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ACP HospitalistWeekly

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In the News for the Week of June 20, 2012

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Highlights

Hospitalist presence didn't impact death, readmission rates for common conditions

Hospitals with hospitalists fared the same on mortality and readmission measures for three specific conditions as those without hospitalists, with one exception, a new study found. More...

CAP patients with hypo- or hypercapnia have greater mortality, need for ICU admission

Hypocapnia and hypercapnia are associated with a greater need for ICU admission and higher 30-day mortality in patients hospitalized with community-acquired pneumonia (CAP), a study found. More...

Alzheimer's disease

Delirium linked to adverse outcomes in hospitalized patients with Alzheimer's disease

Patients with Alzheimer's disease who develop delirium during hospitalization are more likely to have adverse outcomes, according to a new study. More...

Testing

Guidelines on peripheral vascular ultrasound and physiologic testing

New guidelines describe the appropriate uses of arterial ultrasound and physiological testing for patients with known or suspected peripheral vascular disorders. More...

Statins

Lower energy, more exertional fatigue with statins

Statin treatment was associated with less energy and more exertional fatigue, according to a recent analysis. 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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Hospitalist presence didn't impact death, readmission rates for common conditions

Hospitals with hospitalists fared the same on mortality and readmission measures for three specific conditions as those without hospitalists, with one exception, a new study found.

Researchers identified hospitals with 25 or more acute myocardial infarction (AMI) discharges in 2008 using American Hospital Association data, and called them up to six times until they reached a target sample size of 600 participants. They administered surveys to hospital leaders via phone and fax between February 2010 and January 2011 to obtain data on the presence or absence of hospitalists and characteristics of the hospitalist services. For each admission, researchers calculated 30-day risk-standardized mortality and readmission rates for AMI, heart failure and pneumonia for Medicare patients age 65 and up. Presence of hospitalists was correlated with hospital- and patient-level characteristics, and with performance on each outcome measure. Researchers also assessed the relationship between the percentage of patients admitted by hospitalists and each outcome measure.

Of the 598 survey respondents, 72% (n=429) reported use of hospitalist services. There was no statistically significant difference between facilities that used hospitalists or didn't on any outcome measure except risk-stratified readmissions for heart failure, in multivariable models or bivariate analysis. Sites with hospitalists had a lower heart failure readmission rate than those without (24.7% vs. 25. 4%; P<0.0001 on bivariate analysis); the researchers noted the effect size of this finding was small. In the hospitals that used hospitalists, there was no change in any outcome measure associated with increasing percentage of patients admitted by hospitalists (versus admission by another type of clinician). Results were published online June 11 in the Journal of Hospital Medicine.

Despite concerns that hospitalists negatively impact continuity of care, these data didn't find an association between higher readmission rates and use of hospitalists, the researchers noted. Study limitations include the lack of a standardized industry definition of "hospitalist," which could have affected survey response validity; reliance on self-reported data; and the fact that hospitalists may be less likely to provide care for AMI and heart failure than other conditions, so outcome data may not fully capture their influence. "It is likely that multiple factors contribute to performance on outcome measures, including type and mix of hospital personnel, patient care processes and workflow, and system level attributes," the authors concluded. "Interventions leading to improvement on core outcome measures are more complex than simply having a hospital medicine program."

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CAP patients with hypo- or hypercapnia have greater mortality, need for ICU admission

Hypocapnia and hypercapnia are associated with a greater need for ICU admission and higher 30-day mortality in patients hospitalized with community-acquired pneumonia (CAP), a study found.

Researchers conducted a retrospective cohort study of 453 hospitalized patients with an admission diagnosis of CAP at two tertiary teaching hospitals in San Antonio, Texas. All patients had a confirmed infiltrate or other finding consistent with CAP on chest X-ray or computed tomography of the chest within 24 hours of admission, and an arterial blood gas drawn within 24 hours of admission. Patients were stratified into three groups: normal (Paco₂ 35 to 45 mm Hg), hypocapnic (Paco₂ <35 mm Hg) and hypercapnic (Paco₂ >45 mm Hg). Researchers performed multivariate analysis with 30-day mortality as the primary outcome measure and ICU admission, length of stay and need for invasive mechanical ventilation as secondary outcome measures. Results were published in the June CHEST.

Forty-one percent of patients (n=189) had normal Paco_2, 42% (n=194) were hypocapnic and 15% (n=70) were hypercapnic. After adjustment for illness severity, hypocapnic patients had greater 30-day mortality (odds ratio [OR], 2.84) and a greater need for ICU admission (OR, 2.88) compared to patients with normal blood gas measurements. Hypercapnic patients also had a higher 30-day mortality (OR, 3.38) and greater need for ICU admission (OR, 5.35). These differences between groups remained when chronic obstructive pulmonary disease (COPD) patients were excluded from the analysis. There was no statistically significant difference among groups in length of stay or need for invasive mechanical ventilation, though there was a higher need for invasive mechanical ventilation in hypercapnic patients without COPD.

Existing tools to predict 30-day mortality, which also have been recommended to identify patients for ICU admission, have been shown in recent research to not accurately predict ICU admission, the authors noted. These scores don't consider Paco₂ levels as a predictive variable, but "our results suggest that abnormal Paco₂ levels should be considered in severity of illness scores and requires further validation," they wrote. In addition, the existing study found hypo- and hypercapnia were independently associated with 30-day mortality, "with no relationship to respiratory rate or pH level, suggesting they are likely to be intrinsically involved in the poor prognosis of these patients," they wrote.

Alzheimer's disease

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Delirium linked to adverse outcomes in hospitalized patients with Alzheimer's disease

Patients with Alzheimer's disease who develop delirium during hospitalization are more likely to have adverse outcomes, according to a new study.

Researchers performed a prospective cohort study of patients with Alzheimer's disease who were enrolled in the Massachusetts Alzheimer's Disease Research Center patient registry from 1991 to 2006. The goal of the study was to determine the association between hospitalization and delirium and risks for institutionalization, cognitive decline and death. The authors defined cognitive decline as a decrease of at least four points on the Blessed Information-Memory-Concentration test score. Adjusted relative risks (RRs) were calculated by using multivariate analysis. The study results appear in the June 19 Annals of Internal Medicine.

A total of 771 patients at least 65 years of age (mean age, 77.2 years) with a diagnosis of Alzheimer's disease were included in the study. Fifty-seven percent were women, and 95% were white. Over the study period, 367 patients (48%) were hospitalized and 194 (25%) developed delirium. Risks for death and institutionalization were higher in hospitalized patients than in nonhospitalized patients (adjusted RRs, 4.7 and 6.9, respectively) and were increased further in hospitalized patients who developed delirium (adjusted RRs, 5.4 and 9.3, respectively). Hospitalized patients who developed delirium also had an adjusted RR of 1.6 for cognitive decline. Overall, 21% of cognitive decline, 15% of institutionalizations, and 6% of deaths in hospitalized patients were determined to be associated with delirium.

The authors acknowledged that their study was nonrandomized, that some data were missing, and that ethnic minorities were not well represented, among other limitations. However, they concluded that delirium during hospitalization will lead to at least one adverse outcome in approximately one in eight patients with Alzheimer's disease. "Further investigation is greatly needed to determine whether prevention of hospitalization and delirium can decrease the attributable risk for death, institutionalization, and cognitive impairment in the vulnerable and increasing population of persons with [Alzheimer's disease]," the authors wrote.

Testing

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Guidelines on peripheral vascular ultrasound and physiologic testing

New guidelines describe the appropriate uses of arterial ultrasound and physiological testing for patients with known or suspected peripheral vascular disorders.

The criteria, which were released by a collaboration of several medical societies and published by the Journal of the American College of Cardiology on June 11, described 255 clinical scenarios. Of these, 117 were judged to be appropriate uses of noninvasive vascular testing, 84 were rated as uncertain, and 54 were found to be inappropriate. The scenarios cover non-coronary arterial disorders including atherosclerotic occlusive disease (i.e., carotid artery stenosis, lower- and upper-extremity peripheral arterial disease, renal and mesenteric artery occlusive disease), abdominal aortic aneurysms, fibromuscular dysplasia, vasospasm, arterial dissection and arterial trauma.

In general, testing was found to be appropriate when indicated by clinical signs and symptoms, as well as to establish a baseline after revascularization. Follow-up studies for patients with normal findings were generally rated as inappropriate.

The criteria are intended to help clinicians maximize use of the noninvasive vascular laboratory, identify evidence gaps in the field, and serve as a reference for policymakers, the authors said, acknowledging that many potential indications for testing are not included. They noted that this document included more indications for surveillance than appropriate use criteria for other cardiovascular imaging modalities, because optimal clinical management of peripheral vascular disorders requires periodic imaging surveillance.

The criteria were titled "Part I," and the authors wrote that appropriateness criteria for venous ultrasound and physiological testing are currently under development. The criteria were jointly released by the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American College of Radiology, American Institute of Ultrasound in Medicine, American Society of Echocardiography, American Society of Nephrology, Intersocietal Commission for the Accreditation of Vascular Laboratories, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Interventional Radiology, Society for Vascular Medicine, Society for Vascular Surgery, American Academy of Neurology, American Podiatric Medical Association, Society for Clinical Vascular Surgery, Society for Cardiovascular Magnetic Resonance and Society for Vascular Ultrasound.

Statins

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Lower energy, more exertional fatigue with statins

Statin treatment was associated with less energy and more exertional fatigue, according to a recent analysis.

Researchers used data from the University of California, San Diego Statin Study, which included 1,016 patients with low-density lipoprotein levels of 115 to 190 mg/dL and no cardiovascular disease or diabetes. The patients were randomized to daily 20-mg simvastatin, 40-mg pravastatin or placebo. The study participants rated their own change in energy and fatigue with exertion after six months of therapy. The results were published as an online research letter by the Archives of Internal Medicine on June 11.

The study found a significantly larger drop in energy among statin users compared to placebo recipients. The authors used patients' self-ratings to create an energy/exertional fatigue score, and they found a mean drop of −0.21 (P=0.005) in statin patients. Women had an even greater decrease in their mean scores (−0.39, P=0.01). The authors explained that such a drop could indicate four in 10 statin-taking women having worsening energy or fatigue, two in 10 finding either marker to be worse or much worse, or one in 10 having much worse energy and fatigue. Simvastatin appeared to be associated with greater mean drops in the energy/fatigue score than pravastatin.

The findings support previous case reports of statin side effects, the authors concluded. These effects could be important in statin-prescribing decisions, especially for healthier patients who have less expected benefit from the drugs. Lower levels of activity and exertional tolerance could lead to other adverse effects, the authors noted. They called for long-term trials to gather additional evidence and urged physicians to be alert to statin-taking patients' reports of worsened energy and fatigue.

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