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ACP HospitalistWeekly

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In the News for the Week of 5-4-11

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Highlights

CABG rates decline, PCI rates remain steady between 2001 and 2008

The annual rate of coronary artery bypass graft surgery (CABG) in the U.S. declined by more than 30% between 2001 and 2008, while rates of percutaneous coronary intervention (PCI) were steady, a new study found. More...

Measles outbreak report describes potentially avoidable consequences

The course of the largest health care-associated measles outbreak in the post-elimination era offers lessons in outbreak preparedness for other hospitals, according to a new report. More...

Critical care

Fewer calories at first may be better for some mechanically ventilated patients

Initial low-volume enteral nutrition is associated with fewer episodes of gastrointestinal intolerance than full-energy enteral nutrition among mechanically ventilated patients with acute respiratory failure, and it doesn't harm outcomes, a new study found. More...

Hypertension

Consensus document advises treating hypertension in the elderly

Major medical organizations last week released an expert consensus document to help clinicians manage older patients with hypertension, or at risk for hypertension. More...

Cartoon caption contest

Vote for your favorite entry

ACP HospitalistWeekly's cartoon caption contest continues. Readers can vote for their favorite captions to determine the winner. More...

Physician editor: A. Scott Keller, FACP

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Highlights

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CABG rates decline, PCI rates remain steady between 2001 and 2008

The annual rate of coronary artery bypass graft surgery (CABG) in the U.S. declined by more than 30% between 2001 and 2008, while rates of percutaneous coronary intervention (PCI) were steady, a new study found.

The authors sought to find how trends in coronary revascularization had changed in a time period when there were many advances in technology, techniques, guidelines and evidence. They examined data from the Nationwide Inpatient Sample (NIS), which contains patient-level hospital discharge data from about 1,000 hospitals. Coronary revascularizations were identified by procedure codes on NIS claims. Researchers compared age, sex, and geographic distributions between CABG surgery recipients in 2001 versus 2008, as well as PCI recipients in 2001 versus 2008. Since race is unreported for many hospitals in NIS data, they separately calculated the 2001-2008 difference in race among CABG surgery and PCI recipients using Medicare claims. Results were published in the May 4 Journal of the American Medical Association.

There was a 15% decrease in the annual rate of both procedures combined from 2001-2002 to 2007-2008. There were about one-third fewer CABG surgeries performed in 2008 compared to 2001, with the annual rate declining from 1,742 CABG surgeries per million adults per year in 2001-2002 to 1,081 CABG surgeries per million adults per year in 2007-2008 (P<0.001). This decline was observed across sex, age, racial and regional subgroups. PCI rates did not significantly change, with 3,827 PCIs per million adults per year in 2001-2002 versus 3,667 PCIs per million adults per year in 2007-2008 (P=0.74). The number of hospitals in the NIS that provided CABG surgery increased by 12% (212 vs. 241, P=0.03), and the number that provided PCI increased by 26% (246 vs. 331, P<0.001). The median CABG surgery caseload per hospital decreased by 28% (P<0.001). The use of drug-eluting stents, which were approved by the Food and Drug Administration in April 2003, peaked in 2005 at nearly 90%, and fell to 68% by the end of 2008.

The decrease in CABG surgery occurred as a roughly linear trend throughout the period measured, which suggests the decline was not triggered by a single event like a technological advance or new guidelines. The results also suggest several thousand patients who underwent PCI in 2008 would have undergone CABG surgery if patterns of care had not changed dramatically since 2001, the authors noted. While it is possible PCI truly was the best care option for those patients, "our observations combined with those of prior investigators suggest that a sizeable fraction of patients who did not undergo CABG surgery in 2007-2008 might have been appropriate CABG surgery recipients," the authors wrote.

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Measles outbreak report describes potentially avoidable consequences

The course of the largest health care-associated measles outbreak in the post-elimination era offers lessons in outbreak preparedness for other hospitals, according to a new report.

The report, published online by the Journal of Infectious Diseases on April 29, describes 14 confirmed cases of measles seen in Arizona in 2008. The outbreak began with an infected person who came from Switzerland and was treated at a Tucson hospital. Of the infected patients, seven acquired measles in a health care setting. All infected patients were unvaccinated or had unknown vaccination status, and all but two cases (in young children who were pre-vaccination age) could have been prevented by adherence to U.S. immunization policy.

The outbreak was extremely costly; two hospitals spent almost $800,000 on their response. Four patients were hospitalized and two were treated in intensive care, but much of the cost resulted from the need to establish measles immunity among the hospitals' clinicians. Evidence of immunity was lacking for 25% of the clinicians at the two hospitals (9% were eventually found to be seronegative), and about 4,500 clinicians in total ended up receiving emergency vaccination. Outbreak response was also hindered by delayed diagnosis of the index patient, who was hospitalized for multiple days before diagnosis, and failure to strictly adhere to infection control practices, which include isolation and masking of patients.

Because the confirmed cases did not all appear to be linked, it's likely that the outbreak was actually larger than reported with additional community cases, the study authors said, adding that their cost analysis also did not include costs to insurers, health departments and patients. Potentially some of the actions taken and certainly some of the costs could have been prevented by some commonsense measures, concluded an accompanying editorial. The editorialist called for electronification of clinician records, immediate reporting of potential measles cases and wider vaccination of health care workers.

The study authors offered some additional suggestions for improvement: increasing measles awareness among clinicians (so that they consider it early in patients presenting with fever, rash and travel history), allowing only clinicians with immunity to care for measles patients, and instituting screening plans to identify suspected cases for immediate isolation during outbreaks. The Council of State and Territorial Epidemiologists measles clinical case definition was: (1) fever (temperature of at least 101 degrees F [38.3 degrees C]), (2) a generalized maculopapular rash lasting at least 3 days, and (3) presence of cough, coryza, and/or conjunctivitis.

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Critical care

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Fewer calories at first may be better for some mechanically ventilated patients

Initial low-volume enteral nutrition is associated with fewer episodes of gastrointestinal intolerance than full-energy enteral nutrition among mechanically ventilated patients with acute respiratory failure, and it doesn't harm outcomes, a new study found.

In a randomized, open-label study, researchers enrolled 200 patients from two ICUs at a single academic center who were expected to require mechanical ventilation for at least 72 hours and whose primary team intended to initiate or continue enteral nutrition. Patients were randomized to either initial full-energy enteral nutrition (n=102) or initial trophic enteral nutrition (n=98) for six days followed by advancement to full-energy enteral nutrition. Patients in the full-energy group had enteral nutrition initiated at 25 mL/h, with the feeding rate increased by 25 mL/h every six hours until the full-energy feeding rate was achieved. Full-energy feeding rates targeted 25 to 30 kcal/kg of predicted body weight per day of nonprotein energy and 1.2 to 1.6 g/kg of predicted body weight per day of protein. Trophic group patients had enteral nutrition initiated at 10 mL/h. In patients still ventilated at 144 hours, enteral nutrition was advanced to full-energy target feeding rates using the same protocol as for the full-energy feeding group. The primary outcome measure was ventilator-free days to day 28.

The patient groups didn't differ in number of ventilator-free days (median, 23 days; P=0.90), intensive-care-unit-free days (median, 21 days; P=0.64), or mortality to hospital discharge (22.4% for the trophic group vs. 19.6% for the full-energy group; P=0.62). In the first six days, the trophic group had significantly fewer episodes of elevated gastric residual volumes (2% vs. 8% of feeding days; P<0.001) and trends for less diarrhea (19% vs. 24% of feeding days; P=0.08). Both groups received similar durations of enteral nutrition, about five to five-and-a-half days. The trophic group received an average of 15.8% ±11% of goal calories daily through day six compared to 74.8% ±38.5% (P<0.001) for the full-energy group. Results were published in the May Critical Care Medicine.

Consensus guidelines recommend enteral over parenteral nutrition in patients with acute respiratory failure who cannot eat by mouth, and recommend advancing enteral nutrition to full-energy rates over the first 48 to 72 hours. Yet this trial shows that providing trophic enteral nutrition for the first six days leads to similar outcomes as advancing quickly to full-energy rates, while reducing gastrointestinal intolerance. Larger studies are needed to determine the risks and benefits, as well as the optimal composition and timing of starting enteral nutrition in these patients, and to clarify whether supplementation with protein or micronutrients is beneficial, the authors concluded.

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Hypertension

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Consensus document advises treating hypertension in the elderly

Major medical organizations last week released an expert consensus document to help clinicians manage older patients with hypertension, or at risk for hypertension.

Sixty-four percent of U.S. men and 78% of U.S. women older than 65 years have high blood pressure, and only one in three men and one in four women over age 80 have adequate control of their blood pressure, the document noted. Results from the Hypertension in the Very Elderly Trial (HYVET) in 2008 showed clear benefits for using antihypertensive therapy in people 80 years and older, including a 30% reduction in stroke, 23% reduction in cardiac death, 64% reduction in heart failure and 21% reduction in all-cause mortality. That study became the main impetus for the new consensus document, which was published online April 25.

Some of the recommendations addressed in the consensus document include:

• Achieved systolic blood pressure values less than 140 mm Hg are appropriate goals for most patients 79 years of age or younger; for those 80 years of age or older, 140 to 145 mm Hg, if tolerated, can be acceptable.
• Systolic blood pressure less than 130 and diastolic blood pressure less than 65 should be avoided since it is not known at which blood pressure values vital organ perfusion is impaired.
• Angiotensin-converting enzyme inhibitors, beta-blockers, angiotensin-receptor blockers, diuretics and calcium-channel blockers are all effective in lowering blood pressure and reducing cardiovascular outcomes among the elderly. The choice between drugs should be based on efficacy, tolerability, comorbidities and cost.
• Antihypertensive drugs should generally be started at the lowest dose, then increased in gradual increments as tolerated. If the first drug reaches its "full dose" (not necessarily the maximum recommended dose), then a second should be added—a diuretic if it wasn't the first drug. If the antihypertensive response is inadequate after reaching full doses of two classes of drugs, a third drug from another class should be added. When blood pressure is more than 20/10 mm Hg above goal, therapy should be initiated with two antihypertensive drugs. Consider reasons for inadequate response, including polypharmacy, nonadherence and potential drug interactions.
• Conduct routine monitoring of blood pressure, including taking blood pressure measures in the standing position.
• Lifestyle changes may be all that are needed for milder hypertension, and may allow reduction of drug doses. This includes regular physical activity, restriction of salt, weight control, smoking cessation and avoiding excessive alcohol intake (more than two drinks for men and one drink for women daily).
• The high cost of blood pressure-lowering medications contributes to low rates of blood pressure control in the elderly and should be discussed with patients.

The American College of Cardiology (ACC) and the American Heart Association (AHA) released the expert consensus document, which was developed with other medical societies.

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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 captions to determine the winner.

"It's for your bucket list."

"If you suddenly get the urge to kick it, press the call button immediately."

"That's a 'pay-for-performance' jar."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, May 9, with the winner announced in the May 11 issue.

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