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ACP HospitalistWeekly

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In the News for the Week of June 13, 2012

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Highlights

Observation care rate rises, inpatient rate drops, for Medicare patients

The prevalence of observation care increased between 2007 and 2009, while it fell for inpatient care, a new analysis of Medicare patients found. More...

Elevated troponin T may help predict 30-day mortality

Troponin T levels independently predict 30-day mortality after noncardiac surgery, a new study found. More...

Critical care

Disruption of catheter dressings poses major risk for infections

Disruption of catheter dressings is a common risk factor for catheter-related infections and can be partially avoided by using the subclavian insertion site, a new analysis found. More...

Cardiology

Low-dose aspirin associated with bleeding events

Daily use of low-dose aspirin was associated with an increased risk of major gastrointestinal or cerebral bleeding, a study found. More...

From ACP Hospitalist

Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its fifth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine. 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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Observation care rate rises, inpatient rate drops, for Medicare patients

The prevalence of observation care increased between 2007 and 2009, while it fell for inpatient care, a new analysis of Medicare patients found.

Researchers examined Medicare enrollment and claims data from 2007 through 2009. The study population was constructed on a monthly basis; each month, about 29 million beneficiaries met all inclusion criteria for the analysis. Researchers used revenue center codes and the Healthcare Common Procedure Coding System to identify observation stays, and to count the total hours for which observation services were provided. Results were published in the June Health Affairs.

The prevalence of observation stays rose from an average of 2.3 per 1,000 beneficiaries per month in 2007 to 2.9 in 2009. Meanwhile, the prevalence of inpatient stays declined from 23.9 per 1,000 beneficiaries per month to 22.5 in 2009. This means the ratio of observation stays to inpatient admissions rose 34%, from an average of 86.9 observation stays per 1,000 inpatient admissions monthly in 2007 to 116.6 in 2009. The number of hours a patient was held for observation per episode also increased by more than 7%, from an average of 26.2 hours in 2007 to 28.2 hours in 2009. In 2007, 23,841 beneficiaries were held in observation for at least 72 hours, compared to 44,843 in 2009—an 88% increase.

The rising prevalence of hospital observation care is in line with a general shift of Medicare-covered services from inpatient to outpatient settings—which is due in part to policies that affect reimbursement, the authors noted. "Facing more stringent criteria for inpatient admissions and uncertainties over the prospects of retroactive payment denial, physicians may choose to place their patients under observation more often than they would otherwise," they wrote. Readmission penalties may also encourage hospitals to classify patients as under observation rather than inpatient, they noted. Doing so can expose patients to greater out-of-pocket expenses if they are eventually admitted to nursing homes, because they haven't hit the three-day inpatient stay requirement for Medicare coverage of nursing homes, the authors noted. More clarity is needed in clinical practice and Medicare guidelines regarding observation care, they concluded.

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Elevated troponin T may help predict 30-day mortality

Troponin T levels independently predict 30-day mortality after noncardiac surgery, a new study found.

The prospective, international cohort study involved more than 15,000 patients age 45 and older who had noncardiac surgery requiring at least overnight hospital admission. Fourth-generation troponin T (TnT) measurements were taken six to 12 hours after surgery and on postsurgery days 1, 2 and 3. The patients' peak troponin T measurements were collected and compared with 30-day mortality rates.

Overall, 30-day mortality among the patients was 1.9%. In multivariable analysis, the study authors found that troponin T levels of 0.02 ng/mL or higher predicted increased risk of 30-day mortality. Compared to patients whose TnT never went above 0.01 ng/mL, those with a peak of 0.02 ng/mL had an adjusted hazard ratio of death of 2.41. The risk was even higher for patients with peaks of 0.03 to 0.29 ng/mL (hazard ratio, 5.00) and 0.30 ng/mL or above (hazard ratio, 10.48). Within the 30 days after surgery, mortality rates were 1.0%, 4.0%, 9.3% and 16.9% for patients with TnT peaks of 0.01 or greater, 0.02, 0.03 to 0.29, and 0.30 or greater, respectively.

Based on these findings, elevated TnT levels may have predicted 41.8% of the deaths in the study population, researchers calculated. They noted that this multicenter study had consistent results across sites, indicating that the observed TnT thresholds could be relevant worldwide. The study differed from many laboratories' current practice in that specific thresholds were used instead of cutoffs at the 99th percentile or coefficients of variation less than 10%, which often work out to 0.04 ng/mL or higher. These results show that TnT values below 0.04 ng/mL are strongly associated with mortality, the authors said.

The next step in this research would be to determine whether interventions in the immediate post-surgical period (74.2% of patients with elevated TnT had it in the first 24 hours after surgery) could reduce the risk of mortality, the authors said. Aspirin and statin therapy show promise, but large, randomized clinical trials of interventions are needed, they concluded. The study was published in the June 6 Journal of the American Medical Association.

Critical care

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Disruption of catheter dressings poses major risk for infections

Disruption of catheter dressings is a common risk factor for catheter-related infections and can be partially avoided by using the subclavian insertion site, a new analysis found.

Researchers performed a secondary analysis of a multicenter randomized trial conducted at seven ICUs in France. The original trial compared the effects of two dressing change intervals and two types of dressings on catheter-related infection in intensive care. In that study, patients were randomly assigned to one of four treatment groups: standard dressing changed every three days or every seven days, or chlorhexidine gluconate-impregnated sponge changed every three or seven days. Of the 1,636 patients in the original study, 1,419 with at least one dressing change were included in the secondary analysis.

Researchers identified 296 colonized catheters, 29 major catheter-related infections, and 23 catheter-related bloodstream infections. Sixty-seven percent of the 11,036 dressing changes were done before the planned date due to soiling or undressing. Patients with higher Sequential Organ Failure Assessment scores and those receiving renal replacement therapies experienced more dressing disruption, while males and comatose patients had less. At the catheter level, the use of the subclavian insertion site was protective against dressing disruption, the study found.

The number of disruptions was related to a higher risk for colonization of the skin around the catheter at removal (P<0.0001). After the second dressing disruption, the risk of major catheter-related infection and catheter-related bloodstream infection increased more than threefold; it increased more than 12-fold if the final dressing was disrupted. The results appeared in the June Critical Care Medicine.

This analysis "adds major arguments to include dressing integrity in catheter bundles" and "reinforces the need for a postinsertion bundle of care," the authors said. In addition, the data found that subclavian vein access led to a marked decline in dressing disruption, which may explain the significantly lower risk of catheter colonization and catheter-related bloodstream infection compared with jugular or femoral sites. "Our data support the preferential use of the subclavian insertion site," they concluded.

Cardiology

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Low-dose aspirin associated with bleeding events

Daily use of low-dose aspirin was associated with an increased risk of major gastrointestinal or cerebral bleeding, a study found.

Researchers used administrative data from 4.1 million citizens in 12 local health authorities in Italy to identify a cohort of 186,425 individuals taking aspirin (daily doses of 300 mg or less) from January 2003 to December 2008 and 186,425 matched controls who didn't take aspirin.

Results appeared in the June 6 Journal of the American Medical Association. During a median follow-up of 5.7 years, there were 6,907 first episodes of major bleeding requiring hospitalization. There were 4,487 episodes of gastrointestinal bleeding and 2,464 episodes of intracranial hemorrhage.

The incidence rates of total hemorrhagic events were 5.58 (95% CI, 5.39 to 5.77) per 1,000 person-years for those on aspirin and 3.60 (95% CI, 3.48 to 3.72) per 1,000 person-years for those without aspirin use (incidence rate ratio [IRR], 1.55; 95% CI, 1.48 to 1.63). Aspirin was associated with an excess risk of gastrointestinal bleeding (IRR, 1.55; 95% CI, 1.46 to 1.65) and intracranial bleeding (IRR, 1.54; 95% CI, 1.43 to 1.67). Regardless of aspirin use, diabetes was independently associated with an increased risk of major bleeding episodes (IRR, 1.36; 95% CI, 1.28 to 1.44).

The authors noted, "[W]eighing the benefits of aspirin therapy against the potential harms is of particular relevance in the primary prevention setting, in which benefits seem to be lower than expected based on results in high-risk populations. In this population-based cohort, aspirin use was significantly associated with an increased risk of major bleeding, but this association was not observed for patients with diabetes. In this respect, diabetes might represent a different population in terms of both expected benefits and risks associated with antiplatelet therapy."

An editorial noted that guidelines advocating the routine use of aspirin for primary prevention for individuals above a moderate level of risk of coronary heart disease should be carefully considered as this approach may not be advisable for all patients.

From ACP Hospitalist

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Who's tops at your hospital?

ACP Hospitalist is seeking candidates for its fifth annual Top Hospitalists issue in November, which will feature the best and brightest in hospital medicine. Let us know what your colleagues have accomplished in 2012. Do they always go out of their way to educate patients or help new physicians? Did they take charge of a key quality or safety initiative? Maybe they are wizards at solving tricky diagnoses, or selfless about volunteer outreach. Whatever the contribution, if it helped further hospital medicine, we'd like to hear about it.

Recommending a physician is easy: Just visit our online form and tell us who you think we should feature and why. We look forward to receiving your suggestions!

Note: ACP Hospitalist's Top Hospitalist issue is not part of the ACP National Awards Program. Self-nomination is not permitted. Candidates need not be ACP members. The selection process is not scientific. Editorial board members are solely responsible for determining those profiled in the Top Hospitalists issue.

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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About ACP HospitalistWeekly

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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