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ACP HospitalistWeekly

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In the News for the Week of 8-3-11

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Highlights

Hospitalist care associated with higher costs, more medical utilization after discharge

Though hospitalist care is associated with shorter length of stay and lower hospital costs, these are offset by more medical utilization and higher costs after discharge, a new study found. More...

New clinical guideline issued on diagnosis, management of stable COPD

Several collaborating medical societies, including the American College of Physicians (ACP), released new guidelines this week on the diagnosis and management of stable chronic obstructive pulmonary disease (COPD). More...

Readmissions

Multi-pronged intervention reduces readmissions, lowers costs

An intervention comprising inpatient coaching, home visits and post-discharge follow-up calls reduced 30-day readmission rates by 36% in a real-world setting, researchers reported. More...

Cardiology

Apixaban associated with more bleeding, no change in ischemic events

A phase 3 trial of apixaban, a new factor Xa inhibitor, was halted after the drug was found to increase major bleeding in patients taking it after acute coronary syndrome. More...

FDA update

Linezolid and methylene blue cause problems with psychiatric medications

Linezolid and methylene blue can cause serious reactions in patients who are taking serotonergic psychiatric medications, the FDA warned last week. 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, FACP

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Highlights

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Hospitalist care associated with higher costs, more medical utilization after discharge

Though hospitalist care is associated with shorter length of stay and lower hospital costs, these are offset by more medical utilization and higher costs after discharge, a new study found.

In an observational cohort study, researchers analyzed hospital admissions from January 2001 to November 2006 in a representative national sample of 5% of Medicare beneficiaries. Researchers looked at claims for hospital stays, outpatient facility use and physician services. They included only admissions for patients with an identified primary care physician (PCP) before admission, in order to better compare patients cared for by hospitalists versus PCPs. Admissions of patients cared for by both, or neither, were excluded. The main analysis included hospitals with at least 20 admissions cared for by hospitalists and 20 by PCPs during the study period, leaving a final cohort of 58,125 admissions at 454 hospitals. Outcomes of interest were length of stay, hospital charges, discharge location and physician visits, rehospitalization, emergency department visits, and Medicare spending in the 30 days after discharge. Results were published in the Aug. 2 Annals of Internal Medicine.

Among patients cared for by hospitalists, length of stay was 0.64 day less (5.17 days vs. 5.82 days; P<0.001) and hospital charges were $282 lower ($15,019 vs. $15,301; P<0.001) than among those cared for by PCPs. Medicare costs 30 days after discharge were $332 higher for those seen by hospitalists ($3,279 vs. $2,947; P<0.001). Patients under hospitalist care also:

• were less likely to be discharged to home (70.6% vs. 76%; odds ratio [OR], 0.82; 95% CI, 0.78 to 0.86),
• were more likely to have emergency department visits within 30 days of discharge (20.7% vs. 17.8%; OR, 1.18; 95% CI, 1.12 to 1.24),
• were more likely to be readmitted within 30 days post-discharge (19% vs. 17.4%; OR, 1.08; 95% CI, 1.02 to 1.14),
• had fewer visits with their PCPs within 30 days post-discharge (0.62 visits vs. 0.79; P<0.001), and
• had more nursing facility visits within 30 days post-discharge (0.58 vs. 0.52; P<0.001).

Study limitations included that only Medicare patients with an identified PCP and a medical diagnosis were included, thus results might not be generalizable to other kinds of patients. Still, the study's findings indicate that the apparent savings in hospital costs due to hospitalist care is in fact a shifting (and increase) of costs to the post-discharge period, the authors wrote. "If applied to the approximate 25% of Medicare admissions cared for by hospitalists, this represents more than $1.1 billion in additional Medicare costs annually," they wrote. Hospitalists may be more susceptible to behaviors that promote cost shifting, they added, but current efforts toward bundling of payments should reduce incentives for these behaviors.

While the findings raise the question of whether hospitalists discharge their patients "more quickly but less appropriately," such that they bounce back, the results should be interpreted cautiously as the study examined hospitalizations before the time when 30-day readmissions was a quality benchmark, the authors of an accompanying editorial noted. As for why hospitalist care is associated with greater use of post-discharge services, it may be because hospitalists are under pressure to shorten length of stay and thus discharge sicker patients, or because they lack knowledge of outpatient services, they wrote. Ultimately, more studies that follow patients through their course of care are needed, they concluded.

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New clinical guideline issued on diagnosis, management of stable COPD

Several collaborating medical societies, including the American College of Physicians (ACP), released new guidelines this week on the diagnosis and management of stable chronic obstructive pulmonary disease (COPD).

The guideline, which updates and expands on a 2007 ACP guideline on this topic, was developed by a panel with members from ACP, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society, and represents an official, joint guideline from all four organizations. The panel helped develop key questions related to COPD diagnosis and management and evaluated related evidence reviews and tables to arrive at its recommendations, which were approved by unanimous vote. The guideline was published in the Aug. 2 Annals of Internal Medicine.

The guideline recommendations are as follows:

• Spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms (strong recommendation, moderate-quality evidence) but should not be used to screen for airflow obstruction in individuals without respiratory symptoms (strong recommendation, moderate-quality evidence).
• For stable COPD patients with respiratory symptoms and FEV₁ between 60% and 80% predicted, treatment with inhaled bronchodilators may be used (weak recommendation, low-quality evidence).
• For stable COPD patients with respiratory symptoms and FEV₁ less than 60% predicted, treatment with inhaled bronchodilators is recommended (strong recommendation, moderate-quality evidence).
• Clinicians should prescribe monotherapy using either long-acting inhaled anticholinergics or long-acting inhaled β-agonists for symptomatic patients with COPD and FEV₁ less than 60% predicted (strong recommendation, moderate-quality evidence), and should base the choice of specific monotherapy on patient preference, cost, and adverse effect profile.
• Clinicians may administer combination inhaled therapies (long-acting inhaled anticholinergics, long-acting inhaled β-agonists, or inhaled corticosteroids) for symptomatic patients with stable COPD and FEV₁ less than 60% predicted (weak recommendation, moderate-quality evidence).
• Clinicians should prescribe pulmonary rehabilitation for symptomatic patients with an FEV₁ less than 50% predicted (strong recommendation, moderate-quality evidence) and may consider pulmonary rehabilitation for symptomatic or exercise-limited patients with an FEV₁ more than 50% predicted (weak recommendation, moderate-quality evidence).
• Clinicians should prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia (Pao₂ ≤55 mm Hg or Spo₂ ≤88%) (strong recommendation, moderate-quality evidence).

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Readmissions

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Multi-pronged intervention reduces readmissions, lowers costs

An intervention comprising inpatient coaching, home visits and post-discharge follow-up calls reduced 30-day readmission rates by 36% in a real-world setting, researchers reported.

Researchers conducted a quasi-experimental, prospective cohort study from January 2009 through June 2010 among a consecutive convenience sample of fee-for-service Medicare patients at six Rhode Island hospitals. Patients were admitted for cardiac or respiratory conditions or related symptoms, including shortness of breath, sudden weight gain, fever, cough and chest pain. The program expanded in January 2010 to include patients with any diagnosis. The intervention included a coach completing a hospital visit, a home visit, and two follow-up telephone calls. Coaches gave inpatients booklets to record their personal health records and their communication with outpatient clinicians. After discharge, the coaches tried to complete a home visit within three days, a first call within seven to 10 days, and a second call by 30 days. In their follow-up, coaches reinforced use of the personal health records, and emphasized how to recognize signs and symptoms of worsening health before emergencies happened. The second telephone call emphasized the importance of a follow-up visit with a physician and helped the patient locate other support services.

Of 1,888 approached to participate, more than half (1,042) consented, 257 completed the home visit, 238 completed the visit plus one phone call, and 191 received the home visit and both telephone calls. Before the Care Transition Intervention program began, the average readmission rate among the six hospitals was 21.1% (range, 18.1 to 23.1%). After the program, the 30-day readmission rate for those who didn't undergo any part of the intervention was 20%, compared to 12.8% for those who did (odds ratio [OR], 0.61; 95% CI, 0.42 to 0.88). Results appeared in the July 25 Archives of Internal Medicine.

The authors noted recruitment and retention challenges evident in their approximately 55% acceptance and 75% attrition rate among patients who agreed to a home visit. Still, the intervention significantly lowered readmissions in a real-world setting, they noted.

A second study in Archives outlined similar results from a prospective study of an advanced practice nurse-led transitional care program for patients with heart failure. Researchers looked at the effect of a three-month transitional care program in which an advanced practice nurse conducted a home visit within the first 72 hours of discharge, and at least eight home visits for each patient. The follow-up emphasized the nature of the heart failure, patient and caregiver goals, general health behavior and skills, and social support. Nurses were available by telephone seven days a week, and the nurses resumed hospital visits if a readmission occurred. The transitional care program reduced adjusted 30-day readmission rates by 48% compared to the period before the study, but had little effect on length of stay or total 60-day direct costs. The intervention reduced the hospital financial contribution by an average of $227 for each Medicare patient with heart failure.

An editorialist said the successes were tempered by low participation rates for both programs, and noted that the programs save money only if their implementation costs are covered by the savings. "Reimbursements are rarely provided for preventing negative outcomes," he noted.

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Cardiology

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Apixaban associated with more bleeding, no change in ischemic events

A phase 3 trial of apixaban, a new factor Xa inhibitor, was halted after the drug was found to increase major bleeding in patients taking it after acute coronary syndrome.

The double-blind, randomized controlled trial included more than 7,000 patients that had recent acute coronary syndrome and at least two risk factors for recurrent ischemic events and were receiving standard antiplatelet therapy. The participants were randomized to receive either apixaban, 5 mg twice daily, or placebo, and the primary end point was cardiovascular death, myocardial infarction or ischemic stroke. However, after a median follow-up of 241 days, the trial was stopped due to differences between groups in the primary safety outcome—major bleeding. Such bleeding occurred in 1.3% (46 people) of those who received apixaban, compared to 0.5% (18 people) of those on placebo (hazard ratio, 2.59; P=0.001). There were also more intracranial and fatal bleeds in the active group.

No significant difference was found between the groups in rates of cardiovascular death, myocardial infarction or ischemic stroke. The combined outcome occurred in 7.5% of apixaban users compared to 7.9% of placebo users (P=0.51). The study authors noted that phase 2 trials of apixaban and another factor Xa inhibitor, rivaroxaban, had found increases in bleeding but also trends toward reductions in ischemic events. The early discontinuation of this trial—at a lower number of ischemic events than expected—leaves some uncertainty about whether a benefit to the drug could have been found in this study, they said.

This trial included high-risk patients, many with diabetes, heart failure or renal insufficiency, but no differences were seen among the subgroups in the study, such as those receiving aspirin plus clopidogrel versus aspirin alone or those who had or didn't have revascularization. Further investigation is required to determine if the results could also be different in other patient populations, the study authors suggested.

Still, the results of this trial, combined with those of other interventions, such as vitamin K antagonists, "raise doubt about whether meaningful incremental efficacy can be achieved with an acceptable risk of bleeding by combining a long-term oral anticoagulant with both aspirin and a P2Y12-receptor antagonist in patients with coronary disease," the authors concluded. The study was funded by Bristol-Myers Squibb and Pfizer and was published online by the New England Journal of Medicine on July 24.

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FDA update

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Linezolid and methylene blue cause problems with psychiatric medications

Linezolid and methylene blue can cause serious reactions in patients who are taking serotonergic psychiatric medications, the FDA warned last week.

The agency has received reports of serious central nervous system reactions in patients who were taking a serotonergic psychiatric medication when they received either linezolid or methylene blue. Although the exact mechanism of this drug interaction is unknown, linezolid and methylene blue inhibit the action of monoamine oxidase A, so it is believed that the combination of drugs causes high levels of serotonin to build up in the brain, known as serotonin syndrome. Signs and symptoms of serotonin syndrome include mental changes (confusion, hyperactivity, memory problems), muscle twitching, excessive sweating, shivering or shaking, diarrhea, trouble with coordination and/or fever.

The FDA recommends that methylene blue or linezolid generally not be given to patients taking serotonergic drugs. However, there are some conditions that may be life-threatening or require urgent treatment with the drugs. For methylene blue, those exceptions may include when it is used in the emergency treatment of methemoglobinemia, ifosfamide-induced encephalopathy, or cyanide poisoning. For linezolid, exceptions may include treatment of vancomycin-resistant Enterococcus faecium (VRE) infections or nosocomial pneumonia and complicated skin and skin structure infections, including cases caused by methicillin-resistant Staphylococcus aureus (MRSA).

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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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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated