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Bias in the clinical setting can impact patient care
SAN ANTONIO – Physicians and other health care providers may harbor implicit, or unconscious, biases that contribute to health care disparities, patient communication researcher Stacey Passalacqua, PhD, said here at the annual meeting of the American College of Chest Physicians.
Implicit biases are beliefs or attitudes, for example, about certain social groups, that exist outside of a health care provider’s conscious awareness, said Dr. Passalacqua of the department of communication at the University of Texas, San Antonio. If bias is implicit, it can be difficult self-assess.
among other social, ethnic, and racial groups, Dr. Passalacqua told attendees in workshops at the meeting.
“If a health care provider has negative biases toward a particular patient – maybe they think that these patients doesn’t care that much about their health or that they really have no interest in participating – then obviously that health care provider is far less likely to engage that patient in shared decision making,” she said in a video interview.
Diagnosis and treatment are subject to influence by the bias that physicians have toward certain patient groups, according to Dr. Passalacqua. For example, she said women with heart disease are less likely to be accurately diagnosed.
The bias in the medical setting might be mitigated by the presence of more individuals from the at-risk groups in the health care workforce, she added. In one recent retrospective study, investigators found that after an MI, a woman treated by a male physician was associated with higher mortality, while women and men had similar outcomes when treated by female physicians.
“That is one of the reasons why it is so important to have a diverse workforce, to have health care providers of different ethnicities, of different genders, or different backgrounds, because they are less subject to some of these implicit biases that we know are highly problematic in health care,” she said in the interview.
Dr. Passalacqua had no disclosures related to her presentation.
SAN ANTONIO – Physicians and other health care providers may harbor implicit, or unconscious, biases that contribute to health care disparities, patient communication researcher Stacey Passalacqua, PhD, said here at the annual meeting of the American College of Chest Physicians.
Implicit biases are beliefs or attitudes, for example, about certain social groups, that exist outside of a health care provider’s conscious awareness, said Dr. Passalacqua of the department of communication at the University of Texas, San Antonio. If bias is implicit, it can be difficult self-assess.
among other social, ethnic, and racial groups, Dr. Passalacqua told attendees in workshops at the meeting.
“If a health care provider has negative biases toward a particular patient – maybe they think that these patients doesn’t care that much about their health or that they really have no interest in participating – then obviously that health care provider is far less likely to engage that patient in shared decision making,” she said in a video interview.
Diagnosis and treatment are subject to influence by the bias that physicians have toward certain patient groups, according to Dr. Passalacqua. For example, she said women with heart disease are less likely to be accurately diagnosed.
The bias in the medical setting might be mitigated by the presence of more individuals from the at-risk groups in the health care workforce, she added. In one recent retrospective study, investigators found that after an MI, a woman treated by a male physician was associated with higher mortality, while women and men had similar outcomes when treated by female physicians.
“That is one of the reasons why it is so important to have a diverse workforce, to have health care providers of different ethnicities, of different genders, or different backgrounds, because they are less subject to some of these implicit biases that we know are highly problematic in health care,” she said in the interview.
Dr. Passalacqua had no disclosures related to her presentation.
SAN ANTONIO – Physicians and other health care providers may harbor implicit, or unconscious, biases that contribute to health care disparities, patient communication researcher Stacey Passalacqua, PhD, said here at the annual meeting of the American College of Chest Physicians.
Implicit biases are beliefs or attitudes, for example, about certain social groups, that exist outside of a health care provider’s conscious awareness, said Dr. Passalacqua of the department of communication at the University of Texas, San Antonio. If bias is implicit, it can be difficult self-assess.
among other social, ethnic, and racial groups, Dr. Passalacqua told attendees in workshops at the meeting.
“If a health care provider has negative biases toward a particular patient – maybe they think that these patients doesn’t care that much about their health or that they really have no interest in participating – then obviously that health care provider is far less likely to engage that patient in shared decision making,” she said in a video interview.
Diagnosis and treatment are subject to influence by the bias that physicians have toward certain patient groups, according to Dr. Passalacqua. For example, she said women with heart disease are less likely to be accurately diagnosed.
The bias in the medical setting might be mitigated by the presence of more individuals from the at-risk groups in the health care workforce, she added. In one recent retrospective study, investigators found that after an MI, a woman treated by a male physician was associated with higher mortality, while women and men had similar outcomes when treated by female physicians.
“That is one of the reasons why it is so important to have a diverse workforce, to have health care providers of different ethnicities, of different genders, or different backgrounds, because they are less subject to some of these implicit biases that we know are highly problematic in health care,” she said in the interview.
Dr. Passalacqua had no disclosures related to her presentation.
REPORTING FROM CHEST 2018
CT for evaluating pulmonary embolism overused
SAN ANTONIO – The recommended approach to evaluating suspected pulmonary embolism is “greatly underutilized” in the Veterans Health Administration system, Nancy Hsu, MD, said at the annual meeting of the American College of Chest Physicians.
Most Veterans Affairs sites did not require incorporation of a clinical decision rule (CDR) and highly sensitive D-dimer prior to ordering CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), according to results of a survey by Dr. Hsu and her coinvestigator, Guy Soo Hoo, MD.
While CTPA has become the imaging modality of choice for evaluating suspected PE, it is overused and potentially avoidable in one-third of cases, said Dr. Hsu, who is with the VA Greater Los Angeles Healthcare System.
“In the 10 years following the advent of CTPA use, there was a 14-fold increase in usage, but there was no change in mortality,” Dr. Hsu said. “This is consistent with overdiagnosis.”
Dr. Hsu said.
Dr. Hsu and Dr. Soo Hoo surveyed 606 individuals at 18 Veterans Integrated Service Networks (VISNs) and 143 medical centers. A total of 120 fully completed questionnaires were analyzed.
Most respondents (63%) were chiefs, and 80% had 11+ years of experience, Dr. Hsu reported.
Almost all respondents (85%) said CDR with or without D-dimer was not required before ordering a CTPA, survey results show, while only about 7% required both.
“A very small minority of [Veterans Integrated Service Networks], or geographic regions, contained even one hospital that adhered to the guidelines,” Dr. Hsu added.
Though further analysis was limited by sample size, the average CTPA yield for PE appeared to be higher when both components were used in the evaluation, according to Dr. Hsu, who noted an 11.9% yield for CDR plus D-dimer.
Use of CTPA appeared lower at sites with CDR and D-dimer testing, Dr. Hsu added.
These results suggest a need for further research to compare CTPA use and yield in sites that have the algorithm in place, Dr. Hsu told attendees at the meeting.
Adherence to the CDR plus D-dimer diagnostic strategy is “modest at best” despite being a Top 5 Choosing Wisely recommendation in pulmonary medicine, Dr. Hsu told attendees.
The biggest barrier to optimal practice may be the fear of having a patient who “falls through the cracks” based on false-negative CDR and D-dimer data, according to Dr. Hsu.
On the other hand, judicious use of CTPA likely avoids negative sequelae related to radiation, contrast exposure, and treatment-related bleeding, Dr. Hsu said.
“It’s all about balancing risks and benefits,” she said from the podium in a discussion of the study results.
Dr. Hsu and Dr. Soo Hoo disclosed that they had no relationships relevant to their research.
SOURCE: Hsu N et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.937
SAN ANTONIO – The recommended approach to evaluating suspected pulmonary embolism is “greatly underutilized” in the Veterans Health Administration system, Nancy Hsu, MD, said at the annual meeting of the American College of Chest Physicians.
Most Veterans Affairs sites did not require incorporation of a clinical decision rule (CDR) and highly sensitive D-dimer prior to ordering CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), according to results of a survey by Dr. Hsu and her coinvestigator, Guy Soo Hoo, MD.
While CTPA has become the imaging modality of choice for evaluating suspected PE, it is overused and potentially avoidable in one-third of cases, said Dr. Hsu, who is with the VA Greater Los Angeles Healthcare System.
“In the 10 years following the advent of CTPA use, there was a 14-fold increase in usage, but there was no change in mortality,” Dr. Hsu said. “This is consistent with overdiagnosis.”
Dr. Hsu said.
Dr. Hsu and Dr. Soo Hoo surveyed 606 individuals at 18 Veterans Integrated Service Networks (VISNs) and 143 medical centers. A total of 120 fully completed questionnaires were analyzed.
Most respondents (63%) were chiefs, and 80% had 11+ years of experience, Dr. Hsu reported.
Almost all respondents (85%) said CDR with or without D-dimer was not required before ordering a CTPA, survey results show, while only about 7% required both.
“A very small minority of [Veterans Integrated Service Networks], or geographic regions, contained even one hospital that adhered to the guidelines,” Dr. Hsu added.
Though further analysis was limited by sample size, the average CTPA yield for PE appeared to be higher when both components were used in the evaluation, according to Dr. Hsu, who noted an 11.9% yield for CDR plus D-dimer.
Use of CTPA appeared lower at sites with CDR and D-dimer testing, Dr. Hsu added.
These results suggest a need for further research to compare CTPA use and yield in sites that have the algorithm in place, Dr. Hsu told attendees at the meeting.
Adherence to the CDR plus D-dimer diagnostic strategy is “modest at best” despite being a Top 5 Choosing Wisely recommendation in pulmonary medicine, Dr. Hsu told attendees.
The biggest barrier to optimal practice may be the fear of having a patient who “falls through the cracks” based on false-negative CDR and D-dimer data, according to Dr. Hsu.
On the other hand, judicious use of CTPA likely avoids negative sequelae related to radiation, contrast exposure, and treatment-related bleeding, Dr. Hsu said.
“It’s all about balancing risks and benefits,” she said from the podium in a discussion of the study results.
Dr. Hsu and Dr. Soo Hoo disclosed that they had no relationships relevant to their research.
SOURCE: Hsu N et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.937
SAN ANTONIO – The recommended approach to evaluating suspected pulmonary embolism is “greatly underutilized” in the Veterans Health Administration system, Nancy Hsu, MD, said at the annual meeting of the American College of Chest Physicians.
Most Veterans Affairs sites did not require incorporation of a clinical decision rule (CDR) and highly sensitive D-dimer prior to ordering CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), according to results of a survey by Dr. Hsu and her coinvestigator, Guy Soo Hoo, MD.
While CTPA has become the imaging modality of choice for evaluating suspected PE, it is overused and potentially avoidable in one-third of cases, said Dr. Hsu, who is with the VA Greater Los Angeles Healthcare System.
“In the 10 years following the advent of CTPA use, there was a 14-fold increase in usage, but there was no change in mortality,” Dr. Hsu said. “This is consistent with overdiagnosis.”
Dr. Hsu said.
Dr. Hsu and Dr. Soo Hoo surveyed 606 individuals at 18 Veterans Integrated Service Networks (VISNs) and 143 medical centers. A total of 120 fully completed questionnaires were analyzed.
Most respondents (63%) were chiefs, and 80% had 11+ years of experience, Dr. Hsu reported.
Almost all respondents (85%) said CDR with or without D-dimer was not required before ordering a CTPA, survey results show, while only about 7% required both.
“A very small minority of [Veterans Integrated Service Networks], or geographic regions, contained even one hospital that adhered to the guidelines,” Dr. Hsu added.
Though further analysis was limited by sample size, the average CTPA yield for PE appeared to be higher when both components were used in the evaluation, according to Dr. Hsu, who noted an 11.9% yield for CDR plus D-dimer.
Use of CTPA appeared lower at sites with CDR and D-dimer testing, Dr. Hsu added.
These results suggest a need for further research to compare CTPA use and yield in sites that have the algorithm in place, Dr. Hsu told attendees at the meeting.
Adherence to the CDR plus D-dimer diagnostic strategy is “modest at best” despite being a Top 5 Choosing Wisely recommendation in pulmonary medicine, Dr. Hsu told attendees.
The biggest barrier to optimal practice may be the fear of having a patient who “falls through the cracks” based on false-negative CDR and D-dimer data, according to Dr. Hsu.
On the other hand, judicious use of CTPA likely avoids negative sequelae related to radiation, contrast exposure, and treatment-related bleeding, Dr. Hsu said.
“It’s all about balancing risks and benefits,” she said from the podium in a discussion of the study results.
Dr. Hsu and Dr. Soo Hoo disclosed that they had no relationships relevant to their research.
SOURCE: Hsu N et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.937
REPORTING FROM CHEST 2018
Key clinical point: The recommended approach to evaluating suspected pulmonary embolism was underutilized in VA facilities.
Major finding: 85% of respondents said incorporation of a clinical decision rule plus highly sensitive D-dimer was not required prior to CTPA.
Study details: Analysis of 120 survey questionnaires completed by individuals working in Veterans Integrated Service Networks and medical centers.
Disclosures: Study authors reported no conflicts of interest.
Source: Hsu N et al. CHEST 2018 Oct. doi: 10/1016/j.chest.2018.08.937.
ICU infections: Chlorhexidine wipes tame MRSA, CRE
according to a report presented at ID Week 2018.
The move prevented an estimated eight methicillin-resistant Staphylococcus aureus (MRSA) and three carbapenem-resistant Enterobacteriaceae (CRE) infections and saved the medical center more than $150,000 in the year following the November 2016 switch.
The goal was to address the rate of MRSA bacteremia, which was higher than national ICU averages. Contact precautions began to make less sense as MRSA became more common in the surrounding community, and “we just wanted to get rid of contact precautions,” said study lead Jason Moss, DO, an infectious disease fellow at the university.
Contact precautions are expensive, make patients feel isolated, and according to some studies, lead to worse outcomes, he said at the annual scientific meeting on infectious diseases.
Decolonization is not routine in most ICUs, but it’s gaining traction. Guidelines recommend chlorhexidine bathing with wipes to stop CRE transmission, and chlorhexidine is used to prevent central line–associated bloodstream infections (CLABSI).
A recent analysis of 17 trials found marked decreases in MRSA and CLABSI with decolonization and concluded that chlorhexidine bathing “appears to be of the most clinical benefit when infection rates are high for a given ICU population,” as was the case in Kentucky (Crit Care. 2016 Nov 23;20[1]:379).
When researchers compared the year before the change to the year after, “we were pretty surprised at how much the rates of infection and colonization decreased. There have been some people that have been doing this in the ICU, but probably not to our extent. If you want to get rid of contact precautions, this is a great process to do it with,” Dr. Moss said.
Rates of colonization with MRSA or CRE fell from about 14 isolates per 10,000 patient-days to fewer than 6 (P = .026). Infection rates fell from 3.9 isolates per 10,000 patient-days to 2 (P = .083). Combined rates of infections and colonizations fell from almost 18 isolates per 10,000 patient-days to fewer than 8 (P = .010).
Decolonization is now standard practice at the university. Every ICU patient gets a one-time povidone iodine nasal swab at admission, then daily baths with 2% chlorhexidine gluconate applied by impregnated wipe. It usually takes four or five wipes to do the entire body.
Spending on gowns fell from about $153,000 per year to just under $60,000, but spending on wipes went up from about $2,700 to $275,000, and spending on povidone iodine nasal swabs went up to more than $100,000.
When balanced against the money not spent on those 11 prevented infections, however, the program saved the medical center about $152,000 in its first year, according to Dr. Moss and his team.
There was no funding for the work, and the investigators had no disclosures.
SOURCE: Moss J et al. ID Week 2018, Abstract 32.
according to a report presented at ID Week 2018.
The move prevented an estimated eight methicillin-resistant Staphylococcus aureus (MRSA) and three carbapenem-resistant Enterobacteriaceae (CRE) infections and saved the medical center more than $150,000 in the year following the November 2016 switch.
The goal was to address the rate of MRSA bacteremia, which was higher than national ICU averages. Contact precautions began to make less sense as MRSA became more common in the surrounding community, and “we just wanted to get rid of contact precautions,” said study lead Jason Moss, DO, an infectious disease fellow at the university.
Contact precautions are expensive, make patients feel isolated, and according to some studies, lead to worse outcomes, he said at the annual scientific meeting on infectious diseases.
Decolonization is not routine in most ICUs, but it’s gaining traction. Guidelines recommend chlorhexidine bathing with wipes to stop CRE transmission, and chlorhexidine is used to prevent central line–associated bloodstream infections (CLABSI).
A recent analysis of 17 trials found marked decreases in MRSA and CLABSI with decolonization and concluded that chlorhexidine bathing “appears to be of the most clinical benefit when infection rates are high for a given ICU population,” as was the case in Kentucky (Crit Care. 2016 Nov 23;20[1]:379).
When researchers compared the year before the change to the year after, “we were pretty surprised at how much the rates of infection and colonization decreased. There have been some people that have been doing this in the ICU, but probably not to our extent. If you want to get rid of contact precautions, this is a great process to do it with,” Dr. Moss said.
Rates of colonization with MRSA or CRE fell from about 14 isolates per 10,000 patient-days to fewer than 6 (P = .026). Infection rates fell from 3.9 isolates per 10,000 patient-days to 2 (P = .083). Combined rates of infections and colonizations fell from almost 18 isolates per 10,000 patient-days to fewer than 8 (P = .010).
Decolonization is now standard practice at the university. Every ICU patient gets a one-time povidone iodine nasal swab at admission, then daily baths with 2% chlorhexidine gluconate applied by impregnated wipe. It usually takes four or five wipes to do the entire body.
Spending on gowns fell from about $153,000 per year to just under $60,000, but spending on wipes went up from about $2,700 to $275,000, and spending on povidone iodine nasal swabs went up to more than $100,000.
When balanced against the money not spent on those 11 prevented infections, however, the program saved the medical center about $152,000 in its first year, according to Dr. Moss and his team.
There was no funding for the work, and the investigators had no disclosures.
SOURCE: Moss J et al. ID Week 2018, Abstract 32.
according to a report presented at ID Week 2018.
The move prevented an estimated eight methicillin-resistant Staphylococcus aureus (MRSA) and three carbapenem-resistant Enterobacteriaceae (CRE) infections and saved the medical center more than $150,000 in the year following the November 2016 switch.
The goal was to address the rate of MRSA bacteremia, which was higher than national ICU averages. Contact precautions began to make less sense as MRSA became more common in the surrounding community, and “we just wanted to get rid of contact precautions,” said study lead Jason Moss, DO, an infectious disease fellow at the university.
Contact precautions are expensive, make patients feel isolated, and according to some studies, lead to worse outcomes, he said at the annual scientific meeting on infectious diseases.
Decolonization is not routine in most ICUs, but it’s gaining traction. Guidelines recommend chlorhexidine bathing with wipes to stop CRE transmission, and chlorhexidine is used to prevent central line–associated bloodstream infections (CLABSI).
A recent analysis of 17 trials found marked decreases in MRSA and CLABSI with decolonization and concluded that chlorhexidine bathing “appears to be of the most clinical benefit when infection rates are high for a given ICU population,” as was the case in Kentucky (Crit Care. 2016 Nov 23;20[1]:379).
When researchers compared the year before the change to the year after, “we were pretty surprised at how much the rates of infection and colonization decreased. There have been some people that have been doing this in the ICU, but probably not to our extent. If you want to get rid of contact precautions, this is a great process to do it with,” Dr. Moss said.
Rates of colonization with MRSA or CRE fell from about 14 isolates per 10,000 patient-days to fewer than 6 (P = .026). Infection rates fell from 3.9 isolates per 10,000 patient-days to 2 (P = .083). Combined rates of infections and colonizations fell from almost 18 isolates per 10,000 patient-days to fewer than 8 (P = .010).
Decolonization is now standard practice at the university. Every ICU patient gets a one-time povidone iodine nasal swab at admission, then daily baths with 2% chlorhexidine gluconate applied by impregnated wipe. It usually takes four or five wipes to do the entire body.
Spending on gowns fell from about $153,000 per year to just under $60,000, but spending on wipes went up from about $2,700 to $275,000, and spending on povidone iodine nasal swabs went up to more than $100,000.
When balanced against the money not spent on those 11 prevented infections, however, the program saved the medical center about $152,000 in its first year, according to Dr. Moss and his team.
There was no funding for the work, and the investigators had no disclosures.
SOURCE: Moss J et al. ID Week 2018, Abstract 32.
REPORTING FROM ID WEEK 2018
Key clinical point: For high rates of MRSA and CRE in the ICU, consider decolonization instead of contact precautions.
Major finding: Rates of colonization with MRSA or CRE fell from about 14 isolates per 10,000 patient-days to fewer than 6; infection rates fell from 3.9 isolates to 2 per 10,000 patient-days.
Study details: Review of ICU quality improvement initiative
Disclosures: There was no funding for the work, and the investigators had no disclosures.
Source: Moss J et al. ID Week 2018, Abstract 32.
Readmissions after GI bleeds
Clinical question: What is the rate of hospital readmission within 30 days of nonvariceal upper GI hemorrhage, and what are its effects on mortality, morbidity, and health care use in the United States?
Background: Nonvariceal upper GI hemorrhage is the most common GI emergency that leads to hospital admission (approximately 300,000 admissions/year in the United States). Because of the advances in endoscopic therapy and overall medical care, associated in-hospital mortality has been steadily decreasing. As a result of Medicare and Medicaid shifts toward an alternative payment model, quantifying hospital readmission rate after an episode of nonvariceal upper GI hemorrhage and measuring its effects on patient outcomes and resource use have become a key step in both improving treatment outcomes and health care reimbursement.
Study design: Retrospective study.
Setting: The Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project Nationwide Readmission Database for the year 2014.
Synopsis: The study collected data on hospital readmissions for 203,220 adults who were hospitalized for urgent nonvariceal upper gastrointestinal hemorrhage and discharged. The primary outcome was rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity (shock and prolonged mechanical ventilation), and resource use (length of stay and total hospitalization costs and charges).
The rate of readmission was determined to be 13%, with only 18% caused by recurrent nonvariceal upper gastrointestinal bleeding. The rate of death among readmissions was higher than that among index admissions, and a higher proportion of readmitted patients had morbidities requiring prolonged mechanical ventilation. The total economic in-hospital burden was $30.3 million in costs and $108 million in charges over the span of readmission-associated 133,368 hospital days. Independent predictors of readmission were having Medicaid insurance, having a higher comorbidity score, having a lower income, residence in a metropolitan area, hemorrhagic shock, and longer stays in the hospital.
Bottom line: Readmissions within 30 days of discharge for upper GI hemorrhage are associated with higher morbidity and mortality and lead to higher resource use.
Citation: Abougergi M et al. Thirty-day readmission among patients with nonvariceal upper gastrointestinal hemorrhage and effects on outcomes. Gastroenterology. 2018 Jul;155(1):38-46.
Dr. White is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Clinical question: What is the rate of hospital readmission within 30 days of nonvariceal upper GI hemorrhage, and what are its effects on mortality, morbidity, and health care use in the United States?
Background: Nonvariceal upper GI hemorrhage is the most common GI emergency that leads to hospital admission (approximately 300,000 admissions/year in the United States). Because of the advances in endoscopic therapy and overall medical care, associated in-hospital mortality has been steadily decreasing. As a result of Medicare and Medicaid shifts toward an alternative payment model, quantifying hospital readmission rate after an episode of nonvariceal upper GI hemorrhage and measuring its effects on patient outcomes and resource use have become a key step in both improving treatment outcomes and health care reimbursement.
Study design: Retrospective study.
Setting: The Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project Nationwide Readmission Database for the year 2014.
Synopsis: The study collected data on hospital readmissions for 203,220 adults who were hospitalized for urgent nonvariceal upper gastrointestinal hemorrhage and discharged. The primary outcome was rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity (shock and prolonged mechanical ventilation), and resource use (length of stay and total hospitalization costs and charges).
The rate of readmission was determined to be 13%, with only 18% caused by recurrent nonvariceal upper gastrointestinal bleeding. The rate of death among readmissions was higher than that among index admissions, and a higher proportion of readmitted patients had morbidities requiring prolonged mechanical ventilation. The total economic in-hospital burden was $30.3 million in costs and $108 million in charges over the span of readmission-associated 133,368 hospital days. Independent predictors of readmission were having Medicaid insurance, having a higher comorbidity score, having a lower income, residence in a metropolitan area, hemorrhagic shock, and longer stays in the hospital.
Bottom line: Readmissions within 30 days of discharge for upper GI hemorrhage are associated with higher morbidity and mortality and lead to higher resource use.
Citation: Abougergi M et al. Thirty-day readmission among patients with nonvariceal upper gastrointestinal hemorrhage and effects on outcomes. Gastroenterology. 2018 Jul;155(1):38-46.
Dr. White is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Clinical question: What is the rate of hospital readmission within 30 days of nonvariceal upper GI hemorrhage, and what are its effects on mortality, morbidity, and health care use in the United States?
Background: Nonvariceal upper GI hemorrhage is the most common GI emergency that leads to hospital admission (approximately 300,000 admissions/year in the United States). Because of the advances in endoscopic therapy and overall medical care, associated in-hospital mortality has been steadily decreasing. As a result of Medicare and Medicaid shifts toward an alternative payment model, quantifying hospital readmission rate after an episode of nonvariceal upper GI hemorrhage and measuring its effects on patient outcomes and resource use have become a key step in both improving treatment outcomes and health care reimbursement.
Study design: Retrospective study.
Setting: The Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project Nationwide Readmission Database for the year 2014.
Synopsis: The study collected data on hospital readmissions for 203,220 adults who were hospitalized for urgent nonvariceal upper gastrointestinal hemorrhage and discharged. The primary outcome was rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity (shock and prolonged mechanical ventilation), and resource use (length of stay and total hospitalization costs and charges).
The rate of readmission was determined to be 13%, with only 18% caused by recurrent nonvariceal upper gastrointestinal bleeding. The rate of death among readmissions was higher than that among index admissions, and a higher proportion of readmitted patients had morbidities requiring prolonged mechanical ventilation. The total economic in-hospital burden was $30.3 million in costs and $108 million in charges over the span of readmission-associated 133,368 hospital days. Independent predictors of readmission were having Medicaid insurance, having a higher comorbidity score, having a lower income, residence in a metropolitan area, hemorrhagic shock, and longer stays in the hospital.
Bottom line: Readmissions within 30 days of discharge for upper GI hemorrhage are associated with higher morbidity and mortality and lead to higher resource use.
Citation: Abougergi M et al. Thirty-day readmission among patients with nonvariceal upper gastrointestinal hemorrhage and effects on outcomes. Gastroenterology. 2018 Jul;155(1):38-46.
Dr. White is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
GARFIELD-AF registry: DOACs cut mortality 19%
MUNICH – Treatment of real-world patients newly diagnosed with atrial fibrillation using a direct oral anticoagulant led to benefits that tracked the advantages previously seen in randomized, controlled trials of these drugs, based on findings from more than 26,000 patients enrolled in a global registry.
Atrial fibrillation patients enrolled in the GARFIELD-AF(Global Anticoagulant Registry in the Field) study who started treatment with a direct oral anticoagulant (DOAC) had a 19% relative risk reduction in all-cause mortality during 2 years of follow-up, compared with patients on an oral vitamin K antagonist (VKA) regimen (such as warfarin), a statistically significant difference after adjustment for 30 demographic, clinical, and registry variables, A. John Camm, MD, said at the annual congress of the European Society of Cardiology. The analysis also showed trends toward lower rates of stroke or systemic thrombosis as well as major bleeding events when patients received a DOAC, compared with those on VKA, but these differences were not statistically significant, reported Dr. Camm, a professor of clinical cardiology at St. George’s University of London.
The analyses run by Dr. Camm and his associates also confirmed the superiority of oral anticoagulation. There was an adjusted 17% relative risk reduction in all-cause mortality during 2-year follow-up in patients on any form of oral anticoagulation, compared with patients who did not receive anticoagulation, a statistically significant difference. The comparison of patients on any oral anticoagulant with those not on treatment also showed a significant lowering of stroke or systemic embolism, as well as a 36% relative increase in the risk for a major bleeding episode that was close to statistical significance.
These findings in a registry of patients undergoing routine care “suggest that the effectiveness of oral anticoagulants in randomized clinical trials can be translated to the broad cross section of patients treated in everyday practice,” Dr. Camm said. However, he highlighted two important qualifications to the findings.
First, the analysis focused on the type of anticoagulation patients received at the time they entered the GARFIELD-AF registry and did not account for possible changes in treatment after that. Second, the analysis did not adjust for additional potential confounding variables, which Dr. Camm was certain existed and affected the findings.
“I’m concerned that a confounder we have not been able to account for is the quality of medical care that patients received,” he noted. “The substantial reduction in mortality [using a DOAC, compared with a VKA] is not simply due to reductions in stroke or major bleeding. We must look at other explanations, such as differences in quality of care and access to care.”
The analyses have also not yet looked at outcomes based on the specific DOAC a patient received – apixaban, dabigatran, edoxaban, or rivaroxaban – something that Dr. Camm said is in the works.
GARFIELD-AF enrolled nearly 35,000 patients with newly diagnosed atrial fibrillation and at least one stroke risk factor in 35 countries from April 2013 to September 2016. The analysis winnowed this down to 26,742 patients who also had a CHA2DS2-VASc score of at least 2 (which identifies patients with a high thrombotic risk) and had complete enrollment and follow-up data.
GARFIELD-AF was funded in part by Bayer. Dr. Camm reported being an adviser to Bayer, Boehringer Ingelheim, Daiichi Sankyo, and Pfizer/Bristol-Myers Squibb.
MUNICH – Treatment of real-world patients newly diagnosed with atrial fibrillation using a direct oral anticoagulant led to benefits that tracked the advantages previously seen in randomized, controlled trials of these drugs, based on findings from more than 26,000 patients enrolled in a global registry.
Atrial fibrillation patients enrolled in the GARFIELD-AF(Global Anticoagulant Registry in the Field) study who started treatment with a direct oral anticoagulant (DOAC) had a 19% relative risk reduction in all-cause mortality during 2 years of follow-up, compared with patients on an oral vitamin K antagonist (VKA) regimen (such as warfarin), a statistically significant difference after adjustment for 30 demographic, clinical, and registry variables, A. John Camm, MD, said at the annual congress of the European Society of Cardiology. The analysis also showed trends toward lower rates of stroke or systemic thrombosis as well as major bleeding events when patients received a DOAC, compared with those on VKA, but these differences were not statistically significant, reported Dr. Camm, a professor of clinical cardiology at St. George’s University of London.
The analyses run by Dr. Camm and his associates also confirmed the superiority of oral anticoagulation. There was an adjusted 17% relative risk reduction in all-cause mortality during 2-year follow-up in patients on any form of oral anticoagulation, compared with patients who did not receive anticoagulation, a statistically significant difference. The comparison of patients on any oral anticoagulant with those not on treatment also showed a significant lowering of stroke or systemic embolism, as well as a 36% relative increase in the risk for a major bleeding episode that was close to statistical significance.
These findings in a registry of patients undergoing routine care “suggest that the effectiveness of oral anticoagulants in randomized clinical trials can be translated to the broad cross section of patients treated in everyday practice,” Dr. Camm said. However, he highlighted two important qualifications to the findings.
First, the analysis focused on the type of anticoagulation patients received at the time they entered the GARFIELD-AF registry and did not account for possible changes in treatment after that. Second, the analysis did not adjust for additional potential confounding variables, which Dr. Camm was certain existed and affected the findings.
“I’m concerned that a confounder we have not been able to account for is the quality of medical care that patients received,” he noted. “The substantial reduction in mortality [using a DOAC, compared with a VKA] is not simply due to reductions in stroke or major bleeding. We must look at other explanations, such as differences in quality of care and access to care.”
The analyses have also not yet looked at outcomes based on the specific DOAC a patient received – apixaban, dabigatran, edoxaban, or rivaroxaban – something that Dr. Camm said is in the works.
GARFIELD-AF enrolled nearly 35,000 patients with newly diagnosed atrial fibrillation and at least one stroke risk factor in 35 countries from April 2013 to September 2016. The analysis winnowed this down to 26,742 patients who also had a CHA2DS2-VASc score of at least 2 (which identifies patients with a high thrombotic risk) and had complete enrollment and follow-up data.
GARFIELD-AF was funded in part by Bayer. Dr. Camm reported being an adviser to Bayer, Boehringer Ingelheim, Daiichi Sankyo, and Pfizer/Bristol-Myers Squibb.
MUNICH – Treatment of real-world patients newly diagnosed with atrial fibrillation using a direct oral anticoagulant led to benefits that tracked the advantages previously seen in randomized, controlled trials of these drugs, based on findings from more than 26,000 patients enrolled in a global registry.
Atrial fibrillation patients enrolled in the GARFIELD-AF(Global Anticoagulant Registry in the Field) study who started treatment with a direct oral anticoagulant (DOAC) had a 19% relative risk reduction in all-cause mortality during 2 years of follow-up, compared with patients on an oral vitamin K antagonist (VKA) regimen (such as warfarin), a statistically significant difference after adjustment for 30 demographic, clinical, and registry variables, A. John Camm, MD, said at the annual congress of the European Society of Cardiology. The analysis also showed trends toward lower rates of stroke or systemic thrombosis as well as major bleeding events when patients received a DOAC, compared with those on VKA, but these differences were not statistically significant, reported Dr. Camm, a professor of clinical cardiology at St. George’s University of London.
The analyses run by Dr. Camm and his associates also confirmed the superiority of oral anticoagulation. There was an adjusted 17% relative risk reduction in all-cause mortality during 2-year follow-up in patients on any form of oral anticoagulation, compared with patients who did not receive anticoagulation, a statistically significant difference. The comparison of patients on any oral anticoagulant with those not on treatment also showed a significant lowering of stroke or systemic embolism, as well as a 36% relative increase in the risk for a major bleeding episode that was close to statistical significance.
These findings in a registry of patients undergoing routine care “suggest that the effectiveness of oral anticoagulants in randomized clinical trials can be translated to the broad cross section of patients treated in everyday practice,” Dr. Camm said. However, he highlighted two important qualifications to the findings.
First, the analysis focused on the type of anticoagulation patients received at the time they entered the GARFIELD-AF registry and did not account for possible changes in treatment after that. Second, the analysis did not adjust for additional potential confounding variables, which Dr. Camm was certain existed and affected the findings.
“I’m concerned that a confounder we have not been able to account for is the quality of medical care that patients received,” he noted. “The substantial reduction in mortality [using a DOAC, compared with a VKA] is not simply due to reductions in stroke or major bleeding. We must look at other explanations, such as differences in quality of care and access to care.”
The analyses have also not yet looked at outcomes based on the specific DOAC a patient received – apixaban, dabigatran, edoxaban, or rivaroxaban – something that Dr. Camm said is in the works.
GARFIELD-AF enrolled nearly 35,000 patients with newly diagnosed atrial fibrillation and at least one stroke risk factor in 35 countries from April 2013 to September 2016. The analysis winnowed this down to 26,742 patients who also had a CHA2DS2-VASc score of at least 2 (which identifies patients with a high thrombotic risk) and had complete enrollment and follow-up data.
GARFIELD-AF was funded in part by Bayer. Dr. Camm reported being an adviser to Bayer, Boehringer Ingelheim, Daiichi Sankyo, and Pfizer/Bristol-Myers Squibb.
REPORTING FROM THE ESC CONGRESS 2018
Key clinical point:
Major finding: Direct oral anticoagulant–treated patients had a 19% relative reduction in all-cause death, compared with patients on a vitamin K antagonist.
Study details: The GARFIELD-AF registry, which included 26,742 patients with newly diagnosed atrial fibrillation.
Disclosures: GARFIELD-AF was funded in part by Bayer. Dr. Camm has been an adviser to Bayer, Boehringer Ingelheim, Daiichi Sankyo, and Pfizer/Bristol-Myers Squibb.
Smoking cessation drugs do not increase CV risk
Clinical question: Do pharmacotherapies used in tobacco cessation treatment significantly increase the risk of cardiovascular events?
Background: Although it is known that smoking cessation is the most beneficial enhancement of cardiovascular health, many clinicians may be hesitant to prescribe pharmacotherapies because of concerns regarding adverse events. This study reports the cardiovascular safety findings from EAGLES (Evaluating Adverse Events in a Global Smoking Cessation Study) and its nontreatment extension trial.
Study design: Double-blind, randomized, triple-dummy, placebo- and active-controlled trial and its nontreatment extension trial.
Setting: Conducted by 140 multinational centers, EAGLES was a trial in cohorts of smokers with and without psychiatric disease that assessed the safety and efficacy of pharmacotherapies used for smoking cessation.
The EAGLES extension trial is a nontreatment extension of EAGLES. It began with the first dose of medication and included those who completed an additional 28 weeks of observation.
Synopsis: The study included approximately 8,000 participants aged 18-75 years who smoked 10 or more cigarettes per day and were interested in quitting. The study monitored the development of a major adverse cardiovascular event (MACE), such as cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, during treatment with varenicline, bupropion hydrochloride, nicotine replacement therapy, and placebo therapy. Other end points included determining the occurrence of MACE along with other peripheral vascular disease that required either intervention, coronary revascularization, or hospitalization for unstable angina (MACE+).
There were no significant differences in time to MACE or MACE+ overall across all observation periods.
Possible limitations of the study were its exclusion criteria and baseline characteristics of participants. The study excluded participants with unstable psychiatric illness, active substance abuse, clinically significant cardiovascular disease in the 2 months prior to the study entry (MI or coronary artery bypass graft), clinically significant cerebrovascular disease in the 2 months prior to study entry (stroke or documented transient ischemic attack), or inadequate control of hypertension as judged by investigators at screening and baseline. Of the included participants, greater than 66% of the participants were in the low risk (less than 10%) cardiovascular risk category, less than 10% had diabetes, less than 5% had coronary heart disease, and less than 1% had carotid artery disease.
Bottom line: The findings provide evidence that, in a general population of smokers, smoking cessation medications do not increase the risk of serious cardiovascular events.
Citation: Benowitz N et al. Cardiovascular safety of varenicline, bupropion, and nicotine patch in smoker. JAMA Intern Med. 2018 May;178(5):622-31.
Dr. White is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Clinical question: Do pharmacotherapies used in tobacco cessation treatment significantly increase the risk of cardiovascular events?
Background: Although it is known that smoking cessation is the most beneficial enhancement of cardiovascular health, many clinicians may be hesitant to prescribe pharmacotherapies because of concerns regarding adverse events. This study reports the cardiovascular safety findings from EAGLES (Evaluating Adverse Events in a Global Smoking Cessation Study) and its nontreatment extension trial.
Study design: Double-blind, randomized, triple-dummy, placebo- and active-controlled trial and its nontreatment extension trial.
Setting: Conducted by 140 multinational centers, EAGLES was a trial in cohorts of smokers with and without psychiatric disease that assessed the safety and efficacy of pharmacotherapies used for smoking cessation.
The EAGLES extension trial is a nontreatment extension of EAGLES. It began with the first dose of medication and included those who completed an additional 28 weeks of observation.
Synopsis: The study included approximately 8,000 participants aged 18-75 years who smoked 10 or more cigarettes per day and were interested in quitting. The study monitored the development of a major adverse cardiovascular event (MACE), such as cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, during treatment with varenicline, bupropion hydrochloride, nicotine replacement therapy, and placebo therapy. Other end points included determining the occurrence of MACE along with other peripheral vascular disease that required either intervention, coronary revascularization, or hospitalization for unstable angina (MACE+).
There were no significant differences in time to MACE or MACE+ overall across all observation periods.
Possible limitations of the study were its exclusion criteria and baseline characteristics of participants. The study excluded participants with unstable psychiatric illness, active substance abuse, clinically significant cardiovascular disease in the 2 months prior to the study entry (MI or coronary artery bypass graft), clinically significant cerebrovascular disease in the 2 months prior to study entry (stroke or documented transient ischemic attack), or inadequate control of hypertension as judged by investigators at screening and baseline. Of the included participants, greater than 66% of the participants were in the low risk (less than 10%) cardiovascular risk category, less than 10% had diabetes, less than 5% had coronary heart disease, and less than 1% had carotid artery disease.
Bottom line: The findings provide evidence that, in a general population of smokers, smoking cessation medications do not increase the risk of serious cardiovascular events.
Citation: Benowitz N et al. Cardiovascular safety of varenicline, bupropion, and nicotine patch in smoker. JAMA Intern Med. 2018 May;178(5):622-31.
Dr. White is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Clinical question: Do pharmacotherapies used in tobacco cessation treatment significantly increase the risk of cardiovascular events?
Background: Although it is known that smoking cessation is the most beneficial enhancement of cardiovascular health, many clinicians may be hesitant to prescribe pharmacotherapies because of concerns regarding adverse events. This study reports the cardiovascular safety findings from EAGLES (Evaluating Adverse Events in a Global Smoking Cessation Study) and its nontreatment extension trial.
Study design: Double-blind, randomized, triple-dummy, placebo- and active-controlled trial and its nontreatment extension trial.
Setting: Conducted by 140 multinational centers, EAGLES was a trial in cohorts of smokers with and without psychiatric disease that assessed the safety and efficacy of pharmacotherapies used for smoking cessation.
The EAGLES extension trial is a nontreatment extension of EAGLES. It began with the first dose of medication and included those who completed an additional 28 weeks of observation.
Synopsis: The study included approximately 8,000 participants aged 18-75 years who smoked 10 or more cigarettes per day and were interested in quitting. The study monitored the development of a major adverse cardiovascular event (MACE), such as cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, during treatment with varenicline, bupropion hydrochloride, nicotine replacement therapy, and placebo therapy. Other end points included determining the occurrence of MACE along with other peripheral vascular disease that required either intervention, coronary revascularization, or hospitalization for unstable angina (MACE+).
There were no significant differences in time to MACE or MACE+ overall across all observation periods.
Possible limitations of the study were its exclusion criteria and baseline characteristics of participants. The study excluded participants with unstable psychiatric illness, active substance abuse, clinically significant cardiovascular disease in the 2 months prior to the study entry (MI or coronary artery bypass graft), clinically significant cerebrovascular disease in the 2 months prior to study entry (stroke or documented transient ischemic attack), or inadequate control of hypertension as judged by investigators at screening and baseline. Of the included participants, greater than 66% of the participants were in the low risk (less than 10%) cardiovascular risk category, less than 10% had diabetes, less than 5% had coronary heart disease, and less than 1% had carotid artery disease.
Bottom line: The findings provide evidence that, in a general population of smokers, smoking cessation medications do not increase the risk of serious cardiovascular events.
Citation: Benowitz N et al. Cardiovascular safety of varenicline, bupropion, and nicotine patch in smoker. JAMA Intern Med. 2018 May;178(5):622-31.
Dr. White is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Obesity paradox extends to PE patients
SAN ANTONIO – compared with those who are not obese, according to results of a retrospective analysis covering 13 years and nearly 2 million PE discharges.
The obese patients in the analysis had a lower mortality risk, despite receiving more thrombolytics and mechanical intubation, said investigator Zubair Khan, MD, an internal medicine resident at the University of Toledo (Ohio) Medical Center.
“Surprisingly, the mortality of PE was significantly less in obese patients,” Dr. Khan said in a podium presentation at the annual meeting of the American College of Chest Physicians. “When we initiated the study, we did not expect this result.”
The association between obesity and lower mortality, sometimes called the “obesity paradox,” has been observed in studies of other chronic health conditions including stable heart failure, coronary artery disease, unstable angina, MI, and also in some PE studies, Dr. Khan said.
The study by Dr. Khan and his colleagues, based on the National Inpatient Sample (NIS) database, included adults with a primary discharge diagnosis of PE between 2002 and 2014. They included 1,959,018 PE discharges, of which 312,770 (16%) had an underlying obesity diagnosis.
Obese PE patients had more risk factors and more severe disease but had an overall mortality of 2.2%, compared with 3.7% in PE patients without obesity (P less than .001), Dr. Khan reported.
Hypertension was significantly more prevalent in the obese PE patients (65% vs. 50.5%; P less than .001), as was chronic lung disease and chronic liver disease, he noted in his presentation.
Obese patients more often received thrombolytics (3.6% vs. 1.9%; P less than .001) and mechanical ventilation (5.8% vs. 4%; P less than .001), and more frequently had cardiogenic shock (0.65% vs. 0.45%; P less than .001), he said.
The obese PE patients were more often female, black, and younger than 65 years of age, it was reported.
Notably, the prevalence of obesity in PE patients more than doubled over the course of the study period, from 10.2% in 2002 to 22.6% in 2014, Dr. Khan added.
The paradoxically lower mortality in obese patients might be explained by increased levels of endocannabinoids, which have shown protective effects in rat and mouse studies, Dr. Khan told attendees at the meeting.
“I think it’s a rich area for more and further research, especially in basic science,” Dr. Khan said.
Dr. Khan and his coauthors disclosed that they had no relationships relevant to the study.
SOURCE: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.
SAN ANTONIO – compared with those who are not obese, according to results of a retrospective analysis covering 13 years and nearly 2 million PE discharges.
The obese patients in the analysis had a lower mortality risk, despite receiving more thrombolytics and mechanical intubation, said investigator Zubair Khan, MD, an internal medicine resident at the University of Toledo (Ohio) Medical Center.
“Surprisingly, the mortality of PE was significantly less in obese patients,” Dr. Khan said in a podium presentation at the annual meeting of the American College of Chest Physicians. “When we initiated the study, we did not expect this result.”
The association between obesity and lower mortality, sometimes called the “obesity paradox,” has been observed in studies of other chronic health conditions including stable heart failure, coronary artery disease, unstable angina, MI, and also in some PE studies, Dr. Khan said.
The study by Dr. Khan and his colleagues, based on the National Inpatient Sample (NIS) database, included adults with a primary discharge diagnosis of PE between 2002 and 2014. They included 1,959,018 PE discharges, of which 312,770 (16%) had an underlying obesity diagnosis.
Obese PE patients had more risk factors and more severe disease but had an overall mortality of 2.2%, compared with 3.7% in PE patients without obesity (P less than .001), Dr. Khan reported.
Hypertension was significantly more prevalent in the obese PE patients (65% vs. 50.5%; P less than .001), as was chronic lung disease and chronic liver disease, he noted in his presentation.
Obese patients more often received thrombolytics (3.6% vs. 1.9%; P less than .001) and mechanical ventilation (5.8% vs. 4%; P less than .001), and more frequently had cardiogenic shock (0.65% vs. 0.45%; P less than .001), he said.
The obese PE patients were more often female, black, and younger than 65 years of age, it was reported.
Notably, the prevalence of obesity in PE patients more than doubled over the course of the study period, from 10.2% in 2002 to 22.6% in 2014, Dr. Khan added.
The paradoxically lower mortality in obese patients might be explained by increased levels of endocannabinoids, which have shown protective effects in rat and mouse studies, Dr. Khan told attendees at the meeting.
“I think it’s a rich area for more and further research, especially in basic science,” Dr. Khan said.
Dr. Khan and his coauthors disclosed that they had no relationships relevant to the study.
SOURCE: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.
SAN ANTONIO – compared with those who are not obese, according to results of a retrospective analysis covering 13 years and nearly 2 million PE discharges.
The obese patients in the analysis had a lower mortality risk, despite receiving more thrombolytics and mechanical intubation, said investigator Zubair Khan, MD, an internal medicine resident at the University of Toledo (Ohio) Medical Center.
“Surprisingly, the mortality of PE was significantly less in obese patients,” Dr. Khan said in a podium presentation at the annual meeting of the American College of Chest Physicians. “When we initiated the study, we did not expect this result.”
The association between obesity and lower mortality, sometimes called the “obesity paradox,” has been observed in studies of other chronic health conditions including stable heart failure, coronary artery disease, unstable angina, MI, and also in some PE studies, Dr. Khan said.
The study by Dr. Khan and his colleagues, based on the National Inpatient Sample (NIS) database, included adults with a primary discharge diagnosis of PE between 2002 and 2014. They included 1,959,018 PE discharges, of which 312,770 (16%) had an underlying obesity diagnosis.
Obese PE patients had more risk factors and more severe disease but had an overall mortality of 2.2%, compared with 3.7% in PE patients without obesity (P less than .001), Dr. Khan reported.
Hypertension was significantly more prevalent in the obese PE patients (65% vs. 50.5%; P less than .001), as was chronic lung disease and chronic liver disease, he noted in his presentation.
Obese patients more often received thrombolytics (3.6% vs. 1.9%; P less than .001) and mechanical ventilation (5.8% vs. 4%; P less than .001), and more frequently had cardiogenic shock (0.65% vs. 0.45%; P less than .001), he said.
The obese PE patients were more often female, black, and younger than 65 years of age, it was reported.
Notably, the prevalence of obesity in PE patients more than doubled over the course of the study period, from 10.2% in 2002 to 22.6% in 2014, Dr. Khan added.
The paradoxically lower mortality in obese patients might be explained by increased levels of endocannabinoids, which have shown protective effects in rat and mouse studies, Dr. Khan told attendees at the meeting.
“I think it’s a rich area for more and further research, especially in basic science,” Dr. Khan said.
Dr. Khan and his coauthors disclosed that they had no relationships relevant to the study.
SOURCE: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.
REPORTING FROM CHEST 2018
Key clinical point: The obesity paradox observed in other chronic conditions held true in this study of patients with pulmonary embolism (PE).
Major finding: Obese PE patients had more risk factors and more severe disease, but an overall mortality of 2.2% vs 3.7% in nonobese PE patients.
Study details: Retrospective analysis of the National Inpatient Sample (NIS) database including almost 2 million individuals with a primary discharge diagnosis of PE.
Disclosures: Study authors had no disclosures.
Source: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.
Vancomycin loading boost yields better C. diff outcomes
SAN FRANCISCO – A heightened loading dose of vancomycin may lead to faster recovery and greater efficacy in Clostridium difficile infections, according to the results of a quasi-experimental study presented at an annual scientific meeting on infectious diseases.
The study looked at a loading dose of 500 mg of vancomycin delivered four times per day for the first 48 hours, followed by a step down to 125 mg every 6 hours. It came on the heels of an attempted randomized, clinical trial that was inconclusive because of insufficient recruitment. Still, the results were promising enough to convince the Yale New Haven Hospital to make it standard practice in C. difficile patients.
Samad Tirmizi, PharmD, an infectious disease pharmacist at Stony Brook University (N.Y.), shares the results of a comparison of outcomes before and after the initiation of this treatment protocol in a video interview.
The approach grew out of concerns that vancomycin may not achieve sufficient concentrations in the colon early in treatment. A pharmacokinetics study published in 2010 suggested that a high initial loading led to higher fecal vancomycin levels, even in patients with increased stool frequency (BMC Infect Dis. 2010 Dec 30;10:363).
SOURCE: Tirmizi S et al. IDWeek 2018, Abstract 1980.
SAN FRANCISCO – A heightened loading dose of vancomycin may lead to faster recovery and greater efficacy in Clostridium difficile infections, according to the results of a quasi-experimental study presented at an annual scientific meeting on infectious diseases.
The study looked at a loading dose of 500 mg of vancomycin delivered four times per day for the first 48 hours, followed by a step down to 125 mg every 6 hours. It came on the heels of an attempted randomized, clinical trial that was inconclusive because of insufficient recruitment. Still, the results were promising enough to convince the Yale New Haven Hospital to make it standard practice in C. difficile patients.
Samad Tirmizi, PharmD, an infectious disease pharmacist at Stony Brook University (N.Y.), shares the results of a comparison of outcomes before and after the initiation of this treatment protocol in a video interview.
The approach grew out of concerns that vancomycin may not achieve sufficient concentrations in the colon early in treatment. A pharmacokinetics study published in 2010 suggested that a high initial loading led to higher fecal vancomycin levels, even in patients with increased stool frequency (BMC Infect Dis. 2010 Dec 30;10:363).
SOURCE: Tirmizi S et al. IDWeek 2018, Abstract 1980.
SAN FRANCISCO – A heightened loading dose of vancomycin may lead to faster recovery and greater efficacy in Clostridium difficile infections, according to the results of a quasi-experimental study presented at an annual scientific meeting on infectious diseases.
The study looked at a loading dose of 500 mg of vancomycin delivered four times per day for the first 48 hours, followed by a step down to 125 mg every 6 hours. It came on the heels of an attempted randomized, clinical trial that was inconclusive because of insufficient recruitment. Still, the results were promising enough to convince the Yale New Haven Hospital to make it standard practice in C. difficile patients.
Samad Tirmizi, PharmD, an infectious disease pharmacist at Stony Brook University (N.Y.), shares the results of a comparison of outcomes before and after the initiation of this treatment protocol in a video interview.
The approach grew out of concerns that vancomycin may not achieve sufficient concentrations in the colon early in treatment. A pharmacokinetics study published in 2010 suggested that a high initial loading led to higher fecal vancomycin levels, even in patients with increased stool frequency (BMC Infect Dis. 2010 Dec 30;10:363).
SOURCE: Tirmizi S et al. IDWeek 2018, Abstract 1980.
REPORTING FROM IDWEEK 2018
Association between hospice length of stay and health care costs
Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.
Study design: Cross-sectional observational study.
Setting: Using the United States Renal Data System registry.
Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.
Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.
The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.
Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.
Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.
Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.
Study design: Cross-sectional observational study.
Setting: Using the United States Renal Data System registry.
Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.
Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.
The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.
Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.
Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.
Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.
Study design: Cross-sectional observational study.
Setting: Using the United States Renal Data System registry.
Synopsis: With the use of data from the United States Renal Data System from 2000-2014, the study examined the relationship between health care utilization during the last month and that of the last week of life among patients with maintenance hemodialysis. The investigators used patients who had renal failure as a primary hospice diagnosis regardless of the decision to discontinue hemodialysis before death. Hospital admission, ICU admission, death in the hospital, and one or more inpatient intensive procedures were used as measures for health care utilization.
Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.
The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.
Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.
Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.
Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.
Pulmonary NP ensures care continuity, reduces readmissions
SAN ANTONIO – Unplanned whose discharge process involved a pulmonary nurse practitioner to coordinate continuity of care, a study of more than 70 patients has found.
Despite an increase over time in the rate of discharges, readmissions fell, Sarah Barry, CRNP, of Children’s Hospital of Philadelphia (CHOP), said at the annual meeting of the American College of Chest Physicians.
“The technology-dependent pediatric population who is going home with tracheostomy and ventilator dependence is at risk for hospital readmission, and having an advanced practice provider in a continuity role promotes adherence to our standards of practice and improves transition to home,” Ms. Barry said in an interview.
She noted previous research showing that 40% of 109 home mechanical ventilation patients discharged between 2003 and 2009 had unplanned readmissions, 28% of which occurred within the first month after discharge.
Nearly two thirds (64%) of those readmissions were related to a pulmonary and/or tracheostomy problem. That study also found that changes in condition management 1 week before discharge, such as medications, ventilator settings, or feeding regimens, was associated with unplanned readmission.
That research “makes us ask ourselves if our readmissions are avoidable and what can we do to get these kids home safe and to keep them home,” Ms. Barry told attendees, adding that CHOP was unhappy with their readmission rates.
“Kids were often not making it to their first pulmonary appointment, and it was a burden for these families,” she said. “We questioned whether or not having a nurse practitioner in a role to promote adherence to our standards would have a positive impact on our unplanned route.”
They evaluated the effect of such an NP on unplanned readmissions among tracheostomy/ventilator-supported children. The NP’s role was to track patients, mostly from the progressive care unit, who required a tracheostomy and ventilator and were expected to be discharged home or to a long-term care facility. The NP provided continuity for medical management and coordinated care at discharge.
“We also do not make changes for 2 weeks before discharge so that we can focus on all the other coordination that goes into getting these kids home,” Ms. Barry said.
She reviewed the patients’ electronic charts to record time to scheduled follow-up visit, days until hospital readmission, admitting diagnosis at readmission, and length of stay after readmission. With consideration for the time needed for transition into this new process, the population studied was assessed within three cohorts.
The first cohort comprised the 22 children discharged between April 2016 and March 2017, the full year before a pulmonary NP began coordinating the discharge process. These patients averaged 1.8 discharges per month with an initial follow-up of 2-12 weeks.
Just over a quarter (27%) of the first cohort were readmitted before their scheduled follow-up, ranging from 2 to 25 days after discharge. Five percent were readmitted within a week of discharge, and 27% were readmitted within a month; their average length of stay was 13 days after readmission. Most (83%) of these discharges were respiratory related while the other 17% were gastrointestinal related.
The second cohort involved the 11 patients discharged between April 2017 and August 2017, the first 5 months after a pulmonary NP began overseeing the discharge readiness process.
“We chose 5 months because it took about 5months for me to develop my own protocols and standards of practice,” Ms. Barry explained.
An average 2.2 discharges occurred monthly with 2-8 weeks of initial postdischarge follow-up. Though nearly half these children (45%) were readmitted before their scheduled follow-up, their length of stay was shorter, an average of 11 days.
Readmission within a week after discharge occurred among 27% of the children, and 45% of them were readmitted within a month of discharge. Sixty percent of these patients were readmitted for respiratory issues, compared with 40% with GI issues.
The third cohort included all 38 patients discharged from September 2017 to August 2018, the year after a pulmonary NP had become fully established in the continuity role, with an average 3.2 discharges occurred per month. Readmission rates were considerably lower: Eighteen percent of patients were readmitted before their scheduled follow-up appointment, which ranged from 1 to 13 weeks after discharge.
Five percent were readmitted within a week of discharge, and 24% were readmitted within a month, ranging from 1 to 26 days post discharge. But length of stay was shorter still at an average of 9 days.
The reasons for readmission varied more in this cohort: While 56% were respiratory related, 22% were related to fever, and 11% were related to neurodevelopment concerns or social reasons, such as necessary involvement of social services.
Ms. Barry’s colleague, Howard B. Panitch, MD, also on the staff of CHOP, noted during the discussion that the NP’s role is invaluable in “keeping the inpatient teams honest.
“She reminds her colleagues in critical care that you can’t make that ventilator change when on your way out the door or very close to discharge.”
Ms. Barry had no disclosures. No external funding was noted.
SOURCE: Barry S et al. CHEST 2018 Oct. doi: 10.1016/j.chest.2018.08.743.
SAN ANTONIO – Unplanned whose discharge process involved a pulmonary nurse practitioner to coordinate continuity of care, a study of more than 70 patients has found.
Despite an increase over time in the rate of discharges, readmissions fell, Sarah Barry, CRNP, of Children’s Hospital of Philadelphia (CHOP), said at the annual meeting of the American College of Chest Physicians.
“The technology-dependent pediatric population who is going home with tracheostomy and ventilator dependence is at risk for hospital readmission, and having an advanced practice provider in a continuity role promotes adherence to our standards of practice and improves transition to home,” Ms. Barry said in an interview.
She noted previous research showing that 40% of 109 home mechanical ventilation patients discharged between 2003 and 2009 had unplanned readmissions, 28% of which occurred within the first month after discharge.
Nearly two thirds (64%) of those readmissions were related to a pulmonary and/or tracheostomy problem. That study also found that changes in condition management 1 week before discharge, such as medications, ventilator settings, or feeding regimens, was associated with unplanned readmission.
That research “makes us ask ourselves if our readmissions are avoidable and what can we do to get these kids home safe and to keep them home,” Ms. Barry told attendees, adding that CHOP was unhappy with their readmission rates.
“Kids were often not making it to their first pulmonary appointment, and it was a burden for these families,” she said. “We questioned whether or not having a nurse practitioner in a role to promote adherence to our standards would have a positive impact on our unplanned route.”
They evaluated the effect of such an NP on unplanned readmissions among tracheostomy/ventilator-supported children. The NP’s role was to track patients, mostly from the progressive care unit, who required a tracheostomy and ventilator and were expected to be discharged home or to a long-term care facility. The NP provided continuity for medical management and coordinated care at discharge.
“We also do not make changes for 2 weeks before discharge so that we can focus on all the other coordination that goes into getting these kids home,” Ms. Barry said.
She reviewed the patients’ electronic charts to record time to scheduled follow-up visit, days until hospital readmission, admitting diagnosis at readmission, and length of stay after readmission. With consideration for the time needed for transition into this new process, the population studied was assessed within three cohorts.
The first cohort comprised the 22 children discharged between April 2016 and March 2017, the full year before a pulmonary NP began coordinating the discharge process. These patients averaged 1.8 discharges per month with an initial follow-up of 2-12 weeks.
Just over a quarter (27%) of the first cohort were readmitted before their scheduled follow-up, ranging from 2 to 25 days after discharge. Five percent were readmitted within a week of discharge, and 27% were readmitted within a month; their average length of stay was 13 days after readmission. Most (83%) of these discharges were respiratory related while the other 17% were gastrointestinal related.
The second cohort involved the 11 patients discharged between April 2017 and August 2017, the first 5 months after a pulmonary NP began overseeing the discharge readiness process.
“We chose 5 months because it took about 5months for me to develop my own protocols and standards of practice,” Ms. Barry explained.
An average 2.2 discharges occurred monthly with 2-8 weeks of initial postdischarge follow-up. Though nearly half these children (45%) were readmitted before their scheduled follow-up, their length of stay was shorter, an average of 11 days.
Readmission within a week after discharge occurred among 27% of the children, and 45% of them were readmitted within a month of discharge. Sixty percent of these patients were readmitted for respiratory issues, compared with 40% with GI issues.
The third cohort included all 38 patients discharged from September 2017 to August 2018, the year after a pulmonary NP had become fully established in the continuity role, with an average 3.2 discharges occurred per month. Readmission rates were considerably lower: Eighteen percent of patients were readmitted before their scheduled follow-up appointment, which ranged from 1 to 13 weeks after discharge.
Five percent were readmitted within a week of discharge, and 24% were readmitted within a month, ranging from 1 to 26 days post discharge. But length of stay was shorter still at an average of 9 days.
The reasons for readmission varied more in this cohort: While 56% were respiratory related, 22% were related to fever, and 11% were related to neurodevelopment concerns or social reasons, such as necessary involvement of social services.
Ms. Barry’s colleague, Howard B. Panitch, MD, also on the staff of CHOP, noted during the discussion that the NP’s role is invaluable in “keeping the inpatient teams honest.
“She reminds her colleagues in critical care that you can’t make that ventilator change when on your way out the door or very close to discharge.”
Ms. Barry had no disclosures. No external funding was noted.
SOURCE: Barry S et al. CHEST 2018 Oct. doi: 10.1016/j.chest.2018.08.743.
SAN ANTONIO – Unplanned whose discharge process involved a pulmonary nurse practitioner to coordinate continuity of care, a study of more than 70 patients has found.
Despite an increase over time in the rate of discharges, readmissions fell, Sarah Barry, CRNP, of Children’s Hospital of Philadelphia (CHOP), said at the annual meeting of the American College of Chest Physicians.
“The technology-dependent pediatric population who is going home with tracheostomy and ventilator dependence is at risk for hospital readmission, and having an advanced practice provider in a continuity role promotes adherence to our standards of practice and improves transition to home,” Ms. Barry said in an interview.
She noted previous research showing that 40% of 109 home mechanical ventilation patients discharged between 2003 and 2009 had unplanned readmissions, 28% of which occurred within the first month after discharge.
Nearly two thirds (64%) of those readmissions were related to a pulmonary and/or tracheostomy problem. That study also found that changes in condition management 1 week before discharge, such as medications, ventilator settings, or feeding regimens, was associated with unplanned readmission.
That research “makes us ask ourselves if our readmissions are avoidable and what can we do to get these kids home safe and to keep them home,” Ms. Barry told attendees, adding that CHOP was unhappy with their readmission rates.
“Kids were often not making it to their first pulmonary appointment, and it was a burden for these families,” she said. “We questioned whether or not having a nurse practitioner in a role to promote adherence to our standards would have a positive impact on our unplanned route.”
They evaluated the effect of such an NP on unplanned readmissions among tracheostomy/ventilator-supported children. The NP’s role was to track patients, mostly from the progressive care unit, who required a tracheostomy and ventilator and were expected to be discharged home or to a long-term care facility. The NP provided continuity for medical management and coordinated care at discharge.
“We also do not make changes for 2 weeks before discharge so that we can focus on all the other coordination that goes into getting these kids home,” Ms. Barry said.
She reviewed the patients’ electronic charts to record time to scheduled follow-up visit, days until hospital readmission, admitting diagnosis at readmission, and length of stay after readmission. With consideration for the time needed for transition into this new process, the population studied was assessed within three cohorts.
The first cohort comprised the 22 children discharged between April 2016 and March 2017, the full year before a pulmonary NP began coordinating the discharge process. These patients averaged 1.8 discharges per month with an initial follow-up of 2-12 weeks.
Just over a quarter (27%) of the first cohort were readmitted before their scheduled follow-up, ranging from 2 to 25 days after discharge. Five percent were readmitted within a week of discharge, and 27% were readmitted within a month; their average length of stay was 13 days after readmission. Most (83%) of these discharges were respiratory related while the other 17% were gastrointestinal related.
The second cohort involved the 11 patients discharged between April 2017 and August 2017, the first 5 months after a pulmonary NP began overseeing the discharge readiness process.
“We chose 5 months because it took about 5months for me to develop my own protocols and standards of practice,” Ms. Barry explained.
An average 2.2 discharges occurred monthly with 2-8 weeks of initial postdischarge follow-up. Though nearly half these children (45%) were readmitted before their scheduled follow-up, their length of stay was shorter, an average of 11 days.
Readmission within a week after discharge occurred among 27% of the children, and 45% of them were readmitted within a month of discharge. Sixty percent of these patients were readmitted for respiratory issues, compared with 40% with GI issues.
The third cohort included all 38 patients discharged from September 2017 to August 2018, the year after a pulmonary NP had become fully established in the continuity role, with an average 3.2 discharges occurred per month. Readmission rates were considerably lower: Eighteen percent of patients were readmitted before their scheduled follow-up appointment, which ranged from 1 to 13 weeks after discharge.
Five percent were readmitted within a week of discharge, and 24% were readmitted within a month, ranging from 1 to 26 days post discharge. But length of stay was shorter still at an average of 9 days.
The reasons for readmission varied more in this cohort: While 56% were respiratory related, 22% were related to fever, and 11% were related to neurodevelopment concerns or social reasons, such as necessary involvement of social services.
Ms. Barry’s colleague, Howard B. Panitch, MD, also on the staff of CHOP, noted during the discussion that the NP’s role is invaluable in “keeping the inpatient teams honest.
“She reminds her colleagues in critical care that you can’t make that ventilator change when on your way out the door or very close to discharge.”
Ms. Barry had no disclosures. No external funding was noted.
SOURCE: Barry S et al. CHEST 2018 Oct. doi: 10.1016/j.chest.2018.08.743.
REPORTING FROM CHEST 2018
Key clinical point: Use of pulmonary NP for continuity care decreases unplanned readmissions among pediatric tracheostomy/ventilator patients.
Major finding: Unplanned readmission rates declined from 27% to 18% before the patient’s first follow-up appointment.
Study details: A retrospective electronic chart review of 71 tracheostomy/ventilator-dependent children discharged between April 2016 and August 2018 at Children’s Hospital of Philadelphia.
Disclosures: Ms. Barry had no disclosures. No external funding was noted.
Source: Barry S et al. CHEST 2018 Oct. doi: 10.1016/j.chest.2018.08.743.