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Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease.

JAMA. 2010 Jun 16;303(23):2359-67

Authors: Lindenauer PK, Pekow PS, Lahti MC, Lee Y, Benjamin EM, Rothberg MB

CONTEXT: Systemic corticosteroids are beneficial for patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD); however, their optimal dose and route of administration are uncertain. OBJECTIVE: To compare the outcomes of patients treated with low doses of steroids administered orally to those treated with higher doses administered intravenously. DESIGN, SETTING, AND PATIENTS: A pharmacoepidemiological cohort study conducted at 414 US hospitals involving patients admitted with acute exacerbation of COPD in 2006 and 2007 to a non-intensive care setting and who received systemic corticosteroids during the first 2 hospital days. MAIN OUTCOME MEASURES: A composite measure of treatment failure, defined as the initiation of mechanical ventilation after the second hospital day, inpatient mortality, or readmission for acute exacerbation of COPD within 30 days of discharge. Length of stay and hospital costs. RESULTS: Of 79,985 patients, 73,765 (92%) were initially treated with intravenous steroids, whereas 6220 (8%) received oral treatment. We found that 1.4% (95% confidence interval [CI], 1.3%-1.5%) of the intravenously and 1.0% (95% CI, 0.7%-1.2%) of the orally treated patients died during hospitalization, whereas 10.9% (95% CI, 10.7%-11.1%) of the intravenously and 10.3% (95% CI, 9.5%-11.0%) of the orally treated patients experienced the composite outcome. After multivariable adjustment, including the propensity for oral treatment, the risk of treatment failure among patients treated orally was not worse than for those treated intravenously (odds ratio [OR], 0.93; 95% CI, 0.84-1.02). In a propensity-matched analysis, the risk of treatment failure was significantly lower among orally treated patients (OR, 0.84; 95% CI, 0.75-0.95), as was length of stay and cost. Using an adaptation of the instrumental variable approach, increased rate of treatment with oral steroids was not associated with a change in the risk of treatment failure (OR for each 10% increase in hospital use of oral steroids, 1.00; 95% CI, 0.97-1.03). A total of 1356 (22%) patients initially treated with oral steroids were switched to intravenous therapy later in the hospitalization. CONCLUSION: Among patients hospitalized for acute exacerbation of COPD low-dose steroids administered orally are not associated with worse outcomes than high-dose intravenous therapy.

PMID: 20551406 [PubMed - indexed for MEDLINE]

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Effects of an adverse-drug-event alert system on cost and quality outcomes in community hospitals.

Am J Health Syst Pharm. 2010 Apr 15;67(8):613-20

Authors: Piontek F, Kohli R, Conlon P, Ellis JJ, Jablonski J, Kini N

PURPOSE: The effects of an adverse-drug-event (ADE) alert system on cost and quality outcomes in community hospitals were evaluated. METHODS: This retrospective observational study evaluated the effects of an ADE alert system in seven hospitals in the Trinity Health network. Outcomes for all inpatients admitted to these hospitals after and one year before the deployment of an ADE alert system were evaluated. Inpatients in two network hospitals that lacked any computerized ADE alert system constituted the external control group. Administrative data were gathered for patients from these facilities for the same time frames as for the preimplementation and postimplementation groups. Primary outcomes evaluated included pharmacy department costs, variable drug costs, and mortality rates. Secondary outcomes included total hospitalization costs, length of hospital stay (LOS), rate of readmission, and case-mix index. Mean differences in primary and secondary outcome measures across all four groups were examined using analysis of variance. RESULTS: Significant decreases in mean pharmacy department costs per patient were observed from preimplementation to postimplementation (p < 0.001), while pharmacy department costs increased significantly in the external control group (p = 0.029). Drug costs decreased significantly from baseline (p < 0.001) in the postimplementation group. Drug costs increased significantly in the external control group (p = 0.029). Severity-adjusted mortality rates and LOS decreased significantly in the postimplementation group. Total patient hospitalization costs, both crude and severity adjusted, significantly increased in both groups. CONCLUSION: Implementation of an ADE alert system in seven community hospitals demonstrated significant decreases in pharmacy department costs, variable drug costs, and severity-adjusted mortality rates.

PMID: 20360588 [PubMed - indexed for MEDLINE]

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The syndrome of inappropriate antidiuretic hormone: prevalence, causes and consequences.

Eur J Endocrinol. 2010 Jun;162 Suppl 1:S5-12

Authors: Hannon MJ, Thompson CJ

Hyponatraemia is the commonest electrolyte abnormality found in hospital inpatients, and is associated with a greatly increased morbidity and mortality. The syndrome of inappropriate antidiuretic hormone (SIADH) is the most frequent cause of hyponatraemia in hospital inpatients. SIADH is the clinical and biochemical manifestation of a wide range of disease processes, and every case warrants investigation of the underlying cause. In this review, we will examine the prevalence, pathophysiology, clinical characteristics and clinical consequences of hyponatraemia due to SIADH.

PMID: 20164214 [PubMed - indexed for MEDLINE]

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Estimate of renal function in oldest old inpatients by MDRD study equation, Mayo Clinic equation and creatinine clearance.

J Nephrol. 2010 May-Jun;23(3):306-13

Authors: Carnevale V, Pastore L, Camaioni M, Mellozzi M, Sabatini M, Arietti E, Fusilli S, Scillitani A, Pontecorvi M

BACKGROUND: Patients older than 85 years are increasingly admitted to hospital care settings. Despite this, the clinical employment of equations for estimating glomerular filtration rate (GFR) has been scarcely investigated so far in this age group. Our study compared 2 commonly employed equations to estimate GFR, as well as measured 24-hour creatinine clearance (CrCl), in patients aged >or=85 years. METHODS: Seventy-three patients consecutively admitted over 4 months to our Internal Medicine Department had an accurate 24-hour urinary collection, as well as serum and urinary creatinine determinations. Measured CrCl was compared with the GFR values estimated by the Modification of Diet in Renal Disease (MDRD) Study and Mayo Clinic quadratic (MCQ) equations. RESULTS: GFR values derived by MDRD and MCQ equations and CrCl significantly differed from each other in the whole sample. CrCl negatively correlated with age (r=-0.389, p<0.001), at variance with GFR levels obtained by both the MDRD and the MCQ equations. The 3 estimates of renal function significantly correlated with each other, these correlations persisting after correcting for age, serum albumin and 24-hour urinary creatinine. Despite the visual impression of Bland and Altman plots, the overall agreement between methods was poor. Moreover, the proportion of patients classified by the 3 GFR estimates into each stage of kidney disease as specified in the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines significantly differed. CONCLUSIONS: In patients older than 85 years, the tested equations for estimation of GFR and the measured 24-hour CrCl provide significantly different results, so that they may not be used interchangeably in clinical practice.

PMID: 20155719 [PubMed - indexed for MEDLINE]

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The validity of average 8-h pain intensity assessment in cancer patients.

Eur J Pain. 2010 Apr;14(4):441-5

Authors: Caraceni A, Zecca E, Martini C, Brunelli C, Pigni A, Gorni G, Galbiati A, Ibazeta M, Hjermstad M, Kaasa S

Aim of this study was to validate the use of subjective average pain assessment over an 8-h time period to evaluate cancer pain intensity. A sample of 95 consecutive cancer inpatients were asked to score on 0-10 numerical scales the intensity of their pain at hourly intervals, and then, at the 8th hour, to rate their average pain intensity over the last 8h. Agreement between the average of the 8 hourly measures (8hA) and the single patient-rated average (PA8h) was examined with the intraclass correlation coefficient (ICC) and the absolute difference (AD) between the two measurements. Associations between AD, gender, age older than 70, somatic pain, visceral pain, neuropathic pain, pain on movement and the presence of pain exacerbations during the 8-h period, were also examined. Average pain intensity scores were very similar with the two measurement schedules: 3.4 for 8hA and 3.7 for PA8h, with a median AD of 0.44 points. Only six patients (6.3%) showed ADs higher than 2 points. Also the ICC (0.85) showed a substantial agreement between the two schedules. Among the examined variables, gender, age over 70years and presence of pain exacerbations showed a significant association with the agreement level. Overall, our results support the validity of a subjective average pain measurement over 8-h period in cancer patients.

PMID: 19692275 [PubMed - indexed for MEDLINE]

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Using in situ simulation to improve in-hospital cardiopulmonary resuscitation.

Jt Comm J Qual Patient Saf. 2010 May;36(5):209-16

Authors: Lighthall GK, Poon T, Harrison TK

BACKGROUND: There is widespread recognition that the conduct of cardiac resuscitation is problematic. In situ simulation has been used to train and evaluate cardiac arrest teams’ performance in the hospital setting, but in work at a university-affiliated, tertiary care facility, the simulated cardiac arrests were used to understand how well health care providers and their environment function during arrests, with the goal of a rapid intervention to correct problem areas. Latent conditions–innate, mostly hidden, workplace factors–can have a large detrimental impact on resuscitation efforts. METHODS: Observations from a series of unannounced simulated cardiac arrests undertaken at diverse locations within a university-affiliated, tertiary care hospital were a component of an ongoing initiative to improve performance of emergency cardiovascular care. RESULTS: Fourteen cardiac arrest simulations revealed 24 hazardous findings, approximately two thirds of which had a high likelihood of compromising patient survival if they had occurred during an actual cardiac arrest. Categories of problems included active errors by teams and individuals and systemic or latent errors of the environment. Because the simulations were designed with the goal of discovering and documenting errors, most errors led to further actions, policies, and procedures that were rapidly adopted by the medical center to prevent their recurrence. CONCLUSIONS: In situ simulation of cardiac arrests elicits lifelike behaviors and allows engagement of all personnel and resources applicable to real arrests. This method allowed for remedial plans to be developed before further harm could occur. Accordingly, in situ simulation of high-risk events may be a useful, efficient technique that complements existing quality assurance processes in hospitals.

PMID: 20480753 [PubMed - indexed for MEDLINE]

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Challenging the holy grail of hospital accreditation: a cross sectional study of inpatient satisfaction in the field of cardiology.

BMC Health Serv Res. 2010;10:120

Authors: Sack C, Lütkes P, Günther W, Erbel R, Jöckel KH, Holtmann GJ

BACKGROUND: Subjective parameters such as quality of life or patient satisfaction gain importance as outcome parameters and benchmarks in health care. In many countries hospitals are now undergoing accreditation as mandatory or voluntary measures. It is believed but unproven that accreditations positively influence quality of care and patient satisfaction. The present study aims to assess in a defined specialty (cardiology) the relationship between patient satisfaction (as measured by the recommendation rate) and accreditation status. METHODS: Consecutive patients discharged from 25 cardiology units received a validated patient satisfaction questionnaire. Data from 3,037 patients (response rate > 55%) became available for analysis. Recommendation rate was used as primary endpoint. Different control variables such as staffing level were considered. RESULTS: The 15 accredited units did not differ significantly from the 10 non-accredited units regarding main hospital (i.e. staffing levels, no. of beds) and patient (age, gender) characteristics. The primary endpoint "recommendation rate of a given hospital" for accredited hospitals (65.6%, 95% Confidence Interval (CI) 63.4 – 67.8%) and hospitals without accreditation (65.8%, 95% CI 63.1-68.5%) was not significantly different. CONCLUSION: Our results support the notion that – at least in the field of cardiology – successful accreditation is not linked with measurable better quality of care as perceived by the patient and reflected by the recommendation rate of a given institution. Hospital accreditation may represent a step towards quality management, but does not seem to improve overall patient satisfaction.

PMID: 20459873 [PubMed - indexed for MEDLINE]

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Appropriateness of gastrointestinal consultations for hospitalized patients in an academic medical center.

J Postgrad Med. 2010 Jan-Mar;56(1):17-20

Authors: Cohen M, Niv Y

BACKGROUND: Consultation of experts in the internal medicine or surgery subspecialties is needed in the hospitalized population according to decisions of the house staff. Sometimes the referrals are not justified, consuming time and money without a significant change in the patient outcome. OBJECTIVES: The aim of our retrospective study was to evaluate justification of consecutive referrals of hospitalized patients for gastroenterology consultation. MATERIALS AND METHODS: Request for consultation was deemed not justified when at least one of the following parameters was found: No contribution to case management, discharge before consultation, cancellation at the last minute, and a recommendation for ambulatory management or surgery. RESULTS: In August-September 2006, there were 232 requests for gastroenterology consultations. Of them 127 (54.7%) were men. The average age was 64.13+/-20.33 years. Ninety-four (40.2%) of the cases had been hospitalized because of other reasons than the consultation issue. Consultation was not justified in 60 patients (25.9%). Ambulatory management was a possibility in 151 cases (65.0%). Request for colonoscopy and gastrointestinal background disease were the only significant predictive factors for justification of consultation, P < 0.0001 for both. CONCLUSIONS: In one fourth of the cases, gastroenterology consultation was not justified according to our strict criteria.

PMID: 20393244 [PubMed - indexed for MEDLINE]

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Right ventricular dysfunction is an independent predictor for mortality in ST-elevation myocardial infarction patients presenting with cardiogenic shock on admission.

Eur J Heart Fail. 2010 Mar;12(3):276-82

Authors: Engström AE, Vis MM, Bouma BJ, van den Brink RB, Baan J, Claessen BE, Kikkert WJ, Sjauw KD, Meuwissen M, Koch KT, de Winter RJ, Tijssen JG, Piek JJ, Henriques JP

AIMS: Despite improvement in prognosis for ST-elevation myocardial infarction (STEMI) patients, mortality remains high in STEMI patients presenting with cardiogenic shock (CS). Right ventricular (RV) dysfunction is an established independent predictor for adverse prognosis in STEMI patients without CS. The purpose of our study was to determine the prognostic value of RV dysfunction on admission in STEMI patients presenting in CS. METHODS AND RESULTS: Two hundred and ninety-two consecutive STEMI patients with CS on admission were treated by primary percutaneous coronary intervention (PCI) from January 1997 through March 2005. RV function was assessed by measurement of tricuspid annular plane systolic excursion (TAPSE) on early echocardiography in 184 of 292 patients. Right ventricular dysfunction was defined as a TAPSE of <or=14 mm. Right ventricular dysfunction was present on early echocardiography in 70 of 184 patients (38%). The Kaplan-Meier estimate for overall 4-year survival was 57%. Kaplan-Meier estimates for 4-year survival in patients with and without RV dysfunction were 33 and 73%, respectively (P< 0.001). Cox-regression analysis revealed a hazard ratio of 2.1 (95% CI 1.3-3.4, P = 0.002) for RV dysfunction when adjusted for age, glucose on admission, and LVEF < 40%. In patients with and without RV dysfunction, the right coronary artery was the infarct-related artery in 41 and 28% of patients, respectively (P = 0.06). CONCLUSION: In STEMI patients presenting with CS on admission and treated with primary PCI, RV dysfunction as assessed by echocardiography is an independent predictor for long-term mortality.

PMID: 20089520 [PubMed - indexed for MEDLINE]

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Guidelines versus clinical practice in antimicrobial therapy for COPD.

Lung. 2010 Apr;188(2):173-8

Authors: Farkas JD, Manning HL

Limited information is available about current practice patterns involving the use of antibiotics in the inpatient management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). We sought to characterize current patterns of antibiotic use and to compare them to evidence-based guidelines. This study is a retrospective case series of patients at a regional tertiary care medical center. Charts were reviewed to identify patients admitted between January 2006 and 2008 with an initial diagnosis of AECOPD who had no evidence of another infectious process and who were not immunocompromised. Relevant data extracted from charts included initial clinical presentation, antibiotic administration, microbiological studies, and hospital course. One hundred sixteen admissions meeting inclusion criteria were identified. There was no statistically significant relationship between the presence of an established indication for antibiotic administration and the use of antibiotics, with roughly 75% of patients in all groups receiving therapy. A significant fraction of patients received combination therapy that was more appropriate for the management of pneumonia than for AECOPD. There were significant deviations between practice patterns and guidelines regarding the use and selection of antibiotics. Some of these may reflect areas of uncertainty in the primary literature and varying sets of guidelines.

PMID: 20066545 [PubMed - indexed for MEDLINE]

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CT scan for suspected acute abdominal process: impact of combinations of IV, oral, and rectal contrast.

World J Surg. 2010 Apr;34(4):699-703

Authors: Hill BC, Johnson SC, Owens EK, Gerber JL, Senagore AJ

BACKGROUND There are limited data available on the ability of computed tomography (CT) to accurately diagnose abdominopelvic pathology in acutely ill inpatients suspected of having an acute abdominal process. The purpose of this study was to evaluate the diagnostic accuracy of abdominal/pelvic CT with varying use of contrast agents in hospitalized patients. METHODS A retrospective review of all hospital inpatients (3/1/07-5/31/07) who underwent urgent or emergent abdominal/pelvic CT with any combination of contrast, intravenous (IV), oral, rectal, or unenhanced for a suspected acute abdominal process was performed. Data collected included demographics, combination of contrast used, CT diagnosis, time from CT scan to subsequent intervention, intervention type, and actual diagnosis of the acute abdominal process. Accuracy of CT was compared between enhanced and unenhanced imaging using Fisher's exact test. RESULTS A total of 661 patients were identified. Use of IV contrast alone was found in 54.2% of CT scans and was correct in 92.5% of cases. IV and oral contrast was used in 22.2% of CT scans and was 94.6% correct. Unenhanced imaging was performed in 16.2% and was correct in 92.5%. Oral contrast alone was used in 7.0% and was 93.5% correct. There was no significant difference in the ability to correctly diagnose a suspected acute abdominal process when enhanced CT imaging was compared to unenhanced (p > 0.05). CONCLUSIONS CT contrast administration in critically ill hospitalized patients is not necessary to accurately diagnose an acute abdominal process. Eliminating the use of contrast may improve patient comfort, decrease patient risk, and minimize financial cost.

PMID: 20054539 [PubMed - indexed for MEDLINE]

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Utilizing audit and feedback to improve hospitalists’ performance in tobacco dependence counseling.

Nicotine Tob Res. 2010 Jun 11;

Authors: Kisuule F, Necochea A, Howe EE, Wright S

INTRODUCTION: Hospitalized smokers benefit from smoking cessation counseling and nicotine replacement therapy (NRT). However, inpatient providers who care for hospitalized patients carry out these preventive measures inconsistently. METHODS: We designed a peer-led audit and feedback intervention to improve (a) the frequency of smoking cessation counseling and (b) the appropriateness of the prescribing of NRT by hospitalist practitioners in our hospital. Documentation of tobacco cessation counseling in progress notes and discharge summaries and the ordering and dosing of NRT were assessed for 30 hospitalists before and after an intervention. This intervention included specific feedback on their counseling and prescribing practices as well as education and was delivered as part of a one-on-one academic detailing session. RESULTS: Five hundred and forty five and 1,119 patient-days were considered for this analysis in the pre- and postperiods, respectively. Documentation of tobacco dependence counseling in progress notes increased from 36% to 44% (p = .002) and from 7.5% to 46.8% in discharge summaries (p < .0001) following the intervention. The appropriateness of NRT dosing increased from 26% (before) to 64% (after) the intervention (p < .0001). DISCUSSION: A peer-led audit and feedback intervention for hospitalists significantly increases the frequency of smoking cessation counseling and the adequacy of NRT prescribing for hospitalized smokers.

PMID: 20542995 [PubMed - as supplied by publisher]

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Discharge documentation of patients discharged to subacute facilities: a three-year quality improvement process across an integrated health care system.

Jt Comm J Qual Patient Saf. 2010 Jun;36(6):243-51

Authors: Gandara E, Ungar J, Lee J, Chan-Macrae M, O’Malley T, Schnipper JL

BACKGROUND: Effective communication among physicians during hospital discharge is critical to patient care. Partners Healthcare (Boston) has been engaged in a multi-year process to measure and improve the quality of documentation of all patients discharged from its five acute care hospitals to subacute facilities. METHODS: Partners first engaged stakeholders to develop a consensus set of 12 required data elements for all discharges to subacute facilities. A measurement process was established and later refined. Quality improvement interventions were then initiated to address measured deficiencies and included education of physicians and nurses, improvements in information technology, creation of or improvements in discharge documentation templates, training of hospitalists to serve as role models, feedback to physicians and their service chiefs regarding reviewed cases, and case manager review of documentation before discharge. To measure improvement in quality as a result of these efforts, rates of simultaneous inclusion of all 12 applicable data elements ("defect-free rate") were analyzed over time. RESULTS: Some 3,101 discharge documentation packets of patients discharged to subacute facilities from January 1, 2006, through September 2008 were retrospectively studied. During the 11 monitored quarters, the defect-free rate increased from 65% to 96% (p < .001 for trend). The largest improvements were seen in documentation of preadmission medication lists, allergies, follow-up, and warfarin information. CONCLUSIONS: Institution of rigorous measurement, feedback, and multidisciplinary, multimodal quality improvement processes improved the inclusion of data elements in discharge documentation required for safe hospital discharge across a large integrated health care system.

PMID: 20564885 [PubMed - in process]

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Combination therapy in hypertension.

J Am Soc Hypertens. 2010 Jan-Feb;4(1):42-50

Authors: Gradman AH, Basile JN, Carter BL, Bakris GL,

The goal of antihypertensive therapy is to abolish the risks associated with blood pressure (BP) elevation without adversely affecting quality of life. Drug selection is based on efficacy in lowering BP and in reducing cardiovascular (CV) end points including stroke, myocardial infarction, and heart failure. Although the choice of initial drug therapy exerts some effect on long-term outcomes, it is evident that BP reduction per se is the primary determinant of CV risk reduction. Available data suggest that at least 75% of patients will require combination therapy to achieve contemporary BP targets, and increasing emphasis is being placed on the practical tasks involved in consistently achieving and maintaining goal BP in clinical practice. It is within this context that the American Society of Hypertension presents this Position Paper on Combination Therapy for Hypertension. It will address the scientific basis of combination therapy, present the pharmacologic rationale for choosing specific drug combinations, and review patient selection criteria for initial and secondary use. The advantages and disadvantages of single pill (fixed) drug combinations, and the implications of recent clinical trials involving specific combination strategies will also be discussed.

PMID: 20374950 [PubMed - indexed for MEDLINE]

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Postoperative pneumonia in elderly patients receiving acid suppressants: a retrospective cohort analysis.

BMJ. 2010;340:c2608

Authors: Redelmeier DA, McAlister FA, Kandel CE, Lu H, Daneman N

OBJECTIVE: To test whether gastric acid suppressants are associated with an increased risk of postoperative pneumonia in patients undergoing elective surgery. DESIGN: Population-wide retrospective cohort analysis. SETTING: Canadian acute care hospitals between 1 April 1992 and 31 March 2008. Patients Consecutive patients aged >65 years admitted for an elective operation. OUTCOME MEASURE: Postoperative pneumonia recorded in inpatient postoperative notes. RESULTS: A total of 593 265 patients were included, of whom about 21% were taking an acid suppressant (most commonly omeprazole or ranitidine). Overall, 6389 patients developed postoperative pneumonia, with a rate significantly higher for those taking acid suppressants (13 per 1000) than controls (10 per 1000), equivalent to a 30% increase in frequency (odds ratio 1.30 (95% confidence interval 1.23 to 1.38), P<0.001). However, no increase in risk was observed after adjustment for duration of surgery, site of surgery, and other confounders (odds ratio 1.02 (0.96 to 1.09), P=0.48). The general safety of acid suppressants extended to those patients prescribed proton pump inhibitors, experiencing long term treatment, receiving high doses, and undergoing high risk procedures. CONCLUSION: After adjustment for patient and surgical characteristics, acid suppressants are not associated with an increased risk of postoperative pneumonia among elderly patients admitted for elective surgery.

PMID: 20566596 [PubMed - in process]

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