Alexander R. Carbo, MD, SFHM

Clinical question: Is there a score that will predict the mortality rate in elderly patients presenting with a non-ST-elevation myocardial infarction (NSTEMI)?

Background: Although they represent only 9% of patients in clinical trials, patients over the age of 75 make up one third of patients with NSTEMI, accounting for more than half of NSTEMI-related mortality.

Study design: Retrospective cohort analysis for score calculator design, with prospective cohort validation.

Setting: The retrospective cohort was derived from a meta-analysis of 55 papers. The prospective validation arm used a cohort of patients from a randomized multicenter Italian trial.

Synopsis: The authors developed and validated a mortality predictor for patients 75 and older who present with an NSTEMI. The calculator: hemoglobin less than 10 g/dl (two points), elevated troponin levels, ECG ischemic changes, estimated glomerular filtration rate (eGFR) less than 45, previous vascular event (one point each two). The calculator predicted probabilities of death in one year ranging from 2% (score of zero) to 75% (score of six). The calculator allowed stratification into low (score: zero to one), intermediate (score: two), or high (score: three or greater) risk. High-risk patients appeared to benefit from intervention with significantly reduced risk for mortality (odds ratio 0.44).

Bottom line: A simple risk calculator stratifies elderly patients into low, intermediate, or high risk to predict mortality from NSTEMI. High-risk patients appear to achieve a mortality benefit from intervention.

Citation: Angeli F, Cavallini C, Verdecchia P, et al. A risk score for predicting 1-year mortality in patients ≥75 years of age presenting with non-ST-elevation acute coronary syndrome. Am J Cardiol. 2015;116(2):208-213.

Clinical question: Is there a score that will predict the mortality rate in elderly patients presenting with a non-ST-elevation myocardial infarction (NSTEMI)?

Background: Although they represent only 9% of patients in clinical trials, patients over the age of 75 make up one third of patients with NSTEMI, accounting for more than half of NSTEMI-related mortality.

Study design: Retrospective cohort analysis for score calculator design, with prospective cohort validation.

Setting: The retrospective cohort was derived from a meta-analysis of 55 papers. The prospective validation arm used a cohort of patients from a randomized multicenter Italian trial.

Synopsis: The authors developed and validated a mortality predictor for patients 75 and older who present with an NSTEMI. The calculator: hemoglobin less than 10 g/dl (two points), elevated troponin levels, ECG ischemic changes, estimated glomerular filtration rate (eGFR) less than 45, previous vascular event (one point each two). The calculator predicted probabilities of death in one year ranging from 2% (score of zero) to 75% (score of six). The calculator allowed stratification into low (score: zero to one), intermediate (score: two), or high (score: three or greater) risk. High-risk patients appeared to benefit from intervention with significantly reduced risk for mortality (odds ratio 0.44).

Bottom line: A simple risk calculator stratifies elderly patients into low, intermediate, or high risk to predict mortality from NSTEMI. High-risk patients appear to achieve a mortality benefit from intervention.

Citation: Angeli F, Cavallini C, Verdecchia P, et al. A risk score for predicting 1-year mortality in patients ≥75 years of age presenting with non-ST-elevation acute coronary syndrome. Am J Cardiol. 2015;116(2):208-213.

Clinical question: Is there a score that will predict the mortality rate in elderly patients presenting with a non-ST-elevation myocardial infarction (NSTEMI)?

Background: Although they represent only 9% of patients in clinical trials, patients over the age of 75 make up one third of patients with NSTEMI, accounting for more than half of NSTEMI-related mortality.

Study design: Retrospective cohort analysis for score calculator design, with prospective cohort validation.

Setting: The retrospective cohort was derived from a meta-analysis of 55 papers. The prospective validation arm used a cohort of patients from a randomized multicenter Italian trial.

Synopsis: The authors developed and validated a mortality predictor for patients 75 and older who present with an NSTEMI. The calculator: hemoglobin less than 10 g/dl (two points), elevated troponin levels, ECG ischemic changes, estimated glomerular filtration rate (eGFR) less than 45, previous vascular event (one point each two). The calculator predicted probabilities of death in one year ranging from 2% (score of zero) to 75% (score of six). The calculator allowed stratification into low (score: zero to one), intermediate (score: two), or high (score: three or greater) risk. High-risk patients appeared to benefit from intervention with significantly reduced risk for mortality (odds ratio 0.44).

Bottom line: A simple risk calculator stratifies elderly patients into low, intermediate, or high risk to predict mortality from NSTEMI. High-risk patients appear to achieve a mortality benefit from intervention.

Citation: Angeli F, Cavallini C, Verdecchia P, et al. A risk score for predicting 1-year mortality in patients ≥75 years of age presenting with non-ST-elevation acute coronary syndrome. Am J Cardiol. 2015;116(2):208-213.

Case

A 31-year-old male with a history of asthma is admitted with an asthma exacerbation. He has no regular outpatient provider. He denies tobacco use and reports that he is in a monogamous relationship with his girlfriend. On rounds, a medical student mentions that new HIV screening guidelines have been released recently and asks whether this patient should be screened for HIV.

Background

By the mid-2000s, approximately one to 1.2 million people in the United States were infected with HIV.¹ Approximately one quarter of these patients are estimated to be unaware of their HIV status, and this subgroup is believed responsible for a disproportionately higher percentage of new HIV infections each year.¹

While older HIV screening recommendations focused on screening patients who were deemed to be at high risk for HIV infection, there has been a paradigm change in recent years toward universal screening of all patients.^2,3 The ultimate goal is for earlier identification of infected patients, which will, in turn, lead to earlier treatment and better prevention efforts.

Universal screening has been supported by a number of different professional societies and screening guidelines.⁴

2013 Guideline

In 2013, the United States Preventive Services Task Force (USPSTF) issued new recommendations regarding HIV screening. Although the previous USPSTF guidelines (released in 2005) recommended screening patients who were believed to be at increased risk for contracting HIV, the 2013 guidelines now recommend screening all patients aged 15 to 65.⁴

Screening patients outside of this age range is recommended if the patient is deemed to be at increased risk for contracting HIV.⁴ The USPSTF provides criteria for identifying patients who are at increased risk of contracting HIV. These include:

• Men who have sex with men;
• People having unprotected vaginal or anal intercourse;
• People using injection drugs;
• People exchanging sex for drugs or money; and
• People requesting testing for other sexually transmitted diseases (STDs).⁴

Patients are also considered to be high risk if their sexual partners are infected with HIV, are bisexual, or use injection drugs.⁴

The shift toward universal HIV screening has been a trend for many years, because risk-based targeting of HIV screening will miss a significant number of HIV infections.² In fact, the 2013 recommendations bring the USPSTF guidelines into agreement with current CDC guidelines, which were released in 2006.²

The CDC, in its 2006 guidelines, recommended screening for all patients 13 to 64 years old unless HIV prevalence in the patient population has been found to be less than 0.1%, the minimum prevalence deemed necessary for HIV screening to be cost-effective.² The CDC guidelines also recommend HIV screening for all patients starting treatment for tuberculosis, patients being screened for STDs, and patients visiting STD clinics regardless of chief complaint.² They recommend that HIV screening be performed in an “opt-out” fashion, meaning that patients are informed that screening will be performed unless they decline.² Furthermore, they recommend against the need for a separate written consent form for HIV screening, as well as the prior requirement that pre-screening counseling be performed, because these requirements were felt to create potential time constraint barriers that prevented providers from screening patients.²

The CDC and the USPSTF are less conclusive with regard to frequency of rescreening for HIV infection. Both recommend rescreening patients considered high risk for HIV infection, but the interval for rescreening has not been concretely defined.^2,4 The guidelines urge providers to use clinical judgment in deciding when to rescreen for HIV infection.² For example, one reason for rescreening cited by the CDC would be the initiation of a new sexual relationship.²

In the 2013 guidelines, the USPSTF also recommends screening all pregnant women, including those presenting in labor without a known HIV status.⁴ This stance is supported by the American College of Gynecologists and Obstetricians.³ In high-risk patients with a negative screening test early in pregnancy, consideration should be given to repeat testing in the third trimester.³ Routinely screening pregnant women for HIV and starting appropriate therapy in positive patients has lowered the incidence of perinatal HIV transmission dramatically.²

Rationale

There are several reasons behind the shift to universal HIV screening, regardless of risk. First, providers often do not accurately identify patients’ HIV risk, often because patients are not aware of their actual risk or are uncomfortable discussing their high-risk behaviors with healthcare providers.² Using risk factors as a basis of screening will miss a significant number of HIV-positive patients.⁴

Additionally, screening all patients will result in the detection of HIV infection in a greater number of patients during the early asymptomatic phase, rather than when they later become symptomatic from HIV or AIDS.^2,4 Recent data has led the International Antiviral Society—USA Panel to issue updated recommendations advising initiation of antiretroviral therapy at all CD4 levels.⁵ Studies and observational data suggest that this could result in reduced AIDS complications and death rates.⁴

Early detection of HIV infection also has the potential of reducing spread of the virus.^2,4 It has been suggested that early initiation of antiretroviral therapy could reduce risk of transmission to noninfected partners by lowering viral load in the infected patient.² Knowledge of HIV status has also been shown to reduce high-risk behaviors.⁴

Moreover, by facilitating earlier detection of HIV, universal screening will allow for earlier and better counseling for infected patients.⁴ This has the potential to further alter behaviors and possibly reduce transmission of HIV and/or other sexually transmitted diseases.⁴ Additionally, routine screening of pregnant women allows for better detection of HIV-infected mothers.³ With appropriate interventions during pregnancy, including antiretroviral therapy, rates of mother-to-child transmission have decreased significantly.⁴

On the other hand, potential harms from HIV screening were considered during the USPSTF analysis, including risk of false positive test results, as well as the side effects of antiretroviral medications.⁴ Although there are known short-term and long-term side effects of antiretroviral medications, some of these side effects can be avoided by changing drug regimens.⁴ For many other side effects, the benefits appeared to outweigh the risks of these medications.⁴

Studies have also shown some potential side effects in infants exposed to antiretroviral medications, but the overall evidence is not strong.⁴ In the end, thorough analysis performed by the USPSTF resulted in the opinion that the benefits of HIV screening far outweigh the associated risks.⁴

Challenges for Hospitalists

Several potential drawbacks to universal HIV screening are relatively unique to hospitalists and other providers of hospital-based care.6 First, hospitalists must be prepared to counsel patients regarding their test results, particularly if patients are hospitalized for another issue. Second, hospitalists must be able to communicate these test results to primary care providers in a timely fashion, a challenge that is not unique to HIV testing.

The biggest concern for hospitalists is what to do with HIV test results that are still pending at the time of hospital discharge. Hospitalists will likely face this issue more as increasing numbers of patients are screened in a growing number of medical settings, including the ED and inpatient admissions. Hospitalists who plan to screen inpatients for HIV testing must ensure that these issues have been worked out prior to screening.

Back to the Case

Looking back to the initial case discussion, based on the 2006 CDC and 2013 USPSTF guidelines, this patient should be offered HIV screening if he has not been tested previously. Although the patient states that he is in a monogamous relationship and does not report any high-risk behaviors, patients often do not recognize the true risk associated with their behaviors and fail to accurately report them.² Additionally, patients often are embarrassed by high-risk behaviors and may not report them completely to providers.²

The patient has admitted that he does not seek medical care on a regular basis. This inpatient admission may be his only interaction with the medical field for some time, and thus his only opportunity to undergo screening. But, prior to screening the patient, the hospitalist must ensure that he or she will be able to counsel the patient regarding test results, will be able to communicate those results to the patient’s primary care physician, and will be able to handle pending results if the patient is discharged before the test results are returned.

Drs. Gwyn, Carbo and Li are hospitalists at Beth Israel Deaconess Medical Center in Boston.

References

1. Branson B. Current HIV epidemiology and revised recommendations for HIV testing in health-care settings. J Med Virol. 2007;79 Suppl 1:S6-S10.
2. Moyer VA; U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159(1):51-60.
3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.
4. Clark J, Lampe MA, Jamieson DJ. Testing women for human immunodeficiency virus infection: who, when, and how? Clin Obstet Gynceol. 2008;51(3):507-517.
5. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society–USA Panel. JAMA. 2012;308(4):387-402.
6. Arbelaez C, Wright EA, Losina E, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med. 2012;42(1):7-14.

Case

A 31-year-old male with a history of asthma is admitted with an asthma exacerbation. He has no regular outpatient provider. He denies tobacco use and reports that he is in a monogamous relationship with his girlfriend. On rounds, a medical student mentions that new HIV screening guidelines have been released recently and asks whether this patient should be screened for HIV.

Background

By the mid-2000s, approximately one to 1.2 million people in the United States were infected with HIV.¹ Approximately one quarter of these patients are estimated to be unaware of their HIV status, and this subgroup is believed responsible for a disproportionately higher percentage of new HIV infections each year.¹

While older HIV screening recommendations focused on screening patients who were deemed to be at high risk for HIV infection, there has been a paradigm change in recent years toward universal screening of all patients.^2,3 The ultimate goal is for earlier identification of infected patients, which will, in turn, lead to earlier treatment and better prevention efforts.

Universal screening has been supported by a number of different professional societies and screening guidelines.⁴

2013 Guideline

In 2013, the United States Preventive Services Task Force (USPSTF) issued new recommendations regarding HIV screening. Although the previous USPSTF guidelines (released in 2005) recommended screening patients who were believed to be at increased risk for contracting HIV, the 2013 guidelines now recommend screening all patients aged 15 to 65.⁴

Screening patients outside of this age range is recommended if the patient is deemed to be at increased risk for contracting HIV.⁴ The USPSTF provides criteria for identifying patients who are at increased risk of contracting HIV. These include:

• Men who have sex with men;
• People having unprotected vaginal or anal intercourse;
• People using injection drugs;
• People exchanging sex for drugs or money; and
• People requesting testing for other sexually transmitted diseases (STDs).⁴

Patients are also considered to be high risk if their sexual partners are infected with HIV, are bisexual, or use injection drugs.⁴

The shift toward universal HIV screening has been a trend for many years, because risk-based targeting of HIV screening will miss a significant number of HIV infections.² In fact, the 2013 recommendations bring the USPSTF guidelines into agreement with current CDC guidelines, which were released in 2006.²

The CDC, in its 2006 guidelines, recommended screening for all patients 13 to 64 years old unless HIV prevalence in the patient population has been found to be less than 0.1%, the minimum prevalence deemed necessary for HIV screening to be cost-effective.² The CDC guidelines also recommend HIV screening for all patients starting treatment for tuberculosis, patients being screened for STDs, and patients visiting STD clinics regardless of chief complaint.² They recommend that HIV screening be performed in an “opt-out” fashion, meaning that patients are informed that screening will be performed unless they decline.² Furthermore, they recommend against the need for a separate written consent form for HIV screening, as well as the prior requirement that pre-screening counseling be performed, because these requirements were felt to create potential time constraint barriers that prevented providers from screening patients.²

The CDC and the USPSTF are less conclusive with regard to frequency of rescreening for HIV infection. Both recommend rescreening patients considered high risk for HIV infection, but the interval for rescreening has not been concretely defined.^2,4 The guidelines urge providers to use clinical judgment in deciding when to rescreen for HIV infection.² For example, one reason for rescreening cited by the CDC would be the initiation of a new sexual relationship.²

In the 2013 guidelines, the USPSTF also recommends screening all pregnant women, including those presenting in labor without a known HIV status.⁴ This stance is supported by the American College of Gynecologists and Obstetricians.³ In high-risk patients with a negative screening test early in pregnancy, consideration should be given to repeat testing in the third trimester.³ Routinely screening pregnant women for HIV and starting appropriate therapy in positive patients has lowered the incidence of perinatal HIV transmission dramatically.²

Rationale

There are several reasons behind the shift to universal HIV screening, regardless of risk. First, providers often do not accurately identify patients’ HIV risk, often because patients are not aware of their actual risk or are uncomfortable discussing their high-risk behaviors with healthcare providers.² Using risk factors as a basis of screening will miss a significant number of HIV-positive patients.⁴

Additionally, screening all patients will result in the detection of HIV infection in a greater number of patients during the early asymptomatic phase, rather than when they later become symptomatic from HIV or AIDS.^2,4 Recent data has led the International Antiviral Society—USA Panel to issue updated recommendations advising initiation of antiretroviral therapy at all CD4 levels.⁵ Studies and observational data suggest that this could result in reduced AIDS complications and death rates.⁴

Early detection of HIV infection also has the potential of reducing spread of the virus.^2,4 It has been suggested that early initiation of antiretroviral therapy could reduce risk of transmission to noninfected partners by lowering viral load in the infected patient.² Knowledge of HIV status has also been shown to reduce high-risk behaviors.⁴

Moreover, by facilitating earlier detection of HIV, universal screening will allow for earlier and better counseling for infected patients.⁴ This has the potential to further alter behaviors and possibly reduce transmission of HIV and/or other sexually transmitted diseases.⁴ Additionally, routine screening of pregnant women allows for better detection of HIV-infected mothers.³ With appropriate interventions during pregnancy, including antiretroviral therapy, rates of mother-to-child transmission have decreased significantly.⁴

On the other hand, potential harms from HIV screening were considered during the USPSTF analysis, including risk of false positive test results, as well as the side effects of antiretroviral medications.⁴ Although there are known short-term and long-term side effects of antiretroviral medications, some of these side effects can be avoided by changing drug regimens.⁴ For many other side effects, the benefits appeared to outweigh the risks of these medications.⁴

Studies have also shown some potential side effects in infants exposed to antiretroviral medications, but the overall evidence is not strong.⁴ In the end, thorough analysis performed by the USPSTF resulted in the opinion that the benefits of HIV screening far outweigh the associated risks.⁴

Challenges for Hospitalists

Several potential drawbacks to universal HIV screening are relatively unique to hospitalists and other providers of hospital-based care.6 First, hospitalists must be prepared to counsel patients regarding their test results, particularly if patients are hospitalized for another issue. Second, hospitalists must be able to communicate these test results to primary care providers in a timely fashion, a challenge that is not unique to HIV testing.

The biggest concern for hospitalists is what to do with HIV test results that are still pending at the time of hospital discharge. Hospitalists will likely face this issue more as increasing numbers of patients are screened in a growing number of medical settings, including the ED and inpatient admissions. Hospitalists who plan to screen inpatients for HIV testing must ensure that these issues have been worked out prior to screening.

Back to the Case

Looking back to the initial case discussion, based on the 2006 CDC and 2013 USPSTF guidelines, this patient should be offered HIV screening if he has not been tested previously. Although the patient states that he is in a monogamous relationship and does not report any high-risk behaviors, patients often do not recognize the true risk associated with their behaviors and fail to accurately report them.² Additionally, patients often are embarrassed by high-risk behaviors and may not report them completely to providers.²

The patient has admitted that he does not seek medical care on a regular basis. This inpatient admission may be his only interaction with the medical field for some time, and thus his only opportunity to undergo screening. But, prior to screening the patient, the hospitalist must ensure that he or she will be able to counsel the patient regarding test results, will be able to communicate those results to the patient’s primary care physician, and will be able to handle pending results if the patient is discharged before the test results are returned.

Drs. Gwyn, Carbo and Li are hospitalists at Beth Israel Deaconess Medical Center in Boston.

References

1. Branson B. Current HIV epidemiology and revised recommendations for HIV testing in health-care settings. J Med Virol. 2007;79 Suppl 1:S6-S10.
2. Moyer VA; U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159(1):51-60.
3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.
4. Clark J, Lampe MA, Jamieson DJ. Testing women for human immunodeficiency virus infection: who, when, and how? Clin Obstet Gynceol. 2008;51(3):507-517.
5. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society–USA Panel. JAMA. 2012;308(4):387-402.
6. Arbelaez C, Wright EA, Losina E, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med. 2012;42(1):7-14.

Case

A 31-year-old male with a history of asthma is admitted with an asthma exacerbation. He has no regular outpatient provider. He denies tobacco use and reports that he is in a monogamous relationship with his girlfriend. On rounds, a medical student mentions that new HIV screening guidelines have been released recently and asks whether this patient should be screened for HIV.

Background

By the mid-2000s, approximately one to 1.2 million people in the United States were infected with HIV.¹ Approximately one quarter of these patients are estimated to be unaware of their HIV status, and this subgroup is believed responsible for a disproportionately higher percentage of new HIV infections each year.¹

While older HIV screening recommendations focused on screening patients who were deemed to be at high risk for HIV infection, there has been a paradigm change in recent years toward universal screening of all patients.^2,3 The ultimate goal is for earlier identification of infected patients, which will, in turn, lead to earlier treatment and better prevention efforts.

Universal screening has been supported by a number of different professional societies and screening guidelines.⁴

2013 Guideline

In 2013, the United States Preventive Services Task Force (USPSTF) issued new recommendations regarding HIV screening. Although the previous USPSTF guidelines (released in 2005) recommended screening patients who were believed to be at increased risk for contracting HIV, the 2013 guidelines now recommend screening all patients aged 15 to 65.⁴

Screening patients outside of this age range is recommended if the patient is deemed to be at increased risk for contracting HIV.⁴ The USPSTF provides criteria for identifying patients who are at increased risk of contracting HIV. These include:

• Men who have sex with men;
• People having unprotected vaginal or anal intercourse;
• People using injection drugs;
• People exchanging sex for drugs or money; and
• People requesting testing for other sexually transmitted diseases (STDs).⁴

Patients are also considered to be high risk if their sexual partners are infected with HIV, are bisexual, or use injection drugs.⁴

The shift toward universal HIV screening has been a trend for many years, because risk-based targeting of HIV screening will miss a significant number of HIV infections.² In fact, the 2013 recommendations bring the USPSTF guidelines into agreement with current CDC guidelines, which were released in 2006.²

The CDC, in its 2006 guidelines, recommended screening for all patients 13 to 64 years old unless HIV prevalence in the patient population has been found to be less than 0.1%, the minimum prevalence deemed necessary for HIV screening to be cost-effective.² The CDC guidelines also recommend HIV screening for all patients starting treatment for tuberculosis, patients being screened for STDs, and patients visiting STD clinics regardless of chief complaint.² They recommend that HIV screening be performed in an “opt-out” fashion, meaning that patients are informed that screening will be performed unless they decline.² Furthermore, they recommend against the need for a separate written consent form for HIV screening, as well as the prior requirement that pre-screening counseling be performed, because these requirements were felt to create potential time constraint barriers that prevented providers from screening patients.²

The CDC and the USPSTF are less conclusive with regard to frequency of rescreening for HIV infection. Both recommend rescreening patients considered high risk for HIV infection, but the interval for rescreening has not been concretely defined.^2,4 The guidelines urge providers to use clinical judgment in deciding when to rescreen for HIV infection.² For example, one reason for rescreening cited by the CDC would be the initiation of a new sexual relationship.²

In the 2013 guidelines, the USPSTF also recommends screening all pregnant women, including those presenting in labor without a known HIV status.⁴ This stance is supported by the American College of Gynecologists and Obstetricians.³ In high-risk patients with a negative screening test early in pregnancy, consideration should be given to repeat testing in the third trimester.³ Routinely screening pregnant women for HIV and starting appropriate therapy in positive patients has lowered the incidence of perinatal HIV transmission dramatically.²

Rationale

There are several reasons behind the shift to universal HIV screening, regardless of risk. First, providers often do not accurately identify patients’ HIV risk, often because patients are not aware of their actual risk or are uncomfortable discussing their high-risk behaviors with healthcare providers.² Using risk factors as a basis of screening will miss a significant number of HIV-positive patients.⁴

Additionally, screening all patients will result in the detection of HIV infection in a greater number of patients during the early asymptomatic phase, rather than when they later become symptomatic from HIV or AIDS.^2,4 Recent data has led the International Antiviral Society—USA Panel to issue updated recommendations advising initiation of antiretroviral therapy at all CD4 levels.⁵ Studies and observational data suggest that this could result in reduced AIDS complications and death rates.⁴

Early detection of HIV infection also has the potential of reducing spread of the virus.^2,4 It has been suggested that early initiation of antiretroviral therapy could reduce risk of transmission to noninfected partners by lowering viral load in the infected patient.² Knowledge of HIV status has also been shown to reduce high-risk behaviors.⁴

Moreover, by facilitating earlier detection of HIV, universal screening will allow for earlier and better counseling for infected patients.⁴ This has the potential to further alter behaviors and possibly reduce transmission of HIV and/or other sexually transmitted diseases.⁴ Additionally, routine screening of pregnant women allows for better detection of HIV-infected mothers.³ With appropriate interventions during pregnancy, including antiretroviral therapy, rates of mother-to-child transmission have decreased significantly.⁴

On the other hand, potential harms from HIV screening were considered during the USPSTF analysis, including risk of false positive test results, as well as the side effects of antiretroviral medications.⁴ Although there are known short-term and long-term side effects of antiretroviral medications, some of these side effects can be avoided by changing drug regimens.⁴ For many other side effects, the benefits appeared to outweigh the risks of these medications.⁴

Studies have also shown some potential side effects in infants exposed to antiretroviral medications, but the overall evidence is not strong.⁴ In the end, thorough analysis performed by the USPSTF resulted in the opinion that the benefits of HIV screening far outweigh the associated risks.⁴

Challenges for Hospitalists

Several potential drawbacks to universal HIV screening are relatively unique to hospitalists and other providers of hospital-based care.6 First, hospitalists must be prepared to counsel patients regarding their test results, particularly if patients are hospitalized for another issue. Second, hospitalists must be able to communicate these test results to primary care providers in a timely fashion, a challenge that is not unique to HIV testing.

The biggest concern for hospitalists is what to do with HIV test results that are still pending at the time of hospital discharge. Hospitalists will likely face this issue more as increasing numbers of patients are screened in a growing number of medical settings, including the ED and inpatient admissions. Hospitalists who plan to screen inpatients for HIV testing must ensure that these issues have been worked out prior to screening.

Back to the Case

Looking back to the initial case discussion, based on the 2006 CDC and 2013 USPSTF guidelines, this patient should be offered HIV screening if he has not been tested previously. Although the patient states that he is in a monogamous relationship and does not report any high-risk behaviors, patients often do not recognize the true risk associated with their behaviors and fail to accurately report them.² Additionally, patients often are embarrassed by high-risk behaviors and may not report them completely to providers.²

The patient has admitted that he does not seek medical care on a regular basis. This inpatient admission may be his only interaction with the medical field for some time, and thus his only opportunity to undergo screening. But, prior to screening the patient, the hospitalist must ensure that he or she will be able to counsel the patient regarding test results, will be able to communicate those results to the patient’s primary care physician, and will be able to handle pending results if the patient is discharged before the test results are returned.

Drs. Gwyn, Carbo and Li are hospitalists at Beth Israel Deaconess Medical Center in Boston.

References

1. Branson B. Current HIV epidemiology and revised recommendations for HIV testing in health-care settings. J Med Virol. 2007;79 Suppl 1:S6-S10.
2. Moyer VA; U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159(1):51-60.
3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17.
4. Clark J, Lampe MA, Jamieson DJ. Testing women for human immunodeficiency virus infection: who, when, and how? Clin Obstet Gynceol. 2008;51(3):507-517.
5. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society–USA Panel. JAMA. 2012;308(4):387-402.
6. Arbelaez C, Wright EA, Losina E, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med. 2012;42(1):7-14.

Background: After initial infection, 10%–25% of patients experience recurrent CDI. The identification of patients at high risk of recurrence would be beneficial for therapeutic decision-making.

Study design: Retrospective cohort study.

Setting: Large, urban, academic medical center.

Synopsis: Authors included 4,196 patients with an initial infection defined by a positive C. diff toxin assay and unformed stools. A repeat positive toxin within 42 days of completing treatment for the initial infection represented recurrent CDI. Multiple characteristics were examined to identify risks of recurrent infection, including demographics and those related to acute and chronic disease. A logistic regression model was used to identify risk factors for recurrence. Recurrent CDI occurred in 425 patients (10.1%). Age, fluoroquinolone and high-risk antibiotic use, community-acquired healthcare-associated infection, multiple hospitalizations, and gastric acid suppression were found to predict recurrent infection through multivariate analysis. Limitations of the study included potential confounding, use of observational data, and generalizability given the urban academic medical center setting. This prediction model differs from previously developed models in that it identifies factors present at the onset of infection.

Bottom line: Multiple factors identified at the onset of illness can predict CDI recurrence.

Citation: Zilberberg MD, Reske K, Olsen M, Yan Y, Dubberke ER. Development and validation of a recurrent Clostridium difficile risk-prediction model. J Hosp Med. 2014;9(7):418-423. TH

Background: After initial infection, 10%–25% of patients experience recurrent CDI. The identification of patients at high risk of recurrence would be beneficial for therapeutic decision-making.

Study design: Retrospective cohort study.

Setting: Large, urban, academic medical center.

Synopsis: Authors included 4,196 patients with an initial infection defined by a positive C. diff toxin assay and unformed stools. A repeat positive toxin within 42 days of completing treatment for the initial infection represented recurrent CDI. Multiple characteristics were examined to identify risks of recurrent infection, including demographics and those related to acute and chronic disease. A logistic regression model was used to identify risk factors for recurrence. Recurrent CDI occurred in 425 patients (10.1%). Age, fluoroquinolone and high-risk antibiotic use, community-acquired healthcare-associated infection, multiple hospitalizations, and gastric acid suppression were found to predict recurrent infection through multivariate analysis. Limitations of the study included potential confounding, use of observational data, and generalizability given the urban academic medical center setting. This prediction model differs from previously developed models in that it identifies factors present at the onset of infection.

Bottom line: Multiple factors identified at the onset of illness can predict CDI recurrence.

Citation: Zilberberg MD, Reske K, Olsen M, Yan Y, Dubberke ER. Development and validation of a recurrent Clostridium difficile risk-prediction model. J Hosp Med. 2014;9(7):418-423. TH

Background: After initial infection, 10%–25% of patients experience recurrent CDI. The identification of patients at high risk of recurrence would be beneficial for therapeutic decision-making.

Study design: Retrospective cohort study.

Setting: Large, urban, academic medical center.

Synopsis: Authors included 4,196 patients with an initial infection defined by a positive C. diff toxin assay and unformed stools. A repeat positive toxin within 42 days of completing treatment for the initial infection represented recurrent CDI. Multiple characteristics were examined to identify risks of recurrent infection, including demographics and those related to acute and chronic disease. A logistic regression model was used to identify risk factors for recurrence. Recurrent CDI occurred in 425 patients (10.1%). Age, fluoroquinolone and high-risk antibiotic use, community-acquired healthcare-associated infection, multiple hospitalizations, and gastric acid suppression were found to predict recurrent infection through multivariate analysis. Limitations of the study included potential confounding, use of observational data, and generalizability given the urban academic medical center setting. This prediction model differs from previously developed models in that it identifies factors present at the onset of infection.

Bottom line: Multiple factors identified at the onset of illness can predict CDI recurrence.

Citation: Zilberberg MD, Reske K, Olsen M, Yan Y, Dubberke ER. Development and validation of a recurrent Clostridium difficile risk-prediction model. J Hosp Med. 2014;9(7):418-423. TH

Clinical question: Does targeting a higher mean arterial pressure (MAP) in patients with septic shock lead to decreased mortality compared with targeting a more typical MAP range?

Background: The ideal blood pressure target for patients with septic shock is not currently known. There is some clinical evidence that patients with chronic arterial hypertension may require higher blood pressure to sustain kidney function.

Study design: Multicenter, randomized, stratified, open-label clinical trial.

Setting: ICUs at 29 centers in France

Synopsis: Researchers randomized 776 patients with septic shock to receive vasopressor treatment to maintain a MAP of 80-85 mmHg (high-target group) or 65-70 mmHg (low-target group). There was no significant difference between groups in the primary outcome of death at 28 days (HR in the high target group 1.07; 95% CI 0.84-1.38; P=0.57).

In patients with chronic arterial hypertension, those who were randomized to the high-target group had a reduced risk of doubling of plasma creatinine or need for renal-replacement therapy from days one to seven. Patients in the high-target group received larger amounts of vasopressors and for a longer period of time. There was no difference between the groups in the overall incidence of serious adverse events, though significantly more patients in the high-target group (6.7%) developed new onset atrial fibrillation compared with those in the low-target group (2.8%).

Bottom line: Mortality at 28 days was not significantly different in patients with septic shock who were randomized to a higher MAP target compared to patients who had a lower MAP target; this lower target encompasses the 65 mmHg target that is listed in the Surviving Sepsis Campaign guidelines.

Citation: Asfar P, Meziani F, Hamel JF, et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med. 2014;370(17):1583-1593.

Clinical question: Does targeting a higher mean arterial pressure (MAP) in patients with septic shock lead to decreased mortality compared with targeting a more typical MAP range?

Background: The ideal blood pressure target for patients with septic shock is not currently known. There is some clinical evidence that patients with chronic arterial hypertension may require higher blood pressure to sustain kidney function.

Study design: Multicenter, randomized, stratified, open-label clinical trial.

Setting: ICUs at 29 centers in France

Synopsis: Researchers randomized 776 patients with septic shock to receive vasopressor treatment to maintain a MAP of 80-85 mmHg (high-target group) or 65-70 mmHg (low-target group). There was no significant difference between groups in the primary outcome of death at 28 days (HR in the high target group 1.07; 95% CI 0.84-1.38; P=0.57).

In patients with chronic arterial hypertension, those who were randomized to the high-target group had a reduced risk of doubling of plasma creatinine or need for renal-replacement therapy from days one to seven. Patients in the high-target group received larger amounts of vasopressors and for a longer period of time. There was no difference between the groups in the overall incidence of serious adverse events, though significantly more patients in the high-target group (6.7%) developed new onset atrial fibrillation compared with those in the low-target group (2.8%).

Bottom line: Mortality at 28 days was not significantly different in patients with septic shock who were randomized to a higher MAP target compared to patients who had a lower MAP target; this lower target encompasses the 65 mmHg target that is listed in the Surviving Sepsis Campaign guidelines.

Citation: Asfar P, Meziani F, Hamel JF, et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med. 2014;370(17):1583-1593.

Clinical question: Does targeting a higher mean arterial pressure (MAP) in patients with septic shock lead to decreased mortality compared with targeting a more typical MAP range?

Background: The ideal blood pressure target for patients with septic shock is not currently known. There is some clinical evidence that patients with chronic arterial hypertension may require higher blood pressure to sustain kidney function.

Study design: Multicenter, randomized, stratified, open-label clinical trial.

Setting: ICUs at 29 centers in France

Synopsis: Researchers randomized 776 patients with septic shock to receive vasopressor treatment to maintain a MAP of 80-85 mmHg (high-target group) or 65-70 mmHg (low-target group). There was no significant difference between groups in the primary outcome of death at 28 days (HR in the high target group 1.07; 95% CI 0.84-1.38; P=0.57).

In patients with chronic arterial hypertension, those who were randomized to the high-target group had a reduced risk of doubling of plasma creatinine or need for renal-replacement therapy from days one to seven. Patients in the high-target group received larger amounts of vasopressors and for a longer period of time. There was no difference between the groups in the overall incidence of serious adverse events, though significantly more patients in the high-target group (6.7%) developed new onset atrial fibrillation compared with those in the low-target group (2.8%).

Bottom line: Mortality at 28 days was not significantly different in patients with septic shock who were randomized to a higher MAP target compared to patients who had a lower MAP target; this lower target encompasses the 65 mmHg target that is listed in the Surviving Sepsis Campaign guidelines.

Citation: Asfar P, Meziani F, Hamel JF, et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med. 2014;370(17):1583-1593.

Clinical question: Do different thresholds for red blood cell (RBC) transfusion influence the risk of infection, and does leukocyte reduction also influence the risk of infection?

Background: RBC transfusion is a common and costly medical intervention performed across U.S. hospitals. Scientists suspect that RBC transfusion may have immunomodulatory properties and may affect a patient’s risk of acquiring various infections.

Study design: Meta-analysis and systematic review.

Setting: International adult, pediatric, obstetric medical and surgical wards, and ICUs.

Synopsis: Eighteen studies performed were included in the meta-analysis of published randomized trials comparing restrictive to liberal RBC transfusion strategies in which infectious outcomes were reported. Patient enrollment spanned from 1994 to 2012. Six of the trials included pediatric patients. For adult patients, the restrictive RBC transfusion threshold ranged from 6.4–9.7 g/dL, while the liberal target ranged from 9-11.3 g/dL in included trials.

The overall pooled risk ratio for the association of restrictive vs. liberal transfusion threshold with infection was 0.99 (95% CI, 0.78-0.99; P=0.033). A decreased risk of infection with the use of a restrictive transfusion compared with a liberal threshold persisted in studies of leukocyte-reduced blood products.

Bottom line: Restrictive RBC transfusion thresholds are associated with a decreased risk of acquiring healthcare-associated infections compared with liberal transfusion thresholds.

Citation: Rohde JM, Dimcheff DE, Blumberg N, et al. Health care-associated infection after red blood cell transfusion: A systematic review and meta-analysis. JAMA. 2014;311(13):1317-1326.

Clinical question: Do different thresholds for red blood cell (RBC) transfusion influence the risk of infection, and does leukocyte reduction also influence the risk of infection?

Background: RBC transfusion is a common and costly medical intervention performed across U.S. hospitals. Scientists suspect that RBC transfusion may have immunomodulatory properties and may affect a patient’s risk of acquiring various infections.

Study design: Meta-analysis and systematic review.

Setting: International adult, pediatric, obstetric medical and surgical wards, and ICUs.

Synopsis: Eighteen studies performed were included in the meta-analysis of published randomized trials comparing restrictive to liberal RBC transfusion strategies in which infectious outcomes were reported. Patient enrollment spanned from 1994 to 2012. Six of the trials included pediatric patients. For adult patients, the restrictive RBC transfusion threshold ranged from 6.4–9.7 g/dL, while the liberal target ranged from 9-11.3 g/dL in included trials.

The overall pooled risk ratio for the association of restrictive vs. liberal transfusion threshold with infection was 0.99 (95% CI, 0.78-0.99; P=0.033). A decreased risk of infection with the use of a restrictive transfusion compared with a liberal threshold persisted in studies of leukocyte-reduced blood products.

Bottom line: Restrictive RBC transfusion thresholds are associated with a decreased risk of acquiring healthcare-associated infections compared with liberal transfusion thresholds.

Citation: Rohde JM, Dimcheff DE, Blumberg N, et al. Health care-associated infection after red blood cell transfusion: A systematic review and meta-analysis. JAMA. 2014;311(13):1317-1326.

Clinical question: Do different thresholds for red blood cell (RBC) transfusion influence the risk of infection, and does leukocyte reduction also influence the risk of infection?

Background: RBC transfusion is a common and costly medical intervention performed across U.S. hospitals. Scientists suspect that RBC transfusion may have immunomodulatory properties and may affect a patient’s risk of acquiring various infections.

Study design: Meta-analysis and systematic review.

Setting: International adult, pediatric, obstetric medical and surgical wards, and ICUs.

Synopsis: Eighteen studies performed were included in the meta-analysis of published randomized trials comparing restrictive to liberal RBC transfusion strategies in which infectious outcomes were reported. Patient enrollment spanned from 1994 to 2012. Six of the trials included pediatric patients. For adult patients, the restrictive RBC transfusion threshold ranged from 6.4–9.7 g/dL, while the liberal target ranged from 9-11.3 g/dL in included trials.

The overall pooled risk ratio for the association of restrictive vs. liberal transfusion threshold with infection was 0.99 (95% CI, 0.78-0.99; P=0.033). A decreased risk of infection with the use of a restrictive transfusion compared with a liberal threshold persisted in studies of leukocyte-reduced blood products.

Bottom line: Restrictive RBC transfusion thresholds are associated with a decreased risk of acquiring healthcare-associated infections compared with liberal transfusion thresholds.

Citation: Rohde JM, Dimcheff DE, Blumberg N, et al. Health care-associated infection after red blood cell transfusion: A systematic review and meta-analysis. JAMA. 2014;311(13):1317-1326.

Clinical question: Are CT scans of the head diagnostically helpful in hospitalized patients with delirium?

Background: Studies have investigated the use of head CT scans for the evaluation of delirium in the ED, but there is scant information about the utility of head CT scans in the assessment of the hospitalized patient with delirium.

Study design: Retrospective medical record review.

Setting: Large academic medical center in Massachusetts.

Synopsis: This study was designed to assess whether head CT scans obtained on patients without a history of head trauma, fall, known intracranial process, or new neurologic deficit were useful in the workup of delirium. During a two-year period, 1,714 CT scans of the head were performed, and 398 listed the indication for the scan as “delirium, altered mental status, confusion, encephalopathy, somnolence, or unresponsiveness.” Patients with the risk factors of trauma, fall, new neurologic deficit, and known intracranial process were excluded, and 220 patients’ records were reviewed.

Only six head CT scans (2.7%) revealed an acute intracranial process. Many chronic findings were noted, such as atrophy, small vessel ischemic disease, and old stroke. The authors found that the diagnostic utility was low for a head CT scan in a patient with delirium but noted no risk factors. There may be a subset of patients in whom the diagnostic yield is higher, such as those on anticoagulation or more obtunded patients.

Bottom line: In delirious inpatients without a history of head trauma, fall, known intracranial process, or new neurologic deficit, head CT scan has low diagnostic utility.

Citation: Theisen-Toupal J, Breu AC, Mattison ML, Arnaout R. Diagnostic yield of head computed tomography for the hospitalized medical patient with delirium [published online ahead of print April 15, 2014]. J Hosp Med.

Clinical question: Are CT scans of the head diagnostically helpful in hospitalized patients with delirium?

Background: Studies have investigated the use of head CT scans for the evaluation of delirium in the ED, but there is scant information about the utility of head CT scans in the assessment of the hospitalized patient with delirium.

Study design: Retrospective medical record review.

Setting: Large academic medical center in Massachusetts.

Synopsis: This study was designed to assess whether head CT scans obtained on patients without a history of head trauma, fall, known intracranial process, or new neurologic deficit were useful in the workup of delirium. During a two-year period, 1,714 CT scans of the head were performed, and 398 listed the indication for the scan as “delirium, altered mental status, confusion, encephalopathy, somnolence, or unresponsiveness.” Patients with the risk factors of trauma, fall, new neurologic deficit, and known intracranial process were excluded, and 220 patients’ records were reviewed.

Only six head CT scans (2.7%) revealed an acute intracranial process. Many chronic findings were noted, such as atrophy, small vessel ischemic disease, and old stroke. The authors found that the diagnostic utility was low for a head CT scan in a patient with delirium but noted no risk factors. There may be a subset of patients in whom the diagnostic yield is higher, such as those on anticoagulation or more obtunded patients.

Bottom line: In delirious inpatients without a history of head trauma, fall, known intracranial process, or new neurologic deficit, head CT scan has low diagnostic utility.

Citation: Theisen-Toupal J, Breu AC, Mattison ML, Arnaout R. Diagnostic yield of head computed tomography for the hospitalized medical patient with delirium [published online ahead of print April 15, 2014]. J Hosp Med.

Clinical question: Are CT scans of the head diagnostically helpful in hospitalized patients with delirium?

Background: Studies have investigated the use of head CT scans for the evaluation of delirium in the ED, but there is scant information about the utility of head CT scans in the assessment of the hospitalized patient with delirium.

Study design: Retrospective medical record review.

Setting: Large academic medical center in Massachusetts.

Synopsis: This study was designed to assess whether head CT scans obtained on patients without a history of head trauma, fall, known intracranial process, or new neurologic deficit were useful in the workup of delirium. During a two-year period, 1,714 CT scans of the head were performed, and 398 listed the indication for the scan as “delirium, altered mental status, confusion, encephalopathy, somnolence, or unresponsiveness.” Patients with the risk factors of trauma, fall, new neurologic deficit, and known intracranial process were excluded, and 220 patients’ records were reviewed.

Only six head CT scans (2.7%) revealed an acute intracranial process. Many chronic findings were noted, such as atrophy, small vessel ischemic disease, and old stroke. The authors found that the diagnostic utility was low for a head CT scan in a patient with delirium but noted no risk factors. There may be a subset of patients in whom the diagnostic yield is higher, such as those on anticoagulation or more obtunded patients.

Bottom line: In delirious inpatients without a history of head trauma, fall, known intracranial process, or new neurologic deficit, head CT scan has low diagnostic utility.

Citation: Theisen-Toupal J, Breu AC, Mattison ML, Arnaout R. Diagnostic yield of head computed tomography for the hospitalized medical patient with delirium [published online ahead of print April 15, 2014]. J Hosp Med.

Clinical question: Does an increased hospitalist workload lead to increased costs, longer lengths of stay, and worse medical outcomes?

Background: There is evidence that increased resident physician workloads contribute to adverse medical outcomes, but this has not been assessed in the hospital medicine setting. In a recent national survey of hospitalists, almost half reported that they had managed workloads that felt “unsafe.”

Study design: Retrospective cohort study.

Setting: Academic community health system in Delaware.

Synopsis: This study examined the effect of hospital occupancy and hospitalist workloads, using both daily relative value units (RVUs) and hospitalists’ daily patient census, on length of stay (LOS), hospital costs, inpatient mortality, activation of rapid response system (a proxy measure for decompensation), and 30-day readmission rates. Authors reviewed 20,241 hospitalizations and found that when hospitalist daily censuses exceeded 15 patients (or RVU of 25), length of stay increased “exponentially.” Increased workloads were not associated with worsening medical outcomes or diminished patient satisfaction scores.

The authors caution that the significantly increased costs and LOS at higher patient censuses raise concerns that hospital policies that incentivize productivity may “undermine larger system efforts targeting efficiency and costs of care.” They also suggest that hospitalist groups’ staffing approaches need to accommodate fluctuations in hospital occupancy.

Bottom line: When a hospitalist’s workload exceeds a census of 15 patients, the length of stay and cost may increase dramatically.

Article Reference: Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174(5):786-793.

Clinical question: Does an increased hospitalist workload lead to increased costs, longer lengths of stay, and worse medical outcomes?

Background: There is evidence that increased resident physician workloads contribute to adverse medical outcomes, but this has not been assessed in the hospital medicine setting. In a recent national survey of hospitalists, almost half reported that they had managed workloads that felt “unsafe.”

Study design: Retrospective cohort study.

Setting: Academic community health system in Delaware.

Synopsis: This study examined the effect of hospital occupancy and hospitalist workloads, using both daily relative value units (RVUs) and hospitalists’ daily patient census, on length of stay (LOS), hospital costs, inpatient mortality, activation of rapid response system (a proxy measure for decompensation), and 30-day readmission rates. Authors reviewed 20,241 hospitalizations and found that when hospitalist daily censuses exceeded 15 patients (or RVU of 25), length of stay increased “exponentially.” Increased workloads were not associated with worsening medical outcomes or diminished patient satisfaction scores.

The authors caution that the significantly increased costs and LOS at higher patient censuses raise concerns that hospital policies that incentivize productivity may “undermine larger system efforts targeting efficiency and costs of care.” They also suggest that hospitalist groups’ staffing approaches need to accommodate fluctuations in hospital occupancy.

Bottom line: When a hospitalist’s workload exceeds a census of 15 patients, the length of stay and cost may increase dramatically.

Article Reference: Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174(5):786-793.

Clinical question: Does an increased hospitalist workload lead to increased costs, longer lengths of stay, and worse medical outcomes?

Background: There is evidence that increased resident physician workloads contribute to adverse medical outcomes, but this has not been assessed in the hospital medicine setting. In a recent national survey of hospitalists, almost half reported that they had managed workloads that felt “unsafe.”

Study design: Retrospective cohort study.

Setting: Academic community health system in Delaware.

Synopsis: This study examined the effect of hospital occupancy and hospitalist workloads, using both daily relative value units (RVUs) and hospitalists’ daily patient census, on length of stay (LOS), hospital costs, inpatient mortality, activation of rapid response system (a proxy measure for decompensation), and 30-day readmission rates. Authors reviewed 20,241 hospitalizations and found that when hospitalist daily censuses exceeded 15 patients (or RVU of 25), length of stay increased “exponentially.” Increased workloads were not associated with worsening medical outcomes or diminished patient satisfaction scores.

The authors caution that the significantly increased costs and LOS at higher patient censuses raise concerns that hospital policies that incentivize productivity may “undermine larger system efforts targeting efficiency and costs of care.” They also suggest that hospitalist groups’ staffing approaches need to accommodate fluctuations in hospital occupancy.

Bottom line: When a hospitalist’s workload exceeds a census of 15 patients, the length of stay and cost may increase dramatically.

Article Reference: Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174(5):786-793.

Clinical question: In patients at risk for vascular complications undergoing noncardiac surgery, do the benefits of aspirin outweigh the risks?

Background: Aspirin has been shown to reduce the rate of myocardial infarction (MI) and major vascular events in patients not undergoing surgery. The benefits of initiating or continuing aspirin in patients undergoing surgery, balanced by the potential increase in bleeding risk, have not been widely studied.

Study design: International randomized placebo-controlled trial with a 2-by-2 factorial design.

Setting: One hundred thirty-five hospitals in 23 countries, from 2010-2013.

Synopsis: The study enrolled 10,010 patients, with a mean age of 68.6 years. Inclusion criteria were age >45 years old and risk for vascular complications, defined as a history of coronary artery disease, peripheral vascular disease, or cerebrovascular accident; major vascular surgery; or at least three of the following: age >70, congestive heart failure, transient ischemic attack, hypertension, diabetes mellitus type 2, creatinine >2 mg/dL, recent smoking, undergoing major surgery, or urgent/emergent surgery.

Groups were stratified by current use of aspirin and then assigned to aspirin or placebo; patients on aspirin held it a median of seven days before surgery. Those in the active group received 200 mg of aspirin pre-operatively. Patients not previously on aspirin then continued aspirin at 100 mg/day for 30 days; those on aspirin previously received 100 mg/day for seven days and then resumed their prior dose.

No difference was found in the primary outcome of death or non-fatal MI at 30 days, but aspirin was noted to increase the risk of major bleeding (4.6% vs. 3.8%, P=0.04), most commonly occurring at the surgical site (78.3%) and the GI tract (9.3%). Because major bleeding can be associated with peri-operative MI, this may have counteracted the cardiovascular benefits of aspirin.

Bottom line: Peri-operative administration of aspirin to patients at risk for vascular complications undergoing noncardiac surgery does not decrease the risk of peri-operative death or MI and may increase the risk of post-operative bleeding.

Citation: Devereaux PJ, Mrkobrada M, Sessler DI, et al. POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494-1503.

Clinical question: In patients at risk for vascular complications undergoing noncardiac surgery, do the benefits of aspirin outweigh the risks?

Background: Aspirin has been shown to reduce the rate of myocardial infarction (MI) and major vascular events in patients not undergoing surgery. The benefits of initiating or continuing aspirin in patients undergoing surgery, balanced by the potential increase in bleeding risk, have not been widely studied.

Study design: International randomized placebo-controlled trial with a 2-by-2 factorial design.

Setting: One hundred thirty-five hospitals in 23 countries, from 2010-2013.

Synopsis: The study enrolled 10,010 patients, with a mean age of 68.6 years. Inclusion criteria were age >45 years old and risk for vascular complications, defined as a history of coronary artery disease, peripheral vascular disease, or cerebrovascular accident; major vascular surgery; or at least three of the following: age >70, congestive heart failure, transient ischemic attack, hypertension, diabetes mellitus type 2, creatinine >2 mg/dL, recent smoking, undergoing major surgery, or urgent/emergent surgery.

Groups were stratified by current use of aspirin and then assigned to aspirin or placebo; patients on aspirin held it a median of seven days before surgery. Those in the active group received 200 mg of aspirin pre-operatively. Patients not previously on aspirin then continued aspirin at 100 mg/day for 30 days; those on aspirin previously received 100 mg/day for seven days and then resumed their prior dose.

No difference was found in the primary outcome of death or non-fatal MI at 30 days, but aspirin was noted to increase the risk of major bleeding (4.6% vs. 3.8%, P=0.04), most commonly occurring at the surgical site (78.3%) and the GI tract (9.3%). Because major bleeding can be associated with peri-operative MI, this may have counteracted the cardiovascular benefits of aspirin.

Bottom line: Peri-operative administration of aspirin to patients at risk for vascular complications undergoing noncardiac surgery does not decrease the risk of peri-operative death or MI and may increase the risk of post-operative bleeding.

Citation: Devereaux PJ, Mrkobrada M, Sessler DI, et al. POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494-1503.

Clinical question: In patients at risk for vascular complications undergoing noncardiac surgery, do the benefits of aspirin outweigh the risks?

Background: Aspirin has been shown to reduce the rate of myocardial infarction (MI) and major vascular events in patients not undergoing surgery. The benefits of initiating or continuing aspirin in patients undergoing surgery, balanced by the potential increase in bleeding risk, have not been widely studied.

Study design: International randomized placebo-controlled trial with a 2-by-2 factorial design.

Setting: One hundred thirty-five hospitals in 23 countries, from 2010-2013.

Synopsis: The study enrolled 10,010 patients, with a mean age of 68.6 years. Inclusion criteria were age >45 years old and risk for vascular complications, defined as a history of coronary artery disease, peripheral vascular disease, or cerebrovascular accident; major vascular surgery; or at least three of the following: age >70, congestive heart failure, transient ischemic attack, hypertension, diabetes mellitus type 2, creatinine >2 mg/dL, recent smoking, undergoing major surgery, or urgent/emergent surgery.

Groups were stratified by current use of aspirin and then assigned to aspirin or placebo; patients on aspirin held it a median of seven days before surgery. Those in the active group received 200 mg of aspirin pre-operatively. Patients not previously on aspirin then continued aspirin at 100 mg/day for 30 days; those on aspirin previously received 100 mg/day for seven days and then resumed their prior dose.

No difference was found in the primary outcome of death or non-fatal MI at 30 days, but aspirin was noted to increase the risk of major bleeding (4.6% vs. 3.8%, P=0.04), most commonly occurring at the surgical site (78.3%) and the GI tract (9.3%). Because major bleeding can be associated with peri-operative MI, this may have counteracted the cardiovascular benefits of aspirin.

Bottom line: Peri-operative administration of aspirin to patients at risk for vascular complications undergoing noncardiac surgery does not decrease the risk of peri-operative death or MI and may increase the risk of post-operative bleeding.

Citation: Devereaux PJ, Mrkobrada M, Sessler DI, et al. POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494-1503.

Clinical question: Do fibrinolytics decrease mortality rates in intermediate-risk pulmonary emboli?

Background: Over the past 40 years, fibrinolytics have been studied in fewer than 1,000 patients with pulmonary emboli. Previous studies have shown improvement in hemodynamic response, though the evidence for clinical outcomes such as death and hemodynamic collapse have not been studied adequately in intermediate-risk pulmonary emboli.

Study design: Randomized, double-blinded, placebo-controlled trial.

Setting: Seventy-six sites in 13 countries.

Synopsis: The PEITHO [Pulmonary EmbolIsm THrOmbolysis] trial randomized 1,006 patients in a double-blind fashion. All patients had acute pulmonary emboli with evidence of right ventricular dysfunction on computed tomography scan or echocardiogram, as well as an elevated troponin, in the absence of hemodynamic compromise. Patients received tenecteplase and heparin or placebo and heparin. The primary outcome was death and hemodynamic decompensation.

The primary outcome was found in 2.6% of the treatment group and 5.6% in the placebo group (P=0.02), favoring the treatment group; however, there was no difference in death at seven days (1.2% vs. 1.8%; P=0.42) and 30 days (2.4% vs. 3.2%; P=0.42). Additionally, there were higher rates of extracranial bleeding (6.3% vs. 1.2%; P=<0.001) and stroke (2.4% vs. 0.2%; P=0.003) in the tenecteplase group than in the placebo group. Of the 12 strokes in the treatment group, 11 were hemorrhagic.

Bottom line: Treatment of intermediate-risk pulmonary emboli with fibrinolytics may improve hemodynamics; however, there is no mortality benefit, and fibrinolytic therapy carries an increased risk of bleeding and stroke.

Citation: Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-1411.

Clinical question: Do fibrinolytics decrease mortality rates in intermediate-risk pulmonary emboli?

Background: Over the past 40 years, fibrinolytics have been studied in fewer than 1,000 patients with pulmonary emboli. Previous studies have shown improvement in hemodynamic response, though the evidence for clinical outcomes such as death and hemodynamic collapse have not been studied adequately in intermediate-risk pulmonary emboli.

Study design: Randomized, double-blinded, placebo-controlled trial.

Setting: Seventy-six sites in 13 countries.

Synopsis: The PEITHO [Pulmonary EmbolIsm THrOmbolysis] trial randomized 1,006 patients in a double-blind fashion. All patients had acute pulmonary emboli with evidence of right ventricular dysfunction on computed tomography scan or echocardiogram, as well as an elevated troponin, in the absence of hemodynamic compromise. Patients received tenecteplase and heparin or placebo and heparin. The primary outcome was death and hemodynamic decompensation.

The primary outcome was found in 2.6% of the treatment group and 5.6% in the placebo group (P=0.02), favoring the treatment group; however, there was no difference in death at seven days (1.2% vs. 1.8%; P=0.42) and 30 days (2.4% vs. 3.2%; P=0.42). Additionally, there were higher rates of extracranial bleeding (6.3% vs. 1.2%; P=<0.001) and stroke (2.4% vs. 0.2%; P=0.003) in the tenecteplase group than in the placebo group. Of the 12 strokes in the treatment group, 11 were hemorrhagic.

Bottom line: Treatment of intermediate-risk pulmonary emboli with fibrinolytics may improve hemodynamics; however, there is no mortality benefit, and fibrinolytic therapy carries an increased risk of bleeding and stroke.

Citation: Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-1411.

Clinical question: Do fibrinolytics decrease mortality rates in intermediate-risk pulmonary emboli?

Background: Over the past 40 years, fibrinolytics have been studied in fewer than 1,000 patients with pulmonary emboli. Previous studies have shown improvement in hemodynamic response, though the evidence for clinical outcomes such as death and hemodynamic collapse have not been studied adequately in intermediate-risk pulmonary emboli.

Study design: Randomized, double-blinded, placebo-controlled trial.

Setting: Seventy-six sites in 13 countries.

Synopsis: The PEITHO [Pulmonary EmbolIsm THrOmbolysis] trial randomized 1,006 patients in a double-blind fashion. All patients had acute pulmonary emboli with evidence of right ventricular dysfunction on computed tomography scan or echocardiogram, as well as an elevated troponin, in the absence of hemodynamic compromise. Patients received tenecteplase and heparin or placebo and heparin. The primary outcome was death and hemodynamic decompensation.

The primary outcome was found in 2.6% of the treatment group and 5.6% in the placebo group (P=0.02), favoring the treatment group; however, there was no difference in death at seven days (1.2% vs. 1.8%; P=0.42) and 30 days (2.4% vs. 3.2%; P=0.42). Additionally, there were higher rates of extracranial bleeding (6.3% vs. 1.2%; P=<0.001) and stroke (2.4% vs. 0.2%; P=0.003) in the tenecteplase group than in the placebo group. Of the 12 strokes in the treatment group, 11 were hemorrhagic.

Bottom line: Treatment of intermediate-risk pulmonary emboli with fibrinolytics may improve hemodynamics; however, there is no mortality benefit, and fibrinolytic therapy carries an increased risk of bleeding and stroke.

Citation: Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-1411.

Clinical question: What new recommendations are made in the AHA/ACC/HRS atrial fibrillation guidelines?

Background: This is the AHA’s first comprehensive update on atrial fibrillation since 2006; there were two intervening focused updates in 2011.

Synopsis: The majority of the new recommendations center on patient selection for anticoagulation and the role of the new oral anticoagulants.

CHA2DS2-VASc is now recommended over CHADS2 for evaluation of stroke risk, with anticoagulation recommended for a score of two or greater, or for a patient with any prior history of stroke or transient ischemic attack.

Warfarin, direct thrombin inhibitors, or factor Xa inhibitors may be considered in patients with normal renal function. Reduced doses of these medications may be considered in patients with moderate to severe renal dysfunction but have not been studied in clinical trials.

Warfarin remains the drug of choice for patients on hemodialysis and those with hemodynamically significant mitral stenosis or aortic valve replacement.

The clinical utility of bleeding risk scores remains insufficient for formal recommendations. There is sparse evidence on which to base recommendations for bridging, but additional studies, such as the BRIDGE trial, are ongoing. A liberal rate control strategy targeting heart rates <110 in asymptomatic patients with preserved systolic function is reasonable; ideal rate control targets remain controversial.

Citation: January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society [published online ahead of print April 10, 2014]. Circulation.

Clinical question: What new recommendations are made in the AHA/ACC/HRS atrial fibrillation guidelines?

Background: This is the AHA’s first comprehensive update on atrial fibrillation since 2006; there were two intervening focused updates in 2011.

Synopsis: The majority of the new recommendations center on patient selection for anticoagulation and the role of the new oral anticoagulants.

CHA2DS2-VASc is now recommended over CHADS2 for evaluation of stroke risk, with anticoagulation recommended for a score of two or greater, or for a patient with any prior history of stroke or transient ischemic attack.

Warfarin, direct thrombin inhibitors, or factor Xa inhibitors may be considered in patients with normal renal function. Reduced doses of these medications may be considered in patients with moderate to severe renal dysfunction but have not been studied in clinical trials.

Warfarin remains the drug of choice for patients on hemodialysis and those with hemodynamically significant mitral stenosis or aortic valve replacement.

The clinical utility of bleeding risk scores remains insufficient for formal recommendations. There is sparse evidence on which to base recommendations for bridging, but additional studies, such as the BRIDGE trial, are ongoing. A liberal rate control strategy targeting heart rates <110 in asymptomatic patients with preserved systolic function is reasonable; ideal rate control targets remain controversial.

Citation: January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society [published online ahead of print April 10, 2014]. Circulation.

Clinical question: What new recommendations are made in the AHA/ACC/HRS atrial fibrillation guidelines?

Background: This is the AHA’s first comprehensive update on atrial fibrillation since 2006; there were two intervening focused updates in 2011.

Synopsis: The majority of the new recommendations center on patient selection for anticoagulation and the role of the new oral anticoagulants.

CHA2DS2-VASc is now recommended over CHADS2 for evaluation of stroke risk, with anticoagulation recommended for a score of two or greater, or for a patient with any prior history of stroke or transient ischemic attack.

Warfarin, direct thrombin inhibitors, or factor Xa inhibitors may be considered in patients with normal renal function. Reduced doses of these medications may be considered in patients with moderate to severe renal dysfunction but have not been studied in clinical trials.

Warfarin remains the drug of choice for patients on hemodialysis and those with hemodynamically significant mitral stenosis or aortic valve replacement.

The clinical utility of bleeding risk scores remains insufficient for formal recommendations. There is sparse evidence on which to base recommendations for bridging, but additional studies, such as the BRIDGE trial, are ongoing. A liberal rate control strategy targeting heart rates <110 in asymptomatic patients with preserved systolic function is reasonable; ideal rate control targets remain controversial.

Citation: January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society [published online ahead of print April 10, 2014]. Circulation.