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ACP HospitalistWeekly

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In the News for the Week of 10-26-11

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Highlights

Medicare proposes changes to conditions of participation

The Centers for Medicare and Medicaid Services (CMS) proposed major changes to existing regulations last week, with the release of two sets of proposed rules and one finalized rule that the agency predicts will save the health care system nearly $1.1 billion per year by removing unnecessary regulations. More...

U.S. hospitalizations for heart failure have declined, study finds

Hospitalizations for heart failure in the U.S. declined considerably from 1998 to 2008, although less so among black men, according to a new study. More...

Perioperative care

Patients with IBD at increased risk of postoperative DVT, PE

Patients with inflammatory bowel disease (IBD) are at greater risk of developing deep vein thrombosis or pulmonary embolism after surgery than those without IBD, a new study found. More...

Readmissions

Hospital readmission risk prediction models perform poorly, review finds

Most risk prediction models for hospital readmissions do not perform well, according to a new systematic review. More...

Stroke

Statins not associated with intracerebral hemorrhage, meta-analysis indicates

A recent meta-analysis found no evidence of an association between statins and intracerebral hemorrhage (ICH). More...

From the College

Join ACP's online discussion group for hospitalists

ACP members are invited to participate in ACP's Special Interest Groups, a private online community that allows members to share experiences, questions and creative solutions with like-minded physicians at their own convenience. More...

Cartoon caption contest

And the winners are …

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. More...

Physician editor: A. Scott Keller, MD, FACP

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Highlights

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Medicare proposes changes to conditions of participation

The Centers for Medicare and Medicaid Services (CMS) proposed major changes to existing regulations last week, with the release of two sets of proposed rules and one finalized rule that the agency predicts will save the health care system nearly $1.1 billion per year by removing unnecessary regulations.

The largest of the changes revises CMS' conditions for participation for hospitals to promote higher quality and safer health care. The proposed rule is targeted at three major areas: care transitions from the hospital, patient-centered care, and hospital quality improvement programs, according to a commentary by CMS officials, published online in the Journal of the American Medical Association on Oct. 18. The last attempt at major changes to the conditions for participation was made unsuccessfully in 1997, the commentary noted.

Among other changes, the proposed rule would allow inpatients to self-administer home medications and advanced practice registered nurses to be granted hospital practice privileges. The rule would also eliminate the requirement for authentication of verbal orders within 48 hours and the requirement to immediately report the death of any patient wearing soft, two-point restraints. The rule would allow integrated care plans involving multiple disciplines (to replace stand-alone nursing care plans) and a single governing body for multiple hospitals. To facilitate contracting and telemedicine, critical access hospitals will no longer be required to provide diagnostic and therapeutic services, laboratory services and radiology services.

The proposed changes to the conditions of participation are open for comment for 60 days, as is a proposed rule relating to providers other than hospitals. That rule is aimed at eliminating duplicative, overlapping, outdated and conflicting regulatory requirements for providers such as end-stage renal disease facilities and durable medical equipment suppliers, according to a CMS press release.

The third rule, which was just finalized, makes changes to the health and safety requirements for ambulatory surgical centers.

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U.S. hospitalizations for heart failure have declined, study finds

Hospitalizations for heart failure in the U.S. declined considerably from 1998 to 2008, although less so among black men, according to a new study.

Researchers analyzed data from all Medicare beneficiaries in the U.S. and Puerto Rico hospitalized at acute care hospitals from 1998 and 2008 with heart failure as a principal discharge diagnosis code. The goal of the study was to detect changes in rates of heart failure hospitalization and one-year mortality rates in the U.S. as a whole and by state or territory. Main outcome measures were changes in demographic characteristics and comorbid conditions as well as rates of hospitalization and one-year mortality. The study results appeared in the Oct. 19 Journal of the American Medical Association.

Overall, data from 55,097,390 Medicare beneficiaries were analyzed. After adjusting for age, sex and race, the authors found that the heart failure hospitalization rate decreased from 2,845 per 100,000 person-years in 1998 to 2,007 per 100,000 person-years in 2008 (P<0.001; relative decline, 29.5%). Heart failure hospitalization rates adjusted for age decreased during the study period among all categories of race and sex. For all race-sex categories, rate of decline was lowest among black men (4,142 to 3,201 per 100,000 person-years), even after adjustment for age (incidence rate ratio, 0.81; 95% CI, 0.79 to 0.84). One-year mortality rates adjusted for risk decreased from 31.7% to 29.6% from 1999 to 2008 (P<0.001; relative decline, 6.6%). Changes in rates of hospitalization and one-year mortality varied geographically: Hospitalizations decreased statistically slower than the mean in three states and significantly faster than the mean in 16 states, while one-year mortality rates increased in five states and decreased significantly in four.

The authors noted that they only examined Medicare beneficiaries, that they could not determine whether changes in medical coding had affected their findings, and that they could not investigate differences in subtypes of heart failure, among other limitations. However, they concluded that overall risk-adjusted heart failure hospitalizations in the U.S. declined significantly from 1998 to 2008, primarily because fewer patients were being hospitalized (as opposed to a reduction in the frequency of hospitalizations), and that the rate of decline was lowest among black men.

The authors of an accompanying editorial applauded the study as the first to document improved heart failure hospitalization rates in the U.S. but noted that the event rate after discharge for a heart failure hospitalization "remains unacceptably high and requires immediate attention." The editorialists suggested exploring the following strategies for improvement:

• Treat beyond clinical congestion to "subclinical congestion" (patients with high left venticular filling pressures);
• Systematically assess and correct cardiac abnormalities;
• Treat noncardiac comorbid conditions, such as hypertension, renal dysfunction and diabetes;
• Increase use of underused therapies known to improve hospitalization rates, such as digoxin and eplerenone; and
• Schedule postdischarge visits promptly, especially in high-risk patients.

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Perioperative care

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Patients with IBD at increased risk of postoperative DVT, PE

Patients with inflammatory bowel disease (IBD) are at greater risk of developing deep vein thrombosis or pulmonary embolism after surgery than those without IBD, a new study found.

In a retrospective cohort study, researchers used 2008 data from 211 hospitals that participated in the National Surgical Quality Improvement Program. Patients without IBD (n=269,119) were compared with patients with IBD (n=2,249) for occurrence of deep vein thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI) or stroke within 30 days of surgery. The study results were published online Oct. 17 by Archives of Surgery.

Of patients with IBD, 2.5% (n=57) had DVT or PE, compared with 1.0% of patients without IBD (P<0.001). Patients with IBD who underwent nonintestinal surgery had a higher rate of DVT or PE (5%) compared to patients without IBD (0.8%; P=0.002). Regression analysis, meant to control for confounders, found IBD was a significant predictor of DVT or PE (odds ratio, 2.03; 95% CI, 1.52 to 2.70). There was no significant mortality difference between patients who had DVT or PE with IBD versus without IBD. In both groups, 0.4% of patients had stroke or MI (9 patients with IBD versus 1,164 patients without IBD, P=0.68).

While it's been known for many decades that patients with IBD are at increased risk of DVT and PE, standard DVT and PE guidelines don't recommend enhanced prophylaxis for these patients, the authors noted. The current study adds to the body of research in examining the risk of a subgroup of patients with IBD who undergo surgery, they said. Its finding of a twofold increased risk of DVT or PE for patients with IBD who undergo surgery "suggest[s] that standard DVT and PE prophylaxis should be reconsidered for this patient group," the authors concluded.

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Readmissions

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Hospital readmission risk prediction models perform poorly, review finds

Most risk prediction models for hospital readmissions do not perform well, according to a new systematic review.

Researchers searched the databases of MEDLINE, CINAHL, the Cochrane Library and EMBASE from their inception through early-to-mid 2011 and performed hand searches of retrieved reference lists. They looked for studies in English of readmission risk prediction models used for medical patients in both derivation and validation cohorts. Studies weren't limited by diagnosis in medical populations but were excluded if they focused on psychiatric, surgical or pediatric populations or were from developing nations. From each study, researchers abstracted data on the population, setting, number of patients in each cohort, timeframe of readmission outcome, readmission rate, range of readmission rates according to predicted risk, and model discrimination. Study results were published in the Oct. 19 Journal of the American Medical Association.

Out of 7,843 citations reviewed, 30 studies of 26 unique models met the authors' inclusion criteria. Several of the models are currently being used in clinical, research and policy arenas. Twenty-three of the studies were based on U.S. data, while there were two each from Australia and England and one each from Ireland, Switzerland and Canada. Thirty-day readmission rate was the most commonly reported outcome, though some models chose other follow-up intervals that ranged from 14 days to four years. One model specifically addressed preventable readmissions. Most models had poor predictive ability. Fourteen models that were based on retrospective administrative data could possibly be used for hospital comparisons, but the nine of those tested on U.S. populations had poor discriminative ability (c statistic range, 0.55 to 0.65). Seven of the models could possibly be used to identify high-risk patients for intervention early in hospitalization (c statistic range, 0.56 to 0.72) and five could be used at hospital discharge (c statistic range, 0.68 to 0.83). While most models included variables for comorbidities and previous use of medical services, few examined variables associated with overall health and function, social determinants of health or illness severity.

In light of public reporting requirements and financial penalties for hospitals with high readmission rates, the poor discriminative ability of most models in the study raises concerns about the ability to fairly compare hospital performance, the authors said. "Until risk prediction and risk adjustment become more accurate, it seems inappropriate to compare hospitals in this way and reimburse (or penalize) them on the basis of risk-standardized readmission rates," the authors wrote. Still, while overall predictive ability was poor, the authors did find that "high- and low-risk scores were associated with a clinically meaningful gradient of readmission rates. This is important given resource constraints and the need to selectively apply potentially costly care transition interventions," they wrote.

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Stroke

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Statins not associated with intracerebral hemorrhage, meta-analysis indicates

A recent meta-analysis found no evidence of an association between statins and intracerebral hemorrhage (ICH).

Because a recent large, randomized controlled trial suggested a link between statin use and risk for ICH, the authors of the current study performed a large systematic review and meta-analysis of the existing literature to examine the potential association. They searched 17 electronic databases, manually screened bibliographies, reviewed proceedings abstracts, and consulted experts to find published and unpublished trials that included data on ICH and use of statins.

Studies were excluded if they combined statins with other classes of lipid-lowering drugs and if they only looked at ICH after thrombolysis for acute ischemic stroke. In the former case, however, the authors contacted study authors to determine whether data that analyzed statins separately were available. The authors calculated summary risk ratios and 95% confidence intervals using DerSimonian-Laird random-effects models, and they analyzed included studies separately by type (i.e., randomized trials, cohort studies and case-control studies). Results of the meta-analysis were published online Oct. 17 by Circulation.

Overall, data from 23 randomized trials and 19 observational studies, involving a total of 248,391 patients and 14,784 ICHs, were included. No association was seen between statins and ICH in randomized trials (risk ratio, 1.10; 95% confidence interval [CI], 0.86 to 1.41), cohort studies (risk ratio, 0.94; 95% CI, 0.81 to 1.10) or case-control studies (risk ratio, 0.60; 95% CI, 0.41 to 0.88). The case-control studies had substantial heterogeneity while the cohort studies and randomized trials did not. The authors performed sensitivity analyses according to characteristics of study design and patients as well as degree of cholesterol lowering, but the results did not markedly change.

The authors cautioned that their analysis did not allow access to individual patient data, that adherence to statin therapy was low in the observational studies, and that they could not determine the possible effect of statin use on different subtypes of ICH. However, they concluded that their large meta-analysis found no evidence indicating an association between ICH and statins, and noted that if such a risk does exist, it is probably small and does not outweigh statins' benefits. "Because risk factors for nonlobar [ICH] are similar to those for atherosclerotic events. . ., clinicians should continue to use treatment algorithms that base the initiation of statins on each individual's global risk for cardiovascular events," they wrote.

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From the College

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Join ACP's online discussion group for hospitalists

ACP members are invited to participate in ACP's Special Interest Groups, a private online community that allows members to share experiences, questions and creative solutions with like-minded physicians at their own convenience.

The special interest group forums are free and exclusive to ACP members. Members can connect with fellow colleagues in hospital medicine to discuss topics such as work schedule, practice type, and inpatient versus observation status as well as share tips for getting the most out of committee work. Signup is required as space is limited. More information is available online.

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Cartoon caption contest

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And the winners are …

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. The vote was tied this week, with two winners who will share in the prize.

"I asked you to put on an unna boot, not tuna boot."

—Submitted by John A. Magaldi, MD, FACP, from Torrington, Conn.

"Well, to the untrained eye, this may appear to be a red herring."

—Submitted by Steven W. Ressler, MD, ACP Member, from Scottsdale, Ariz.

Readers cast 91 ballots online to choose the winning entry. Thanks to all who voted! The winning entries each captured 40.7% of the votes.

The runner-up was:

"Clearly we can ALL benefit from tail coverage…."

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