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ACP HospitalistWeekly

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In the News for the Week of 5-25-11

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Highlights

Bleeding risk with dabigatran varies by dose, patient age

The bleeding risk associated with dabigatran compared to warfarin is reduced at a lower dose and in patients younger than 75 years, a new study found. More...

Telemedicine reduced mortality, LOS in ICUs

Implementation of a tele-intensive care unit (ICU) reduced mortality and length of stay at one academic medical center. More...

Cardiology

Cardiac rehab after PCI associated with reduced mortality

Patients who participated in cardiac rehabilitation (CR) after percutaneous coronary intervention (PCI) were less likely to die than those who didn't, a study found. More...

Infectious disease

Shorter treatment regimen may be effective for latent TB

A shorter, less complex treatment regimen may be effective for treating latent tuberculosis (TB), according to a new study sponsored by the Centers for Disease Control and Prevention (CDC). More...

Emergency medicine

Market forces are main drivers behind emergency department closures

Nonrural hospitals most likely to close their emergency departments (EDs) are smaller, for-profit institutions that have safety-net status and are in the lowest quartile of profit margins, a study found. More...

From ACP Hospitalist

Suggest a colleague as a Top Hospitalist

ACP Hospitalist is seeking candidates for our fourth annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2011, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, leadership, mentorship or quality improvement. 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...

Editorial note: ACP HospitalistWeekly will not be published next week due to the Memorial Day holiday.

Physician editor: A. Scott Keller, FACP

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Highlights

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Bleeding risk with dabigatran varies by dose, patient age

The bleeding risk associated with dabigatran compared to warfarin is reduced at a lower dose and in patients younger than 75 years, a new study found.

Researchers studied bleeding risk for 18,113 patients with atrial fibrillation who had at least one additional risk factor for stroke. They were randomized to either 110 mg dabigatran twice a day, 150 mg dabigatran twice daily, or warfarin dosing adjusted to an international normalized ratio (INR) of 2.0 to 3.0. Patients were followed for a median of two years. Major bleeding was the main safety outcome, and stroke or systemic embolism was the main efficacy outcome. Major bleeding was defined as bleeding associated with a reduction in hemoglobin level of ≥2.0 g/dL, transfusion of ≥2U of blood, or symptomatic bleeding into a critical area or organ. Major bleeding was separated into intracranial (intracerebral, subdural) and extracranial (gastrointestinal, nongastrointestinal). Relative risks of major bleeding were examined in prespecified age subgroups of <65, 65 to 74 and ≥75 years. Results were published online May 16 in Circulation.

In general, the 110-mg, twice-daily dose of dabigatran was associated with a lower risk of major bleeding than warfarin (2.87% vs. 3.57%; P=0.002), while the 150-mg, twice daily dabigatran dose had a similar risk as warfarin (3.31 vs. 3.57%; P=0.32). The lower-dose dabigatran regimen was associated with a lower risk of major bleeding than warfarin in patients aged <75 years (1.89% vs. 3.04%; P<0.001) and a similar risk in those aged ≥75 years (4.43% vs. 4.37%; P=0.89). The higher-dose dabigatran regimen was also associated with a lower bleeding risk in patients aged <75 years (2.12% vs. 3.04%; P<0.001) but a trend toward higher risk of major bleeding in those aged ≥75 years (5.10% vs. 4.37%; P=0.07). The interaction with age (P<0.001) was evident for extracranial bleeding but not for intracranial bleeding; the risk of the latter was lower with dabigatran than warfarin, regardless of age. Both doses of dabigatran were associated with a lower risk of minor bleeding than warfarin; the higher dose was associated with more gastrointestinal bleeding than warfarin.

A finding of a greater-than-twofold higher risk of major bleeding with either dabigatran or warfarin in patients with a creatinine clearance less than 50 mL/min (vs. those with ≥80 mL/min clearance) is consistent with published reports that renal function is a powerful predictor of bleeding risk in patients who take warfarin, the authors noted. In general, this study's results indicate that for patients younger than 75 years, "the higher dabigatran dose seems preferable because of the lower risk of stroke without any increased risk of bleeding," while the 110-mg dabigatran dose might be considered for patients 75 years and older, they concluded.

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Telemedicine reduced mortality, LOS in ICUs

Implementation of a tele-intensive care unit (ICU) reduced mortality and length of stay at one academic medical center.

The prospective study included more than 6,000 adults admitted to seven ICUs at the University of Massachusetts from April 2005 through September 2007. Outcomes before and after the implementation of the tele-ICU were compared. The hospital mortality rate decreased from 13.6% to 11.8% and length of stay decreased from 13.3 days to 9.8. Study authors attributed some of the success on these measures to improved adherence to best practices for preventing certain conditions: deep vein thrombosis (prophylaxis increased from 85% to 99%), stress ulcers (83% to 96%), cardiovascular problems (80% to 99%), and ventilator-associated pneumonia (33% to 52%). The study found significant decreases in the rate of ventilator-associated pneumonia (from 13% to 1.6%) and catheter-related bloodstream infections (from 1% to 0.6%).

Researchers also observed that the tele-ICU care sped up response to alerts of patients' physiological instability and allowed patients admitted during off-hours to have assistance with their care plan and monitoring by a rested, on-duty intensivist. More patients were also put on noninvasive ventilation instead of mechanical ventilation, which the study authors speculated could be due to emergency physicians being more comfortable using noninvasive ventilation when they knew patients would be monitored by the tele-ICU.

The authors noted that their medical center had previously tried to improve best practice adherence and preventable complication rates through educational outreach and checklist-based reminders, without achieving the results shown by the tele-ICU. They concluded that tele-ICUs can provide benefits even to hospitals that already have daytime intensivist staffing and active quality improvement efforts. Results were published online May 16 by the Journal of the American Medical Association.

An accompanying editorial noted that another recent trial of a tele-ICU found no benefit to the intervention. A key difference was that on-site physicians in the prior study could decline the assistance of the remote intensivist, while this study had no opt-out provision. The tele-intensivists in the current study were also more active participants, reviewing patients' care to make sure it conformed to best practices and stated care plans, in addition to remote monitoring. The differing results show that implementation of a tele-ICU is not a universal solution to care deficiencies, but a potential tool for quality improvement, the editorialist concluded.

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Cardiology

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Cardiac rehab after PCI associated with reduced mortality

Patients who participated in cardiac rehabilitation (CR) after percutaneous coronary intervention (PCI) were less likely to die than those who didn't, a study found.

In a retrospective analysis of data from 2,395 consecutive PCI patients, researchers examined the association of CR with all-cause mortality (primary outcome) and cardiac mortality, myocardial infarction and revascularization (secondary outcomes). They used three statistical techniques to examine the data, which came from patients in Olmsted County, Minnesota between 1994 and 2008. CR participation was defined as having attended at least one outpatient session within three months of the index PCI. The mean number of CR sessions per participant was 13.5. Patients were followed for a median of 6.3 years. Results were published online May 16 in Circulation.

During the study follow-up, 503 patients died (199 cardiac deaths), 394 had myocardial infarction, and 755 had revascularization procedures. Forty percent of the cohort (n=964) participated in CR, which was associated with a significant decrease in all-cause mortality by all three statistical techniques (hazard ratio, 0.53 to 0.55; P<0.001). The association was similar for men and women, older and younger patients, and for patients undergoing elective or nonelective PCI. A nonsignificant trend toward decreased cardiac mortality was also seen in CR participants, though there was no observed effect for myocardial infarction or revascularization. The number of PCI patients needed to treat with CR to prevent one death was 34 at one year after PCI and 22 at five years after PCI.

It's well known that CR helps lower mortality rates after myocardial infarction, but a similar association has been scarcely explored with PCI, the authors wrote. The current study finds CR participation is associated with lower mortality rates, which bolsters support for existing clinical practice guidelines, performance measures, and insurance coverage protocols that recommend CR after PCI, they said. The association of lower mortality with CR might occur due to the beneficial physical effects of exercise, improved medication adherence, risk factor control, reduced inflammation, increased identification and treatment for depression, and increased psychosocial support, the authors wrote.

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Infectious disease

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Shorter treatment regimen may be effective for latent TB

A shorter, less complex treatment regimen may be effective for treating latent tuberculosis (TB), according to a new study sponsored by the Centers for Disease Control and Prevention (CDC).

Researchers performed a 10-year study of 8,053 patients with latent TB infection who were two years of age and older and resided in countries with low or medium TB incidence, mostly the U.S. and Canada. Patients were randomly assigned to receive directly observed therapy with rifapentine, 900 mg once weekly for three months, and isoniazid, 900 mg once weekly for three months, or to standard therapy, which was self-administered daily isoniazid, 300 mg, for nine months. Outcome measures were adverse events related to treatment, treatment adherence, survival and development of TB disease. The study results were presented May 16 at the American Thoracic Society International Conference in Denver and summarized in a CDC press release.

Patients were followed for 33 months from study enrollment. The new treatment regimen and the standard treatment regimen were found to have similar safety and effectiveness for prevention of new TB cases (7 new cases vs. 15 new cases, respectively). In addition, more patients in the new regimen group than in the standard regimen group completed treatment (82% vs. 69%).

Based on the trial's results, the CDC is currently developing new guidelines for use of the shorter treatment regimen in the U.S. The researchers cautioned, however, that their results apply only to countries where TB incidence is relatively low. "Additional studies will likely be needed before this new regimen can be recommended in countries with a high incidence of TB, especially those with high HIV prevalence and where the risk of TB re-infection is greater," the CDC said.

A fact sheet about the trial is online.

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Emergency medicine

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Market forces are main drivers behind emergency department closures

Nonrural hospitals most likely to close their emergency departments (EDs) are smaller, for-profit institutions that have safety-net status and are in the lowest quartile of profit margins, a study found.

From 1990 to 2009, 1,041 nonrural EDs closed, at an average of 89 per year. In that same time period, 374 nonrural hospitals opened EDs. (The study did not measure rural EDs.) To find out why the nonrural EDs closed, researchers looked at information from 1990 to 2009 from American Hospital Association surveys and merged it with data from the Healthcare Cost Report Information System from the Centers for Medicare and Medicaid Services, the Area Resource File, a wage index from Prospective Payment System impact files, and a widely accepted measure of local hospital competition, the Herfindahl index. Results were published in the May 19 issue of the Journal of the American Medical Association.

Closed EDs were more likely than open EDs to:

• be located at for-profit hospitals (26% vs. 16%, P<0.001),
• have fewer visitors (22,404 annual visits vs. 33,691 annual visits P<0.001),
• have profit margins in the lowest quartile (36% vs. 18%, P<0.001),
• exist in highly competitive markets (34% vs. 17%, P<0.001),
• exist in counties with high shares of minority populations (36% vs. 31%, P=0.005),
• exist in counties with high shares of the population in poverty (37% vs. 31%, P<0.001), and
• exist in counties in which more than 15% of the individuals lacked insurance (42% vs. 36%, P=0.002).

Except for poverty, all these factors are market driven, the authors noted, adding that the same market forces that drive hospital closures may be stronger for ED closures. "As more of these patients lose access to primary care, an increasing number of emergency departments are meeting criteria as safety-net facilities, which suggests that more emergency departments may be at risk of closing in the future," the authors wrote.

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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 fourth annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2011, 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 18, 2011, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2011 issue.

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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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