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ACP HospitalistWeekly

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In the News for the Week of 6-29-11

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Highlights

Hospitalization rates for sepsis, septicemia have risen in U.S., CDC reports

Rates of hospitalization for sepsis and septicemia more than doubled from 2000 through 2008, according to a new data brief from the Centers for Disease Control and Prevention's National Center for Health Statistics. More...

Tool helps estimate heart failure patients' risk for low quality of life

Researchers have designed a simple tool to help recognize heart failure patients who, at the time of hospital discharge, are at high risk for death or an unfavorable quality of life. More...

Perioperative care

VTE less common with laparoscopic versus open colorectal surgery

Venous thromboembolism (VTE) appears to be less common after laparoscopic colorectal surgery than after open colorectal surgery, according to a new study. More...

Stroke

43% of ischemic stroke patients discharged with high blood pressure

Forty-three percent of patients hospitalized with acute ischemic stroke were discharged with elevated blood pressure, and 33% had uncontrolled blood pressure six months later, a new analysis found. More...

FDA update

Warning about varenicline in patients with CVD

A warning will be added to smoking cessation aid varenicline (Chantix) to indicate that the drug may be associated with a small increased risk of certain cardiovascular adverse events in patients who have cardiovascular disease, the FDA announced last week. 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. 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Editorial note: ACP HospitalistWeekly will not be published next week due to the Independence Day holiday.

Physician editor: A. Scott Keller, FACP

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Highlights

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Hospitalization rates for sepsis, septicemia have risen in U.S., CDC reports

Rates of hospitalization for sepsis and septicemia more than doubled from 2000 through 2008, according to a new data brief from the Centers for Disease Control and Prevention's National Center for Health Statistics.

Researchers analyzed data from the 2008 National Hospital Discharge Survey to examine trends in care for hospitalized patients with sepsis and septicemia. They found that the rate of a principal diagnosis of these conditions increased from 11.6 per 10,000 population in 2000 to 24.0 per 10,000 population in 2008, and that the rate of a principal or secondary diagnosis increased 70%, from 22.1 to 37.7 per 10,000 population. Patients age 65 and older were much more likely to be hospitalized for septicemia or sepsis than those younger than 65 (122.2 per 10,000 population vs. 9.5 per 10,000 population). Hospitalizations for septicemia and sepsis were associated with longer hospital stays than other conditions (8.4 days vs. 4.8 days), as well as higher in-hospital mortality rates (17% vs. 2%). The costs of treating sepsis and septicemia have also risen, to an estimated $14.6 billion in 2008, but mortality rates remained high even with increased spending. Only 2% of hospitalizations in 2008 were for sepsis or septicemia, but they accounted for 17% of inpatient deaths.

The authors hypothesized that the increases in sepsis and septicemia hospitalization rates may be due to an aging, chronically ill population; increased use of invasive procedures, chemotherapy, immunosuppressive drugs, and transplantation; and increased antibiotic resistance. Clinicians may also have been more likely to code for these conditions due to enhanced awareness during the study period, they noted. The complete data brief is available online.

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Tool helps estimate heart failure patients' risk for low quality of life

Researchers have designed a simple tool to help recognize heart failure patients who, at the time of hospital discharge, are at high risk for death or an unfavorable quality of life.

Current prognostic models for heart failure patients focus only on death or readmissions, but quality-of-life (QoL) prognosis can help with shared decision-making between physicians and patients, noted the authors of the study, published online June 21 by Circulation: Cardiovascular Quality and Outcomes. Researchers analyzed data from 1,458 heart failure patients in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial. Baseline data, including formal health status measures, were taken for these patients within 48 hours of hospital admission as well as one week and 24 weeks after hospital discharge. Health status was measured via the Kansas City Cardiomyopathy Questionnaire (KCCQ), a 23-item self-administered questionnaire for heart failure patients with scores ranging from 0 to 100, with higher scores reflecting better health status. The primary end point of the analysis was a composite of all-cause death or unfavorable QoL (defined by KCCQ <45 at weeks one and 24 after discharge).

There were 478 deaths (32.8%) and another 192 patients (13.2%) who had persistently unfavorable QoL throughout follow-up. After adjustment for 23 covariates, independent predictors of the composite end point were:

• low baseline KCCQ score (per 10-U increase in baseline QoL: risk ratio [RR], 0.82; 95% CI, 0.78 to 0.87),
• high B-type natriuretic peptide (500 to 999 pg/mL: RR, 1.27 [95% CI, 1.05 to 1.53]; ≥1000 pg/mL: RR, 1.41 [95% CI, 1.14 to 1.73], both compared with <500 pg/mL),
• hyponatremia (sodium <135 mEq/L: RR, 1.30 [95% CI, 1.04 to 1.62] compared with sodium 135 to 145 mEq/L),
• increased heart rate at discharge (per 10 bpm increase: RR, 1.08 [95% CI, 1.01 to 1.15]),
• decreased systolic blood pressure at discharge (per 10 mm Hg increase: RR, 0.92 [95% CI, 0.88 to 0.97]),
• absence of beta-blocker therapy at discharge (beta-blocker prescribed: RR, 0.80 [95% CI, 0.64 to 0.99]),
• history of diabetes (HR, 1.18 [95% CI, 1.01 to 1.39]), and
• history of arrhythmia (RR, 1.32 [95% CI, 1.08 to 1.60]).

A simplified predischarge heart failure score for later death or unfavorable QoL using nine clinical characteristics had moderate discrimination (c-statistic 0.72), the authors noted. Study limitations include that the findings come from a retrospective, post hoc analysis of patients enrolled in a clinical trial that excluded those with end-stage heart failure and an expected survival of less than six months, thus eliminating patients at the highest risk for adverse outcomes, the authors noted. The cohort was also limited to heart failure patients with reduced left ventricular ejection fraction, and who were younger, mostly white and more likely to be male than community heart failure populations—though it also included patients with high comorbidity, the authors noted.

The results should help physicians adhere to clinical practice guidelines that recommend discussing risk with heart failure inpatients. Providing a prognosis of QoL and death, rather than readmissions and death, gives information "that most directly relates to patients' concerns and experiences," the authors noted. This information can help patients and physicians make appropriate, personalized treatment decisions going forward, they said.

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Perioperative care

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VTE less common with laparoscopic versus open colorectal surgery

Venous thromboembolism (VTE) appears to be less common after laparoscopic colorectal surgery than after open colorectal surgery, according to a new study

Researchers analyzed data from the Nationwide Inpatient Sample to determine how often VTE occurred after colorectal surgery and to identity associated VTE risk factors. Included patients had elective laparoscopic or open colorectal surgery from Jan. 31, 2002 through Dec. 31, 2006. The primary outcome measures were VTE incidence after surgery during the initial hospitalization and VTE according to site of surgery, pathology, and at-risk patient population. The study results were published in the June Archives of Surgery.

A total of 149,304 patients had laparoscopic or open resection during the study period. The mean age was 63.5 years; more than half of the patients were women (53.6%), and most were white (82.8%). VTE incidence was statistically significantly higher in the open group than in the laparoscopic group (2,036 of 141,456 [1.44%] vs. 65 of 7,848 [0.83%]; P<0.001). Patients who had inflammatory bowel disease and those who underwent rectal resection had the highest overall VTE rates, while malignant disease, obesity and congestive heart failure were also found to be statistically significant VTE risk factors regardless of type of surgery. Patients who had laparoscopic resection had significantly shorter hospital stays (6.5 days vs. 9 days) and significantly lower mortality rates (0.8% vs. 3.0%) than those who had open resection (P<0.001 for both comparisons).

The authors noted that they may have missed some cases of laparoscopic surgery in the database and that data on follow-up and thromboprophylaxis were not available, among other limitations. However, they concluded that VTE incidence overall is lower after laparoscopic than open colorectal surgery and that certain patient characteristics and conditions also seemed to increase VTE risk significantly. Their findings may help to guide decisions about appropriate VTE prophylaxis in patients undergoing these procedures, the authors wrote.

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Stroke

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43% of ischemic stroke patients discharged with high blood pressure

Forty-three percent of patients hospitalized with acute ischemic stroke were discharged with elevated blood pressure, and 33% had uncontrolled blood pressure six months later, a new analysis found.

Researchers examined a sample of patients (n=3,987) who had were admitted to a Veterans Affairs Medical Center and hospitalized for ischemic stroke in 2007. They analyzed blood pressure control (defined as <140/90 mm Hg) at discharge, and excluded 347 who had died, enrolled in hospice, or had unknown discharge disposition. Another 258 patients were excluded for missing race data, leaving 3,382 patients from 129 facilities for the first analysis. Researchers also examined all antihypertensive medications prescribed at admission and discharge, and compared to see if patients received a new prescription for a drug class at discharge. In a second analysis, they looked at blood pressure control within six months after stroke, excluding those who had died, were readmitted within 30 days, were lost to follow-up, or didn't have blood pressure or race recorded, leaving 1,915 from 125 facilities. Results were published online June 21 by Circulation: Cardiovascular Quality and Outcomes.

About sixty-three percent of the study population was white, and 98% were men. Forty-seven percent were younger than age 65, 29% had a history of cerebrovascular disease, and 37% had a history of cardiovascular disease. Among the stroke patients in the first analysis, 43% had their last documented blood pressure before discharge as ≥140/90 mm Hg. Black race, diabetes and hypertension history were associated with lower odds for controlled blood pressure at discharge. Of the stroke patients seen within six months of their index event, 32.8% still had uncontrolled blood pressure. By six months after the event, neither race nor diabetes was associated with blood pressure control, while history of hypertension continued to predict lower odds of control. For each 10-point increase in systolic blood pressure at discharge over 140 mm Hg , the odds of control within six months after discharge decreased by 12%. Receipt of a new blood pressure medication at discharge was associated with decreased odds of blood pressure control at six months, possibly because sicker patients are more likely to get new prescriptions and have poor control, the authors wrote.

The study data suggest that heightened efforts to improve management of hypertension at discharge and follow-up may benefit certain subgroups of patients, given that hypertension is causally involved in nearly 70% of all stroke cases and puts patients at risk for cardiovascular events, the authors said. Secondary prevention should include efforts to start risk factor control and antihypertensive medication before discharge. Future interventions could target those at highest risk for poorly controlled blood pressure, including those with a prior diagnosis of hypertension and multiple comorbidities, including diabetes, the authors said.

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FDA update

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Warning about varenicline in patients with CVD

A warning will be added to smoking cessation aid varenicline (Chantix) to indicate that the drug may be associated with a small increased risk of certain cardiovascular adverse events in patients who have cardiovascular disease, the FDA announced last week.

The warning is based on FDA review of a placebo-controlled trial of varenicline in 700 smokers with cardiovascular disease. Quit rates were higher in patients taking the active drug but certain cardiovascular events, including angina pectoris, nonfatal myocardial infarction, need for coronary revascularization, and new diagnosis of peripheral vascular disease or admission for a procedure for the treatment of peripheral vascular disease, were reported more frequently in patients treated with varenicline. However, the study was not designed to have statistical power to detect differences between the arms on the safety endpoints, an FDA press release said.

The FDA recommends that clinicians weigh the known benefits of the drug against potential risks when deciding whether to use it in smokers with cardiovascular disease, given that smoking is an independent and major risk factor for cardiovascular disease, and smoking cessation is of particular importance in this patient population. Patients should be counseled to seek medical attention if they experience new or worsening symptoms of cardiovascular disease while taking the drug.

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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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