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ACP HospitalistWeekly

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In the News for the Week of 11-9-11

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Highlights

Patient satisfaction with hospitalists matches results for PCPs

Patients were about equally satisfied when they were cared for by hospitalists or primary care physicians, a new study found. More...

New CABG guideline updates perioperative medication recommendations

New guidelines for the management of patients undergoing coronary artery bypass graft surgery (CABG) address patient selection, the role of CABG versus percutaneous coronary interventions (PCI), and the use of aspirin and other platelet therapies before and after surgery. More...

Pneumonia

SMRT-CO predicts early ICU transfer in CAP patients

The SMRT-CO score outperformed the CURB-65 as a method for predicting which pneumonia patients will require early transfer to the intensive care unit (ICU), according to a new study. More...

Geriatrics

Comprehensive geriatric assessment improves survival in older adults, study finds

Comprehensive geriatric assessment of older adults appears to improve hospital survival, a new study indicates. More...

Cartoon caption contest

Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...

Physician editor: A. Scott Keller, MD, FACP

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Highlights

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Patient satisfaction with hospitalists matches results for PCPs

Patients were about equally satisfied when they were cared for by hospitalists or primary care physicians, a new study found.

The study used data from random telephone interviews of medicine service patients discharged from three Massachusetts hospitals between 2003 and 2009. More than 8,000 patients were surveyed about their satisfaction—more than half cared for by primary care physicians (PCPs) and the rest by hospitalists. The results were released early online by the Journal of Hospital Medicine on Oct. 31.

Overall, satisfaction scores were slightly higher for PCPs than hospitalists (4.24 out of 5 vs. 4.20; P=0.04), but the difference cannot be considered clinically significant, the study authors concluded. When results were separated by individual hospital and hospitalist group, no statistical differences were found. On the subcategories of satisfaction with physician behavior, pain management and communication, hospitalists and PCPs scored about the same (all P values >0.23). In addition, similar numbers of hospitalists and PCPs scored in the highest satisfaction categories (79.2% vs. 80.5%; P=0.17) and lowest (5.1% vs. 4.5%; P=0.19). Satisfaction with both groups improved significantly and equivalently over the course of the study.

The findings are reassuring, the authors concluded, since previous studies have shown that patients value continuity of care highly. However, few previous studies have examined whether the discontinuity of hospitalist care negatively affects patient satisfaction. The results of this first investigation (involving 59 hospitalists from five programs) may indicate that other aspects of care—such as good communication—may actually be more important to patient satisfaction than continuity. The study was limited by its single geographic area, low rate of patient response (similar to other post-discharge surveying) and the possibility of confounding by an unidentified factor, the authors acknowledged.

Studies like this one may no longer be possible given the growth of the hospitalist industry, the authors noted. They suggested that future research in this area could survey patients who have been cared for by hospitalists to identify specific methods to maximize their satisfaction.

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New CABG guideline updates perioperative medication recommendations

New guidelines for the management of patients undergoing coronary artery bypass graft surgery (CABG) address patient selection, the role of CABG versus percutaneous coronary interventions (PCI), and the use of aspirin and other platelet therapies before and after surgery.

The guideline writers, representing the American College of Cardiology Foundation and the American Heart Association, noted that use of PCI has expanded and physicians have become more skilled at it, driving changes in the recommendations. The 2011 guidelines note that CABG to improve survival is recommended for patients with significant (≥50% diameter stenosis) left main coronary artery stenosis. However PCI is a "reasonable alternative" to CABG in selected stable patients with left main CAD who have a low risk of PCI complications and an increased risk of adverse surgical outcomes. The guidelines also note that CABG to improve survival is beneficial in patients with significant (≥70% diameter) stenoses in three major coronary arteries (with or without involvement of the proximal LAD artery) or in the proximal LAD plus one other major coronary artery. Regarding management of angina, the guidelines state that CABG or PCI to improve symptoms is beneficial in patients with one or more significant (≥70% diameter) coronary artery stenoses amenable to revascularization and unacceptable angina despite guideline-directed medical therapy.

Preoperative and postoperative antiplatelet therapy were reexamined because platelet aggregation has become much better, with more drugs available since the last set of guidelines were developed. Specifically, the 2011 guideline notes that aspirin should be administered to CABG patients preoperatively, and that in patients receiving elective CABG, clopidogrel and ticagrelor should be discontinued for at least five days before elective surgery (or at least 24 hours, if possible, for patients needing urgent CABG). Postoperatively, aspirin should be given within six hours of surgery (if it was not initiated preoperatively) and then continued indefinitely. Clopidogrel is a "reasonable alternative" in patients who are allergic to aspirin.

The new guideline addresses numerous other issues, such as the appropriate choice of bypass graft conduit; the use of off-pump CABG versus traditional on-pump CABG; and CABG in specific patient subsets, such as those with diabetes.

The guideline recommends using a "heart team" approach in which the interventional cardiologist and the cardiac surgeon review the patient's condition, determine the pros and cons of each treatment option, and then present this information to the patient, allowing him or her to make a more informed decision.

The revised guideline was based on a formal literature review of studies published in the past 10 years. The societies released the guideline online, and it will appear in the Dec. 6 issues of the Journal of the American College of Cardiology and Circulation: Journal of the American Heart Association.

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Pneumonia

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SMRT-CO predicts early ICU transfer in CAP patients

The SMRT-CO score outperformed the CURB-65 as a method for predicting which pneumonia patients will require early transfer to the intensive care unit (ICU), according to a new study.

The retrospective, case-control study involved 460 patients admitted to the general ward of a hospital between 2003 and 2009 with community-acquired pneumonia (CAP). The groups had similar baseline characteristics, but 115 of the patients required transfer to the ICU within 48 hours of admission. The patients' scores on the CURB-65 (confusion, urea level, respiratory rate, blood pressure and age ≥65) and SMRT-CO (systolic blood pressure, multilobar chest radiography involvement, respiratory rate, tachycardia, confusion and oxygenation) were compared. The study results were released early online by the Journal of Hospital Medicine on Oct. 31.

Overall, the researchers found that composite scores combining data from the emergency department and the general ward had better sensitivity and area under the curve (AUC) for predicting ICU transfer than scores using data from only one setting (P<0.001). The composite SMRT-CO score performed the best; a score of at least 2 had 76.5% sensitivity, 67.5% specificity and 0.81 AUC. In contrast, a CURB-65 score of at least 3 had 36.5% sensitivity, 86.3% specificity and 0.66 AUC (difference between the scores on sensitivity and AUC, P<0.001).

Based on the results, study authors concluded that a composite SMRT-CO score is a useful clinical tool for predicting early ICU transfers and intensive respiratory or vasopressor support in patients with CAP. The SMRT-CO is also easier to use than other severity scores, since it requires only chest radiography and pulse oximetry in addition to basic clinical information. If the score had been used to determine placement of the studied patients, three-quarters of those eventually transferred to the ICU would have been moved 24 to 28 hours earlier, the authors calculated.

However, 112 patients would have been transferred unnecessarily and 27 of the patients who did end up requiring transfer would not have been transferred based on the SMRT-CO score. The high frequency of false-positive and false-negative results might limit the clinical utility of the score, the study authors noted. But as of now, no tools with very high positive or negative likelihood ratios to predict ICU transfer have been developed. The authors concluded that while validation of their results in a prospective cohort is needed, a high composite SMRT-CO score might be used to alert clinicians to closely monitor patients for the next 48 hours or to support a clinician's decision to transfer a patient to the ICU.

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Geriatrics

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Comprehensive geriatric assessment improves survival in older adults, study finds

Comprehensive geriatric assessment of older adults appears to improve hospital survival, a new study indicates.

Researchers performed a review and meta-analysis of randomized, controlled trials comparing comprehensive geriatric assessment with usual care of adults at least 65 years of age who were admitted to the hospital because of an emergency. Comprehensive geriatric assessment was defined as "a multidimensional interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long term follow-up." It could be performed by mobile teams in general medicine units or in units designated for the purpose. The primary outcome measure was living at home, while secondary outcome measures included death, dependence, deterioration, residential care, activities of daily living, cognitive status, length of stay, readmissions and resource use. The study results were published online Oct. 27 by BMJ.

The analysis included 22 trials involving 10,315 participants from six countries. Patients who received comprehensive geriatric assessment were more likely than those who received usual care to be living at home after scheduled follow-up. Their odds ratios were 1.16 (P=0.003) at a median of 12 months and 1.25 (P<0.001) at a median of six months. Patients who received comprehensive geriatric assessment were also less likely to be living in residential care (odds ratio, 0.78; P<0.001) and to die or have a deteriorating condition (odds ratio, 0.76; P=0.001), and were more likely to have an improvement in cognition (standardized mean difference, 0.08; P=0.02). Benefit seemed to be derived from geriatric units rather than from geriatric teams, the authors said.

The authors noted that they were unable to compare different geriatric assessment models or care provided in acute and post-acute units, among other limitations. However, they concluded that more older patients are likely to survive hospital admission and return to home if they receive comprehensive geriatric assessment during their hospital stay. They noted that the benefits found in their analysis seemed to arise solely from trials of geriatric wards and were not seen for geriatic consult teams on general wards. The authors called for further evaluation of which patients would benefit most and which types of geriatric assessment are most effective.

The authors of an accompanying editorial also called for more research but said the current study clearly indicates that comprehensive geriatric assessment should be standard practice for hospitalized older adults. Systems of care will need to be redesigned to accommodate such assessments, they said, and costs might initially increase. "However, in the longer term comprehensive geriatric assessment not only improves patient outcomes but may save costs by reducing hospital readmissions and lowering the need for long term nursing home care," the editorialists wrote.

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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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