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Beta-Blockers May Increase Risk of Perioperative MACEs in Patients with Uncomplicated Hypertension
Clinical question: Does taking a perioperative beta-blocker increase the risk of major adverse cardiovascular events (MACEs) and all-cause mortality in low-risk patients with essential hypertension (HTN)?
Background: Guidelines for the use of perioperative beta-blockers are being reevaluated due to concerns about validity of prior studies that supported the use of perioperative beta-blockers. This study sought to evaluate effectiveness and safety of beta-blockers in patients with uncomplicated HTN.
Study design: Observational cohort study.
Setting: Denmark.
Synopsis: This study included 55,320 hypertensive patients using at least two antihypertensive drugs who underwent non-cardiac surgery. Of these, 14,644 patients were treated with a beta-blocker. Patients with secondary cardiovascular conditions, renal disease, or liver disease were excluded; 30-day MACEs and all-cause mortality were analyzed.
In patients treated with a beta-blocker, the incidence of 30-day MACEs was 1.32% compared with 0.84% in the non-beta-blockers group; 30-day mortality in those treated with beta-blocker was 1.9% compared with 1.3% in the non-beta-blocker group. Risk of beta-blocker-associated MACEs was higher in patients 70 and older. Causality cannot be concluded based on observational data.
Bottom line: In patients with uncomplicated HTN, treatment with a beta-blocker may be associated with increased 30-day risk of perioperative MACEs after non-cardiac surgery.
Citation: Jorgensen ME, Hlatky MA, Kober L, et al. Beta-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.
Clinical question: Does taking a perioperative beta-blocker increase the risk of major adverse cardiovascular events (MACEs) and all-cause mortality in low-risk patients with essential hypertension (HTN)?
Background: Guidelines for the use of perioperative beta-blockers are being reevaluated due to concerns about validity of prior studies that supported the use of perioperative beta-blockers. This study sought to evaluate effectiveness and safety of beta-blockers in patients with uncomplicated HTN.
Study design: Observational cohort study.
Setting: Denmark.
Synopsis: This study included 55,320 hypertensive patients using at least two antihypertensive drugs who underwent non-cardiac surgery. Of these, 14,644 patients were treated with a beta-blocker. Patients with secondary cardiovascular conditions, renal disease, or liver disease were excluded; 30-day MACEs and all-cause mortality were analyzed.
In patients treated with a beta-blocker, the incidence of 30-day MACEs was 1.32% compared with 0.84% in the non-beta-blockers group; 30-day mortality in those treated with beta-blocker was 1.9% compared with 1.3% in the non-beta-blocker group. Risk of beta-blocker-associated MACEs was higher in patients 70 and older. Causality cannot be concluded based on observational data.
Bottom line: In patients with uncomplicated HTN, treatment with a beta-blocker may be associated with increased 30-day risk of perioperative MACEs after non-cardiac surgery.
Citation: Jorgensen ME, Hlatky MA, Kober L, et al. Beta-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.
Clinical question: Does taking a perioperative beta-blocker increase the risk of major adverse cardiovascular events (MACEs) and all-cause mortality in low-risk patients with essential hypertension (HTN)?
Background: Guidelines for the use of perioperative beta-blockers are being reevaluated due to concerns about validity of prior studies that supported the use of perioperative beta-blockers. This study sought to evaluate effectiveness and safety of beta-blockers in patients with uncomplicated HTN.
Study design: Observational cohort study.
Setting: Denmark.
Synopsis: This study included 55,320 hypertensive patients using at least two antihypertensive drugs who underwent non-cardiac surgery. Of these, 14,644 patients were treated with a beta-blocker. Patients with secondary cardiovascular conditions, renal disease, or liver disease were excluded; 30-day MACEs and all-cause mortality were analyzed.
In patients treated with a beta-blocker, the incidence of 30-day MACEs was 1.32% compared with 0.84% in the non-beta-blockers group; 30-day mortality in those treated with beta-blocker was 1.9% compared with 1.3% in the non-beta-blocker group. Risk of beta-blocker-associated MACEs was higher in patients 70 and older. Causality cannot be concluded based on observational data.
Bottom line: In patients with uncomplicated HTN, treatment with a beta-blocker may be associated with increased 30-day risk of perioperative MACEs after non-cardiac surgery.
Citation: Jorgensen ME, Hlatky MA, Kober L, et al. Beta-blocker-associated risks in patients with uncomplicated hypertension undergoing noncardiac surgery. JAMA Intern Med. 2015;175(12):1923-1931.
Pharmacist Involvement in Transitional Care Can Reduce Return ED Visits, Inpatient Readmissions
Clinical question: Does pharmacist involvement in transitions of care decrease medication errors (MEs), adverse drug events (ADEs), and 30-day ED visits and inpatient readmissions?
Background: Previous studies show pharmacist involvement in discharge can reduce ADEs and improve patient satisfaction, but there have been inconsistent data on the impact of pharmacist involvement on readmissions, ADEs, and MEs.
Study design: Prospective, randomized, single-period, longitudinal study.
Setting: Northwestern Memorial Hospital, Chicago.
Synopsis: Investigators included 278 patients (137 in study arm, 141 in control arm) in the final analysis. The study arm received intensive pharmacist involvement on admission and discharge, followed by phone calls at three, 14, and 30 days post-discharge. The study arm had lower composite 30-day ED visits and inpatient readmission rates compared to the control group (25% vs. 39%; P=0.001) but did not have lower isolated inpatient readmission rates (20% vs. 24%; P=0.43). ADEs and MEs were not significantly different between the two groups.
This study had extensive exclusion criteria, limiting the patient population to which these results can be applied. It was underpowered, which could have prevented the detection of a significant improvement in readmission rates.
Care transitions are high-risk periods in patient care, and there is benefit to continuity of care of an interdisciplinary team, including pharmacists.
Bottom line: Pharmacist involvement in transitions of care was shown to reduce the composite of ED visits and inpatient readmissions.
Citation: Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.
Clinical question: Does pharmacist involvement in transitions of care decrease medication errors (MEs), adverse drug events (ADEs), and 30-day ED visits and inpatient readmissions?
Background: Previous studies show pharmacist involvement in discharge can reduce ADEs and improve patient satisfaction, but there have been inconsistent data on the impact of pharmacist involvement on readmissions, ADEs, and MEs.
Study design: Prospective, randomized, single-period, longitudinal study.
Setting: Northwestern Memorial Hospital, Chicago.
Synopsis: Investigators included 278 patients (137 in study arm, 141 in control arm) in the final analysis. The study arm received intensive pharmacist involvement on admission and discharge, followed by phone calls at three, 14, and 30 days post-discharge. The study arm had lower composite 30-day ED visits and inpatient readmission rates compared to the control group (25% vs. 39%; P=0.001) but did not have lower isolated inpatient readmission rates (20% vs. 24%; P=0.43). ADEs and MEs were not significantly different between the two groups.
This study had extensive exclusion criteria, limiting the patient population to which these results can be applied. It was underpowered, which could have prevented the detection of a significant improvement in readmission rates.
Care transitions are high-risk periods in patient care, and there is benefit to continuity of care of an interdisciplinary team, including pharmacists.
Bottom line: Pharmacist involvement in transitions of care was shown to reduce the composite of ED visits and inpatient readmissions.
Citation: Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.
Clinical question: Does pharmacist involvement in transitions of care decrease medication errors (MEs), adverse drug events (ADEs), and 30-day ED visits and inpatient readmissions?
Background: Previous studies show pharmacist involvement in discharge can reduce ADEs and improve patient satisfaction, but there have been inconsistent data on the impact of pharmacist involvement on readmissions, ADEs, and MEs.
Study design: Prospective, randomized, single-period, longitudinal study.
Setting: Northwestern Memorial Hospital, Chicago.
Synopsis: Investigators included 278 patients (137 in study arm, 141 in control arm) in the final analysis. The study arm received intensive pharmacist involvement on admission and discharge, followed by phone calls at three, 14, and 30 days post-discharge. The study arm had lower composite 30-day ED visits and inpatient readmission rates compared to the control group (25% vs. 39%; P=0.001) but did not have lower isolated inpatient readmission rates (20% vs. 24%; P=0.43). ADEs and MEs were not significantly different between the two groups.
This study had extensive exclusion criteria, limiting the patient population to which these results can be applied. It was underpowered, which could have prevented the detection of a significant improvement in readmission rates.
Care transitions are high-risk periods in patient care, and there is benefit to continuity of care of an interdisciplinary team, including pharmacists.
Bottom line: Pharmacist involvement in transitions of care was shown to reduce the composite of ED visits and inpatient readmissions.
Citation: Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.
Displaying Prices to Providers May Reduce Overall Ordering Costs
Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?
Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.
Study design: Systematic review.
Setting: Yale School of Medicine, New Haven, Conn.
Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.
There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).
Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.
Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.
Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.
Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?
Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.
Study design: Systematic review.
Setting: Yale School of Medicine, New Haven, Conn.
Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.
There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).
Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.
Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.
Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.
Clinical question: Does price display impact order costs and volume as well as patient safety outcomes, and is it acceptable to providers?
Background: Up to one-third of national healthcare expenditures are wasteful, with physicians playing a central role in overall cost, purchasing almost all tests and therapies for patients. Increasing the transparency of costs for physicians is one strategy to reduce unnecessary spending.
Study design: Systematic review.
Setting: Yale School of Medicine, New Haven, Conn.
Synopsis: Nineteen publications were selected for final analysis. Thirteen studies reported the impact of price display on costs, nine of which showed a statistically significant decrease in order costs. Only three of eight studies reporting the impact of price display on order volume showed statistically significant decreases in order volume. One study showed adverse safety findings in the form of higher rates of unscheduled follow-up care in a pediatric ED. Physicians were overall satisfied with price display in the five studies reporting this.
There was high heterogeneity among studies, which did not allow for pooling of data. Furthermore, more than half of the studies were conducted more than 15 years ago, limiting their generalizability to the modern era of electronic health records (EHRs).
Overall, this review supports the conclusion that price display has a modest effect on order costs. Additional studies utilizing EHR systems are required to more definitively confirm these findings.
Bottom line: Displaying prices to physicians can have a modest effect on overall order costs.
Citation: Silvestri MT, Bongiovanni TR, Glover JG, Gross CP. Impact of price display on provider ordering: a systematic review. J Hosp Med. 2016;11(1):65-76. doi:10.1002/jhm.2500.
Olfactory Impairment Is Associated With Amnestic MCI
Olfactory impairment is associated with incident amnestic mild cognitive impairment (aMCI) and progression from aMCI to Alzheimer’s disease dementia, according to research published online ahead of print November 16 in JAMA Neurology. The results are consistent with previous data that indicate an association between olfactory impairment and cognitive impairment in late life. Olfactory tests thus may aid neurologists in screening for MCI and MCI that is likely to progress, said the authors.
A Population-Based Study
Rosebud O. Roberts, MB, ChB, Professor of Epidemiology and Neurology at Mayo Clinic in Rochester, Minnesota, and colleagues examined data for participants who were enrolled in the Mayo Clinic Study of Aging between 2004 and 2010 and were evaluated in person. At baseline, investigators asked each participant and an informant questions about memory and administered the Beck Depression Inventory, Beck Anxiety Inventory, the Clinical Dementia Rating scale, Functional Activities Questionnaire, and Neuropsychiatric Inventory Questionnaire. Physicians obtained medical histories from the participants, who underwent a neurologic exam and neuropsychologic testing that assessed memory, executive function, language, and visuospatial skills.
Researchers reviewed participants’ data for a diagnosis of MCI, dementia, or normal cognition. Patients were followed up at 15-month intervals for incident diagnoses of MCI or dementia. The investigators assessed participants’ olfaction using the Brief Smell Identification Test (B-SIT).
B-SIT Score Predicted MCI
A total of 1,430 cognitively normal participants were included in the study. Their mean age was 79.5, 49.4% were men, and their mean duration of education was 14.3 years. Approximately 25% of the cognitively normal participants were APOE ε4 carriers. During a mean 3.5 years of follow-up, 250 cognitively normal participants developed incident MCI. The researchers noted an association between decreasing olfactory identification, as measured by a decrease in the number of correct responses on the B-SIT, and an increased risk of MCI.
Dr. Roberts and colleagues found that the risk of MCI increased with decreasing B-SIT scores. They observed a significant dose-response association across worsening olfaction categories. The associations remained significant after the researchers adjusted for stroke or excluded participants with a history of stroke.
Although the investigators found no significant interaction of smell with sex or with APOE ε4 allele, the hazard ratio (HR) for MCI in men with B-SIT scores less than 9 (compared with men with scores of 9 or higher) was higher (HR, 2.35) than that for women with scores less than 9 (HR, 1.54). Also, the HR in APOE ε4 carriers with B-SIT scores less than 9 was higher (HR, 2.09) than that for noncarriers with scores less than 9 (HR, 1.72).
Impaired olfaction was associated with any MCI and with aMCI. After the researchers adjusted the data for other factors that could affect smell or MCI, the risk of aMCI for the worst B-SIT categories remained significantly elevated for quartile 1 versus quartile 4 (HR, 1.67) and for B-SIT score less than 9, compared with a score of 9 or greater. The B-SIT score was not associated with nonamnestic MCI (naMCI).
Each unit decrease in baseline B-SIT score was significantly associated with a decline in performance in memory, executive function, and language. The investigators noted similar cross-sectional and longitudinal association patterns for the individual test scores, except for Picture Completion.
In all, 221 participants with prevalent MCI were included in the study. Of these people, 36 had naMCI. The frequency of MCI decreased with increasing B-SIT score. During a mean follow-up of 3.1 years, 64 of these participants developed incident dementia. The frequency of any dementia or Alzheimer’s disease dementia decreased, and cognitive performance increased, with increasing B-SIT scores.
Among the 221 participants with prevalent MCI, the risk of dementia increased with decreasing B-SIT score, with a significant dose response across B-SIT categories. The worst B-SIT categories strongly predicted progression from aMCI to Alzheimer’s disease dementia.
Test May Spur Early Intervention
“Odor-identification tests may have use for early detection of persons at risk of cognitive outcomes,” said Dr. Roberts. “The B-SIT could be beneficial for screening to identify cognitively normal persons and persons with MCI who could benefit from early interventions to prevent or modulate risk for progression.” Combining the B-SIT with other predictors of Alzheimer’s disease dementia may help identify patients who should undergo expensive or invasive diagnostic testing to detect Alzheimer’s disease dementia pathology, she added, although the technique requires further investigation.
One weakness of the study is that the investigators could not identify and exclude people with a history of head trauma, allergies, nasal condition, or nasal diseases that could impair olfaction. Also, because of the predominance of northern European ancestry among study participants, the generalizability of the results is directly applicable to persons with similar ancestry. The authors note, however, that studies in multiethnic cohorts have reported similar findings. Because the study was population-based, the potential for selection bias was reduced. Furthermore, the study included a large cohort of cognitively normal participants and participants with MCI, and both sexes were equally represented. Reliable and valid information on covariates was abstracted from community medical records rather than by self-report.
—Erik Greb
Suggested Reading
Roberts RO, Christianson TJ, Kremers WK, et al. Association between olfactory dysfunction and amnestic mild cognitive impairment and Alzheimer disease dementia. JAMA Neurol. 2015 Nov 16 [Epub ahead of print].
Olfactory impairment is associated with incident amnestic mild cognitive impairment (aMCI) and progression from aMCI to Alzheimer’s disease dementia, according to research published online ahead of print November 16 in JAMA Neurology. The results are consistent with previous data that indicate an association between olfactory impairment and cognitive impairment in late life. Olfactory tests thus may aid neurologists in screening for MCI and MCI that is likely to progress, said the authors.
A Population-Based Study
Rosebud O. Roberts, MB, ChB, Professor of Epidemiology and Neurology at Mayo Clinic in Rochester, Minnesota, and colleagues examined data for participants who were enrolled in the Mayo Clinic Study of Aging between 2004 and 2010 and were evaluated in person. At baseline, investigators asked each participant and an informant questions about memory and administered the Beck Depression Inventory, Beck Anxiety Inventory, the Clinical Dementia Rating scale, Functional Activities Questionnaire, and Neuropsychiatric Inventory Questionnaire. Physicians obtained medical histories from the participants, who underwent a neurologic exam and neuropsychologic testing that assessed memory, executive function, language, and visuospatial skills.
Researchers reviewed participants’ data for a diagnosis of MCI, dementia, or normal cognition. Patients were followed up at 15-month intervals for incident diagnoses of MCI or dementia. The investigators assessed participants’ olfaction using the Brief Smell Identification Test (B-SIT).
B-SIT Score Predicted MCI
A total of 1,430 cognitively normal participants were included in the study. Their mean age was 79.5, 49.4% were men, and their mean duration of education was 14.3 years. Approximately 25% of the cognitively normal participants were APOE ε4 carriers. During a mean 3.5 years of follow-up, 250 cognitively normal participants developed incident MCI. The researchers noted an association between decreasing olfactory identification, as measured by a decrease in the number of correct responses on the B-SIT, and an increased risk of MCI.
Dr. Roberts and colleagues found that the risk of MCI increased with decreasing B-SIT scores. They observed a significant dose-response association across worsening olfaction categories. The associations remained significant after the researchers adjusted for stroke or excluded participants with a history of stroke.
Although the investigators found no significant interaction of smell with sex or with APOE ε4 allele, the hazard ratio (HR) for MCI in men with B-SIT scores less than 9 (compared with men with scores of 9 or higher) was higher (HR, 2.35) than that for women with scores less than 9 (HR, 1.54). Also, the HR in APOE ε4 carriers with B-SIT scores less than 9 was higher (HR, 2.09) than that for noncarriers with scores less than 9 (HR, 1.72).
Impaired olfaction was associated with any MCI and with aMCI. After the researchers adjusted the data for other factors that could affect smell or MCI, the risk of aMCI for the worst B-SIT categories remained significantly elevated for quartile 1 versus quartile 4 (HR, 1.67) and for B-SIT score less than 9, compared with a score of 9 or greater. The B-SIT score was not associated with nonamnestic MCI (naMCI).
Each unit decrease in baseline B-SIT score was significantly associated with a decline in performance in memory, executive function, and language. The investigators noted similar cross-sectional and longitudinal association patterns for the individual test scores, except for Picture Completion.
In all, 221 participants with prevalent MCI were included in the study. Of these people, 36 had naMCI. The frequency of MCI decreased with increasing B-SIT score. During a mean follow-up of 3.1 years, 64 of these participants developed incident dementia. The frequency of any dementia or Alzheimer’s disease dementia decreased, and cognitive performance increased, with increasing B-SIT scores.
Among the 221 participants with prevalent MCI, the risk of dementia increased with decreasing B-SIT score, with a significant dose response across B-SIT categories. The worst B-SIT categories strongly predicted progression from aMCI to Alzheimer’s disease dementia.
Test May Spur Early Intervention
“Odor-identification tests may have use for early detection of persons at risk of cognitive outcomes,” said Dr. Roberts. “The B-SIT could be beneficial for screening to identify cognitively normal persons and persons with MCI who could benefit from early interventions to prevent or modulate risk for progression.” Combining the B-SIT with other predictors of Alzheimer’s disease dementia may help identify patients who should undergo expensive or invasive diagnostic testing to detect Alzheimer’s disease dementia pathology, she added, although the technique requires further investigation.
One weakness of the study is that the investigators could not identify and exclude people with a history of head trauma, allergies, nasal condition, or nasal diseases that could impair olfaction. Also, because of the predominance of northern European ancestry among study participants, the generalizability of the results is directly applicable to persons with similar ancestry. The authors note, however, that studies in multiethnic cohorts have reported similar findings. Because the study was population-based, the potential for selection bias was reduced. Furthermore, the study included a large cohort of cognitively normal participants and participants with MCI, and both sexes were equally represented. Reliable and valid information on covariates was abstracted from community medical records rather than by self-report.
—Erik Greb
Olfactory impairment is associated with incident amnestic mild cognitive impairment (aMCI) and progression from aMCI to Alzheimer’s disease dementia, according to research published online ahead of print November 16 in JAMA Neurology. The results are consistent with previous data that indicate an association between olfactory impairment and cognitive impairment in late life. Olfactory tests thus may aid neurologists in screening for MCI and MCI that is likely to progress, said the authors.
A Population-Based Study
Rosebud O. Roberts, MB, ChB, Professor of Epidemiology and Neurology at Mayo Clinic in Rochester, Minnesota, and colleagues examined data for participants who were enrolled in the Mayo Clinic Study of Aging between 2004 and 2010 and were evaluated in person. At baseline, investigators asked each participant and an informant questions about memory and administered the Beck Depression Inventory, Beck Anxiety Inventory, the Clinical Dementia Rating scale, Functional Activities Questionnaire, and Neuropsychiatric Inventory Questionnaire. Physicians obtained medical histories from the participants, who underwent a neurologic exam and neuropsychologic testing that assessed memory, executive function, language, and visuospatial skills.
Researchers reviewed participants’ data for a diagnosis of MCI, dementia, or normal cognition. Patients were followed up at 15-month intervals for incident diagnoses of MCI or dementia. The investigators assessed participants’ olfaction using the Brief Smell Identification Test (B-SIT).
B-SIT Score Predicted MCI
A total of 1,430 cognitively normal participants were included in the study. Their mean age was 79.5, 49.4% were men, and their mean duration of education was 14.3 years. Approximately 25% of the cognitively normal participants were APOE ε4 carriers. During a mean 3.5 years of follow-up, 250 cognitively normal participants developed incident MCI. The researchers noted an association between decreasing olfactory identification, as measured by a decrease in the number of correct responses on the B-SIT, and an increased risk of MCI.
Dr. Roberts and colleagues found that the risk of MCI increased with decreasing B-SIT scores. They observed a significant dose-response association across worsening olfaction categories. The associations remained significant after the researchers adjusted for stroke or excluded participants with a history of stroke.
Although the investigators found no significant interaction of smell with sex or with APOE ε4 allele, the hazard ratio (HR) for MCI in men with B-SIT scores less than 9 (compared with men with scores of 9 or higher) was higher (HR, 2.35) than that for women with scores less than 9 (HR, 1.54). Also, the HR in APOE ε4 carriers with B-SIT scores less than 9 was higher (HR, 2.09) than that for noncarriers with scores less than 9 (HR, 1.72).
Impaired olfaction was associated with any MCI and with aMCI. After the researchers adjusted the data for other factors that could affect smell or MCI, the risk of aMCI for the worst B-SIT categories remained significantly elevated for quartile 1 versus quartile 4 (HR, 1.67) and for B-SIT score less than 9, compared with a score of 9 or greater. The B-SIT score was not associated with nonamnestic MCI (naMCI).
Each unit decrease in baseline B-SIT score was significantly associated with a decline in performance in memory, executive function, and language. The investigators noted similar cross-sectional and longitudinal association patterns for the individual test scores, except for Picture Completion.
In all, 221 participants with prevalent MCI were included in the study. Of these people, 36 had naMCI. The frequency of MCI decreased with increasing B-SIT score. During a mean follow-up of 3.1 years, 64 of these participants developed incident dementia. The frequency of any dementia or Alzheimer’s disease dementia decreased, and cognitive performance increased, with increasing B-SIT scores.
Among the 221 participants with prevalent MCI, the risk of dementia increased with decreasing B-SIT score, with a significant dose response across B-SIT categories. The worst B-SIT categories strongly predicted progression from aMCI to Alzheimer’s disease dementia.
Test May Spur Early Intervention
“Odor-identification tests may have use for early detection of persons at risk of cognitive outcomes,” said Dr. Roberts. “The B-SIT could be beneficial for screening to identify cognitively normal persons and persons with MCI who could benefit from early interventions to prevent or modulate risk for progression.” Combining the B-SIT with other predictors of Alzheimer’s disease dementia may help identify patients who should undergo expensive or invasive diagnostic testing to detect Alzheimer’s disease dementia pathology, she added, although the technique requires further investigation.
One weakness of the study is that the investigators could not identify and exclude people with a history of head trauma, allergies, nasal condition, or nasal diseases that could impair olfaction. Also, because of the predominance of northern European ancestry among study participants, the generalizability of the results is directly applicable to persons with similar ancestry. The authors note, however, that studies in multiethnic cohorts have reported similar findings. Because the study was population-based, the potential for selection bias was reduced. Furthermore, the study included a large cohort of cognitively normal participants and participants with MCI, and both sexes were equally represented. Reliable and valid information on covariates was abstracted from community medical records rather than by self-report.
—Erik Greb
Suggested Reading
Roberts RO, Christianson TJ, Kremers WK, et al. Association between olfactory dysfunction and amnestic mild cognitive impairment and Alzheimer disease dementia. JAMA Neurol. 2015 Nov 16 [Epub ahead of print].
Suggested Reading
Roberts RO, Christianson TJ, Kremers WK, et al. Association between olfactory dysfunction and amnestic mild cognitive impairment and Alzheimer disease dementia. JAMA Neurol. 2015 Nov 16 [Epub ahead of print].
Radiologically Isolated Disease Is Part of the MS Spectrum
The findings of a multicenter, multinational cohort study of radiologically isolated syndrome (RIS) published online ahead of print November 24 in Annals of Neurology offer further evidence that the condition should be considered part of the multiple sclerosis (MS) treatment spectrum because of the rate at which patients progressed to primary progressive MS over the course of the study.
“This is the first report of the temporal course within the preprogression phase for an extremely rare group of subjects originally identified by MRI as having asymptomatic disease, who ultimately experienced progressive symptom evolution consistent with primary progressive MS that could not otherwise be explained by any other mechanism (excessive alcohol use, vitamin deficiencies, etc.),” said Orhun H. Kantarci, MD, Assistant Professor of Neurology at the Mayo Clinic in Rochester, Minnesota.
Dr. Kantarci and his coinvestigators evaluated 453 patients with RIS at 22 centers in the United States, France, Italy, Spain, and Turkey. The researchers also collected data on MRI, lesions, and CSF at baseline and during follow-up for as long as 20 years in certain cohorts. Demographic and clinical data were also analyzed for each patient enrolled.
Ultimately, 128 (28%) of the 453 patients with RIS developed symptomatic MS. Of these patients, 15 (12%) evolved to primary progressive MS and the remaining 113 patients “developed a first acute clinical event related to CNS demyelination consistent with clinically isolated syndrome [CIS]/MS diagnosis.” RIS occurred at a median age of 43.3, with an age range of 20 to 66, and evolved to primary progressive MS at a mean age of 49.1. The median time to conversion was 3.5 years over a median follow-up period of 5.8 years.
Nine patients with primary progressive MS were male, and the remaining six were female. Patients with primary progressive MS were more likely to be men, compared with patients who developed CIS/MS. In addition, median age at the onset of RIS and median age at symptomatic evolution were both older by about 10 years in patients with primary progressive MS versus patients who developed CIS/MS.“The 12% prevalence of primary progressive MS in this large RIS cohort, as well as age at primary progressive MS onset, is strikingly similar to that of large clinical studies in MS,” the authors noted. “Studying RIS, therefore, provides an opportunity to better understand the onset of clinical MS and to test early intervention.”Dr. Kantarci and his associates also pointed out that, in their study, the older age of primary progressive MS onset versus CIS/MS was “clearly” independent of individual follow-up times. Therefore, they also concluded that “age dependence of progressive MS development, in the absence of previous clinical relapses despite having clear subclinically active MS, suggests that biological aging mechanisms may be a significant contributor for development of progressive MS.”
—Deepak Chitnis
Suggested Reading
Kantarci OH, Lebrun C, Siva A, et al. Primary progressive MS evolving from radiologically isolated syndrome. Ann Neurol. 2015 Nov 24 [Epub ahead of print].
The findings of a multicenter, multinational cohort study of radiologically isolated syndrome (RIS) published online ahead of print November 24 in Annals of Neurology offer further evidence that the condition should be considered part of the multiple sclerosis (MS) treatment spectrum because of the rate at which patients progressed to primary progressive MS over the course of the study.
“This is the first report of the temporal course within the preprogression phase for an extremely rare group of subjects originally identified by MRI as having asymptomatic disease, who ultimately experienced progressive symptom evolution consistent with primary progressive MS that could not otherwise be explained by any other mechanism (excessive alcohol use, vitamin deficiencies, etc.),” said Orhun H. Kantarci, MD, Assistant Professor of Neurology at the Mayo Clinic in Rochester, Minnesota.
Dr. Kantarci and his coinvestigators evaluated 453 patients with RIS at 22 centers in the United States, France, Italy, Spain, and Turkey. The researchers also collected data on MRI, lesions, and CSF at baseline and during follow-up for as long as 20 years in certain cohorts. Demographic and clinical data were also analyzed for each patient enrolled.
Ultimately, 128 (28%) of the 453 patients with RIS developed symptomatic MS. Of these patients, 15 (12%) evolved to primary progressive MS and the remaining 113 patients “developed a first acute clinical event related to CNS demyelination consistent with clinically isolated syndrome [CIS]/MS diagnosis.” RIS occurred at a median age of 43.3, with an age range of 20 to 66, and evolved to primary progressive MS at a mean age of 49.1. The median time to conversion was 3.5 years over a median follow-up period of 5.8 years.
Nine patients with primary progressive MS were male, and the remaining six were female. Patients with primary progressive MS were more likely to be men, compared with patients who developed CIS/MS. In addition, median age at the onset of RIS and median age at symptomatic evolution were both older by about 10 years in patients with primary progressive MS versus patients who developed CIS/MS.“The 12% prevalence of primary progressive MS in this large RIS cohort, as well as age at primary progressive MS onset, is strikingly similar to that of large clinical studies in MS,” the authors noted. “Studying RIS, therefore, provides an opportunity to better understand the onset of clinical MS and to test early intervention.”Dr. Kantarci and his associates also pointed out that, in their study, the older age of primary progressive MS onset versus CIS/MS was “clearly” independent of individual follow-up times. Therefore, they also concluded that “age dependence of progressive MS development, in the absence of previous clinical relapses despite having clear subclinically active MS, suggests that biological aging mechanisms may be a significant contributor for development of progressive MS.”
—Deepak Chitnis
The findings of a multicenter, multinational cohort study of radiologically isolated syndrome (RIS) published online ahead of print November 24 in Annals of Neurology offer further evidence that the condition should be considered part of the multiple sclerosis (MS) treatment spectrum because of the rate at which patients progressed to primary progressive MS over the course of the study.
“This is the first report of the temporal course within the preprogression phase for an extremely rare group of subjects originally identified by MRI as having asymptomatic disease, who ultimately experienced progressive symptom evolution consistent with primary progressive MS that could not otherwise be explained by any other mechanism (excessive alcohol use, vitamin deficiencies, etc.),” said Orhun H. Kantarci, MD, Assistant Professor of Neurology at the Mayo Clinic in Rochester, Minnesota.
Dr. Kantarci and his coinvestigators evaluated 453 patients with RIS at 22 centers in the United States, France, Italy, Spain, and Turkey. The researchers also collected data on MRI, lesions, and CSF at baseline and during follow-up for as long as 20 years in certain cohorts. Demographic and clinical data were also analyzed for each patient enrolled.
Ultimately, 128 (28%) of the 453 patients with RIS developed symptomatic MS. Of these patients, 15 (12%) evolved to primary progressive MS and the remaining 113 patients “developed a first acute clinical event related to CNS demyelination consistent with clinically isolated syndrome [CIS]/MS diagnosis.” RIS occurred at a median age of 43.3, with an age range of 20 to 66, and evolved to primary progressive MS at a mean age of 49.1. The median time to conversion was 3.5 years over a median follow-up period of 5.8 years.
Nine patients with primary progressive MS were male, and the remaining six were female. Patients with primary progressive MS were more likely to be men, compared with patients who developed CIS/MS. In addition, median age at the onset of RIS and median age at symptomatic evolution were both older by about 10 years in patients with primary progressive MS versus patients who developed CIS/MS.“The 12% prevalence of primary progressive MS in this large RIS cohort, as well as age at primary progressive MS onset, is strikingly similar to that of large clinical studies in MS,” the authors noted. “Studying RIS, therefore, provides an opportunity to better understand the onset of clinical MS and to test early intervention.”Dr. Kantarci and his associates also pointed out that, in their study, the older age of primary progressive MS onset versus CIS/MS was “clearly” independent of individual follow-up times. Therefore, they also concluded that “age dependence of progressive MS development, in the absence of previous clinical relapses despite having clear subclinically active MS, suggests that biological aging mechanisms may be a significant contributor for development of progressive MS.”
—Deepak Chitnis
Suggested Reading
Kantarci OH, Lebrun C, Siva A, et al. Primary progressive MS evolving from radiologically isolated syndrome. Ann Neurol. 2015 Nov 24 [Epub ahead of print].
Suggested Reading
Kantarci OH, Lebrun C, Siva A, et al. Primary progressive MS evolving from radiologically isolated syndrome. Ann Neurol. 2015 Nov 24 [Epub ahead of print].
Value of Ultra-Brief Cognitive Assessments in Predicting Negative Hospital Outcomes
Clinical question: What is the value of ultra-brief cognitive assessments in predicting hospital outcomes?
Background: Cognitive assessment tools can be used to predict patient outcomes in the hospital setting. Physician time constraints limit use of longer traditional cognitive testing, and little is known about the effectiveness of ultra-brief (less than one minute) assessments and their predictive value.
Study design: Secondary data analysis of a quality improvement project.
Setting: Tertiary, Veterans Administration hospital.
Synopsis: Using data from a prior inpatient database, 3,232 patients over the age of 60 were screened on admission using the modified Richmond Agitation and Sedation Scale (mRASS) for arousal and the months of the year backwards (MOTYB) for attention. Abnormal mRASS and incorrect MOTYB predicted negative hospital outcomes: increased length of stay (incident rate ratio 1.23, 95% CI 1.17-1.3); increased restraint use (risk ratio 5.05, 95% CI); increased hospital mortality (RR 3.46, 95% CI 1.24-9.63); and decreased rates of being discharged home (RR 2.97, 95% CI: 2.42-3.64).
This study highlights the value of two ultra-brief cognitive assessment tools in the prediction of potential poor outcomes during inpatient admission. Hospitalists need to identify high-risk patients, and these tools allow for rapid assessment at the time of admission, without a significant time constraint for the busy hospitalist.
Bottom Line: The use of ultra-brief cognitive assessment tools in patients over age 60 can predict negative inpatient outcomes.
Citation: Yevchak AM, Doherty K, Archambault EG, Kelly B, Fonda JR, Rudolph JL. The association between an ultra-brief cognitive screening in older adults and hospital outcomes. J Hosp Med. 2015;10(10):651-657.
Clinical question: What is the value of ultra-brief cognitive assessments in predicting hospital outcomes?
Background: Cognitive assessment tools can be used to predict patient outcomes in the hospital setting. Physician time constraints limit use of longer traditional cognitive testing, and little is known about the effectiveness of ultra-brief (less than one minute) assessments and their predictive value.
Study design: Secondary data analysis of a quality improvement project.
Setting: Tertiary, Veterans Administration hospital.
Synopsis: Using data from a prior inpatient database, 3,232 patients over the age of 60 were screened on admission using the modified Richmond Agitation and Sedation Scale (mRASS) for arousal and the months of the year backwards (MOTYB) for attention. Abnormal mRASS and incorrect MOTYB predicted negative hospital outcomes: increased length of stay (incident rate ratio 1.23, 95% CI 1.17-1.3); increased restraint use (risk ratio 5.05, 95% CI); increased hospital mortality (RR 3.46, 95% CI 1.24-9.63); and decreased rates of being discharged home (RR 2.97, 95% CI: 2.42-3.64).
This study highlights the value of two ultra-brief cognitive assessment tools in the prediction of potential poor outcomes during inpatient admission. Hospitalists need to identify high-risk patients, and these tools allow for rapid assessment at the time of admission, without a significant time constraint for the busy hospitalist.
Bottom Line: The use of ultra-brief cognitive assessment tools in patients over age 60 can predict negative inpatient outcomes.
Citation: Yevchak AM, Doherty K, Archambault EG, Kelly B, Fonda JR, Rudolph JL. The association between an ultra-brief cognitive screening in older adults and hospital outcomes. J Hosp Med. 2015;10(10):651-657.
Clinical question: What is the value of ultra-brief cognitive assessments in predicting hospital outcomes?
Background: Cognitive assessment tools can be used to predict patient outcomes in the hospital setting. Physician time constraints limit use of longer traditional cognitive testing, and little is known about the effectiveness of ultra-brief (less than one minute) assessments and their predictive value.
Study design: Secondary data analysis of a quality improvement project.
Setting: Tertiary, Veterans Administration hospital.
Synopsis: Using data from a prior inpatient database, 3,232 patients over the age of 60 were screened on admission using the modified Richmond Agitation and Sedation Scale (mRASS) for arousal and the months of the year backwards (MOTYB) for attention. Abnormal mRASS and incorrect MOTYB predicted negative hospital outcomes: increased length of stay (incident rate ratio 1.23, 95% CI 1.17-1.3); increased restraint use (risk ratio 5.05, 95% CI); increased hospital mortality (RR 3.46, 95% CI 1.24-9.63); and decreased rates of being discharged home (RR 2.97, 95% CI: 2.42-3.64).
This study highlights the value of two ultra-brief cognitive assessment tools in the prediction of potential poor outcomes during inpatient admission. Hospitalists need to identify high-risk patients, and these tools allow for rapid assessment at the time of admission, without a significant time constraint for the busy hospitalist.
Bottom Line: The use of ultra-brief cognitive assessment tools in patients over age 60 can predict negative inpatient outcomes.
Citation: Yevchak AM, Doherty K, Archambault EG, Kelly B, Fonda JR, Rudolph JL. The association between an ultra-brief cognitive screening in older adults and hospital outcomes. J Hosp Med. 2015;10(10):651-657.
Criteria for Appropriate Use of Peripherally Inserted Central Catheters
Clinical question: What are criteria for appropriate and inappropriate use of PICCs?
Background: PICCs are commonly used in medical care in a variety of clinical contexts; however, criteria defining the appropriate use of PICCs and practices related to PICC placement have not been previously established.
Study design: A multispecialty panel classified indications for PICC use as appropriate or inappropriate using the RAND/UCLA Appropriateness Method.
Synopsis: Selected appropriate PICC uses include:
- Infusion of peripherally compatible infusates, intermittent infusions, or infrequent phlebotomy in patients with poor or difficult venous access when the expected duration of use is at least six days;
- Phlebotomy at least every eight hours when the expected duration of use is at least six days; and
- Invasive hemodynamic monitoring in a critically ill patient only if the duration of use is expected to exceed 15 days.
Selected appropriate PICC-related practices:
- Verify PICC tip position using a chest radiograph only after non-ECG or non-fluoroscopically guided PICC insertion;
- Provide an interval without a PICC to allow resolution of bacteremia when managing PICC-related bloodstream infections; and
- For PICC-related DVT, provide at least three months of systemic anticoagulation if not otherwise contraindicated.
Selected inappropriate PICC-related practices:
- Adjustment of PICC tips that reside in the lower third of the superior vena cava, cavoatrial junction, or right atrium; and
- Removal or replacement of PICCs that are clinically necessary, well positioned, and functional in the setting of PICC-related DVT or without evidence of catheter-associated bloodstream infection.
Bottom line: A multispecialty expert panel provides guidance for appropriate use of PICCs and PICC-related practices.
Citation: Chopra V, Flanders SA, Saint S, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(6):S1-S40.
Clinical question: What are criteria for appropriate and inappropriate use of PICCs?
Background: PICCs are commonly used in medical care in a variety of clinical contexts; however, criteria defining the appropriate use of PICCs and practices related to PICC placement have not been previously established.
Study design: A multispecialty panel classified indications for PICC use as appropriate or inappropriate using the RAND/UCLA Appropriateness Method.
Synopsis: Selected appropriate PICC uses include:
- Infusion of peripherally compatible infusates, intermittent infusions, or infrequent phlebotomy in patients with poor or difficult venous access when the expected duration of use is at least six days;
- Phlebotomy at least every eight hours when the expected duration of use is at least six days; and
- Invasive hemodynamic monitoring in a critically ill patient only if the duration of use is expected to exceed 15 days.
Selected appropriate PICC-related practices:
- Verify PICC tip position using a chest radiograph only after non-ECG or non-fluoroscopically guided PICC insertion;
- Provide an interval without a PICC to allow resolution of bacteremia when managing PICC-related bloodstream infections; and
- For PICC-related DVT, provide at least three months of systemic anticoagulation if not otherwise contraindicated.
Selected inappropriate PICC-related practices:
- Adjustment of PICC tips that reside in the lower third of the superior vena cava, cavoatrial junction, or right atrium; and
- Removal or replacement of PICCs that are clinically necessary, well positioned, and functional in the setting of PICC-related DVT or without evidence of catheter-associated bloodstream infection.
Bottom line: A multispecialty expert panel provides guidance for appropriate use of PICCs and PICC-related practices.
Citation: Chopra V, Flanders SA, Saint S, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(6):S1-S40.
Clinical question: What are criteria for appropriate and inappropriate use of PICCs?
Background: PICCs are commonly used in medical care in a variety of clinical contexts; however, criteria defining the appropriate use of PICCs and practices related to PICC placement have not been previously established.
Study design: A multispecialty panel classified indications for PICC use as appropriate or inappropriate using the RAND/UCLA Appropriateness Method.
Synopsis: Selected appropriate PICC uses include:
- Infusion of peripherally compatible infusates, intermittent infusions, or infrequent phlebotomy in patients with poor or difficult venous access when the expected duration of use is at least six days;
- Phlebotomy at least every eight hours when the expected duration of use is at least six days; and
- Invasive hemodynamic monitoring in a critically ill patient only if the duration of use is expected to exceed 15 days.
Selected appropriate PICC-related practices:
- Verify PICC tip position using a chest radiograph only after non-ECG or non-fluoroscopically guided PICC insertion;
- Provide an interval without a PICC to allow resolution of bacteremia when managing PICC-related bloodstream infections; and
- For PICC-related DVT, provide at least three months of systemic anticoagulation if not otherwise contraindicated.
Selected inappropriate PICC-related practices:
- Adjustment of PICC tips that reside in the lower third of the superior vena cava, cavoatrial junction, or right atrium; and
- Removal or replacement of PICCs that are clinically necessary, well positioned, and functional in the setting of PICC-related DVT or without evidence of catheter-associated bloodstream infection.
Bottom line: A multispecialty expert panel provides guidance for appropriate use of PICCs and PICC-related practices.
Citation: Chopra V, Flanders SA, Saint S, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(6):S1-S40.
ACP Guidelines for Evaluation of Suspected Pulmonary Embolism
Clinical question: What are best practices for evaluating patients with suspected acute pulmonary embolism (PE)?
Background: Use of CT in the evaluation of PE has increased across all clinical settings without improving mortality. Contrast CT carries the risks of radiation exposure, contrast-induced nephropathy, and incidental findings that require further investigation. The authors highlight evidence-based strategies for evaluation of PE, focusing on delivering high-value care.
Study design: Clinical guideline.
Setting: Literature review of studies across all adult clinical settings.
Synopsis: The clinical guidelines committee of the American College of Physicians conducted a literature search surrounding evaluation of suspected acute PE. From their review, they concluded:
- Pretest probability should initially be determined based on validated prediction tools (Wells score, Revised Geneva);
- In patients found to have low pretest probability and meeting the pulmonary embolism rule-out criteria (PERC), clinicians can forego d-dimer testing;
- In those with intermediate pretest probability or those with low pre-test probability who do not pass PERC, d-dimer measurement should be obtained;
- The d-dimer threshold should be age adjusted and imaging should not be pursued in patients whose d-dimer level falls below this cutoff, while those with positive d-dimers should receive CT pulmonary angiography (CTPA); and
- Patients with high pretest probability should undergo CTPA (or V/Q scan if CTPA is contraindicated) without d-dimer testing.
Bottom line: In suspected acute PE, first determine pretest probability using Wells and Revised Geneva, and then use this probability in conjunction with the PERC and d-dimer (as indicated) to guide decisions about imaging.
Citation: Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2015;163(9):701-711.
Clinical question: What are best practices for evaluating patients with suspected acute pulmonary embolism (PE)?
Background: Use of CT in the evaluation of PE has increased across all clinical settings without improving mortality. Contrast CT carries the risks of radiation exposure, contrast-induced nephropathy, and incidental findings that require further investigation. The authors highlight evidence-based strategies for evaluation of PE, focusing on delivering high-value care.
Study design: Clinical guideline.
Setting: Literature review of studies across all adult clinical settings.
Synopsis: The clinical guidelines committee of the American College of Physicians conducted a literature search surrounding evaluation of suspected acute PE. From their review, they concluded:
- Pretest probability should initially be determined based on validated prediction tools (Wells score, Revised Geneva);
- In patients found to have low pretest probability and meeting the pulmonary embolism rule-out criteria (PERC), clinicians can forego d-dimer testing;
- In those with intermediate pretest probability or those with low pre-test probability who do not pass PERC, d-dimer measurement should be obtained;
- The d-dimer threshold should be age adjusted and imaging should not be pursued in patients whose d-dimer level falls below this cutoff, while those with positive d-dimers should receive CT pulmonary angiography (CTPA); and
- Patients with high pretest probability should undergo CTPA (or V/Q scan if CTPA is contraindicated) without d-dimer testing.
Bottom line: In suspected acute PE, first determine pretest probability using Wells and Revised Geneva, and then use this probability in conjunction with the PERC and d-dimer (as indicated) to guide decisions about imaging.
Citation: Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2015;163(9):701-711.
Clinical question: What are best practices for evaluating patients with suspected acute pulmonary embolism (PE)?
Background: Use of CT in the evaluation of PE has increased across all clinical settings without improving mortality. Contrast CT carries the risks of radiation exposure, contrast-induced nephropathy, and incidental findings that require further investigation. The authors highlight evidence-based strategies for evaluation of PE, focusing on delivering high-value care.
Study design: Clinical guideline.
Setting: Literature review of studies across all adult clinical settings.
Synopsis: The clinical guidelines committee of the American College of Physicians conducted a literature search surrounding evaluation of suspected acute PE. From their review, they concluded:
- Pretest probability should initially be determined based on validated prediction tools (Wells score, Revised Geneva);
- In patients found to have low pretest probability and meeting the pulmonary embolism rule-out criteria (PERC), clinicians can forego d-dimer testing;
- In those with intermediate pretest probability or those with low pre-test probability who do not pass PERC, d-dimer measurement should be obtained;
- The d-dimer threshold should be age adjusted and imaging should not be pursued in patients whose d-dimer level falls below this cutoff, while those with positive d-dimers should receive CT pulmonary angiography (CTPA); and
- Patients with high pretest probability should undergo CTPA (or V/Q scan if CTPA is contraindicated) without d-dimer testing.
Bottom line: In suspected acute PE, first determine pretest probability using Wells and Revised Geneva, and then use this probability in conjunction with the PERC and d-dimer (as indicated) to guide decisions about imaging.
Citation: Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2015;163(9):701-711.
Early Palliative Care Can Save Money
Clinical question: Does time to consult after admission change the effect palliative care consultation has on cost of care?
Background: Studies have shown that early palliative care involvement improves quality of life and survival among cancer patients while reducing the cost of care. Little is known about the optimal timing of palliative care consultation and its effect on cost.
Study design: Prospective, observational study.
Setting: Multi-site, high-volume, tertiary care hospitals with established palliative care teams.
Synopsis: Clinical and cost data were collected for 969 adult patients with advanced cancer admitted to the five participating hospitals. Among those, 256 patients received palliative care consultation and 713 received usual care. Subsamples were created based on time to consultation after admission.
The study found that earlier consultation yielded larger effects on cost savings. There was a 24% reduction in total cost if consultation occurred within two days (95% CI, -$3,438 to -$1,122; P<0.001), with estimated savings of $2,280. For consultation within six days of admission, there was a $1,312 savings (95% CI, -$2,568 to -$ 1,122; P<0.04), consistent with a 14% reduction in total cost.
There are notable limitations to this study. Half of eligible patients were excluded due to incomplete data collection, resulting in a small sample size. Further, these results can be generalized only to inpatients with advanced cancer.
Bottom line: Reducing the time to consultation with palliative care increases cost savings. In advanced cancer patients, a 24% reduction in total costs was realized for consultation within two days following admission.
Citation: May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745-2752.
Clinical question: Does time to consult after admission change the effect palliative care consultation has on cost of care?
Background: Studies have shown that early palliative care involvement improves quality of life and survival among cancer patients while reducing the cost of care. Little is known about the optimal timing of palliative care consultation and its effect on cost.
Study design: Prospective, observational study.
Setting: Multi-site, high-volume, tertiary care hospitals with established palliative care teams.
Synopsis: Clinical and cost data were collected for 969 adult patients with advanced cancer admitted to the five participating hospitals. Among those, 256 patients received palliative care consultation and 713 received usual care. Subsamples were created based on time to consultation after admission.
The study found that earlier consultation yielded larger effects on cost savings. There was a 24% reduction in total cost if consultation occurred within two days (95% CI, -$3,438 to -$1,122; P<0.001), with estimated savings of $2,280. For consultation within six days of admission, there was a $1,312 savings (95% CI, -$2,568 to -$ 1,122; P<0.04), consistent with a 14% reduction in total cost.
There are notable limitations to this study. Half of eligible patients were excluded due to incomplete data collection, resulting in a small sample size. Further, these results can be generalized only to inpatients with advanced cancer.
Bottom line: Reducing the time to consultation with palliative care increases cost savings. In advanced cancer patients, a 24% reduction in total costs was realized for consultation within two days following admission.
Citation: May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745-2752.
Clinical question: Does time to consult after admission change the effect palliative care consultation has on cost of care?
Background: Studies have shown that early palliative care involvement improves quality of life and survival among cancer patients while reducing the cost of care. Little is known about the optimal timing of palliative care consultation and its effect on cost.
Study design: Prospective, observational study.
Setting: Multi-site, high-volume, tertiary care hospitals with established palliative care teams.
Synopsis: Clinical and cost data were collected for 969 adult patients with advanced cancer admitted to the five participating hospitals. Among those, 256 patients received palliative care consultation and 713 received usual care. Subsamples were created based on time to consultation after admission.
The study found that earlier consultation yielded larger effects on cost savings. There was a 24% reduction in total cost if consultation occurred within two days (95% CI, -$3,438 to -$1,122; P<0.001), with estimated savings of $2,280. For consultation within six days of admission, there was a $1,312 savings (95% CI, -$2,568 to -$ 1,122; P<0.04), consistent with a 14% reduction in total cost.
There are notable limitations to this study. Half of eligible patients were excluded due to incomplete data collection, resulting in a small sample size. Further, these results can be generalized only to inpatients with advanced cancer.
Bottom line: Reducing the time to consultation with palliative care increases cost savings. In advanced cancer patients, a 24% reduction in total costs was realized for consultation within two days following admission.
Citation: May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745-2752.
Parental Perceptions of Nighttime Communication Are Strong Predictors of Patient Experience
Clinical question: How does parental perception of overnight pediatric inpatient care affect the overall patient experience?
Background: Restrictions on resident duty hours have become progressively more stringent as attention to the effects of resident fatigue on patient safety has increased. In 2011, the Accreditation Council for Graduate Medical Education (ACGME) limited total weekly duty hours to 80 and reduced shifts for junior trainees to a maximum of 16 hours. As a result, a majority of teaching hospitals have instituted “night float,” or night team models, for overnight coverage of pediatric inpatients. The rapid adoption of night float inpatient coverage models has raised concerns about training residents in a structure that may not foster patient ownership and may promote shift worker mentality. Although communication between healthcare providers and patients/caregivers is known to be a key driver of patient satisfaction, little is known about the quality of communication overnight in the era of night float teams.
Study design: Prospective cohort study utilizing survey methodology.
Setting: Two general pediatric units at a 395-bed, urban, freestanding children’s teaching hospital.
Synopsis: A randomly selected subset of children (0-17 years) with English-speaking parents/caregivers admitted to two general pediatric units was studied over an 18-month period. Both general pediatric and subspecialty service patients, including adolescent, immunology, hematology, and rheumatology, were included. Researchers administered written surveys on weekday (Monday-Thursday) evenings prior to discharge, and surveys were collected either later that evening or in the morning. The surveys included 29 questions that used a five-point Likert scale to assess communication and experience.
These questions covered the following constructs:
- Parent understanding of the medical plan;
- Parent communication and experience with nighttime doctors;
- Parent communication and experience with nighttime nurses;
- Parent perceptions of nighttime interactions between doctors and nurses; and
- Parent overall experience of care during hospitalization.
An open question addressing whether parents had anything else to share about communication during the hospitalization was included. The primary outcome measure was the so-called “top-box” rating of overall experience of care during the hospitalization (from construct five). This outcome was dichotomous based on whether the parent had given the highest rating or not for all five questions in that construct (either “excellent” or “strongly agree”).
A top-box rating of overall experience of care was found to be associated with high mean construct scores regarding communication and experience with doctors (4.85) and nurses (4.87). Top-box overall experience ratings were also associated with top ratings for coordination between daytime and nighttime nurses and for teamwork between nighttime doctors and nurses. Multivariable analysis showed that parents’ rating of direct communications with doctors and nurses and perceived teamwork and communication between doctors and nurses were significant predictors of top-box overall experience.
Bottom line: Parents’ perceptions of direct communications with nighttime doctors and nurses and their perceived teamwork and communication were strong predictors of overall experience of care during pediatric hospitalization.
Citation: Khan A, Rogers JE, Melvin P, et al. Physician and nurse nighttime communication and parents’ hospital experience. Pediatrics. 2015;136(5):e1249-1258.
Clinical question: How does parental perception of overnight pediatric inpatient care affect the overall patient experience?
Background: Restrictions on resident duty hours have become progressively more stringent as attention to the effects of resident fatigue on patient safety has increased. In 2011, the Accreditation Council for Graduate Medical Education (ACGME) limited total weekly duty hours to 80 and reduced shifts for junior trainees to a maximum of 16 hours. As a result, a majority of teaching hospitals have instituted “night float,” or night team models, for overnight coverage of pediatric inpatients. The rapid adoption of night float inpatient coverage models has raised concerns about training residents in a structure that may not foster patient ownership and may promote shift worker mentality. Although communication between healthcare providers and patients/caregivers is known to be a key driver of patient satisfaction, little is known about the quality of communication overnight in the era of night float teams.
Study design: Prospective cohort study utilizing survey methodology.
Setting: Two general pediatric units at a 395-bed, urban, freestanding children’s teaching hospital.
Synopsis: A randomly selected subset of children (0-17 years) with English-speaking parents/caregivers admitted to two general pediatric units was studied over an 18-month period. Both general pediatric and subspecialty service patients, including adolescent, immunology, hematology, and rheumatology, were included. Researchers administered written surveys on weekday (Monday-Thursday) evenings prior to discharge, and surveys were collected either later that evening or in the morning. The surveys included 29 questions that used a five-point Likert scale to assess communication and experience.
These questions covered the following constructs:
- Parent understanding of the medical plan;
- Parent communication and experience with nighttime doctors;
- Parent communication and experience with nighttime nurses;
- Parent perceptions of nighttime interactions between doctors and nurses; and
- Parent overall experience of care during hospitalization.
An open question addressing whether parents had anything else to share about communication during the hospitalization was included. The primary outcome measure was the so-called “top-box” rating of overall experience of care during the hospitalization (from construct five). This outcome was dichotomous based on whether the parent had given the highest rating or not for all five questions in that construct (either “excellent” or “strongly agree”).
A top-box rating of overall experience of care was found to be associated with high mean construct scores regarding communication and experience with doctors (4.85) and nurses (4.87). Top-box overall experience ratings were also associated with top ratings for coordination between daytime and nighttime nurses and for teamwork between nighttime doctors and nurses. Multivariable analysis showed that parents’ rating of direct communications with doctors and nurses and perceived teamwork and communication between doctors and nurses were significant predictors of top-box overall experience.
Bottom line: Parents’ perceptions of direct communications with nighttime doctors and nurses and their perceived teamwork and communication were strong predictors of overall experience of care during pediatric hospitalization.
Citation: Khan A, Rogers JE, Melvin P, et al. Physician and nurse nighttime communication and parents’ hospital experience. Pediatrics. 2015;136(5):e1249-1258.
Clinical question: How does parental perception of overnight pediatric inpatient care affect the overall patient experience?
Background: Restrictions on resident duty hours have become progressively more stringent as attention to the effects of resident fatigue on patient safety has increased. In 2011, the Accreditation Council for Graduate Medical Education (ACGME) limited total weekly duty hours to 80 and reduced shifts for junior trainees to a maximum of 16 hours. As a result, a majority of teaching hospitals have instituted “night float,” or night team models, for overnight coverage of pediatric inpatients. The rapid adoption of night float inpatient coverage models has raised concerns about training residents in a structure that may not foster patient ownership and may promote shift worker mentality. Although communication between healthcare providers and patients/caregivers is known to be a key driver of patient satisfaction, little is known about the quality of communication overnight in the era of night float teams.
Study design: Prospective cohort study utilizing survey methodology.
Setting: Two general pediatric units at a 395-bed, urban, freestanding children’s teaching hospital.
Synopsis: A randomly selected subset of children (0-17 years) with English-speaking parents/caregivers admitted to two general pediatric units was studied over an 18-month period. Both general pediatric and subspecialty service patients, including adolescent, immunology, hematology, and rheumatology, were included. Researchers administered written surveys on weekday (Monday-Thursday) evenings prior to discharge, and surveys were collected either later that evening or in the morning. The surveys included 29 questions that used a five-point Likert scale to assess communication and experience.
These questions covered the following constructs:
- Parent understanding of the medical plan;
- Parent communication and experience with nighttime doctors;
- Parent communication and experience with nighttime nurses;
- Parent perceptions of nighttime interactions between doctors and nurses; and
- Parent overall experience of care during hospitalization.
An open question addressing whether parents had anything else to share about communication during the hospitalization was included. The primary outcome measure was the so-called “top-box” rating of overall experience of care during the hospitalization (from construct five). This outcome was dichotomous based on whether the parent had given the highest rating or not for all five questions in that construct (either “excellent” or “strongly agree”).
A top-box rating of overall experience of care was found to be associated with high mean construct scores regarding communication and experience with doctors (4.85) and nurses (4.87). Top-box overall experience ratings were also associated with top ratings for coordination between daytime and nighttime nurses and for teamwork between nighttime doctors and nurses. Multivariable analysis showed that parents’ rating of direct communications with doctors and nurses and perceived teamwork and communication between doctors and nurses were significant predictors of top-box overall experience.
Bottom line: Parents’ perceptions of direct communications with nighttime doctors and nurses and their perceived teamwork and communication were strong predictors of overall experience of care during pediatric hospitalization.
Citation: Khan A, Rogers JE, Melvin P, et al. Physician and nurse nighttime communication and parents’ hospital experience. Pediatrics. 2015;136(5):e1249-1258.