Vinh-Tung Nguyen, MD

Clinical question: Does the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) risk score more accurately identify patients with atrial fibrillation (Afib) who are at low risk for ischemic stroke than the CHADS2 or CHA2DS2-VASc score?

Background: More accurate and reliable stroke risk prediction tools are needed to optimize anticoagulation decision making in patients with Afib. Recently, a new clinically based risk score, the ATRIA, has been developed and validated. This risk score assigns points based on four age categories (as well as an interaction of age and prior stroke); female gender; renal function; and history of diabetes, congestive heart failure, and hypertension. This study compared the predictive ability of the ATRIA risk score with the CHADS2 and CHA2DS2-VASc risk scores and their implications for anticoagulant treatment in Afib patients.

Study Design: Retrospective cohort study.

Setting: Afib patients not using warfarin from the United Kingdom’s Clinical Practice Research Datalink (CPRD) database, January 1998 to January 2012.

Synopsis: A total of 60,594 patients with Afib were followed until occurrence of ischemic stroke, prescription of warfarin, death, or the study’s end. The annualized stroke rate was 2.99%. Patients with moderate and high-risk CHA2DS2-VASc scores had lower event rates than those with corresponding ATRIA and CHADS2 scores. C-statistics for full point scores were 0.70 (95% CI, 0.69–0.71) for ATRIA and 0.68 (95% CI, 0.67–0.69) for both CHADS2 and CHA2DS2-VASc scores. The net reclassification index of ATRIA compared with CHADS2 and CHA2DS2-VASc risk scores were 0.137 and 0.233, respectively, reflecting that the ATRIA risk score better categorizes patients developing an event.

ATRIA risk score more accurately identified low-risk patients than the CHA2DS2-VASc score assigned to higher-risk categories. The results persisted even after restricting analysis to more recent follow-up, excluding unspecified strokes and excluding renal dysfunction as a predictor. Most improvements with ATRIA were the result of “down classification,” suggesting that using the CHA2DS2-VASc risk score could lead to overtreatment of patients at very low risk of stroke.

Bottom line: The ATRIA risk score better identifies Afib patients who are at low risk for stroke compared to CHADS2 and CHA2DS2-VASc scores.

Citation: van den Ham HA, Klungel OH, Singer DE, Leufkens HG, van Staa TP. Comparative performance of ATRIA, CHADS2, and CHA2DS2-VASc risk scores predicting stroke in patients with atrial fibrillation: results from a national primary care database. J Am Coll Cardiol. 2015;66(17):1851-1959.

Clinical question: Does the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) risk score more accurately identify patients with atrial fibrillation (Afib) who are at low risk for ischemic stroke than the CHADS2 or CHA2DS2-VASc score?

Background: More accurate and reliable stroke risk prediction tools are needed to optimize anticoagulation decision making in patients with Afib. Recently, a new clinically based risk score, the ATRIA, has been developed and validated. This risk score assigns points based on four age categories (as well as an interaction of age and prior stroke); female gender; renal function; and history of diabetes, congestive heart failure, and hypertension. This study compared the predictive ability of the ATRIA risk score with the CHADS2 and CHA2DS2-VASc risk scores and their implications for anticoagulant treatment in Afib patients.

Study Design: Retrospective cohort study.

Setting: Afib patients not using warfarin from the United Kingdom’s Clinical Practice Research Datalink (CPRD) database, January 1998 to January 2012.

Synopsis: A total of 60,594 patients with Afib were followed until occurrence of ischemic stroke, prescription of warfarin, death, or the study’s end. The annualized stroke rate was 2.99%. Patients with moderate and high-risk CHA2DS2-VASc scores had lower event rates than those with corresponding ATRIA and CHADS2 scores. C-statistics for full point scores were 0.70 (95% CI, 0.69–0.71) for ATRIA and 0.68 (95% CI, 0.67–0.69) for both CHADS2 and CHA2DS2-VASc scores. The net reclassification index of ATRIA compared with CHADS2 and CHA2DS2-VASc risk scores were 0.137 and 0.233, respectively, reflecting that the ATRIA risk score better categorizes patients developing an event.

ATRIA risk score more accurately identified low-risk patients than the CHA2DS2-VASc score assigned to higher-risk categories. The results persisted even after restricting analysis to more recent follow-up, excluding unspecified strokes and excluding renal dysfunction as a predictor. Most improvements with ATRIA were the result of “down classification,” suggesting that using the CHA2DS2-VASc risk score could lead to overtreatment of patients at very low risk of stroke.

Bottom line: The ATRIA risk score better identifies Afib patients who are at low risk for stroke compared to CHADS2 and CHA2DS2-VASc scores.

Citation: van den Ham HA, Klungel OH, Singer DE, Leufkens HG, van Staa TP. Comparative performance of ATRIA, CHADS2, and CHA2DS2-VASc risk scores predicting stroke in patients with atrial fibrillation: results from a national primary care database. J Am Coll Cardiol. 2015;66(17):1851-1959.

Clinical question: Does the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) risk score more accurately identify patients with atrial fibrillation (Afib) who are at low risk for ischemic stroke than the CHADS2 or CHA2DS2-VASc score?

Background: More accurate and reliable stroke risk prediction tools are needed to optimize anticoagulation decision making in patients with Afib. Recently, a new clinically based risk score, the ATRIA, has been developed and validated. This risk score assigns points based on four age categories (as well as an interaction of age and prior stroke); female gender; renal function; and history of diabetes, congestive heart failure, and hypertension. This study compared the predictive ability of the ATRIA risk score with the CHADS2 and CHA2DS2-VASc risk scores and their implications for anticoagulant treatment in Afib patients.

Study Design: Retrospective cohort study.

Setting: Afib patients not using warfarin from the United Kingdom’s Clinical Practice Research Datalink (CPRD) database, January 1998 to January 2012.

Synopsis: A total of 60,594 patients with Afib were followed until occurrence of ischemic stroke, prescription of warfarin, death, or the study’s end. The annualized stroke rate was 2.99%. Patients with moderate and high-risk CHA2DS2-VASc scores had lower event rates than those with corresponding ATRIA and CHADS2 scores. C-statistics for full point scores were 0.70 (95% CI, 0.69–0.71) for ATRIA and 0.68 (95% CI, 0.67–0.69) for both CHADS2 and CHA2DS2-VASc scores. The net reclassification index of ATRIA compared with CHADS2 and CHA2DS2-VASc risk scores were 0.137 and 0.233, respectively, reflecting that the ATRIA risk score better categorizes patients developing an event.

ATRIA risk score more accurately identified low-risk patients than the CHA2DS2-VASc score assigned to higher-risk categories. The results persisted even after restricting analysis to more recent follow-up, excluding unspecified strokes and excluding renal dysfunction as a predictor. Most improvements with ATRIA were the result of “down classification,” suggesting that using the CHA2DS2-VASc risk score could lead to overtreatment of patients at very low risk of stroke.

Bottom line: The ATRIA risk score better identifies Afib patients who are at low risk for stroke compared to CHADS2 and CHA2DS2-VASc scores.

Citation: van den Ham HA, Klungel OH, Singer DE, Leufkens HG, van Staa TP. Comparative performance of ATRIA, CHADS2, and CHA2DS2-VASc risk scores predicting stroke in patients with atrial fibrillation: results from a national primary care database. J Am Coll Cardiol. 2015;66(17):1851-1959.

Clinical question: In patients with a first unprovoked VTE, is it safe to use a normalized D-dimer test to stop anticoagulation therapy?

Background: The risk of VTE recurrence after stopping anticoagulation is higher in patients who have elevated D-dimer levels after treatment. It is unknown whether we can use normalized D-dimer levels to guide the decision about whether or not to stop anticoagulation.

Study design: Prospective cohort study.

Setting: Thirteen university-affiliated centers.

Synopsis: Study authors screened 410 adult patients who had a first unprovoked VTE and completed three to seven months of anticoagulation therapy with D-dimer tests. In patients with negative D-dimer tests, anticoagulation was stopped, and D-dimer tests were repeated after a month. In those with two consecutive negative D-dimer tests, anticoagulation was stopped indefinitely; these patients were followed for an average of 2.2 years. Among those 319 patients, there was an overall recurrent VTE rate of 6.7% per patient year. Subgroup analysis was performed among men, women not on estrogen therapy, and women on estrogen therapy; recurrence rates per patient year were 9.7%, 5.4%, and 0%, respectively.

This study used a point-of-care D-dimer test that was either positive or negative; it is unclear if the results can be generalized to all D-dimer tests. Additionally, although the study found a lower recurrence VTE rate among women, the study was not powered for the subgroups.

Bottom line: The high rate of recurrent VTE among men makes the D-dimer test an unsafe marker to use in deciding whether or not to stop anticoagulation for an unprovoked VTE. Among women, D-dimer test can potentially be used to guide length of treatment, but, given the limitations of the study, more evidence is needed.

Citation: Kearon C, Spencer FA, O’Keeffe D, et al. D-Dimer testing to select patients with a first unprovoked venous thromboembolism who can stop anticoagulant therapy. Ann Intern Med. 2015;162(1):27-34.

Clinical question: In patients with a first unprovoked VTE, is it safe to use a normalized D-dimer test to stop anticoagulation therapy?

Background: The risk of VTE recurrence after stopping anticoagulation is higher in patients who have elevated D-dimer levels after treatment. It is unknown whether we can use normalized D-dimer levels to guide the decision about whether or not to stop anticoagulation.

Study design: Prospective cohort study.

Setting: Thirteen university-affiliated centers.

Synopsis: Study authors screened 410 adult patients who had a first unprovoked VTE and completed three to seven months of anticoagulation therapy with D-dimer tests. In patients with negative D-dimer tests, anticoagulation was stopped, and D-dimer tests were repeated after a month. In those with two consecutive negative D-dimer tests, anticoagulation was stopped indefinitely; these patients were followed for an average of 2.2 years. Among those 319 patients, there was an overall recurrent VTE rate of 6.7% per patient year. Subgroup analysis was performed among men, women not on estrogen therapy, and women on estrogen therapy; recurrence rates per patient year were 9.7%, 5.4%, and 0%, respectively.

This study used a point-of-care D-dimer test that was either positive or negative; it is unclear if the results can be generalized to all D-dimer tests. Additionally, although the study found a lower recurrence VTE rate among women, the study was not powered for the subgroups.

Bottom line: The high rate of recurrent VTE among men makes the D-dimer test an unsafe marker to use in deciding whether or not to stop anticoagulation for an unprovoked VTE. Among women, D-dimer test can potentially be used to guide length of treatment, but, given the limitations of the study, more evidence is needed.

Citation: Kearon C, Spencer FA, O’Keeffe D, et al. D-Dimer testing to select patients with a first unprovoked venous thromboembolism who can stop anticoagulant therapy. Ann Intern Med. 2015;162(1):27-34.

Clinical question: In patients with a first unprovoked VTE, is it safe to use a normalized D-dimer test to stop anticoagulation therapy?

Background: The risk of VTE recurrence after stopping anticoagulation is higher in patients who have elevated D-dimer levels after treatment. It is unknown whether we can use normalized D-dimer levels to guide the decision about whether or not to stop anticoagulation.

Study design: Prospective cohort study.

Setting: Thirteen university-affiliated centers.

Synopsis: Study authors screened 410 adult patients who had a first unprovoked VTE and completed three to seven months of anticoagulation therapy with D-dimer tests. In patients with negative D-dimer tests, anticoagulation was stopped, and D-dimer tests were repeated after a month. In those with two consecutive negative D-dimer tests, anticoagulation was stopped indefinitely; these patients were followed for an average of 2.2 years. Among those 319 patients, there was an overall recurrent VTE rate of 6.7% per patient year. Subgroup analysis was performed among men, women not on estrogen therapy, and women on estrogen therapy; recurrence rates per patient year were 9.7%, 5.4%, and 0%, respectively.

This study used a point-of-care D-dimer test that was either positive or negative; it is unclear if the results can be generalized to all D-dimer tests. Additionally, although the study found a lower recurrence VTE rate among women, the study was not powered for the subgroups.

Bottom line: The high rate of recurrent VTE among men makes the D-dimer test an unsafe marker to use in deciding whether or not to stop anticoagulation for an unprovoked VTE. Among women, D-dimer test can potentially be used to guide length of treatment, but, given the limitations of the study, more evidence is needed.

Citation: Kearon C, Spencer FA, O’Keeffe D, et al. D-Dimer testing to select patients with a first unprovoked venous thromboembolism who can stop anticoagulant therapy. Ann Intern Med. 2015;162(1):27-34.

Clinical question: Do patients hospitalized with acute COPD exacerbations have improved outcomes with noninvasive ventilation (NIV) compared to those treated with invasive mechanical ventilation (IMV)?

Background: Previous studies have shown that in select patients, NIV has a mortality benefit over IMV for acute COPD exacerbations requiring hospitalization. NIV may also decrease complication rates and reduce length of stay; however, the previous prospective studies have been small.

Study design: Retrospective cohort study.

Setting: 420 structurally and geographically diverse U.S. hospitals.

Synopsis: Using the Premier Healthcare Informatics database, this study looked at 25,628 patients over 40 years old who were hospitalized with COPD exacerbations. Compared with patients who were initially treated with IMV, patients treated with NIV demonstrated lower mortality rates with an odds ratio of 0.54, lower risk of hospital-acquired pneumonia with an odds ratio of 0.53, and a 32% cost reduction. They also had shorter lengths of stay.

This was a retrospective study using a limited data set, and the authors did not have access to potentially confounding factors between the two groups, including vital signs and blood gases. Additionally, the advantages of NIV were attenuated among patients with pneumonia present on admission, patients with high burden of comorbid diseases, and patients older than 85 years.

Bottom line: Treatment of acute COPD exacerbations with NIV is associated with lower mortality, lower costs, and shorter length of stay as compared with IMV.

Citation: Lindenauer PK, Stefan MS, Shieh MS, Pekow PS, Rothberg MB, Hill NS. Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease. JAMA Intern Med. 2014;174(12):1982-1993.

Clinical question: Do patients hospitalized with acute COPD exacerbations have improved outcomes with noninvasive ventilation (NIV) compared to those treated with invasive mechanical ventilation (IMV)?

Background: Previous studies have shown that in select patients, NIV has a mortality benefit over IMV for acute COPD exacerbations requiring hospitalization. NIV may also decrease complication rates and reduce length of stay; however, the previous prospective studies have been small.

Study design: Retrospective cohort study.

Setting: 420 structurally and geographically diverse U.S. hospitals.

Synopsis: Using the Premier Healthcare Informatics database, this study looked at 25,628 patients over 40 years old who were hospitalized with COPD exacerbations. Compared with patients who were initially treated with IMV, patients treated with NIV demonstrated lower mortality rates with an odds ratio of 0.54, lower risk of hospital-acquired pneumonia with an odds ratio of 0.53, and a 32% cost reduction. They also had shorter lengths of stay.

This was a retrospective study using a limited data set, and the authors did not have access to potentially confounding factors between the two groups, including vital signs and blood gases. Additionally, the advantages of NIV were attenuated among patients with pneumonia present on admission, patients with high burden of comorbid diseases, and patients older than 85 years.

Bottom line: Treatment of acute COPD exacerbations with NIV is associated with lower mortality, lower costs, and shorter length of stay as compared with IMV.

Citation: Lindenauer PK, Stefan MS, Shieh MS, Pekow PS, Rothberg MB, Hill NS. Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease. JAMA Intern Med. 2014;174(12):1982-1993.

Clinical question: Do patients hospitalized with acute COPD exacerbations have improved outcomes with noninvasive ventilation (NIV) compared to those treated with invasive mechanical ventilation (IMV)?

Background: Previous studies have shown that in select patients, NIV has a mortality benefit over IMV for acute COPD exacerbations requiring hospitalization. NIV may also decrease complication rates and reduce length of stay; however, the previous prospective studies have been small.

Study design: Retrospective cohort study.

Setting: 420 structurally and geographically diverse U.S. hospitals.

Synopsis: Using the Premier Healthcare Informatics database, this study looked at 25,628 patients over 40 years old who were hospitalized with COPD exacerbations. Compared with patients who were initially treated with IMV, patients treated with NIV demonstrated lower mortality rates with an odds ratio of 0.54, lower risk of hospital-acquired pneumonia with an odds ratio of 0.53, and a 32% cost reduction. They also had shorter lengths of stay.

This was a retrospective study using a limited data set, and the authors did not have access to potentially confounding factors between the two groups, including vital signs and blood gases. Additionally, the advantages of NIV were attenuated among patients with pneumonia present on admission, patients with high burden of comorbid diseases, and patients older than 85 years.

Bottom line: Treatment of acute COPD exacerbations with NIV is associated with lower mortality, lower costs, and shorter length of stay as compared with IMV.

Citation: Lindenauer PK, Stefan MS, Shieh MS, Pekow PS, Rothberg MB, Hill NS. Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease. JAMA Intern Med. 2014;174(12):1982-1993.

Clinical question: Can the Bova risk model stratify patients with acute PE into stages of increasing risk for 30-day pulmonary embolism (PE)-related complications?

Background: The Bova score is based on four variables assessed at the time of PE diagnosis: heart rate, systolic blood pressure, cardiac troponin, and a marker of right ventricular (RV) dysfunction. In the original study, the Bova risk model was derived from 2,874 normotensive patients with PE. This study performed a retrospective validation of this model on a different cohort of patients.

Study design: Retrospective cohort study.

Setting: Academic urban ED in Madrid, Spain.

Synopsis: Investigators included 1,083 patients with normotensive PE, and the Bova risk score classified 80% into class I, 15% into class II, and 5% into class III—correlating 30-day PE-related complication rates were 4.4%, 18%, and 42%, respectively. When dichotomized into low risk (class I and II) versus intermediate to high risk (class III), the model had a specificity of 97%, a positive predictive value of 42%, and a positive likelihood ratio of 7.9 for predicting 30-day PE-related complications.

The existing risk assessment models, the pulmonary embolism severity index (PESI) and the simplified PESI (sPESI), have been extensively validated but were specifically developed to identity patients with low risk for mortality. The Bova risk model could be used in a stepwise fashion, with the PESI or sPESI model, to further assess intermediate-risk patients.

This model was derived and validated at one single center, so the results may not be generalizable. Additionally, the variables were collected prospectively, but this validation analysis was performed retrospectively.

Bottom line: The Bova risk model accurately stratifies patients with normotensive PE into stages of increasing risk for developing 30-day PE-related complications.

Citation: Fernández C, Bova C, Sanchez O, et al. Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism [published online ahead of print January 29, 2015]. Chest.

Clinical question: Can the Bova risk model stratify patients with acute PE into stages of increasing risk for 30-day pulmonary embolism (PE)-related complications?

Background: The Bova score is based on four variables assessed at the time of PE diagnosis: heart rate, systolic blood pressure, cardiac troponin, and a marker of right ventricular (RV) dysfunction. In the original study, the Bova risk model was derived from 2,874 normotensive patients with PE. This study performed a retrospective validation of this model on a different cohort of patients.

Study design: Retrospective cohort study.

Setting: Academic urban ED in Madrid, Spain.

Synopsis: Investigators included 1,083 patients with normotensive PE, and the Bova risk score classified 80% into class I, 15% into class II, and 5% into class III—correlating 30-day PE-related complication rates were 4.4%, 18%, and 42%, respectively. When dichotomized into low risk (class I and II) versus intermediate to high risk (class III), the model had a specificity of 97%, a positive predictive value of 42%, and a positive likelihood ratio of 7.9 for predicting 30-day PE-related complications.

The existing risk assessment models, the pulmonary embolism severity index (PESI) and the simplified PESI (sPESI), have been extensively validated but were specifically developed to identity patients with low risk for mortality. The Bova risk model could be used in a stepwise fashion, with the PESI or sPESI model, to further assess intermediate-risk patients.

This model was derived and validated at one single center, so the results may not be generalizable. Additionally, the variables were collected prospectively, but this validation analysis was performed retrospectively.

Bottom line: The Bova risk model accurately stratifies patients with normotensive PE into stages of increasing risk for developing 30-day PE-related complications.

Citation: Fernández C, Bova C, Sanchez O, et al. Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism [published online ahead of print January 29, 2015]. Chest.

Clinical question: Can the Bova risk model stratify patients with acute PE into stages of increasing risk for 30-day pulmonary embolism (PE)-related complications?

Background: The Bova score is based on four variables assessed at the time of PE diagnosis: heart rate, systolic blood pressure, cardiac troponin, and a marker of right ventricular (RV) dysfunction. In the original study, the Bova risk model was derived from 2,874 normotensive patients with PE. This study performed a retrospective validation of this model on a different cohort of patients.

Study design: Retrospective cohort study.

Setting: Academic urban ED in Madrid, Spain.

Synopsis: Investigators included 1,083 patients with normotensive PE, and the Bova risk score classified 80% into class I, 15% into class II, and 5% into class III—correlating 30-day PE-related complication rates were 4.4%, 18%, and 42%, respectively. When dichotomized into low risk (class I and II) versus intermediate to high risk (class III), the model had a specificity of 97%, a positive predictive value of 42%, and a positive likelihood ratio of 7.9 for predicting 30-day PE-related complications.

The existing risk assessment models, the pulmonary embolism severity index (PESI) and the simplified PESI (sPESI), have been extensively validated but were specifically developed to identity patients with low risk for mortality. The Bova risk model could be used in a stepwise fashion, with the PESI or sPESI model, to further assess intermediate-risk patients.

This model was derived and validated at one single center, so the results may not be generalizable. Additionally, the variables were collected prospectively, but this validation analysis was performed retrospectively.

Bottom line: The Bova risk model accurately stratifies patients with normotensive PE into stages of increasing risk for developing 30-day PE-related complications.

Citation: Fernández C, Bova C, Sanchez O, et al. Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism [published online ahead of print January 29, 2015]. Chest.

Clinical question: Do minor and minimal head injuries in patients on warfarin lead to significant intracranial bleed?

Background: Warfarin use is common, and many of these patients sustain minor and minimal head injuries. When presenting to the ED, these patients pose a clinical dilemma regarding whether to obtain neuroimaging and/or admit.

Study design: Retrospective cohort study.

Setting: Two urban tertiary care EDs in Ottawa, Canada, over a two-year period.

Synopsis: Using the Canadian National Ambulatory Care Reporting System database and the associated coding data, 259 patients were identified that fit the inclusion criteria GCS ≥13 and INR >1.5. This study showed that the rate of intracranial bleeds in this group of patients was high (15.9%); for minor and minimal head injury groups, the rate was 21.9% and 4.8%, respectively. Additionally, loss of consciousness was associated with higher rates of intracranial bleeding.

The risk of intracranial bleed after a head injury while on warfarin is considerably high, particularly for those patients with minor head injury (21.9%), which is about three times the rate previously reported. Hospitalists evaluating these patients should consider obtaining neuroimaging.

Nonetheless, these rates may be overestimating the true prevalence due to the following: 1) Coding data may overlook minor and minimal head injuries in the presence of more serious injuries, and 2) patients with minimal head injuries may not seek medical care.

Bottom line: Patients sustaining minor head injury while on warfarin have a high rate of intracranial bleed.

Reference: Alrajhi KN, Perry JJ, Forster AJ. Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emer Med. 2015;48(2):137-142.

Clinical question: Do minor and minimal head injuries in patients on warfarin lead to significant intracranial bleed?

Background: Warfarin use is common, and many of these patients sustain minor and minimal head injuries. When presenting to the ED, these patients pose a clinical dilemma regarding whether to obtain neuroimaging and/or admit.

Study design: Retrospective cohort study.

Setting: Two urban tertiary care EDs in Ottawa, Canada, over a two-year period.

Synopsis: Using the Canadian National Ambulatory Care Reporting System database and the associated coding data, 259 patients were identified that fit the inclusion criteria GCS ≥13 and INR >1.5. This study showed that the rate of intracranial bleeds in this group of patients was high (15.9%); for minor and minimal head injury groups, the rate was 21.9% and 4.8%, respectively. Additionally, loss of consciousness was associated with higher rates of intracranial bleeding.

The risk of intracranial bleed after a head injury while on warfarin is considerably high, particularly for those patients with minor head injury (21.9%), which is about three times the rate previously reported. Hospitalists evaluating these patients should consider obtaining neuroimaging.

Nonetheless, these rates may be overestimating the true prevalence due to the following: 1) Coding data may overlook minor and minimal head injuries in the presence of more serious injuries, and 2) patients with minimal head injuries may not seek medical care.

Bottom line: Patients sustaining minor head injury while on warfarin have a high rate of intracranial bleed.

Reference: Alrajhi KN, Perry JJ, Forster AJ. Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emer Med. 2015;48(2):137-142.

Clinical question: Do minor and minimal head injuries in patients on warfarin lead to significant intracranial bleed?

Background: Warfarin use is common, and many of these patients sustain minor and minimal head injuries. When presenting to the ED, these patients pose a clinical dilemma regarding whether to obtain neuroimaging and/or admit.

Study design: Retrospective cohort study.

Setting: Two urban tertiary care EDs in Ottawa, Canada, over a two-year period.

Synopsis: Using the Canadian National Ambulatory Care Reporting System database and the associated coding data, 259 patients were identified that fit the inclusion criteria GCS ≥13 and INR >1.5. This study showed that the rate of intracranial bleeds in this group of patients was high (15.9%); for minor and minimal head injury groups, the rate was 21.9% and 4.8%, respectively. Additionally, loss of consciousness was associated with higher rates of intracranial bleeding.

The risk of intracranial bleed after a head injury while on warfarin is considerably high, particularly for those patients with minor head injury (21.9%), which is about three times the rate previously reported. Hospitalists evaluating these patients should consider obtaining neuroimaging.

Nonetheless, these rates may be overestimating the true prevalence due to the following: 1) Coding data may overlook minor and minimal head injuries in the presence of more serious injuries, and 2) patients with minimal head injuries may not seek medical care.

Bottom line: Patients sustaining minor head injury while on warfarin have a high rate of intracranial bleed.

Reference: Alrajhi KN, Perry JJ, Forster AJ. Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emer Med. 2015;48(2):137-142.

Clinical question: Does a high-calorie, high-protein formula enriched with supplements of arginine, zinc, and antioxidants improve pressure ulcer healing?

Background: Malnutrition is thought to be a major factor in the development and poor healing of pressure ulcers. Trials evaluating whether or not the addition of antioxidants, arginine, and zinc to nutritional formulas improves pressure ulcer healing have been small and inconsistent.

Study design: Multicenter, randomized, controlled, blinded trial.

Setting: Long-term care facilities and patients receiving home care services.

Synopsis: Two hundred patients with stage II, III, or IV pressure ulcers receiving standardized wound care were randomly assigned to a control formula or an experimental formula enriched with arginine, zinc, and antioxidants. At eight weeks, the experimental formula group had an 18.7% (CI, 5.7% to 31.8%, P=0.017) mean reduction in pressure ulcer size compared with the control formula group, although both groups showed efficacy in wound healing.

Nutrition is an important part of wound healing and should be incorporated into the plan of care for the hospitalized patient with pressure ulcers. Hospitalists should be mindful that this study was conducted in non-acute settings, with a chronically ill patient population; more research needs to be done to investigate the effect of these specific immune-modulating nutritional supplements in acutely ill hospitalized patients, given the inconclusive safety profile of certain nutrients such as arginine in severe sepsis.

Bottom line: Enhanced nutritional support with an oral nutritional formula enriched with arginine, zinc, and antioxidants improves pressure ulcer healing in malnourished patients already receiving standard wound care.

Citation: Cereda E, Klersy C, Serioli M, Crespi A, D’Andrea F, OligoElement Sore Trial Study Group. A nutritional formula enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized trial. Ann Intern Med. 2015;162(3):167-174.

Clinical question: Does a high-calorie, high-protein formula enriched with supplements of arginine, zinc, and antioxidants improve pressure ulcer healing?

Background: Malnutrition is thought to be a major factor in the development and poor healing of pressure ulcers. Trials evaluating whether or not the addition of antioxidants, arginine, and zinc to nutritional formulas improves pressure ulcer healing have been small and inconsistent.

Study design: Multicenter, randomized, controlled, blinded trial.

Setting: Long-term care facilities and patients receiving home care services.

Synopsis: Two hundred patients with stage II, III, or IV pressure ulcers receiving standardized wound care were randomly assigned to a control formula or an experimental formula enriched with arginine, zinc, and antioxidants. At eight weeks, the experimental formula group had an 18.7% (CI, 5.7% to 31.8%, P=0.017) mean reduction in pressure ulcer size compared with the control formula group, although both groups showed efficacy in wound healing.

Nutrition is an important part of wound healing and should be incorporated into the plan of care for the hospitalized patient with pressure ulcers. Hospitalists should be mindful that this study was conducted in non-acute settings, with a chronically ill patient population; more research needs to be done to investigate the effect of these specific immune-modulating nutritional supplements in acutely ill hospitalized patients, given the inconclusive safety profile of certain nutrients such as arginine in severe sepsis.

Bottom line: Enhanced nutritional support with an oral nutritional formula enriched with arginine, zinc, and antioxidants improves pressure ulcer healing in malnourished patients already receiving standard wound care.

Citation: Cereda E, Klersy C, Serioli M, Crespi A, D’Andrea F, OligoElement Sore Trial Study Group. A nutritional formula enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized trial. Ann Intern Med. 2015;162(3):167-174.

Clinical question: Does a high-calorie, high-protein formula enriched with supplements of arginine, zinc, and antioxidants improve pressure ulcer healing?

Background: Malnutrition is thought to be a major factor in the development and poor healing of pressure ulcers. Trials evaluating whether or not the addition of antioxidants, arginine, and zinc to nutritional formulas improves pressure ulcer healing have been small and inconsistent.

Study design: Multicenter, randomized, controlled, blinded trial.

Setting: Long-term care facilities and patients receiving home care services.

Synopsis: Two hundred patients with stage II, III, or IV pressure ulcers receiving standardized wound care were randomly assigned to a control formula or an experimental formula enriched with arginine, zinc, and antioxidants. At eight weeks, the experimental formula group had an 18.7% (CI, 5.7% to 31.8%, P=0.017) mean reduction in pressure ulcer size compared with the control formula group, although both groups showed efficacy in wound healing.

Nutrition is an important part of wound healing and should be incorporated into the plan of care for the hospitalized patient with pressure ulcers. Hospitalists should be mindful that this study was conducted in non-acute settings, with a chronically ill patient population; more research needs to be done to investigate the effect of these specific immune-modulating nutritional supplements in acutely ill hospitalized patients, given the inconclusive safety profile of certain nutrients such as arginine in severe sepsis.

Bottom line: Enhanced nutritional support with an oral nutritional formula enriched with arginine, zinc, and antioxidants improves pressure ulcer healing in malnourished patients already receiving standard wound care.

Citation: Cereda E, Klersy C, Serioli M, Crespi A, D’Andrea F, OligoElement Sore Trial Study Group. A nutritional formula enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized trial. Ann Intern Med. 2015;162(3):167-174.

Clinical question: Is there an association between hospital volume and hospital readmission rates?

Background: There is an established association between high patient volume and reduced complications or mortality after surgical procedures; however, readmission represents a different type of quality metric than mortality or complications. Studies on the association between hospital patient volume and readmission rates have been controversial.

Study design: Retrospective, cross-sectional study.

Setting: Acute care hospitals.

Synopsis: The study included 6,916,644 admissions to 4,651 hospitals, where patients were assigned to one of five cohorts: medicine, surgery/gynecology, cardiorespiratory, cardiovascular, and neurology. The hospital with the highest volume group had a hospital-wide mean standardized readmission rate of 15.9%, while the hospital with the lowest volume group had a readmission rate of 14.7%. This was a 1.2 percentage point absolute difference between the two hospitals (95% confidence interval 0.9 to 1.5). This trend continued when specialty cohorts were examined, with the exception of the procedure-heavy cardiovascular cohort.

Results showed a trend toward decreased readmission rates in lower-volume hospitals; however, it is unclear why this trend exists. Possible reasons include different patient populations and different practitioner-to-patient ratios in low-volume hospitals.

Limitations of this study are the inclusion of only patients 65 years and older and the fact that all admissions per patient were included, which may bias the results against hospitals with many frequently admitted patients.

Bottom line: Hospitals with high patient volumes are associated with higher readmission rates, except in procedure-heavy patient groups.

Citation: Horwitz LI, Lin Z, Herrin J, et al.Association of hospital volume with readmission rates: a retrospective cross-sectional study. BMJ. 2015;350:h447.

Clinical question: Is there an association between hospital volume and hospital readmission rates?

Background: There is an established association between high patient volume and reduced complications or mortality after surgical procedures; however, readmission represents a different type of quality metric than mortality or complications. Studies on the association between hospital patient volume and readmission rates have been controversial.

Study design: Retrospective, cross-sectional study.

Setting: Acute care hospitals.

Synopsis: The study included 6,916,644 admissions to 4,651 hospitals, where patients were assigned to one of five cohorts: medicine, surgery/gynecology, cardiorespiratory, cardiovascular, and neurology. The hospital with the highest volume group had a hospital-wide mean standardized readmission rate of 15.9%, while the hospital with the lowest volume group had a readmission rate of 14.7%. This was a 1.2 percentage point absolute difference between the two hospitals (95% confidence interval 0.9 to 1.5). This trend continued when specialty cohorts were examined, with the exception of the procedure-heavy cardiovascular cohort.

Results showed a trend toward decreased readmission rates in lower-volume hospitals; however, it is unclear why this trend exists. Possible reasons include different patient populations and different practitioner-to-patient ratios in low-volume hospitals.

Limitations of this study are the inclusion of only patients 65 years and older and the fact that all admissions per patient were included, which may bias the results against hospitals with many frequently admitted patients.

Bottom line: Hospitals with high patient volumes are associated with higher readmission rates, except in procedure-heavy patient groups.

Citation: Horwitz LI, Lin Z, Herrin J, et al.Association of hospital volume with readmission rates: a retrospective cross-sectional study. BMJ. 2015;350:h447.

Clinical question: Is there an association between hospital volume and hospital readmission rates?

Background: There is an established association between high patient volume and reduced complications or mortality after surgical procedures; however, readmission represents a different type of quality metric than mortality or complications. Studies on the association between hospital patient volume and readmission rates have been controversial.

Study design: Retrospective, cross-sectional study.

Setting: Acute care hospitals.

Synopsis: The study included 6,916,644 admissions to 4,651 hospitals, where patients were assigned to one of five cohorts: medicine, surgery/gynecology, cardiorespiratory, cardiovascular, and neurology. The hospital with the highest volume group had a hospital-wide mean standardized readmission rate of 15.9%, while the hospital with the lowest volume group had a readmission rate of 14.7%. This was a 1.2 percentage point absolute difference between the two hospitals (95% confidence interval 0.9 to 1.5). This trend continued when specialty cohorts were examined, with the exception of the procedure-heavy cardiovascular cohort.

Results showed a trend toward decreased readmission rates in lower-volume hospitals; however, it is unclear why this trend exists. Possible reasons include different patient populations and different practitioner-to-patient ratios in low-volume hospitals.

Limitations of this study are the inclusion of only patients 65 years and older and the fact that all admissions per patient were included, which may bias the results against hospitals with many frequently admitted patients.

Bottom line: Hospitals with high patient volumes are associated with higher readmission rates, except in procedure-heavy patient groups.

Citation: Horwitz LI, Lin Z, Herrin J, et al.Association of hospital volume with readmission rates: a retrospective cross-sectional study. BMJ. 2015;350:h447.

Clinical Question: What is the extent of, and factors associated with, testing overuse in U.S. hospitals for pre-operative evaluation and syncope.

Background: Little is known about the extent and drivers of overuse by hospitalists.

Study design: Two vignettes (pre-operative evaluation and syncope) were mailed to hospitalists. They were asked to identify what most hospitalists at their institution would recommend and “the most likely primary driver of the hospitalist’s decision.”

Setting: Random selection of hospitalists from SHM member database and SHM national meeting attendees.

Synopsis: Investigators mailed 1,753 surveys and received a 68% response rate. For the pre-operative evaluation vignette, 52% of hospitalists reported overuse of pre-operative testing. When a family member was a physician and requested further testing, overuse increased significantly to 65%. For the syncope vignette, any choice involving admission was considered overuse.

Eighty-two percent of respondents reported overuse; when the wife was a lawyer or requested further testing, overuse remained the same. Overuse in both cases was more frequent due to a hospitalist’s desire to reassure patients or themselves, rather than a belief that it was clinically indicated (pre-operative evaluation, 63% vs. 37%; syncope, 69% vs. 31%, P<0.001).

The survey responses do not necessarily represent actual clinical choices, and the hospitalist sample may not be representative of all hospitalists; however, this study shows that efforts to reduce overuse in hospitals need to move beyond financial incentives and/or informing providers of evidence-based recommendations.

Bottom line: A survey of hospitalists showed substantial overuse in two common clinical situations, syncope and pre-operative evaluation, mostly driven by a desire to reassure patients, families, or themselves.

Citation: Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162(2):100-108.

Clinical Question: What is the extent of, and factors associated with, testing overuse in U.S. hospitals for pre-operative evaluation and syncope.

Background: Little is known about the extent and drivers of overuse by hospitalists.

Study design: Two vignettes (pre-operative evaluation and syncope) were mailed to hospitalists. They were asked to identify what most hospitalists at their institution would recommend and “the most likely primary driver of the hospitalist’s decision.”

Setting: Random selection of hospitalists from SHM member database and SHM national meeting attendees.

Synopsis: Investigators mailed 1,753 surveys and received a 68% response rate. For the pre-operative evaluation vignette, 52% of hospitalists reported overuse of pre-operative testing. When a family member was a physician and requested further testing, overuse increased significantly to 65%. For the syncope vignette, any choice involving admission was considered overuse.

Eighty-two percent of respondents reported overuse; when the wife was a lawyer or requested further testing, overuse remained the same. Overuse in both cases was more frequent due to a hospitalist’s desire to reassure patients or themselves, rather than a belief that it was clinically indicated (pre-operative evaluation, 63% vs. 37%; syncope, 69% vs. 31%, P<0.001).

The survey responses do not necessarily represent actual clinical choices, and the hospitalist sample may not be representative of all hospitalists; however, this study shows that efforts to reduce overuse in hospitals need to move beyond financial incentives and/or informing providers of evidence-based recommendations.

Bottom line: A survey of hospitalists showed substantial overuse in two common clinical situations, syncope and pre-operative evaluation, mostly driven by a desire to reassure patients, families, or themselves.

Citation: Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162(2):100-108.

Clinical Question: What is the extent of, and factors associated with, testing overuse in U.S. hospitals for pre-operative evaluation and syncope.

Background: Little is known about the extent and drivers of overuse by hospitalists.

Study design: Two vignettes (pre-operative evaluation and syncope) were mailed to hospitalists. They were asked to identify what most hospitalists at their institution would recommend and “the most likely primary driver of the hospitalist’s decision.”

Setting: Random selection of hospitalists from SHM member database and SHM national meeting attendees.

Synopsis: Investigators mailed 1,753 surveys and received a 68% response rate. For the pre-operative evaluation vignette, 52% of hospitalists reported overuse of pre-operative testing. When a family member was a physician and requested further testing, overuse increased significantly to 65%. For the syncope vignette, any choice involving admission was considered overuse.

Eighty-two percent of respondents reported overuse; when the wife was a lawyer or requested further testing, overuse remained the same. Overuse in both cases was more frequent due to a hospitalist’s desire to reassure patients or themselves, rather than a belief that it was clinically indicated (pre-operative evaluation, 63% vs. 37%; syncope, 69% vs. 31%, P<0.001).

The survey responses do not necessarily represent actual clinical choices, and the hospitalist sample may not be representative of all hospitalists; however, this study shows that efforts to reduce overuse in hospitals need to move beyond financial incentives and/or informing providers of evidence-based recommendations.

Bottom line: A survey of hospitalists showed substantial overuse in two common clinical situations, syncope and pre-operative evaluation, mostly driven by a desire to reassure patients, families, or themselves.

Citation: Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162(2):100-108.

Clinical question: Is functional impairment associated with an increased risk of 30-day readmission?

Background: Many Medicare seniors suffer from some level of impairment in functional status, which, in turn, has been linked to high healthcare utilization. Studies that examine the role of functional impairment with readmission rates are limited.

Study design: Prospective, cohort study.

Setting: Seniors enrolled in the Health and Retirement Study (HRS) with Medicare hospitalizations from Jan. 1, 2000, to Dec. 31, 2010.

Synopsis: The primary outcome was readmissions within 30 days of discharge. Activities of daily living (ADL) scale and instrumental ADL were used as measures of functional impairment.

Overall, 48.3% of patients had preadmission functional impairments with a readmission rate of 15.5%. There was a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty in one or more instrumental ADLs (OR 1.06; 95% CI 0.94-1.20), 14.4% with difficulty in one or more ADLs (OR 1.08; 95% CI 0.96-1.21), 16.5% with dependency in one or two ADLs (OR, 1.26; 95% CI 1.11-1.44), and 18.2% with dependency in three or more ADLs (OR 1.42; 95% CI 1.20-1.69).

This observation was more pronounced in patients admitted for heart failure, MI, and pneumonia (16.9% readmission rate for no impairment vs. 25.7% dependency in three or more ADLs, OR 1.70; 95% CI 1.04-2.78).

Although the study is limited by reliance on survey data and Medicare claim data, functional status may be an important variable in calculating readmission risk and a potential target for intervention.

Bottom line: Functional impairment is associated with an increased risk of 30-day readmission, especially in patients admitted for heart failure, MI, and pneumonia.

Citation: Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175(4):559-565.

Clinical question: Is functional impairment associated with an increased risk of 30-day readmission?

Background: Many Medicare seniors suffer from some level of impairment in functional status, which, in turn, has been linked to high healthcare utilization. Studies that examine the role of functional impairment with readmission rates are limited.

Study design: Prospective, cohort study.

Setting: Seniors enrolled in the Health and Retirement Study (HRS) with Medicare hospitalizations from Jan. 1, 2000, to Dec. 31, 2010.

Synopsis: The primary outcome was readmissions within 30 days of discharge. Activities of daily living (ADL) scale and instrumental ADL were used as measures of functional impairment.

Overall, 48.3% of patients had preadmission functional impairments with a readmission rate of 15.5%. There was a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty in one or more instrumental ADLs (OR 1.06; 95% CI 0.94-1.20), 14.4% with difficulty in one or more ADLs (OR 1.08; 95% CI 0.96-1.21), 16.5% with dependency in one or two ADLs (OR, 1.26; 95% CI 1.11-1.44), and 18.2% with dependency in three or more ADLs (OR 1.42; 95% CI 1.20-1.69).

This observation was more pronounced in patients admitted for heart failure, MI, and pneumonia (16.9% readmission rate for no impairment vs. 25.7% dependency in three or more ADLs, OR 1.70; 95% CI 1.04-2.78).

Although the study is limited by reliance on survey data and Medicare claim data, functional status may be an important variable in calculating readmission risk and a potential target for intervention.

Bottom line: Functional impairment is associated with an increased risk of 30-day readmission, especially in patients admitted for heart failure, MI, and pneumonia.

Citation: Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175(4):559-565.

Clinical question: Is functional impairment associated with an increased risk of 30-day readmission?

Background: Many Medicare seniors suffer from some level of impairment in functional status, which, in turn, has been linked to high healthcare utilization. Studies that examine the role of functional impairment with readmission rates are limited.

Study design: Prospective, cohort study.

Setting: Seniors enrolled in the Health and Retirement Study (HRS) with Medicare hospitalizations from Jan. 1, 2000, to Dec. 31, 2010.

Synopsis: The primary outcome was readmissions within 30 days of discharge. Activities of daily living (ADL) scale and instrumental ADL were used as measures of functional impairment.

Overall, 48.3% of patients had preadmission functional impairments with a readmission rate of 15.5%. There was a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty in one or more instrumental ADLs (OR 1.06; 95% CI 0.94-1.20), 14.4% with difficulty in one or more ADLs (OR 1.08; 95% CI 0.96-1.21), 16.5% with dependency in one or two ADLs (OR, 1.26; 95% CI 1.11-1.44), and 18.2% with dependency in three or more ADLs (OR 1.42; 95% CI 1.20-1.69).

This observation was more pronounced in patients admitted for heart failure, MI, and pneumonia (16.9% readmission rate for no impairment vs. 25.7% dependency in three or more ADLs, OR 1.70; 95% CI 1.04-2.78).

Although the study is limited by reliance on survey data and Medicare claim data, functional status may be an important variable in calculating readmission risk and a potential target for intervention.

Bottom line: Functional impairment is associated with an increased risk of 30-day readmission, especially in patients admitted for heart failure, MI, and pneumonia.

Citation: Greysen SR, Stijacic Cenzer I, Auerbach AD, Covinsky KE. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015;175(4):559-565.

Clinical question: Are multicomponent, nonpharmacological interventions effective in decreasing delirium and falls?

Background: Delirium is prevalent among elderly hospitalized patients and is associated with increased morbidity, length of stay, healthcare costs, and risk of institutionalization. Multicomponent nonpharmacologic interventions have been used to prevent incident delirium in the elderly, but data regarding their effectiveness and impact on preventing poor outcomes are lacking.

Study design: Systematic literature review and meta-analysis.

Setting: Review of medical databases from Jan. 1, 1999, to Dec. 31, 2013.

Synopsis: Fourteen studies were included involving 4,267 elderly patients from 12 acute medical and surgical sites from around the world. There was a 53% reduction in delirium incidence associated with multicomponent, nonpharmacological interventions (OR, 0.47; 95% CI, 0.38-0.58). The odds of falling were 62% lower among intervention patients compared with controls (2.79 vs. 7.05 falls per 1,000 patient-days). The intervention group also showed a decrease in length of stay, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) days and a 5% lower chance of institutionalization (95% CI, 0.71 to 1.26); however, the differences were not statistically significant.

Although the small number and heterogeneity of the studies included limited the analysis, the use of nonpharmacologic interventions appears to be a low-risk, low-cost strategy to prevent delirium. The challenge for the hospitalist in developing a nonpharmacological protocol is to determine which interventions to include; the study did not look at which interventions were most effective.

Bottom line: The use of multicomponent nonpharmacological interventions in older patients can lower the risk of delirium and falls.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.

Clinical question: Are multicomponent, nonpharmacological interventions effective in decreasing delirium and falls?

Background: Delirium is prevalent among elderly hospitalized patients and is associated with increased morbidity, length of stay, healthcare costs, and risk of institutionalization. Multicomponent nonpharmacologic interventions have been used to prevent incident delirium in the elderly, but data regarding their effectiveness and impact on preventing poor outcomes are lacking.

Study design: Systematic literature review and meta-analysis.

Setting: Review of medical databases from Jan. 1, 1999, to Dec. 31, 2013.

Synopsis: Fourteen studies were included involving 4,267 elderly patients from 12 acute medical and surgical sites from around the world. There was a 53% reduction in delirium incidence associated with multicomponent, nonpharmacological interventions (OR, 0.47; 95% CI, 0.38-0.58). The odds of falling were 62% lower among intervention patients compared with controls (2.79 vs. 7.05 falls per 1,000 patient-days). The intervention group also showed a decrease in length of stay, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) days and a 5% lower chance of institutionalization (95% CI, 0.71 to 1.26); however, the differences were not statistically significant.

Although the small number and heterogeneity of the studies included limited the analysis, the use of nonpharmacologic interventions appears to be a low-risk, low-cost strategy to prevent delirium. The challenge for the hospitalist in developing a nonpharmacological protocol is to determine which interventions to include; the study did not look at which interventions were most effective.

Bottom line: The use of multicomponent nonpharmacological interventions in older patients can lower the risk of delirium and falls.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.

Clinical question: Are multicomponent, nonpharmacological interventions effective in decreasing delirium and falls?

Background: Delirium is prevalent among elderly hospitalized patients and is associated with increased morbidity, length of stay, healthcare costs, and risk of institutionalization. Multicomponent nonpharmacologic interventions have been used to prevent incident delirium in the elderly, but data regarding their effectiveness and impact on preventing poor outcomes are lacking.

Study design: Systematic literature review and meta-analysis.

Setting: Review of medical databases from Jan. 1, 1999, to Dec. 31, 2013.

Synopsis: Fourteen studies were included involving 4,267 elderly patients from 12 acute medical and surgical sites from around the world. There was a 53% reduction in delirium incidence associated with multicomponent, nonpharmacological interventions (OR, 0.47; 95% CI, 0.38-0.58). The odds of falling were 62% lower among intervention patients compared with controls (2.79 vs. 7.05 falls per 1,000 patient-days). The intervention group also showed a decrease in length of stay, with a mean difference of -0.16 (95% CI, -0.97 to 0.64) days and a 5% lower chance of institutionalization (95% CI, 0.71 to 1.26); however, the differences were not statistically significant.

Although the small number and heterogeneity of the studies included limited the analysis, the use of nonpharmacologic interventions appears to be a low-risk, low-cost strategy to prevent delirium. The challenge for the hospitalist in developing a nonpharmacological protocol is to determine which interventions to include; the study did not look at which interventions were most effective.

Bottom line: The use of multicomponent nonpharmacological interventions in older patients can lower the risk of delirium and falls.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512-520.