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Contrast nephropathy after computed tomography
Clinical question: Do rates of acute kidney injury (AKI), renal replacement therapy (RRT), or mortality differ between adults receiving contrast-enhanced computed tomography (CT) versus those receiving noncontrast CT?
Background: Published estimates regarding the risk of postcontrast complications are highly variable and recent data show that the risk of postcontrast AKI may be lower than previously suggested.
Study design: Systematic review and meta-analysis..
Setting: Noninterventional studies assessing differences in AKI, new RRT, or mortality among adults who received contrast-enhanced CT, compared with those receiving noncontrast CT.
Synopsis: A search among six databases and Google Scholar from inception through 2016 yielded 28 observational studies meeting inclusion criteria that included 107,335 participants. Twenty-six assessed AKI, 13 assessed need for RRT, and 9 assessed all-cause mortality. Compared with noncontrast CT, contrast-enhanced CT was not significantly associated with AKI (odds ratio, 0.94; 95% confidence interval, 0.83-1.07), RRT (OR, 0.83; 95% CI 0.59-1.16), or all-cause mortality (OR, 1.0; 95% CI 0.73-1.36). The overall risk of bias ranged from low to serious among the included studies. Studies were observational in nature, they were conducted in multiple settings (for example, ICU, emergency department), and the baseline characteristics of included patients were highly variable.
Bottom line: This meta-analysis observed no difference in adverse events between patients receiving contrast-enhanced CT versus those receiving noncontrast CT but should be interpreted with caution given the observational nature of the studies and differing characteristics of the included patients and study settings.
Citation: Aycock RD et al. Acute kidney injury after computed tomography: a meta-analysis. Ann Emerg Med. 2017 Aug 12. doi: 10.1016/j.annemergmed.2017.06.041
Dr. Simonetti is a hospitalist at the University of Colorado School of Medicine.
Clinical question: Do rates of acute kidney injury (AKI), renal replacement therapy (RRT), or mortality differ between adults receiving contrast-enhanced computed tomography (CT) versus those receiving noncontrast CT?
Background: Published estimates regarding the risk of postcontrast complications are highly variable and recent data show that the risk of postcontrast AKI may be lower than previously suggested.
Study design: Systematic review and meta-analysis..
Setting: Noninterventional studies assessing differences in AKI, new RRT, or mortality among adults who received contrast-enhanced CT, compared with those receiving noncontrast CT.
Synopsis: A search among six databases and Google Scholar from inception through 2016 yielded 28 observational studies meeting inclusion criteria that included 107,335 participants. Twenty-six assessed AKI, 13 assessed need for RRT, and 9 assessed all-cause mortality. Compared with noncontrast CT, contrast-enhanced CT was not significantly associated with AKI (odds ratio, 0.94; 95% confidence interval, 0.83-1.07), RRT (OR, 0.83; 95% CI 0.59-1.16), or all-cause mortality (OR, 1.0; 95% CI 0.73-1.36). The overall risk of bias ranged from low to serious among the included studies. Studies were observational in nature, they were conducted in multiple settings (for example, ICU, emergency department), and the baseline characteristics of included patients were highly variable.
Bottom line: This meta-analysis observed no difference in adverse events between patients receiving contrast-enhanced CT versus those receiving noncontrast CT but should be interpreted with caution given the observational nature of the studies and differing characteristics of the included patients and study settings.
Citation: Aycock RD et al. Acute kidney injury after computed tomography: a meta-analysis. Ann Emerg Med. 2017 Aug 12. doi: 10.1016/j.annemergmed.2017.06.041
Dr. Simonetti is a hospitalist at the University of Colorado School of Medicine.
Clinical question: Do rates of acute kidney injury (AKI), renal replacement therapy (RRT), or mortality differ between adults receiving contrast-enhanced computed tomography (CT) versus those receiving noncontrast CT?
Background: Published estimates regarding the risk of postcontrast complications are highly variable and recent data show that the risk of postcontrast AKI may be lower than previously suggested.
Study design: Systematic review and meta-analysis..
Setting: Noninterventional studies assessing differences in AKI, new RRT, or mortality among adults who received contrast-enhanced CT, compared with those receiving noncontrast CT.
Synopsis: A search among six databases and Google Scholar from inception through 2016 yielded 28 observational studies meeting inclusion criteria that included 107,335 participants. Twenty-six assessed AKI, 13 assessed need for RRT, and 9 assessed all-cause mortality. Compared with noncontrast CT, contrast-enhanced CT was not significantly associated with AKI (odds ratio, 0.94; 95% confidence interval, 0.83-1.07), RRT (OR, 0.83; 95% CI 0.59-1.16), or all-cause mortality (OR, 1.0; 95% CI 0.73-1.36). The overall risk of bias ranged from low to serious among the included studies. Studies were observational in nature, they were conducted in multiple settings (for example, ICU, emergency department), and the baseline characteristics of included patients were highly variable.
Bottom line: This meta-analysis observed no difference in adverse events between patients receiving contrast-enhanced CT versus those receiving noncontrast CT but should be interpreted with caution given the observational nature of the studies and differing characteristics of the included patients and study settings.
Citation: Aycock RD et al. Acute kidney injury after computed tomography: a meta-analysis. Ann Emerg Med. 2017 Aug 12. doi: 10.1016/j.annemergmed.2017.06.041
Dr. Simonetti is a hospitalist at the University of Colorado School of Medicine.
Checklists to improve patient safety have mixed results
Clinical question: Do checklists improve patient safety among hospitalized patients?
Background: Systematic reviews of nonrandomized studies suggest checklists may reduce adverse events and medical errors. No study has systematically reviewed randomized trials or summarized the quality of evidence on this topic.
Study design: Systematic review of randomized controlled trials (RCTs) with pooled estimates of 30-day mortality.
Setting: RCTs reporting inpatient safety outcomes.
Synopsis: A search among four databases from inception through 2016 yielded nine studies meeting inclusion criteria. Checklists included tools for daily rounding, discharge planning, patient transfer, surgical safety and infection control procedures, pharmaceutical prescribing, and pain control. Three studies examined 30-day mortality, three studied length of stay, and two reported checklist compliance. Five reported patient outcomes and five reported provider-level outcomes related to patient safety. Findings regarding the effectiveness of checklists across studies were mixed. A random-effects model using pooled data from the three studies assessing 30-day mortality showed lower mortality associated with checklist use (odds ratio, 0.6, 95% confidence interval, 0.41-0.89; P = .01). The methodologic quality of studies was assessed as moderate. The review included studies with substantial heterogeneity in checklists employed and outcomes assessed. Though included studies were supposed to have assessed patient outcomes and not the processes of care, several studies cited did not report such outcomes.
Bottom line: Evidence regarding the effectiveness of clinical checklists on patient safety outcomes is mixed, and there is substantial heterogeneity in the types of checklists employed and outcomes assessed.
Citation: Boyd JM et al. The impact of checklists on inpatient safety outcomes: A systematic review of randomized controlled trials. J Hosp Med. 2017 Aug;12:675-82.
Dr. Simonetti is a hospitalist at the University of Colorado School of Medicine.
Clinical question: Do checklists improve patient safety among hospitalized patients?
Background: Systematic reviews of nonrandomized studies suggest checklists may reduce adverse events and medical errors. No study has systematically reviewed randomized trials or summarized the quality of evidence on this topic.
Study design: Systematic review of randomized controlled trials (RCTs) with pooled estimates of 30-day mortality.
Setting: RCTs reporting inpatient safety outcomes.
Synopsis: A search among four databases from inception through 2016 yielded nine studies meeting inclusion criteria. Checklists included tools for daily rounding, discharge planning, patient transfer, surgical safety and infection control procedures, pharmaceutical prescribing, and pain control. Three studies examined 30-day mortality, three studied length of stay, and two reported checklist compliance. Five reported patient outcomes and five reported provider-level outcomes related to patient safety. Findings regarding the effectiveness of checklists across studies were mixed. A random-effects model using pooled data from the three studies assessing 30-day mortality showed lower mortality associated with checklist use (odds ratio, 0.6, 95% confidence interval, 0.41-0.89; P = .01). The methodologic quality of studies was assessed as moderate. The review included studies with substantial heterogeneity in checklists employed and outcomes assessed. Though included studies were supposed to have assessed patient outcomes and not the processes of care, several studies cited did not report such outcomes.
Bottom line: Evidence regarding the effectiveness of clinical checklists on patient safety outcomes is mixed, and there is substantial heterogeneity in the types of checklists employed and outcomes assessed.
Citation: Boyd JM et al. The impact of checklists on inpatient safety outcomes: A systematic review of randomized controlled trials. J Hosp Med. 2017 Aug;12:675-82.
Dr. Simonetti is a hospitalist at the University of Colorado School of Medicine.
Clinical question: Do checklists improve patient safety among hospitalized patients?
Background: Systematic reviews of nonrandomized studies suggest checklists may reduce adverse events and medical errors. No study has systematically reviewed randomized trials or summarized the quality of evidence on this topic.
Study design: Systematic review of randomized controlled trials (RCTs) with pooled estimates of 30-day mortality.
Setting: RCTs reporting inpatient safety outcomes.
Synopsis: A search among four databases from inception through 2016 yielded nine studies meeting inclusion criteria. Checklists included tools for daily rounding, discharge planning, patient transfer, surgical safety and infection control procedures, pharmaceutical prescribing, and pain control. Three studies examined 30-day mortality, three studied length of stay, and two reported checklist compliance. Five reported patient outcomes and five reported provider-level outcomes related to patient safety. Findings regarding the effectiveness of checklists across studies were mixed. A random-effects model using pooled data from the three studies assessing 30-day mortality showed lower mortality associated with checklist use (odds ratio, 0.6, 95% confidence interval, 0.41-0.89; P = .01). The methodologic quality of studies was assessed as moderate. The review included studies with substantial heterogeneity in checklists employed and outcomes assessed. Though included studies were supposed to have assessed patient outcomes and not the processes of care, several studies cited did not report such outcomes.
Bottom line: Evidence regarding the effectiveness of clinical checklists on patient safety outcomes is mixed, and there is substantial heterogeneity in the types of checklists employed and outcomes assessed.
Citation: Boyd JM et al. The impact of checklists on inpatient safety outcomes: A systematic review of randomized controlled trials. J Hosp Med. 2017 Aug;12:675-82.
Dr. Simonetti is a hospitalist at the University of Colorado School of Medicine.
Rural residents admitted for opioid overdoses increasingly are hospitalized in urban hospitals
Clinical question: Is there an association between rurality and trends and characteristics of hospitalizations for opioid overdose?
Background: Hospitalization for an opioid overdose is an opportunity for intervention, and patients may have different discharge needs depending on their rurality. Differences in patient characteristics or overall trends in opioid overdose hospitalizations by rural status have not been described.
Study design: Time trend (2007-2014) and cross-sectional analysis (2012-2014).
Setting: Nationally representative sample of U.S. hospital discharges.
Synopsis: Using weighted data from the National Inpatient Sample and the American Community Survey, the authors found that 43,935 individuals were hospitalized for opioid overdose in the United States in 2007, increasing to 71,280 in 2014. A total of 99% of urban and 37% of rural residents were admitted to urban hospitals. Hospitalization rates for prescription opioid overdoses were higher among rural residents and increased among rural and urban residents until 2011 before declining among rural residents during 2012-2014. Hospitalization rates for prescription opioid overdoses increased among all groups before they declined among large urban population residents after 2011, declined among rural residents after 2012, and continued to rise among small urban residents. Hospitalization rates for heroin overdose increased across all years in all groups and were higher among urban as compared to rural residents.
Bottom line: Opioid overdose hospitalization is associated with patient rurality and a significant proportion of rural individuals are hospitalized for opioid overdose in urban facilities. These patients may have distinct discharge needs.
Citation: Mosher H et al. Trends in hospitalization for opioid overdose among rural compared to urban residents of the United States, 2007-2014. J Hosp Med. 2017. doi: 10.12788/jhm.2793.
Dr. Simonetti is a hospitalist at the University of Colorado School of Medicine.
Clinical question: Is there an association between rurality and trends and characteristics of hospitalizations for opioid overdose?
Background: Hospitalization for an opioid overdose is an opportunity for intervention, and patients may have different discharge needs depending on their rurality. Differences in patient characteristics or overall trends in opioid overdose hospitalizations by rural status have not been described.
Study design: Time trend (2007-2014) and cross-sectional analysis (2012-2014).
Setting: Nationally representative sample of U.S. hospital discharges.
Synopsis: Using weighted data from the National Inpatient Sample and the American Community Survey, the authors found that 43,935 individuals were hospitalized for opioid overdose in the United States in 2007, increasing to 71,280 in 2014. A total of 99% of urban and 37% of rural residents were admitted to urban hospitals. Hospitalization rates for prescription opioid overdoses were higher among rural residents and increased among rural and urban residents until 2011 before declining among rural residents during 2012-2014. Hospitalization rates for prescription opioid overdoses increased among all groups before they declined among large urban population residents after 2011, declined among rural residents after 2012, and continued to rise among small urban residents. Hospitalization rates for heroin overdose increased across all years in all groups and were higher among urban as compared to rural residents.
Bottom line: Opioid overdose hospitalization is associated with patient rurality and a significant proportion of rural individuals are hospitalized for opioid overdose in urban facilities. These patients may have distinct discharge needs.
Citation: Mosher H et al. Trends in hospitalization for opioid overdose among rural compared to urban residents of the United States, 2007-2014. J Hosp Med. 2017. doi: 10.12788/jhm.2793.
Dr. Simonetti is a hospitalist at the University of Colorado School of Medicine.
Clinical question: Is there an association between rurality and trends and characteristics of hospitalizations for opioid overdose?
Background: Hospitalization for an opioid overdose is an opportunity for intervention, and patients may have different discharge needs depending on their rurality. Differences in patient characteristics or overall trends in opioid overdose hospitalizations by rural status have not been described.
Study design: Time trend (2007-2014) and cross-sectional analysis (2012-2014).
Setting: Nationally representative sample of U.S. hospital discharges.
Synopsis: Using weighted data from the National Inpatient Sample and the American Community Survey, the authors found that 43,935 individuals were hospitalized for opioid overdose in the United States in 2007, increasing to 71,280 in 2014. A total of 99% of urban and 37% of rural residents were admitted to urban hospitals. Hospitalization rates for prescription opioid overdoses were higher among rural residents and increased among rural and urban residents until 2011 before declining among rural residents during 2012-2014. Hospitalization rates for prescription opioid overdoses increased among all groups before they declined among large urban population residents after 2011, declined among rural residents after 2012, and continued to rise among small urban residents. Hospitalization rates for heroin overdose increased across all years in all groups and were higher among urban as compared to rural residents.
Bottom line: Opioid overdose hospitalization is associated with patient rurality and a significant proportion of rural individuals are hospitalized for opioid overdose in urban facilities. These patients may have distinct discharge needs.
Citation: Mosher H et al. Trends in hospitalization for opioid overdose among rural compared to urban residents of the United States, 2007-2014. J Hosp Med. 2017. doi: 10.12788/jhm.2793.
Dr. Simonetti is a hospitalist at the University of Colorado School of Medicine.