medical care until it's absolutely necessary, and thus stay out of the hospital more than 30 days, they said.

Overall, the higher risks of adverse outcomes for AMA patients suggest hospitals should target these patients for discharge transition interventions that might include phone follow-up, home visits or counseling, the authors said. Hospitals should also endeavor to prevent patients from leaving AMA via improvements in clinician communication, access to social services and involvement of family in care decisions, they noted. "Whether targeting patients before or after discharge, clear communication is likely to play a significant role in improving outcomes," the authors concluded.

An article about how to approach inpatients who want to leave AMA appeared in ACP Hospitalist's March issue.

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Infections

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Ceftaroline monotherapy is effective in treating complicated skin and skin structure infections

Ceftaroline is as effective as vancomycin plus aztreonam in treating complicated skin and skin structure infection (cSSSI), an analysis found.

Ceftaroline was evaluated as treatment for cSSSI in two identical phase 3 clinical trials, of which researchers did a pooled analysis. The combined randomized, controlled trials comprised 693 patients who received ceftaroline (600 mg every 12 hours) and 685 who received vancomycin plus aztreonam (1 g every 12 hours) for 5 to 14 days. Patients came from 111 study centers in Europe, Latin America and the U.S.; baseline characteristics of the treatment groups were comparable. Therapy was deemed complete based on investigator determination that all signs and symptoms of infection had resolved or improved so that no more antimicrobial therapy was needed. Each of the two trials met the primary objective of noninferiority in the clinical cure rate. The analysis was published in the Sept. 15 Clinical Infectious Diseases.

Clinical cure rates were similar for ceftaroline and vancomycin plus aztreonam in the clinically evaluable population (91.6% vs. 92.7%) and the modified intent-to-treat population (85.9% vs. 85.5%) population, as well as in patients infected with methicillin-resistant Staphylococcus aureus (93.4% vs. 94.3%). Clinical cure rates were similar between patients infected with single or multiple pathogens, across infection types, and between patients with common comorbidities such as diabetes mellitus and peripheral vascular disease. Rates of adverse events, serious adverse events, discontinuations because of an adverse event, and death were also similar between the treatment groups. There was a trend toward a higher clinical cure rate for patients with bacteremia who were treated with vancomycin plus aztreonam, but the significance of this is unknown due to the small number of cases, the authors said. Also, the efficacy of aztreonam was better than ceftaroline against Pseudomonas aeruginosa and Proteus mirabilis.

Limitations of the study include small numbers of black, Asian and elderly patients, and the exclusion of patients younger than 18 years old, the authors acknowledged. They concluded nonetheless that ceftaroline is well-tolerated and effective, and is a potential monotherapy alternative for treating cSSSI.

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Inappropriate therapy for health care-associated skin infections may lengthen hospital stay

Inappropriate empiric therapy for health care-associated complicated skin and skin structure infections (cSSSIs) is common and may increase length of stay, according to a new study.

Researchers performed an industry-sponsored single-center retrospective cohort study in patients hospitalized with a cSSSI to examine the association between inappropriate empiric therapy and outcomes. Health care-associated infection was defined as occurring in patients who had recently been hospitalized, had recently taken antibiotics, had received hemodialysis, and/or had recently transferred from a nursing home. Infected patients who did not receive targeted antimicrobial therapy within 24 hours of culture were considered to have received inappropriate therapy. The study's primary outcome was length of stay, while the secondary outcome was mortality. The results were published online Aug. 23 by the Journal of Hospital Medicine.

Seven hundred seventeen patients were hospitalized with a culture-positive cSSSI. The infection was determined to be health care-associated in 527 (73.5%); of these, 405 (76.9%) received appropriate treatment. Inappropriate treatment was more common in African-American patients and in patients with end-stage renal disease, and recent hospitalization was the most common risk factor for health care-associated cSSSI. Decubitus ulcers (29.5% vs. 10.9%, P<0.001), device-associated infection (42.6% vs. 28.6%, P=0.004) and bacteremia (68.9% vs. 57.8%, P=0.028) were more common in those who received inappropriate treatment than in those who received appropriate treatment, while rates of methicillin-resistant Staphylococcus aureus infection and mortality rates did not differ between groups. After adjusting for potential confounders, the authors found that inappropriate treatment appeared to increase length of stay by 1.8 days (95% CI, 1.4 to 2.3 days).

The study was performed at only one center, affecting its generalizability, and lacked information on outcomes after hospitalization, among other limitations. However, the authors concluded that almost 25% of patients with health care-associated cSSSIs don't receive appropriate empiric therapy, resulting in a significant increase in length of stay. They called for future studies to examine risk stratification for resistant organisms in this population. Stratifying risk at the bedside, they wrote, "may assure improved utilization of appropriately targeted empiric therapy that will both optimize individual patient outcomes and reduce the risk of emergence of antimicrobial resistance."

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Medicare update

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Medicare expands tobacco cessation coverage

Medicare will now pay for tobacco cessation counseling even if a patient does not have a tobacco-related disease, the Department of Health and Human Services (HHS) announced last week.

Under the new coverage, any smoker covered by Medicare will be able to receive tobacco cessation counseling from a qualified physician or other Medicare-recognized practitioner. Previously, tobacco counseling was covered only for individuals diagnosed with a recognized tobacco-related disease or who showed signs or symptoms of such a disease.

The new benefit will cover two individual tobacco cessation counseling attempts per year, each of which may include up to four sessions. The policy will apply to services under Parts A and B of Medicare. Beneficiaries will continue to have access to smoking-cessation prescription medication through Part D. Under the Affordable Care Act, effective Jan. 1, 2011, Medicare will cover preventive care services, including this tobacco cessation counseling, at no cost to beneficiaries. Later this year, Medicaid benefits will also be expanded to cover tobacco counseling for pregnant beneficiaries, according to HHS.

An estimated 4.5 million of the 46 million Americans who smoke are Medicare beneficiaries 65 or older and fewer than 1 million are younger than 65 and are covered by Medicare due to a disability, a press release reported.

An article about how to help inpatients quit smoking appeared in the January issue of ACP Hospitalist.

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Cartoon caption contest

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And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

"Did you say you were a little horse? Or a little hoarse?"

This issue's winning cartoon caption was submitted by Patricia J. Peterson, FACP, in practice in Longview, Wash. Readers cast 101 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry captured 62.4% of the votes.

The runners-up were:
"I think we need to up your dose of Lasix."
"I’ll need to take a look with my oatoscope."

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